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003086 (RPL)P.O. BOX1504 Building'53x„365 , Madero. 78-105 CALLE ESTADO AddresLA QUINTA, CALIFORNIA 92253 Ownpr Hanaferd Mailing Address pp BUILDING: TYPE CONST:. OCC:'GRP.- aline _ R A.P. Number f�� i'.� tf 62 •=� . 1'' City Zip Tel. .9221-13 Legal Description Contractor ... .... ,.... .... .. .. _ .. : - Project Description P F P'0019 Address .City .. La Quinta State Lic. P Tel.. . . 225,3 -.564"':'5070 City & Classlf: .� 476 Lic. # Sq. Ft. No. No. Dw. -Size • Stories • Units Arch:; E6gr., ._.. .. . • Designer New EX .- Add ❑ Alter ❑'. Repair'❑ - Demolition ❑. .: Address Tel. City Zip State _. Lic.'#' _ LICENSED CONTRACTOR'S DECLARATION '• I hereby affirm that I am licensed under provisions of Chapter 9 (commencingwith Section 7000) Division 3 Business a of of the and Professions Code, and my license is in full -force and effect. SIGNATURE DATE _. - ,- ,-. - .- • • " OWNER -BUILDER DECLARATION Estimated Valuation hereby affirm that I am exempt from the Contractors License Law for the following " {at ' 6I - reason: (Sec, 7031.S,Business and ,Professions. Code: Any city on county which, requires a as SLr♦ _ . permittoconstruct, alter, improve,. demolish,, or repair•any.structure,. prior to its issuance also - .. , - ... . ' requires the applicant for,such permit to file a signed statement that.he is licensed. pursuant to PERMIT - AMOUNT the provisions o/ the Contractor's • License Law, Chapter 9 (commencing with ,Section 7000) of. - •. Division 3 of the Business and Professions Code," or that: he is exempt therefrom; %and the basis- for the alleged exemption. Any, violation Section 7031.5 by 'any • for Dep.. - •,.. of applicant a permitPlan'.Chk. •- subjects the applicant to a civil penalty of not more than five -hundred dollars ($500): ''•_ '❑ .. Plan Chk'. Bal. , lift', 13 I, as. owner of the property, or my employees with wages,astheir sole compensation, will do the work, and the structure is. not intended.or offered .for sale. (Sec. 7044, Buisness'and ... Const. ,- . - " • Professions Code: The Contractor's License Law does not apply''to an owner o/ property..who builds or improves thereon and who does such work himself or throughhis own 'employees, Mech. - provided that such improvements are not intended or offered: for sale. If, however, the building ' 16 6� • or improvement is sold within one year of completion,. the owner -builder :will -have the burden> -• EleCtrlbHl .- - �'% .� . t.✓ - of proving that he did not build or improve for the purpose of sale.), ❑ I, as ownerof the property, am exclusively contracting with licensed contractors tocon= 'Plumbing - slruct the project.: (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner o/ property who builds or improves thereon, and who contracts /or .- "S.M.I. ' - - .714 such projects with a contractors) licensed pursuant to the Contractor's License Law.) . .. - Grading am exempt under Sec. B. & P.C. for this reason- Driveway Enc. Date owner ' Infrastructure WORKERS' COMPENSATION DECLARATION ' t'hereby affirm that I have a certificate of consent to self -insure, or a certificate of Worker's Compensation Insurance, or a certified copy thereof. (Sec: • 3800, Labor Code.). 'Policy No. Company I V& O Copy,is filed with the city. .O. Certified copy is hereby furnished. +t TOTAL CERTIFICATE OF EXEMPTION FROM WORKERS' REMARKS f iT ;E' i„. �1 �i+..7, {j'j+-j_ q� 4 17 _ 4 '# t COMPENSATION INSURANCE (This section need not be completed i/ the permit is for -one hundred dollars,($100) valuation - - •- .or less.). I certify that in the performance of tha 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. 'Date. .. owrier . NOTICE TO APPLICANT: If, after making this .Certificate- of Exemption you should, become "• -ZONE: BY, ' subject to' the Workers” Compensation provisions' of the. Labor Code, `you must forthwith comply with such provisions or this permit shall be deemed revoked. - • - Minimum Setback Distances: -. - Front.Setback from Center Line Rear Setback from Rear Prop. Line CONSTRUCTION LENDING AGENCY + Side Street Sback from �ienter Llhe et hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec: 3097; civil code.) •: - Side Setback from:Property Line - Lender's Name Lender's Address ' FINAL DATE _ INSPECTOR This is'a building permit when properly filled out, signed Arid validated, and'is subject to .• _ expiration if work thereunder is suspended for 180 days. .. ~ ' r I. certify that I have read this application and state that the above information is correct. "I Issued by: '• Date - .4 E ;17 /. A .Permit agree to comply with'all city and county ordinances'and state laws relating to building construction, and hereby authorize representatives -of"this.•city to enter the above•: _ • mentioned property for inspection purposes.. ' - - •, , . „• - Validated by: Signatureofapplicant Date Mailing Address Validation: City, State, Zip HARD COPY CONSTRUCTION ESTIMATE NO. ELECTRICAL FEES NO. PLUMBING FEES IST FL. SQ. FT. p $ 2ND FL.SQ. FT. ® POR. SQ. FT. ® GAR. SO. FT. ® CAR P. SQ. FT. ® WALL SQ. FT. ® SQ. FT. ® ESTIMATED CONSTRUCTION VALUATION $ UNITS MOBILEHOME SVC. POWER OUTLET YARD SPKLR SYSTEM BAR SINK ROOF DRAINS DRAINAGE PIPING DRINKING FOUNTAIN URINAL WATER PIPING NOTE: Not to be used as property tax valuation SLAB GRADE FLOOR DRAIN MECHANICAL FEES BONDING WATER SOFTENER VENT SYSTEM FAN EVAP.000L HOOD SIGN WASHER(AUTO)(DISH) APPLIANCE DRYER ROUGH WIRING% �y GARBAGE DISPOSAL FURNACE UNIT WALL FLOOR SUSPENDED ROCK STORAGE LAUNDRY TRAY AIR HANDLING UNIT CFM KITCHEN SINK ABSORPTION SYSTEM. B.T.U. TEMP USE PERMIT SVC WATER CLOSET COMPRESSOR HP POLE, TEMIPERM LAVATORY HEATING SYSTEM FORCED GRAVITY AMPERES SERV ENT SHOWER BOILER B.T.U. SQ. FT. ® c BATH TUB SQ. FT. ® c WATER HEATER MAX. HEATER OUTPUT, B.T.U. SO. FT. RESID ® 11/4 c SEWAGE DISPOSAL WATER SYSTEM SQ.FT.GAR ® 3/ac HOUSE SEWER $ GRADING cu. yd. plus x$ _$ GAS PIPING PERMIT FEE FRAMING PERMIT FEE PERMIT FEE DBL TOTAL FEES MICRO FEE MECH.FEE PL.CK.FEE CONST. FEE ELECT. FEE SMI FEE PLUMB. FEE STRUCTURE PLUMBING ELECTRICAL HEATING & AIR COND. SOLAR SETBACK GROUND PLUMBING UNDERGROUND A.C. UNIT COLL. AREA SLAB GRADE ROUGH PLUMBS 1167 BONDING HEATING (ROUGH) STORAGE TANK FORMS SEWER OR SEPTIC TANK ROUGH WIRING% �y DUCT WORK ROCK STORAGE FOUND. REINF. GAS (ROUGH) METER LOOP HEATING (FINAL) OTHER APP./EQUIP. REINF. STEEL,L9 7 GAS (FINAL) TEMP. POLE GROUT WATER HEATER SERVICE FINAL INSP. BOND BEAM WATER SYSTEM FINAL INSP. $ GRADING cu. yd. plus x$ _$ LUMBER GR. FRAMING FINAL INSP. ROOFING REMARKS: VENTILATION FIRE ZONE ROOFING FIREPLACE SPARK ARRESTOR GAR. FIREWALL LATHING MESH INSULATIONISOUND ' FINISH GRADING FINAL INSPECTION CERT. OCC. FENCE FINAL INSPECTOR'S SIGNATURESIINITIALS GARDEN WALL FINAL P.O. BOX 1504 No. 001606 Building 78-105 CALLE ESTADO Address 52+�5 LA QUINTA, CALIFORNIA 92253. Owner - ... �, .. .. ., .. ...... . TM. Mlaxt-mag_ y BUILDING: TYPE CONST. • • V N OCC: GRP... 1'd Mailing Address53-777 A�� Villa A.P. Number, . ��`°:��"°�%��- . _ City .Zip `� Tel.. r-- ' �,y - .... . L .at 9225 :_56 ' Legal_Description a Contractor Project. Description Address __ _. . Sq. Ft. No. . • No. Dw. Size •�_R • Stories • - • Units New' Add ❑ Alter ❑. Repair ❑. Demolition ❑ :.. City- . : - .. - Zip' Zip Tela above Lic. # State Lic. City & Classif.-, •; * - Lic. # - Arch., Engr.; .. _. . .Designer Estimated VBI Uat, ion -. 791..851414 ' Address Plan Chk., Dep. ' - Tel. Sq. Ft. No. . • No. Dw. Size •�_R • Stories • - • Units New' Add ❑ Alter ❑. Repair ❑. Demolition ❑ City Zip State1's'i�' _ ... Lic. # LICENSED CONTRACTOR'S DECLARATION. * - I hereby affirm that 1 am licensed'under provisions of Chapter 9'(commencing with Section+` 7000) of Division 3 of the Business and Professions Code, and my license'is in full force -and' _. - effect.. ... _SIGNATURE DATE OWNER -BUILDER DECLARATION • I hereby affirm that I am exempt from the Contractor's License Law for the following • - reason: (Sec. 7031,5,Susiness and Professions Code:. Any city or county. which requires a ' permit to construct, altei,•improve, demolish, or repair any structure, prior to'its issuance also • requires the applicant for,such-permit to file -a signed statement that. he is licensed pursuant to . the provisions of the Contractor's License Law, Chapter 9 (commencing with Section .7000).of•. • 'DivisioB30/ the Business and Professions Code; or that: he'is.exempt therefrom,, and the'basis • for the alleged exemption. Any violation o/ Section 7031.5• by 'any. applicant for 'a'•permit - subjects -the applicant to' a civil penally o/ not more than. rive hundred dollars .($500). •.- 01 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,'Buisness and . Professions Code: The Contractor's License Law does not apply to an owner o/.property who "builds Estimated VBI Uat, ion -. 791..851414 ' - -• - - _ -- • •- PERMIT- - - - - AMOUNT: •'rr:• Plan Chk., Dep. ' - y a� Plan .Chk. Bal. 292.42 • . COr1St.: J[�w :# '' - Mech. -: - 3�j nAp .: .3li�s.+LJ!3 or improves thereon and who does such work himself or through his own employees, ;.provided that such improvements are not intended, or .offered for sale. If, however, the building or- improvement is sold within one 'year of completion; the owner -builder will have: the burden ,. o/ proving that he did not build or improve for the purpose o/ sale.) . Electrical '•'_ Plumbing 0.1, as owner of the property, -am exclusively contracting with licensed contractors to con-- .. struct•the project. (Sec. 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner or property who builds or improves thereon, and -who•contracts for • such not with a contractor(s) licensed pursuant to the Contractor's License Law.) ❑ 1 am exempt. under. Sec.. B. & P.C.•for this reason S.M':I: - '' 5_57 Grading Driveway Enc. 2, Date Dae =a Owner � �+- ^r' - - _ Infrastructure 1. 7 . , ..- __. . p' .A� - .. WORKERS' COMPENSATION DECLARATION I hereby affirm that I have a certificate of consent to"self-insure, or a certificate of Worker's Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.) - - •' - - - . Policy No. .... _ - Company O Copy is filed with the city. . O Certified copy is'hereby furnished. ' TOTAL REMARKS ' CERTIFICATE OF EXEMPTION FROM _ '.WORKERS' COMPENSATION INSURANCE - - - (This section need ,not be completed it the • permit is for one hundred dollars ($100)' valuation - or less:) .. ... . .. ... _ .. I certify that in the performance of thg 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. . - Date Owner . - NOTICE TO APPLICANT: I/, after making this Certificate of 'Exemption you: should become ' 'subject to the Workers' 'Compensation provisions 'o/.the Labor Code; you•must forthwith comply with such provisions or this permit shall be deemed revoked. - ,ZONE: BY:; - Minimum Setback Distances: - _ • Front Setback ,from Center Line Rear Setback from Rear Prop. Line - • y CONSTRUCTION LENDING AGENCY J I hereby affirm that there is a construction lending agency for the performance of'the'. work for which this permit is issued. (Sec:'3097, Civil, Code.) Side Street Setback from Center Line -• Side Setback from Property,Llne. Lender's 'Name - - Lender's Address FINAL DATE - INSPECTOR <, ' ISSUed by. t Date ►�-I�i'd- i�� Permit - Validated by:' 'This is a -building permit when properly filled but, signed and validated, and is subject to ' expiration if work thereunder is suspended for 180 days. I certify that I have read this application and state that,the above information is correct. agree to comply'with all'city and county ordinances and state laws relating to building'' construction, and hereby authorize representatives --of .this city to enter the. above-,,-, mentioned property for inspection purposes. Signature of applicant Hf f{? I�r�„D te" g+r� Mailing Address A f ' Validation: City, State, Zip' 61894 7 10 Zi 6'633 CK - _ _ j HARD COPY CONSTRUCTION ESTIMATE I NO. I ELECTRICAL FEES I No 1 DI IIMRIMr] CFFC IST FL. SQ. FT. ® $ 2ND FL. SQ. FT. @ FOR. SQ, FT, @ GAR. SQ. FT. @ CAR P. SQ. FT. @ WALL SQ. FT. @ SQ. FT. @ ESTIMATED CONSTRUCTION VALUATION $ UNITS MOBILEHOME SVC. POWER OUTLET YARD SPKLR SYSTEM BAR SINK ROOF DRAINS DRAINAGE PIPING DRINKING FOUNTAIN URINAL WATER PIPING NOTE: Not to be used as property tax valuation A.C. UNIT FLOOR DRAIN MECHANICAL FEES ROUGH PLUMB. WATER SOFTENER VENT SYSTEM FAN EVAP.COOL HOOD SIGN WASHER(AUTO)(DISH) APPLIANCE DRYER SEWER OR SEPTIC TANK GARBAGE DISPOSAL FURNACE UNIT WALL FLOOR SUSPENDED DUCT WORK LAUNDRY TRAY AIR HANDLING UNIT CFM GAS (ROUGH) KITCHEN SINK ABSORPTION SYSTEM. B.T.U. TEMP USE PERMIT SVC WATER CLOSET' COMPRESSOR HP POLE, TEM/PERM LAVATORY HEATING SYSTEM FORCED GRAVITY AMPERES SERV ENT SHOWER BOILER B.T.U. SO. FT. @ c BATH TUB SERVICE SQ. FT. @ c WATER HEATER MAX. HEATER OUTPUT, B.T.U. SQ. FT. RESID @ 11/a c SEWAGE DISPOSAL SQ.FT.GAR @ 3/ac HOUSE SEWER LUMBER GR. FINAL INSP. GAS PIPING PERMIT FEE PERMIT FEE PERMIT FEE DBL TOTAL FEES MICRO FEE MECH.FEE PL.CK.FEE CONST. FEE ELECT. FEE SMI FEE PLUMB. FEE STRUCTURE PLUMBING ELECTRICAL HEATING & AIR COND. SOLAR SETBACK GROUND PLUMBING UNDERGROUND A.C. UNIT COLL. AREA SLAB GRADE ROUGH PLUMB. BONDING HEATING (ROUGH) STORAGE TANK FORMS SEWER OR SEPTIC TANK ROUGH WIRING DUCT WORK ROCK STORAGE FOUND. REINF. GAS (ROUGH) METER LOOP HEATING (FINAL) OTHER APPJEQUIP. REINF. STEEL GAS (FINAL) TEMP. POLE GROUT WATER HEATER SERVICE FINAL INSP. BOND BEAM WATER SYSTEM GRADING CU. yd. $ plus x$ =$ LUMBER GR. FINAL INSP. FRAMING FINAL INSP. ROOFING � � / REMARKS: VENTILATION FIRE ZONE ROOFING FIREPLACE SPARK ARRESTOR GAR. FIREWALL LATHING MESH INSULATIONISOUND FINISH GRADING FINAL INSPECTION CERT. OCC. FENCE FINAL I N,Ytu l uK,b bwrM 1 UKLWINI I IALS_ GARDEN WALL FINAL E0 = C Desert Sands Unified School District H BERMUDA DUNES r RANCHO MIRAGE 82-879 HIGHWAY 111 O INDIO, CALIFORNIA 92201-5878 a (819) 347-8831 ' INDIAN WELLS �► PALM DESERT -b July 3, 1,985 %P LA OUINTA �O INDIO y7 • City of La Quinta Department of Community Development 78-105 Calle Estado La Qui.nta, CA: 92253 Re: Block 181, Lot 8, 53-365 Avenida Madero Gentlemen: The developer of the above'°re.ferenced lot has mi.ti gated its impacts on. our overcrowded: schools _by payment ' of the amount of :$628 per unit to be appl i.ed '-to• th.e' cost of district educational faci-li:ties'.made •necessary by such new development. Sincerely, rL e J.4 John D. Brook's 'Assi scant- Superi:ntende.nt Business Services 'JDB/crm , MANDATORY, MEASURES SS3 3 YS --IV,4A -o, NOTE: All new residential buildi'ngs subject to these standards must contain the.. following measures regardless`of the compliance approach used. DESCRIPTION Mandatory Features and Devices 2-5352(a) 2-5352(1) Minimum ceiling insulation Water heater insulation blanket R-19 weighted average (R-12 or greater) blanket: first 5 feet of pipes -closest to tank insulated (R-3 or'greater) ' Loose fill insulation manufacturer's labeled R -value" 2-5352(j) Pipe insulation on steam and steam - 2 -5352(c) condensate return and recirculating " Minimum wall insulation in framed piping R-3" walls R-11 weighted average (does 2-5352(k).". not apply to exterior mass walls) Swimming pool heating 2-5352(d) 1.. System has " Infiltration control a. On/off switch;on heater 1. Doors and windows weather.- ° b. Weatherproof; plate on stripped 2; All joints -and penetrations heater c.. Plumbed to allow for solar caulked and sealed 3. Doors and windows certified 3' section. of pipe 2. 75 percent thermal efficiency.' 4. -Exhaust systems have damper controls for gas heater 5." Masonry and factory -built 3. Pool.cover fireplaces have a. Tight fitting,. closeable 4. Time clock 5. Directional water inlet metal -or glass door b." Outsid.e.air intake with 2-53.52(l) damper and control Gas cooking appliances equipped with. c. Flue damper and control intermittent, ignition. device, No continuous burning gas .pilot 2-5352(m.) allowed Lighting -25 lumens/watt or greater for 2-5352(f) general lighting in kitchens and Ducts constructed, installed and bathrooms insulated per Chapter 10, 1976,UMC Equipment Efficiency, 2-5352(g) Space conditioning equipment sizing -attach heating and cooling 2-5306 and 2=5307 - HVAC equipment water heaters and shove calculations heads and faucets certified by CEC.- " Indicate make and model number. 2-5352(h) Setback thermostat on all heating Insulation Quality." or cooling systems except heat pumps 2_5303 to 2-5305` Insulation specified or installed -meet CEC quality standards. Indicate type and form. 056:10. RZ 3/28/84, VH/dr Attachment 0 . Fo rm 2 - (Revised 3/84) Climate Zones 2, 4, 6, and 8-15 COMPLIANCE CHECKLIST For low -Rise Residential Buildings ' (except hotels and motels) Step 1: Enter on the form the values for each measure from your,.building plan e and specifications sheet. Step 2:. Enter points on this page while working through the •.point. system Building Shell Measure Points .. *Total Floor Area. �S� f ft2 V 1. Slab-on-Grdund;.Perimeter ft.. Depth in, R- 2., Raised Floor R.Value R. 3. telling Insulation or.Construction*AssembIy , . . . . , , , R-� Attic, Percent of Roof Over Conditioned Space �0_.S ft2 4. Wali Insulation or'.Construttion Assembly. . ,', (_� Glazing; Total '% Floor Area Single Double Tripie S. North4acing, Z ft2 _12 ft2 ft2 6. East -Facing . . ft =0 ft ft 7. South -Facing. ,O Z ft2 ft2. ft2 t S. West -Facing 3 ft2 ft2 ft2 9. Skylight. of ft ft ft 10. Shading Coefficient . -(excluding overhang) a. 'East . . . ..... D Sc b. South... . SC . . . . . c. West ... SC d. North. SC , e, Skylight . . . . . SC . . . . . . . 11.` Horizontal South Overhang length. ft , 12.. Movable.InsInfiltration1(tion, Z F1oot�ea, „ ,., t , 13. Infiltration (indicate tandar Medium or ig t) 14, Thermal Mass Exterior Wall Thermal Mass Area. Heat. Capacity. R -Value . . ft?, HC, R - Interior Thermal Mass -Area, Heat Capacity,. R -Value ft2. , Zlf HC. R-., f/ HVAC System** 15'. Gas Furnace without Refrigeration, Cool ing (Seasonal Efficiency). . . . . . . SE. 16. Heat Pump .(Energy Efficiency Ratio) . . . . , EER 17. Gas Furnace with Refrigeration Cooling Seasonal Efficiency and Seasonal . Energy.Efficiency Ratio r SE SEER 18. Active Solar (Net Solar Fraction, i;)� ZNSr 19:. Zonally Controlled Electric Resistance Space Heating , . (Yes/No) Domestic Water Heating•* 20. Solar with Gas Backup,(Net Solar Fraction, S) , USF A1117 21. Other Water Heating (Describe type) Point System Compliance Total. *Checklist Items; nota point system measure, **Attach' documentation for efficiencies and NSF, ao Z 0 U W m Z O H U W to U Z O F- U W Cn y-u53—O►� 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 Mailing Address `7,0A1 _5 3 -7 1 v City State Zip Code Phone Lia Q %O�.) S 3 1_-5,1,q-3170 'Property Address 'City or Community 'Legal Description of Property (Lot, Parcel Map, Tract) v-.4 Lo�K /kt Lai 'Assessors Parcel No. Water Serving Property From Lot size ? -- r✓33 Signature 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 ❑ Nor]� ri ! \U� Soils feasibility report required Yes ❑ No � f Detailed boring report required Yes ❑ No p t Detailed contour plot required Yes ❑ No ❑ Comments: Soils or boring report by f\ Date Approved by Date Soils Map Page Soil Type Tract File No. Other Number of Bedrooms Septic Tank Size (gallons) Rate Required 2 Type of System New Addition Replacement C. -,CA 'A yk / 4A Leach line sq. ft. of bottom area trench Leach bed (sq. ft. of bottom area bed) Seepage Pit Diameter Number of Pits Seepage Pit Depth B.I. \ Total Depth of Pit r Location of System C (.'r Yii Additional Requirements �• � � r�Z ,�� ., ��a ��f, � Y�'A� S �. (.... �v� -- 1�^ � �.� ( (� '�p.r^ C.� 4. �t-�-P l �- A permit is`approved/denied 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 designed system. ILI Signature of Health Official Date , Receipt No. CA�� 9 District: Riverside ❑ Indio Q� Hemet ❑ DISTRIBUTION: WHITE - Office File YELLOW - Applicant DOH SAN 122 (Rev 10/84) Issued By C) Date PINK - Building Dept. GOLDENROD - Pending File � � Form AyprorW VaTIMANS ADMINISTRATIONtU.S. DaPARTUIENT OF HOUSING AND URMAN DKVIKLOPNISNT HEALTH AUTHORITY APPROVAL HUD/FHA OR VA CASE NO. HUD/FHA OR VA OFFICE miml PART I—TO BE COMPLETED BY HUD/FHA OR VA MORTGAGEE NAME Ar ADDRESS (Inc4ide ZIP Codel MORTGAGOR • - SPONSOR TOTAL• ■YES �/ • INSTALLATION?•• ■ • • OTHER A EA BE MADE • r••• ■YES ON 0 WATER-6UPPLY BY: G ' ■ COMMUNITY SYSTEM■INDIVIDUAL•-•• •• . SEWAGE -DISPOSAL BY: ■ ■ • / ■ • • • r • • • . ■■■■■■■■■■ SOMME ■■■■■■■■■■■■■■■■■■■■■■■■■■ENEMSOMME ■■■■MSOMME M■M■■M■■E■ ■■■■■ ■■■■■ ■■■■■ ■■■■■ ■■■■■ ■■■■■ ■■■■■ ■■■■■ ■■■ ■ ■ ■■■■■ ■■■■■ ■■■■■ ■■■■■ ■■■■■ ■■■■■ ■■■■■ ■■■■■ ■■■■■ ■■■■■ ■■■■■ ■■■■■ ■■■■■ ■■■■■ ■■■■■ ■■■■■ ■■■ ■■ ■■■■■ ■■■■■ ■■■■■ ■■■■■ ■■■■■ ■■ ■■ ■■■■■ ■■■■■ ■■■■■ ■■■■■ ■■■■■ ■■■■■ ■■■■■ ■■■■■ ■■■■■ ■■■■■ M■MMM ■■■■■ ■■■■■ ■■�■■ ■■■■■ ■■■■■ ■■■■■ ■■■■■ ■■■■■ ■■■■■ ■■■■■ ■■■■ ■ ■■■■■ ■■■■■ ■■■■■ ■■■■■ ■■■■■ ■■■■■ ■■■■■ ■■■■■ ■■■■■ ■■■■■ ■■■■■ ■■■■■ ■■■■■ ■■■■■ ■■■■■ ■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■SOMME ■■■■■■■■■■ MOOSE ■■■E■■■■■■N■■■■■■■■■■■■■■M■■■■MOONS ■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■NN■■■■■■■■■■■MM■■■■■■■■■NMN■■■■■EE■■■■MEMO■ ■E■■■■■■■■■■■M■■■■■■■■■■■■■■M■■■N■■■E■■■■E■■■■■■■N■■■■■■E■■■■■■■■M■N■■ It is the opinion of the ■ State ■ County ■ ■ is ■ is not satisfactory as a domestic water -supply for the subject property. It is the opinion of the ■ State ■ County ■ D. system proper maintenance■Can be expected to function satisfactorily, and is not likely to create unsanitary conditions ■ Cannot be expected to function satisfactorily. .. SIG TURE The health authority should complete the appropriate opinion statement above and'affix date, signature and tide in the spaces provided. NOTE: Use of the reverse of this form is at the option of the health authority. III—FORNOTE: PART OFFICE I have reviewed the foregoing and the pertinent Compliance Inspection R..rt and recommend that the individual water -supply system , considered []acceptable 0 not acceptable and that the sewage-"posal be considered 0 acceptable not acceptable ..SIGNATURE T ITL ■HUD ARCHITECTURAL SECTION CHIEF OR DEPUTY CHIEF OVA CHIEF APPRAISAL SECTION OR DESIGNEE vs rvnm eoOJUD, AM 1Utl2 SUPERSEDES VA FORM 266396, OCT 1976, HUD FORM 92673 WHICH WILL NOT BE USED. s BUENA ENGUNEERS, INC. 1731-A Waiter Street VENTURA, CALIFORNIA 93003 (80:5) 642-6727 TO THE FOLLOWING WAS NOTED: DATE A (' J�OjB NCO. M d 7.3 P2 - PROJECT ff �, 336 P 6 AdPw LOCATION p CONT CTOR ,OWNER WEATHER TEMP. 0 AM ° at PM PRESENT AT SITE C[T n,.oa(-A 1 4" 7rit dYl � 87.c a,�� d 1 IF COPIES TO �U�)LIM H&jMnD0R&l ; SIGNED r