0305-258 (COMM)LICENSED CONTRACTOR DECLARATION
I hereby 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
653945 B 09l3t'l�it
Date 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 STATE ASND Policy No. 19106.2001
(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.
Date: ! - 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 to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) - Date/" 2; _ s
BUILDING PERMIT PERMIT# -a
DATE VALUATION LOT O�-2W TRACT
S4.200.00
29894-2
JOB SITE (j
APN
ADDRESS M63.0 I/2 AYRNW, 54
772-320-006
OWNER V
CONTRACTOR/ DESIGNER/ ENGINEER
W) LA QUfN'TA PARTNERS, Lim .
ALL PHASE Ct?NSTRUCTION RTJ
81.100 AVENUE 53
82.822 VIA PALM.MO
Z.A. QL A Cly 92253
INDIO
GA 92201
(760)27.5-7721
CBU 4213
USE OF PERMIT
1500 QALWN UPTIC SYP,TRM FOR. COMFORT S`1'AT1014(91) PER.
HEALTI^IUgI'i1,ISTMENT.APPROVEDi-ILAN9:-C//A;.6.
VALUATION 4X0.00 LS
R5TU' ID COST Or CONNTRITC'1170K
4,W000
PLtIM1MA0 FEE 101.000.419.000 $45.00 '
PIT ft- " Y111 AT. tol 1 UfrMON',N9 PIJAW CHECK.
W,00
LESS PPJr FAM PERS
$0.00
E107 - PIK"I T MUSDUE NW
JU N 2JUN 20 2003•
$0.00
CITY OF LA QUINTA '
11111111 VIII III VIII III 34
FINANCE DEPT.
IE
RECEIPT
DATE'S �r
BY �/
DAT IN ED
I INSPPCTOR
L1
r
't
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
�2A2. C 0
Final
Final
Utility Notice Gas
�Y (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I. n
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
COMMENTS''
;i
COUNTY OF RIVERSIDE COMMUNITY HEALTH AGENCYASSESSOR'S PARCEL NUMBER
-1 1Z
DEPARTMENT OF ENVIRONMENTAL HEALTH —32.0 -00s6
.:.sir,. � , •, ��
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 #
Agent, Contractor, Contact Person
Address City State Zip
Telephone
Owner
Address City State Zip
Telephone
OJob
Property Address
City
Zip
H
t.
/
U
V)
Lot Size
Water Agency/Well
CP, tSUP PUR etc, t
Use of Permit, P/Ij
Ir
ronnk�wx
Legal Description
DBA
CV
,1
w
Dwelling, MH Site Prep., etc.
Signature of Applicant-
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 /yA S• w'- •- • , e.� •/ w r.H.�
(3Staff Specialist Lot Inspection Required
ZC3Holding
Tank Agreements Completed
2
(3 Certification of Existing S.D. System Required
Thomas Bros. Page Grid
W
C)WQCB Clearance Required
❑ Date Lot Inspection Completed: Initials
(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.
Cl 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
s a
1 (
1❑Holding Tank EI Replacement
t Q Addition
T04
Bedrooms, Fixture. Units
_ -• T
r �^ "Y
t
- 50O
/
7/ b
,
Grease Intcp/Lint Trap
Existing
❑"Existing ❑ Connect to Sewer
Gal.
y
Gal.
Sq. Ft.
Bottom Area
Total Linear
Ft.
Sidewall Allowance�.�r-"
ockt,- sq, ft. running ft.
-
Install Linnee(�,)�� ft. long ft. wide
Leach Bed sq. ft.
of Bottom Area
Inlet ested Depth ❑ N/A
with/ inches rock below drainlines
U
Proposed Bottom Tested De
Depth
p
or
Z
Leach lines/bed special design for slope:
(3) Pit Diameter
No. Pits
Pit Below Inlet (B1)
Seepage Pit
Maximum
Other:
0
U
Applicable
`6'
l i
D
Total Depth
Allowable
D�
W
N/A Overburden Factor
❑ 5'
`
TD
Well Review Approved: Date: Well Drilling Permit#
SIGNATURE
Grading Plan Approved: Date:
SIGNATURE
Plan Check Only Approved: Date:
„L�
REMARKS: MW1�<rrlalbJ. A LL.. QQkVKA S&+�0►c_ K �Yli1M LA.M11 ✓ { vtt
A 1 A
awl N .0-k .
TANS Cans mQ&,'T tic. 4O &-..*&L a,,L /a -A S +%
ti 1,. t
This application is APPROVEM.DENIED for the category checked in
SECTION B above, egarding�the design of a disposal system as indicated
on the accompanied p plan, using the requirements set forth in SECTION
C above. A building permit is necessary for the installation of the above-
Revenue Code i Fee $
designed system. No construction is permitted in the required reserved
100% expansion area.
1) Septic Tank must be 100' minimum from any wells. -
Check #
�
Z
(2) Leach lines must be 100' minimum from any wells, including expansion
4
Date Initial
0
area.
H
C)
(3) Sewer lines must be 50' minimum from any wells.
W
U)
(4) Seepage pits must be 150' minimum from any wells, including expansion
RIVERSIDE: 909-955-8980
area.
t .
/�
INDIO: 760-863-7000
`
SOUTHWEST: 909-600-6180
Signature
Date
uen-SAN-irz (Kev mi) Distribution: WHITE—Office File; YELLOW—Applicant; PINK—Bldg. Dept.; GOLDENROD—Plans/Records
A
COUNTY OF RIVERSIDE HEALTH S.ERV'ICES, AGE -
NQ.
DEPARfEN T OF EWIROtNMENTAL HEALTH,
rDEPARTMENT
Fodd _Sewage Mipogdl
OF PUBLIC HEA -- �'t6ilar Pork alSeptic Tank
ID FOR ONE (1) YEAR - r���l�l, �ipt•, Motel sq. Ft. of Leach Line
DATE Of APPROVAL--l�voallinp __�No. �DIa ijr- 8I�fiO�M@ Seepage
_rObfilt�®rciel Building Connection to S®wir
swir�f�ing Pool Connect to Existing
'ice No onsite r'otimmating water softening devices may be discharged into tho iftdividgM §@way@ disposal
system hIOMWith ftPVMd without clearance from the Water Quality Quniroi s@ord.
Water su this lrtattat4atien must be from an approved F�urce
1i1 ewac e " i t a 9 pail 4i�n must cranfaem with reGuire;ri rtts of c sttrRrd Unitntr�? Higt?tlaJn9 Code.
9�tt�tt;c.t°� e faliiti in. excess of ta�l2j feet ��r:l! ttufle?y s �lispusal apprr•�yal.
ht3iti 3 ttt the tea ional 1r1r'ater O�sa:sriI Qorei;oi ward is installation of the sewage
fiP'it it tottqft**the. Riveirside County Environ imenta! Neal?h Services approves the subsurfape se�vagR
�l!�I ref ! 'W, t4okta,n;building permif for ic,sia?iation, construdion.
AT
ty MA�v7t4t r t�ar�'= COUNT CLUB OF THE DESERT
01 � tS to C FORT STATION #1
CNK, !_,� k•¢tiS _ .
De t.uu> .etrrornIlnywell. Po•e./
`'Df+�r,ka ►rtet; r+ * m an 'ell N
Deg�D 50teettn►ttttnum o y ;u SITE PLA ,
Sewer IviDs mu be 5 ,feet minimum frol any L
-Z WO.TeA
rYt 6-rs
� •\ 1��' - ++/.� ��. ~~~.'�~~~ter.~-.w..�,.... i~....,....w....w.
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BUILDING DEPARTMENT
CITY OF LA QUINTA
OFFICE: (760) 777-7012
TO:
ADDRESS:
INSPECTION REQUESTS: (760) 777-7153
DATE: �,gd
CORRECTION NOTICE
INSPECTION: - PERMIT NO.:
Inspector