0306-360 (PLBG)LICENSED CONTRACTOR DECLARATION:
I hereby affirm under penalty of perjury that I am liceVed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
date o Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) I, as owner of the property, or my employees with wages as their sole
compensation, will do the work, and the structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
( ) I am exempt under Section B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
( ) I have and will maintain a certificate of consent to self -insure for workers'
compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
( ) I have and will maintain workers' compensation insurance, as required by
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier :^A<r MLt; ,; Policy No. 1003312.02
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) I certify that in the performance of the work for which this permit is issued,
I shall not employ any person in any manner so as to become subject,,to the
workers' compensation laws of California, and agree that if .l-sfiould.become
subjectA6 the workers' compensation provisions.of•Section 3700 -of the Labor
Code, I shall forthwith comply with those • provisions.
rD`ate: ✓ a.<, = Applicant •`'��>' —
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify,that I have read this application and state that the above information is
correct. I agree to comply with all City, and -State laws relating to the building
construction, and hereby authorize, representatives, of this City'6 enter upon
the above-mentioned property forn�sspection purposes.
/"�' % .off" ,..-N ;oCi� •
�Slgnature (Owner/Agent) "'' Dater ^ sd � 3
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:BUILDING PERMIT PERMIT #
DATE VALUATION LOT TRACT
JOB SITE
ADDRESS
APN
OWNER
CONTRACTOR/DESIGNER/EN (NEER
MA '1"22.",3
H—R,4y;,<> ,. %A C2543
ciKk 1030
USE OF PERMIT
hfa1
at:U�isF�t:ON�f3r,C'`;.�a�>r`Tl(;�Nl�t�Atl,�itt,'G�ivi•At�'
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RECEIPT
DATE�>
c
By'- < ;'
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans 8 Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sfwer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final.
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS:
_
/�—
TOTAL $
Remarks.(,l 1 i�(.(n1
Vopy to:
Cash WaterService G
Check
Money
Order 'r �' Cashier
�i E CVWD-438(11189)
4
COACHELLA VALLEY
WATER DISTRICT.
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CASH•RECEIPT DETAIL
96.086
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Date:
Address:[�/e.:
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Account No. Q 6 ' 3� g' ` �.. p. v:
Lot(s)
Tract
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'G.A. Code
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❑ Backflow(s)
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House Lateral(s)'
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'❑ DetectorCheck(s)
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❑Meter Surcharge
G3/Sariitation•CapacityCharge
❑ W.S.B.F.C.
❑ Temporary Construction Meter `
❑ Turn on Charge
❑ . Uncollected Account - Name
❑ Inspection Fee - Tract -
Fee -
,
❑ Plan Check Fees Water I Sewer. -
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Tract -
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❑ Bond Payment - A.D. - Bond
Assmt.
❑ Customer Deposit
❑ Other
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TOTAL $
Remarks.(,l 1 i�(.(n1
Vopy to:
Cash WaterService G
Check
Money
Order 'r �' Cashier
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17 ;" AWOYei of theses' plaus by the D nrtso¢eat-ol:Pa --
*;. ' �Illth ®t.Riveiside;County doeo no reli®ve the Engin• f
tlBi_qf Atgbitect.of the responsibilit for the Dngine� P ti`- — t"�
lw fie' Architectural
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THIS APPROVAL GRANTED BY — - w
DEPAR MEMF-OF,; Putt 1-- ;HEAL _ ..
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F.ROiV1�-DAT�€ OF...APOAt- - A
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herewith approved, wit ut clewrrntM3X t���4
wage,,.d'
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^ , tnwsicon�bPht �titF�'requrreme otffcu�rent`URifdA[�►rlbing Evd$
Any cutt g gradin fillet to excess o , four (41 feet will nullif, sew? e' } ti
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COUNTY OF (RIVERSIDE, DEPARTMENT OF HEALTH
PERMIT APPLICATION FOR A SUBSURFACE DISPOSAL SYSTEM
Applicant: Submit this form with three copies of a scaled plot plan drawn to county specifications required on the .
attached check list. A non refundable filing fee of $15 is required when the application is submitted. Check must be
made payable to County of Riverside.
Name
7�Zeee7r
Mailing Address
J -,f -a. 1!:576P,e_ e-
City
State
Zip Code
Phone
'P„ roperySAd r s
��yI .O� Gd,.-
Sr�/��P
Z'Cit o o .mC ' munity�^••-
i
'L'egal Description of Property (Lot, Parcel Map, Tract)
LcAip* -0 bl k � wl M ei D Iq 051 Ea Ilia—
'Assessors Parcel No.
Water Serving Property From e11+ O—V 64e
i f e c,Z
%ya 7 Al
lS' nature of Applicant Date
'The above information must be verified from -Building Application
Staff Use — Do Not Write Below This Line
Initial Date
WQCB Clearance required Yes ❑. No
Soils feasibility report required Yes.❑ No
Detailed boring report -required Yes ❑ No
Detailed contour plot.required Yes ❑ No e
Comments:
Soils or boring report by _ + "Date
Approved by ate
Soils .Map Page Soil Type Tract File N6tit fv' 'N6tr�rZJ
Number of Bedrooms
EwtT. �if7IOWA. /V4Kf
Septic Tank Size (gallons)
fT
Rate Required
Type of System
New Addition placement
Leach line sq. ft. of, bottom area trench
Leach bed (sq. ft.(fbottom area bed)
Seepage Pit DiameterNumber
- 61
ofPits /4
Sr
Seepage pit Depth B. 1.
TotaLDe�ptJh of Pit
j
((
Locla��Ion of System
/ C/ _,c,
✓� -C.f-7 v c�[�e-C/` C�GCIv�� !iC%e'v..e�� G�
Additional Requirements vLcc.,._ "ci�r�
A permit 6pproved�� •detmeed for the design of a subsurface disposal system as indicated on the accompanied plot plan
using the requirements set forth in Section B above. A building permit is necessary for the, installation of the above
desi�ned yste
�LI.AJ ,
Signature of Health Official .' - - - Date
Receipt No. " Issued By �W2
District: Riverside 1 Indio .2— Hemet ❑ Date
DISTRIBUTION: WHITE - Office File YELLOW - Applicant PINK - Building Dept.. GOLDENROD - Pending File
DOH SAN 122 (Rev 10/84)