0210-124 (PLBG)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of'Liivision 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
785143 3 10411 /2C
Date ��"� Signature of Contractor f
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.
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 3T.A,19 FUND OF ARI Policy No. 31103-2
(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 I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.r
Date: %? ' ` 'Applicant `� _ •�' �Y
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 to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent)?-�'%" ��' ! Date
BUILDING,KE IT PERMIT #
DATE/ f F VALUATION LOT Mla `E`y� TRACT
t
• i ! 4- $4,200.00 29894.2
JOB SITE
ADDRESS W 1,02 A"WW .54APN
772-31.� C06 .
OWNER
CONTRACTOR/DESIGNER/EN (NEER
ND Lai,. QiJftAt TA PAh"1.n71t- RS, l: Z
WFqPAc c("iAfS -R-o`'Ti0Ai, lfitMc.
8; -100 .ABYSM UE 53
9440 N. 26111 VrREF1'_, 0100
`M..A Qi31RTA CA 92253
i?H(Aa4m AZ 85023
(60.7,)9,6.1323 OD11.0 34M
USE OF PERMIT
COIL - C1:AL
I500'_tAY,.i.CA"Af SEPTIC SYSTEM 1<:i[::f.�9.dItr01�`'':�'P��3C+?7(�i�) PEIZ
f1MIJ111}101AX1'M, 4T APPROVED M'itANS.
VALUATION 4,20. 00 W
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4P i}l�.E�IJ
jt vyg 871 T, �, ��y ;.�,{YWS-Hd1I87.JlTI)C,0777011'
aS� ial�. d i" JY�.i X C1UM71�'M4k 7.
PLUMBING FHE $dg:(sfi
r
D 0
OCT 15 1002
CITY OF LA Q!jl�4TA
FINANCE DEPT.
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IIIIIIIIII�IIIIIIIIIII�II 30
IE
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RECEIPT
DATE ` 0
BY
DATE FINA
INS EC
r
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
i_xterior 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
�IFGas Test
;Appliances
�jt►y3n[_5 lD /`�/
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)
Final
COMMENTS:
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COUNTY OF RIVERSIDE COMMUNITY HEALTH AGENCYASSESSOR'S PARCEL NUMBER
1 12- — 3ZV — 0061
DEPARTMENT OF ENVIRONMENTAL HEALTH
APPLICATION FOR WASTE WATER DISPOSAL APPROVAL
APPLICANT: Submit this form with four copies of a SCALED plot plan (1"=20' to 1"=40' 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
application shall remain valid for a period not to exceed one year from date of payment.
LMS #
Age t, ontractor, Contact Person
Address City State Zip
Telephone
�Z�
00 A S 3 LyA C.i CIM1
740 -2 -IT -712A
Owner
Address City State Zip
Telephone
Q
C -C' O
1' IM A Vk 53 9U% + C...r4 01-12.01
W311 I S01 L
OJob
Property Address
o- 2c.0 1 h_ n
City
LA �-�. C
Zip S
z2 9 3
U
Lot Size
Water Agency/Well
Use of Permit, P/P, SUP, PUP, etc.
'�
Legal Description
DBA
LU
U)
�1 1 � (�
��
�T SeP,
d n q
�_1 V 4 —Z
Dwelling, etc.
SignatttrPA I fcant�:
Date '
FOR OFFICE
USE ONLY
CHECK BOX IF REQUIRED
If any box is checked, this application shall be considered rejected until the
❑ Detailed Contour Plot Plans Required (1 to 5 foot interval)
information is provided and the fee paid. Resubmittals later than 90 days
after date noted below may require repayment of fees.
❑ Other N1' c r wo
ZC3Holding
Tank Agreements Completed
❑ Staff Specialist Lot Inspection Required
❑ Certification of Existing S.D. System Required
Thomas Bros. Page Grid
W❑
WQCB Clearance Required
❑ Date Lot Inspection Completed: Initials
V)
(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 Date
Please call 24 hours PRIOR to inspection.
C/42 / Soils Percolation Boring Report By Lic/Project # Date
Soils Map Page Soil Type Approved By Date
No. of Systems
Type of System(s)
No. Dwelling Units
(1) Septic Tank
Soil Rate
Grease/Sand
1
❑ Holding Tank LI Replacement
New ❑ Addition
Bedrooms, Fixture Units
C
Z, S
Grease Intcp/Lint Trap
l 00
I0D (l
❑ Existing LI Connect to Sewer
Gal.
Gal.
Sq. Ft.
Total Linear
Sidewall Allowance
Leach Bed sq. ft.
Bottom Area
Ft.
ft. rock/ sq. ft. running ft.
Install Line(s) ft. long ft. wide
of Bottom Area
Inlet Tested Depth ❑ N/A
with min. inches rock below drainlines
C i
Proposed Bottom Tested Depth
or
Z
Leach lines/bed special design for slope:
(3) Pit Diameter
No. Pits
Pit Below Inlet (61)
Seepage Pit
Maximum
Other:
O
�
Applicable
*JJ
,.
lO
Total Depth
' q
Allowable
De thS
LULI
N/A Overburden Factor
❑ 5'
TD
Well Review Approved: Date: Well Drilling Permit#
SIGNATURE
Grading Plan Approved: Date:
SIGNATURE
Plan Check Only Approved: Date:
Mp
0 A�At tj : VMw A 4,%
tV %��
REMARKS: I " 1� 1)�P1h1 10rLt— ��
8vt
�J MJA-.
Tim,„ CrAs �,g�
This application is(APPROV D/DENIED for the category checked in
SECTION B above, regardin�he design of a disposal system as indicated
on the accompanied pint plan, using the requirements set forth in SECTION
-
-) 51
C above. A building permit iS necessary for the installation of the above-
Revenue Code Fee $ `
designed system. No construction is Permitted in the required reserved
100% expansion area.
Check #
(1) Septic Tank must be 100' minimum from any wells.
Z
(2) Leach lines must be 100' minimum from any wells, including expansion
Date Initial
O
area.
H
U
(3) Sewer lines must be 50' minimum from any wells.
LU
(4) Seepage pits must be 150' minimum from any wells, including expansion
RIVERSIDE: 909-955-8980
area.
INDIO: 760-863-7000
SignatureSOUTHWEST:
909-600-6180
Date
ULM-snly-1Zz (Kev ttioi) Ulstribution: WHITE—Office File; YELLOW—Applicant; PINK—Bldg. Dept.; GOLDENROD—Plans/Records