9804-0029 (PLBG)54645 Avenida Alvarado
LICENSED CONTRACTOR DECLARATION
I h;eby 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
c\l W Professionals Code, and my License is in full force and effect.
O M License # Lic. Class Exp. Date
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t
ZO Date * '" "Signature of Contractor " =
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Jo
HWW I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
Z( ) 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
N Date Signature of Owner
O"
Ian• d WORKER'S COMPENSATION DECLARATION
. o I hereby affirm under penalty of perjury one of the following declarations:
CC
I- 0 ( ) I have and will maintain a certificate of consent to self -insure for workers'
r X W IL compensation, as provided for by Section 3700 of the Labor Code, for the
1. O J Q performance of the work for which this permit is issued.
CO
< U ( ) I have and will maintain workers' compensation insurance, as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
fl 6 H permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier: I ' J Policy No.cob 5
r. ; t
O
J(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
ate: ft ` f` Applicant' w',4 i`t
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) -c s. Date
OWNER -BUILDER DECLARATION
BUILDINGPERMIT PERMIT# CONTROL#
DATE 8774 p VALUATION fAA. i LOT 9804-029 TRACT 4
4/ 3/98 SIa200.VMM 0
JOB SITE
ADDRESS 44.4545 AVENIDA ALVARADO
APN y.
Afer
OWNER
JANICE C BLOCK
54645 AVENIDA ALVARADO
LA QUINTA CA 92253
CONTRACTOR / DESIGNER /
ALFRED MATTHEW
35150 LILLIAN
CATHRF-DRAL
C766)320.5325
ENGINEER
DECASTRO
LANE
CITY CA 92253
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USE OF PERMIT
bi (RipIE
SEP! IC A'aANDONMENT JEWER CONNECT. PROOF OF CITY BUSINESS
LICENSE REQUIRED 4/6/411 FOR INSPECTION.
1
VALUATION 1,200.00 LS APR
E CITY OF
COST OF CONSTRUCTION
PERMIT FEE SUMMARY
PLUMBING FEE -- SEWER 103-000-419-001) $30.00
SUB -TOTAL CONSTRUCTION AND PLAN CHECK
LESS PRE -PAID FEES
TOTAL PERMIT FEES DUE NOW •
1•
`
0 v .1b8
LA QUINTAESTIMATED
1,200.11)
$30.00
S0.00
$30.00
RECEIPT
DATEfB
it
DQT% F} JA LEj i 1'
INSPECTOR
•c i
f '
INSPECTION RECORD
. OPERATION
DATE
INSPECTOR
OPERATION
•
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts •
'
Slab Grade .
Retum 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
•POOLS
- SPAS
BLOCKWALL APPROVALS
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 PipingPlumbing
Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
1/
O.K. for Finish Plaster
Pool Cover•
Sewer Lateral
/��� .
Sewer Connection
0'
Encapsulation -
4
Gas Piping
.
Gas Test
/ed
Final
COMMENTS:
•
•
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
(.' )
l
Final ,
-
Utility Notice (Perm)
City of La Quinta.c.
Building 8i Safety Division
• P.O. Box 1504
78-495 Calle Tampico
La Quinta, CA 92253.
Building Permit Application and Tracking Sheet
Project type (circle one): New Add'n Alter Repair Demo
COACHELLA VALLEY WATER DISTRICT
CASH RECEIPT DETAIL
Received From71746--LJ21NG 4A XLJ°
Address: —fir— 3 9 I H 16H (Amy l t f, .-57E A. Aqu 1 1)& Se/(r-•
Account No. o J (D / s ,./(9.•(:). % • Lot(s)
Service Address /4L/t A%• /4L VAi AuO
❑ Meter(s)
❑ Service(s)
D Backflow(s)
❑ House Lateral(s)
❑ DetectorCheck(s)
❑ Meter Surcharge
XSanitation Capacity Charge
❑ W.S.B.F.C.
❑ Temporary Construction Meter
D Turn on Charge
❑ Uncollected Account - Name
D Inspection Fee - Tract -
Fee -
El Plan Check Fees Water / Sewer - •
Tract -
D Bond Payment - A.D. - Bond
Asamt
O Customer Deposit
❑ Other
/' Remarks:
'Copy to:
• /.PL! tiP4. Rmitor
'1: 4720
Date: 4 - 3 - q� •
Tract
G.A. Code
I9�S°":
TOTAL ' $ . 19 a 3
Gt//J JU Q •
Water Service
Money
Cashier %�
•
-SANCO
PUMPING SERVICE
2502 Morongo Trail
Palm Springs, CA 92264
(619)327-8859
;l' 910541
STREET
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PAYMENT DUE UPON RECEIPT
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OF RIVERSIDE DEPARTMENT OF HEALTH
ENVIRONMENTAL HEALTH SERVICESPERMIT
asasssors Parcel No.
—
PAppllcant:COUNTY
APPLICATION FOR A SUBSURFACE SEWAGE DISPOSAL SYSTEM
Submit this form with four copies of a scaled plot plan (1-20 scale) drawn to County speculations as indicated on the attached check list
A non-refundable filing fee (see below) 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 approval.
VERIFY ITEMS IN SECTION A FROM BUILDING & SAFETY APPLICATION BUILDING DEPARTMENT APPUCATION LOG*
Agent, Contractor, Contact Person
-T'AM(0 QEUELo?MFNT, IN(
Phone
360o -046y
Address & Phone
Owner
Sf/Me''
Phone
Mailing Address
1P.0 • Bo X 46y'y
City Y
?ALAI,CESEer
State
C4
Zip
yz1GI
Job Property Addresa U, -
ALVA eAno
Legal Description Prop. (PM, Tract t
t_01 7 BLIc 2&? Gu ,r
Lot Size
SOX 100
OAgenc y
Use of Permit P/P, CU, etc. 64,,,,,..404
Other /
Gam,L64. cZa_...06f
"
CEdi d -s
C ' J
sA 6
DwelnPre
-,-/2 / . 0A11/31-
`i- - 13, - 8 9
Signature of Applicant
Date
CATEGORY: REV CODE FE
Ar`SUBSURFACE DISPOSAL 1238 $45. .
❑ MULTIPLE PARCELS WITHIN SAME
LAND DMSION
a. 1st 4 Parcels (Each) 1238 $45.00
b. Each Parcel after 4 7344 $16.00
❑ Rereview (2nd review same parcel) 7344 $16.00
❑ Site Evaluation in Conjunction with
Critical Area 7346 $86.00
❑ Site Evaluation Lot Less than
10,000 Sq. Ft. 7347 $86.00
CATEGORY: REV CODE FEE
0 SITE EVALUATION UPON REQUEST 7349 $42.00
(NO PLOT PLAN)
0 SEWER/SEPTIC VERIFICATION 7348 $11.00
(Less than 1 year)
0 PREUMINARY ELECTIVE 7352 $45.00
EVALUATION (Attach DOH SAN 53)
0 HOLDING TANK 7351 $45.00
0 ALTERNATIVE/EXPERIMENTAL 7345 5132.00
SYSTEM
/ INf DATE
Holding'.dinHolding'.Tank Agreements Completed 0 Yes 13 13 V
I
Certification of Existing S.D. System Required 0 Yes N I
WQCB Clearance required. (Attach Form 0 Yes "No
DOH SAN 007, Santa Ana Region Only)
Solis Percolation Report Required. 0 Yes
Special Feasibility Boring Report Required. 0 Yes
Detailed Contour Plot Plans Required (1 to 5 ft. interval) 0 Yes
Other ❑ Yes
Staff Specialist Lot Inspection Required 0 Yes No
Lot Inspection Date
Soils boring report by Proj/ect'* Date
p , .
Soils Map Page Soil Type Co( Approved by 1 A---- Date Y.- / 4- 0 -7
No. of Systems
,%
/
T of Systems)
0 Holding Tank 0 Existing
e],I ew ❑Replacement
No. Dwelling Unita ( 1)
Bedrooms,-Fixtr Mnits
38D 444x,
(1) Septic Tank
fy
/vvU Gal
Soil Rate Greese/Sand
/ Intcp
4`Y (#0,/,Gr Gal
N.42) Leach Line Sq. Ft.
'Bottom
Sldewali allowance
R rock/ sq. R
d
Install-. Line(s) ft long ft wide with
Le h Bed sq.ft
of bottorrt ar@a,`
.
min. crc►res—rock:below drehrlirtea a
per running ft. /
Leachlines/bed special design for slope:
Applicable
(3) Pit Diameter
t
'
No. Pits
Pit Below
Inlet (BI)
/ 1
Seepage P11 Total Depth.
. " f
Max( . Allowable Depth
T
`
N/A t Overburden factor _
No. 2 System /Up+
REMARKS . r'>_. 61 4,... i Z/.1--er _. /di° GGi-a4...n. c e.e,
-ll.A,/?,, 0 ,Gt., ...- et,-, / P as./ /.
/1
D % ,1 S iG-, jrf /; X$2i ..,,
This application is OVED o • ED for the category checked in SECTION B above, regarding the design of a subsurface disposal system as indicated
on the accompanied p of pe using the requirements set forth in SECTION C above. A building permit is necessary for the installation of the
above -designed system. No construction is permitted in the required reserved 10096 ex.. nsion area.
(1 Septic tank and sewer lines must be 50' minimum from any wells//J • t 2^leaC& h''Ce'vr•4G
2) Leach lines must be 100' minimum `from any wells, including exp: L
) slo a -6-
OW Seepage pits must
% 1550'' minnii-mum from any wells, including exxppanns • n a - - N
ate `. % +i 1n1'-(2' n4
Signature of Health Official %sf'eteA_ 61,C Gil C.ki -/3-p • ''4 i°,1/P:-
RECEIPT NO
DISTRICT: 0 Riverside, ❑"'Indio 0 Hemet q Perris .❑ Rancho Calif. 0 Blythe
DOH SAN 122 (Rev. 5/88) DISTRIBUTION: WHITE - Office file YELLOW - Applicant PINK - Bldg. Dept GOLDENROD - Plans/Records