486 (6)NOTE:
With proper validation
this form constitutes an f CITY OF LA QUINTA '
encroachment permit
t APPLICATION FOR PERMIT
PUBLIC WORKS.'CONSTRUCTION (ENCROACHMENT) .
F
For the construction of public or private curbs, driveways, pavements, sidewalks, parking lots, sewers; water, mains .
and other like public works improvements in connection with MINOR IMPROVEMENTS and APPROVED SUBDIVISIONS
DATE%
LOCAT
(Street address or Description of
PUP OS156 QONSTFiIJCT
Subdivision Improvement Permit - Class III
Mino Im ro emen Permit Class. IV
Sketch (attach construction plans if appropriate)
DE CRIP ION OF CO UCTION f iKdF 1 -'-G-ram'- --
DIMENSION OF INSTALLATION OR REMOVAL
SIZE OF EXCAVATION, IF NEEDED `
APPROXIMATE TIME WHEN WORK WILL BEGIN•
APPROXIMATE TIME OF COMPLETION
ESTIMATED CONSTRUCTION'COST $
(Including removal of al I 'obstruction,' materials,, and debris, backfilling, com-'.'
paction and placing permanent resurfacing and/or replacing improvements)
In consideration of the granting of this permit, the applicant hereby agrees to: `
Indemnify, defend and save the City; its authorized agents, officers, representatives and employees, harmless from and against any and all
penalties, liabilities or loss resulting from claims or. court action and arising out of any accident, loss or damage. to. persons or property
happening or occurring as a proximate result of any work undertaken under the permit granted pu uant to this application'
Notify the Administrative Authority 'at least twenty-four (24) hours. in' -'advance of the time whe w "rk will be started.
Comply with all applicable City Ordinances, the terms and conditions, f the per .f d all a li ble rules and r ations of the City of
La Quinta and to pay for any additional replacement necessary as the result o / work.
lgnature an �`,ent
Name of Applicant (please print) Business A4dfess, Telephone No.
Name of Contractor and Job Foreman Business Address Telephone No.
c2��
Cori�pyctorjs,License No. - . / A fi =/ �. . -7 t z City Business License No.
Applicant's Insurance Company / t Policy Number
FEES: Subdivision Improvement Permit —Class III
Public improvements: 3% of estimated construction costs
Private improvements: 3% of estimated construction costs
Minor Improvement Permit —'Class IV: See attached schedule
Inspection Fee $
Permit "Fee
Penalty..
Cash Deposit -Surety Bond
if required
TOTAL: " $
Receipt No.
Received by Date '
Recorded by
N° 486
PERMIT VALIDATION
PERMIT NO.
DATE APPROVED
EXPIRATION DATE
DATE ISSUED
By
Administrative Authority
TELEPHONE:.(619) 564-2246 -
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