0103•,; NOTE: t
With proper proper validation
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CITY OF LA-QUINTA
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encroachment permit
APPLICATION FOR" PERMIT -
PUBLIC WORKS. CONSTRUCTION (ENCROACHMENT) �� I psw�
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For the, construction of public or private curbs, driveways-, pavements, sidewalks,parking lots, sewers, water mains l
and other'like public works improvements in connection with MINOR IMPROVEMENTS and APPROVED SUBDIVISIONS•
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Subdivision 'Improvement Permit — Class III
` DATE:_ Atril 11, 1985 Minor Improvement Permit Class 1V
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LOCATION OF CONSTRUCTION 52-175 allenida Ruai ez
(Street addressor Description of Location)
r PURPOSE•OF. CONSTRUCTION Dr1Veymy Apron Sketch (attach constructiontans if a
p appropriate)
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DESCRIPTION OF CONSTRUCTION
DIMENSION OF.INSTALLATION OR REMOVAL •Y �.
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' SIZE OF EXCAVATION, IF NEEDED l '
APPROXIMATE TIME WHEN WORK WILL BEGIN "
APPROXIMATE TIME OF COMPLETION
ESTIMATED CONSTRUCTION COST $
(Including removal of all obstruction, materials, and debris, backfilling, com-
om
paction
paction and placing permanent resurfacing and/or replacing improvements)
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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 aW .'
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.ariy work undertaken under the permit granted pursuant to this application.
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Notify the Administrative Authority at least -,twenty-four (24) hours in.advance of -the time when work will be started.
? Comply with all applicable City 'Ordinances; the terms and conditions of the permit and all applicable rules and regulations of'the City of
La Quinta and to pay for any additional replacement necessary as the result of this work.
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S` � ` • vel.,•,_ � � ' •
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Signature of Applicant or Agent
s • Name of Applicant ('please print)',Business Address Telephone No..
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' Name of Contractor and Job'Foreman Business Address Telephone No..
,Contra6tor's"License No. City Business License NoY
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Applicant's Insurance Company Policy Number ,
H
Y FEES: Subdivision Improvement Permit — Class I I I
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Public improvements: 3% of estimated construction costs `
Private improvements: 3% of estimated construction costs
Minor, Improvement Permit — Class IV: See attached schedule "�
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Inspection Fee' ;$ ..
PERMIT VALIDATION
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1' ').Permit F {
' -Fee
PERMIT NO.
. Penalty '
Cash Deposit-Surety.Bprid ' .DATE APPROVED 4-41—R5
,• if required
EXPIRATIONDATE w �
TOTAL• $" ;
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• • . DATE'I'SSUED. " ) .�._J
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Receipt No. \
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° I,Received by. y..
Date Administrative Authority,
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Recorded byTELEPHONE:„(619) 564-2246
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