PLBG (0403-047)78065 Main St Ste 104, 110
0403-047
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
13 ltU3
b''i"
Date ` Signature of Contractor ls--
t
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
S6ttion 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 MID Policy No. 14401.2,9.03
(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 Section3700 of the Labor
Code I shall,forthwith''comply with those provisions,
'rDate:i'r'oa H✓•%APPlicant
s
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. f`
Signature (Owner/Agent) - r -`e Dates -, Y d
J/
--BUILDING PERMIT PERMIT#
DATE VALUATION LOT 040"47 TRACT
JOB SITE
APN
ADDRESS: 7",1S MAIN l r2.P= .S'13 1104•^. 0
— K
OWNER
CONTRACTOR/DESIGNER/ENGINEER
X
MARMT HCbNUM
7 8.080 GAL LE OITl•ADO, BMET. 201 "
78.080 9ALY tj' =TAM S' 20 t
1.,.F,qult m CA 12253
LAQe.7M,—CA CA. 92253
Q60}771»25157 C°TJA 5407
USE OF PERMIT
.I Z,T7!'d4T A1iC
'
114NOT z.LLAT1ON OF 2500 0A.L.I 014 OR&AZ.L 13VTERCIEPT 7 a.Xf 5113=3
109-106 (MA 14 STREW 8.0 Oi2a.1s }, PER PLAN AND 14FALT14 Drr-f
Rt'i ArJ' AL.
V.A.LLIA fiION 4,500.00 U9
E9MAATt: D CONT OF C'4)1ViJ,YRU(, 1rJ
4,500.00
PiMff .'d' IP PILO' €4tTIil.YMARY
iJ:lbi 'tNCi :t ; l 01-€iCj 3W 119>Lt00 $2`tl,ti0
f
' 49
t.t t ,l°!•91.r .ib. r SSc.L9 e.iS. :V ISND.I .LP AlYECK
°
$27.00
:r1ES3 PRE-F tU) f=3
D
$r3,U0
MAR 16 004 PSLRr n_:rr. 0M3DU A0W
UINTA
C'F APICE DEPT.
$27,00
RECEIPT
D T.E + r
BY !
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
I 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
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 Piping
Plumbing Final
' Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewe: Connection
Encapsulation
Gas Piping
Gas Test
Appli. noes
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
Final
Utility Notice (Perm)
•F • , .. }_'i?.. JS. 43" ay ,.y yr z.,.s .aLi.7Y. F1t'*s - . t - y, ,ftH...,,`ww
.t:. {` acs LY i r A•; % Y . w
V' COMM ,-•:...
urea.# - iy RIVERSIDE UNtY: HEK.S,TH AGENCY :,
.
DEPARTMENT OF.ENVIRQ ENTALEALTH' <r
' da•Y .r -'t• }.4'Y4 i3 ', „{`'r Jif ? i Y. - '. c`
,fPLAN CORR _ N
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Plan .Check # 403-071:
'Date10/9/03
DBA Main Street Bistro
Address -104, Main Street 0-104, La Quints : ? ;°
Plans Submitted b S -r Tom Brown Phone 578-1953 a r.
Owner Ed Cosick --mow Addr1M71
F Phone
y ." -- ... %Jxru .. ]•J?"_t'!. :-F-[rr?-ki'a +`"};-'-+ .; .'_-., f:-. i ` 9 _
The plans are now approved subject to the oondition§-P' be ow and the attached compliance sheet -'-0-6., :..=
1. Hood duct sizes are not specified in the plan.: Use. ft -,f0 C" Q duct sizes to ensure correct grease captu .
:..r..::...--..;:..,: K
....
Hood #19 (range) must be :56 square feet (approx 0-k 9"t #85 (char Moller) must be• 1'squar9
2. All floor, wall and ceiling finishes to food service areas:'" '_ be smooth and easily cleanable including W s
waitress and self service'stations such asdMk dispensers µest ,
3. All food and utensil sinks must be plumbed to floor sinks=through approved air gaps. --The mop sink must be
h64Z
of the floor basin style BehiNNS
nd ail three sinks in the lash zee the finish must be water proof to a height of 8
4. All e)tenor and restroom doors must be _self dosing: =rExtedor doors must also be sealed against entry by
vermin. The deliverydoor air curtain must deliver air at v 1600 fps at a height of 3' above the floor
5. The number of lockers provided shall be equal, or greater than the number of workers assigned to a peak
shift _
6. An air balance report will be required prior to completion of the final inspection
7. Approval of this plan does not include approval by local land use, water or sewer agencies. Prior to
-.,nom,,_., -
commencing construction or undertaking improvement __'=b b hitthese plans to the'Riverside County Land Use
Agency located at 82675' Hwy 111, Room 201 _ Indio CA 92201 p dne (760) 853-7000. A facility may not
receive an Environmental Health Permit without this approval; which wig b6-9- prior•to the final inspection
' .. - 7 i,2. ' 1. '. °•H tom" ..' :: ';{}:.1 a;. ., T..- .. ,.. ,.
S•,r.:.
.. - ... - f !-:t•o Std' ':`'..' e? r --t' d ''a.•. - .... N.._-., .. :. ._ -.
CONSTRUCTION INSPECTIONS: Contact the Plan Clredaer for a Yary when construction is approximately
801/o complete, with plumbing, rough ventilation; acct woo- ,:Rieq for on shoald be made at least five (
workin m advance. A "°°'`'
g compliance guide is attached to this plan oomoctron sheet AIl 000a sot otheawise addressed on the
plan cosection must be performed in accordance with the grade nes set foci thein. A FINAL INSPECTION MUST be made upon
completion of ALL work'including finished detail& APPROVAL to operate sllaII not be granted, or remodeled areas approved to
operate, until the facility has passed the FINAL INSPECTION, and "APPLICATION TO OPERATE" has been completed and
PERMIT FEES have been paid:_,
Request for inspection should be made at least five (5) working days in advance
3 yr ^< .,.. x .
PLANS CHECKED BY David E. Day r ayf`:.dw.s `<" Phone (760) 320-1048
I acknowledge the corrections noted herein and as indi the plans and to incorporate ' • _
them during construction:
- _ Signature
ASSESSOR'S PARCEL NUMBER
COUNiY OF COMMUNITY ''EALTH AGENCY
Jj,DEPARTMESNT..OF;.ENVIRONMENTAL ALTH `
ATION FOR. WASTEWATER DISPOSAL APPROVAL
is . ; :., ,-, ,.:, t. i •.
yyr°i'. If :r ^: • .t.• af:;:';;g7;.'.: ;;!q^',: ,:.. '.::;:;_ r,:r.} ... : 'r ;', ' . ;-. , .
' `•::i?: fir;. c.,, . .:..• [ i.
rLICANT
S '
P 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
W . a
Address ZZip
/ /CityState
Telephone /
Owner
Address City I
iState Zip
Telephone
Z
I---
Job Property /_'Addresss s % l
Cl t: ; o.i, . ' ;' '1 ': ': i •':: ,
ZIP
U
Lot Size ..;
Water Agency/Well
% a of PaQr t, PjP, SU ,PUP etc.
Legal Description.:
DBA
Sw e,+
i AUV
v
jMtt, .
IYJ.v I 04
Dwelling, MH Site Prep., etc.BfAv
Signature of Applica
Date
.,
R.:
} t` `: ri ::.•;.:.y w : ' , ,.i...; FOR OFFICE
USE ONLY. :. t ,'y;•,.
''e.
,CHECK:BOX IF REQUIRED
;If,ari ..sbox'Is-checked, this application shell be'considered rejected until the
❑ Detailed Contour Plot Plans Required (1 to 5 foot interval)
(:
Infonrietionlis,provided and the fee paid..Resubmittals -later than 90 days
after; date:;noted below may 'require repayment of fees.:' : , y
❑ Other
❑ Holdrng Yank Agreements Completed : ,
❑ Staff Specialist Lot Inspection Required
Z
O
❑,*Certification.of.Existing S.D.System Required . . ..
t
Thomas Bros..Page : Grid
U
' `•
'Date
'
,
❑ WOCB' Clearance Required `°
LlW Lot Inspection Cbrnpleted: Initials
U)
(Attach for DOH-SAN-0.07, Santa Ana -Region Only). -
G
-
V, °
t;
..
L3 -Soils Percola,hon Report Required ; • .
Remarks:
n
'
t `
❑ Maintenance Booklet' Provided
Y;
❑'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.
,d
/Soils,'Percolation-Boring Report By Lic/Project # +6 It`' ' `
Date
Soils. Map Page- Soil Type Approved By Date
•
No;.-of S stemsY;'
Type of System(s).
No. Dwelling- Units
1 Septic Tank
Soil Rate
Gmmw&JS=d
a
:,;.:`;x.;_;;; ;::;,?
❑ Holding Tank';":❑ Replacement
Bedrooms, Fixture Units
r
```i;
Grease intc /Lint Trap
"'•
i ' z
❑ New EI Addition
'.❑
„ O C)
;:;
,, ?:: •,:
❑Existing 1: Connect to Sewer
Gal.
Gal.
Sqz Ft::,.: =; ;, '`
Total Linear *;:;
Sidewall Allowance
Leach Bed sq. ft.
•;.
Bottom Area
Ft
ft. rock/ sq. ft. running ft.
Install Lines) ft. long ft. wide
of Bottom Area
! Y" i ' :
f+
7 ;•,'
Inlet Tested Depth ❑ N/A
with min. Inches rock below drainlines
U
Proposed Bottom Tested Depth
or
Z
Leach ;lines/bed special, design.for slope:
(3) Pij!Qi,ameter
No. Pits
Pit Below Inlet (Bt)
seepitge Pit
Maximum
Other:
O
'
Total Depth,
Allowable
W
: , :.;::• ..
N/A Overburden Factor ' . '
(35- ❑ 6'
TD
Depth
r;
,Well. Review Approved: Date: Well Drilling Peerrmit#
?;
.....' ...'siarwTtme Y,.
- ....: '=
Grading' Plan. Approved: Date: tS^
P SIGNATURE
x:
Plan .Check-OnlyApproved: Date:
j ISG
/ CT'y't4S •: .Q«►Vt ,, ► !' T h
REMARKS: •. S a✓tiL
t Nc ck. rvtutT
Akio
; 1 „• Cl ' ha'A.06- covttooi5
CkVIA to Q
!,
This':'a licetio'n s •APPROVE /DENIED for the category checked in
Pp 9 Y
SECTION B. abov re ardin a design of a disposal system as Indicated
9 9 P Y
i
or) the` accoinpanie n, using the requirements set forth in SECTION
C`above: A building is necessary for the installation the
1 [
Revenue Code_ 3 S Fee $
permit of above-
as"a
designed system. No construction Is permitted In the rsaulred reserved
100% expansion area.. '..:: '.. :.`:• ;',.:: ;;, ;. ..
...;.•.':;'• ..L• ,•:. ,... i•..•a ,.. p. ..: .,iii: .•• a •..r.:' ..
Check # I
(1)'°.Septic Tank.must be 100' minimum from any wells.,
'Leach
V
Z
(2) Ilnes must be 100' minimum from any wells, Including expansion
Date 1 101 n3 Initial
O
(~j
(3) Sewer lines, must be 50' minimum from any wells.
W
(4) Seepage pits must be 150' minimum from any wells, Including expansion
RIVERSIDE: 909-955-8980
area.
:.
INDIO: 760-863-7000
SOUTHWEST: 909-600-6180
Signature .:'
I•
Date
DEH -SAN -122 (Rev 8101) Uistnouuon: vvmi i t --unite rue; TtLwvv—Appucant; riNK—niag. uept.; %1ULUtNmuU—mansRtecoras
I)
w
nrtic va sff.
1. REFER TO SPEQiiCAT10H SHEET Ka S-218
2. REFER TO SPECi1CAl10H SHEET NQ 5-252
3. REFER 70 SPEWCATIOM SHEET0Q 5-251
Dot
SECTION A -A
ALL OWNS" IN
MpES
G-3750
C-4500
MODEL A 9 C 0
£ f I
C
M
PC G-1000 50 48 65 74
74 24 3/4
4 1/2
41 1/2
PC C-3750 59 51 14 74
74 29 3/4
4 1/2
50 1/2
PC 0-4500 42 1/2 110 1/2 77 1/2 85
85 303/4
5
53 1/2
owivn71oi sKancAmoms
MODEL C-3000
G-3750
C-4500
LEMGTIt 31' -Lt'
31'-0
31 -0"
VADIH 10'-0"
10-0"
I1'-0"
@ELOW O&ET 4'-Y
4'-11"
s-2 I/2
TAXK HEIG"T V -S"
V-2"
'-5 1/2
T
YAUME
10 GRAM M
r'Be st IDIK
sm
mus
Loiku
IIRt:3S
3M nw-4
810 & ODE
1 1 RNIS
Lam_ -OBJ
Now
OUTLET st4E t11s
OUTLET
END _MEW
GK -ASE W7ERGEPTOR WD SAMUMC.
THREE MANHOLES EXTEWM'70 OWE
DESIGNED FOR DWCT H-20.LOADM
OF MANHOLE EXTUMS
3000 THRU 4500 alllOdd
P.O. aox bw
HIGHLAND, CA t2346
909 793-7602 BO0 945-8265
Fox: 909 793-128.3
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INV 35:5 L a !. DEVELOPERS
EXPENSE.
TA CONTRACTOR
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OUT '' _ _ .._.... COORDINATE.
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