02-0373 (PLBG)LICENSED CONTRACTOR DECLARATION
I heresy affirm under penalty of perjury that I am licensed 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
263214 C42 i 02M/20i
(pate 1�A I/ - Signature of Contractor-!
OWNER -BUILDER DECLARATIO
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).
O I am exempt under Section B&P.C. for this reason V.:
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 Policy No.
[••P. Tri .^ftp 1 •l��C✓1 6! On
dL A 11 L' W2�T?/
(This section need not be completed if the permit valuation is for $100.00 or less).
( ) I certifyith'at in the performance of the work for which this permit is issued,
I shall notemploy any person in any manner so as to become subject to the
worked 7compensation laws of California, and agree that if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
9 e, I shall forthwith comply with -those provisions.
Dater Applicant �L
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, indemnity
& 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 to enter upon
the ab(ove-mentioned property for inspection purposes. %
Signature (Owner/Agent) /� DateJ / r �
BUILDING
�-
PERMITPERMIT# -
DATE VALUATION LOT4�J TRACT
02/231200 51,800.00
JOB SITE APN y
ADDRESS 80-111 AVENUE 52 69-290-d15
OWNER CONTRACTOR/DESIGNER/ENGINEER
rt rl 'AN F BADEN A-1 C.ESSIPJ'; 1, NER :'ICF, INC,
11 TT .
80111 AVENUE 52 .16819 LfrrLE 010RONG0 RD.
LA,OiJli<7TA C,A 5t°?253 D,ESCRTHOT'SPRING: CA, 92244
(76))129-6875 URN 3$0
USE OF PERMIT
PLUli►3ING
RTPLA.Ci. 7. AMACIM, ,`,M J 0E 11I i PER MI ALTIMERP i' APMO V AL
i'Al liat'iiON
1,500,00 LS
���•r's�wn .� `Y`Y;`�a ��sl � ��' f"^ !,°°'3" a• )ti:�•F,�i1_+:' � 2 °•t3,��
PLUI:MBINGi-WEE S-47. 5i1
SU'R-TOTAL, f'C;DNKfR1i(:Z'*.N.r ANT) P L, AN (",laF,OK $17 10
LIUS PRE.P.'JED ftuq $0.01)
f0fAl.,PEMNU4 MRS DUE NOW
#� IIIIIiIIVIIIIIIVIIIIIII 47
IE
RECEIPT DATE BY DA 0/Q0 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 & 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
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
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Poo L_ gg"ml
z3 DU
Final
_ _
.&/_L
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:
u
ASSESSOR'S PARCEL NUMBER
COUNTY OF RIVERSIDE HEALTH SERVICES AGENCY
DEPARTMENT OF ENVIRONMENTAL HEALTH
PERMIT APPLICATION FOR A SUBSURFACE SEWAGE DISPOSAL SYSTEM
APPLICANT. Submit this form with four copies of a SCALED plot plan (1-20 SCALE) drawn to County specifications as indicated on the attached check list.
A non-refundable filing fee is required when the application is submitted. Check must be made payable to the County of Riverside. Approval of this applica-
tion shall remain valid for a period not to exceed one year from date of payment.
LMS #
Agent, Contractor, Contact Person
Address city State Zip
Telephone
Owner
Address City State Zip
Telephone
ZO
Job Property Address
City
Zip
WLot
Size
`Water Agency_/Well �' . ,
Use of Permit, P/P, SUP, PUP, etc.
Legal Description
Dwelling'j)MH Site Prep, etc,"
Signature of Applicant ,
Date
q
CHECK BOX IF REQUIRED
If any box is checked, this application shall be considered rejected until
❑ Detailed Contour Plot Plans Required (1 to 5 foot interval)
the information is provided and the fee paid. Resubmittals later than 90
days after date noted below may require repayment of fees.
❑ Staff Specialist Lot Inspection Required
m
❑ Holding Tank Agreements Completed
Thomas Bros. Page Grid
Z
O
❑Certification of Existing S.D. System Required
❑Date Lot Inspection Completed: Initials
U
❑ WQCB Clearance Required
LU
(Attach for DOH -SAN -007, Santa Ana Region Only)
Remarks:
❑ Soils Percolation Report Required
❑ Maintenance Booklet Provided
❑ Special Feasibility Boring Report Required
❑ Final Inspection by Department of Environmental Health is required.
❑ Rereview Required Initials DateJr
Please call 24 hours PRIOR to inspection.
C/42 / Soils Percolation Boring Report by Uc/Project # Date
Soils Map Page Soil Type Approved By Date
No of Systems
Tie of System(s) ��
No. Dwelling Units i� 1Cj,';
(1) Septic Tank
Soil Rate
Grease/Sand
Holding Tank Replacement
HAddition
Bedrooms Fixture Unita
/
Grease Intcp/lint Trap
New
I
Existin 9
Gal. ;i
' i
Gal.
SqP Ft.
Total Linear
Sidewall Allowance
�� ` ��� " '"
Leach Bed sq. ft. of
Bott�r{iArea
�Line_(s) "'
Bottom Area
ft. took/ sq. ft. running ft.
Install ft. long ft. wide with
Inlet Tested Depth - ❑ NA
min. inches rock below drainlines or
U
Proposed Bottom Tested Depth
Z
Leach lines/bed special design for slope:
(3) Pit Diameter
No. Pits
Pit Below Inlet (BI)
Seepage Pit
Maximum
Other:
O"
Total Depth
Allowable
I.-
Applicable<�
n
-
Depth
LLI
N/A Overburden Factor
V a&
TD
Well Review Approved: Date: Well Drilling Permit #
SIGNATURE
Grading Plan Approved: Date:
SIGNATURE
Sewer Verification Approved: Date:
Plan Check Only Approved: Date:
REMARKS:
This application is"APPROVED/DENIED for thb-category checked in SECTION, 8FOR
OFFICE USE ONLY
above, regarding the design of a subsurface disposal system as indicated on the
acompanied plot plan, using the requirements set forth in SECTION C above. A build-
ing permit is necessary for the installation of the above -designed system. No cow
struction Is permitted in the required reserved 100% expansion area.
Revenue code Fee $
(1) Septic Tank must be 100' minimum from any wells.
0 Check #
(2) Leach lines must be 100' minimum from any wells, including expansion area.
Date Initial
0
(3) Sewer lines must be 50' minimum from any wells.
Z
(4) Seepage pits must be 150' minimum from any wells, including expansion area.
U
W
U)
Signature of Health Official
e,
Date
utn-sap-i ZZ tMev sronl Dismounon: wHi I E—Unice mie; YLLLUW—Applicant; PINK—Bldg. Dept.; GOLDENROL—Plans/Records
X tt
COUNTY OF RIVERSUE k-EALTil SERVICES
DEPARTMENT OF E6U'VIROMEN iAL M1=AL7F8
Food
-- Sewage Disposal
J Z S 2F Td /1E flETC/1-+•+�.v�i
Trailer Park - /Si Gala Septic Tarik � C,4,-) 72) /lE-vr4iN3 Cdv jEar/� Con/nuC7a.)
f+ypl Apt., Hotel p M Sq. Ft..pf Leach, Line r /
(+ !-!1Owe��ng FX(Sr(3 By� �— fJo. b Dia_/�BI^'/� TD /1? Seepane pit TD /LE�cAcE
f _ G,SWercial Building Connection to Sewer EX/sr. PF-�P•4G�
j-._ imming Pool Connect to Cxir"ting S.S.D.o.
X No oh-sils? rog.mcirating i -Valu $+:liming devicas rn-7k' I?o discharged into tl,r` indivHual se,&,agq dis-Dsa..l
system here:.r th approvod ` 4hout ck i.ranco frorn cio Water aivaiiiy Control BOrird.
Water sui:c{y cervi i. thi�s� r <+p. lation must ha from an approved ,ouice L'x/,l'T. (C UWP)
All sewage c;isccs (ii5yi5%(i4!�i� muni conform tivi[h req+�iremeni3 of current Unifi:rni 1umb rig C "..e.
Any cutting, gcadinf, or filling in excess of two(2) feet will nullify sewage di-1-pos I val.
Approval hcis been obtained from the Regional Water Quality Control Board for installation of iho sewage
disposal system.
This is to certify that the Riverside County Environmental Health Services approves the subsurface sewage
disposal plot plan to obtain building permit fo •nstallation, constru n.
•
,-)ATE .2,- 3 - DD BY—'-
i0A,IrN',TAIN I lvlga ' v ;`� s:.'�S AR . MIN FROM ANY WEU yv wc,/
MIN, 10' FROM ANY bVieE THEE AR WATER MAc(V.,—j!!�e kLe_-_v
/.
/V O 7r— AK e_�
A",
s
1
9' 4r,, •_ � r d22j S YY .1-11-�s ' &-�-ppTOVM Of.these pluu by Ohs DaPnrt. ent o4 root,
i} E A R
VAND F't�.� 4 �plth of Riveraide County does not relieve the EngiT-
iS VP�i w �F � �� �� � yRr ar { 4-1teet of the responsibility for dw sinew
FROM DATt OF APPROVAL. or wvehimi.tarW .A
0
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