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BLDG (0404-030) + SFD (04384)53825 Avenida Martinez 0404-030 04384 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 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 7' ,7!Slgnature 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 Policy No. (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 sFrall 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..,, ;P Date: y f 74 %lApolicant % ✓".. ' - 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 inseection purposes. ,-Signature (Owner/Agent) %7 ' . ' Date.l 2 'BUILDING PERMIT PERMIT# E1yU:0 DATE,04 f( , VALUATION LOT TRACT JOB SITE ADDRESS I)A MARI.Lk APN OWNER CONTRACTOR / DESIGNER / EN (NEER i DANM, RI:dvttK:f''= t7i7d F -R B J]LrER 53-8.'25 AV04MIN1oMX1 Z LA (,A)Dd xA CJS?. 92253 < ) C.gx i i - n ,3 USE OF PERMIT URNEIZALlT, L7't1 i / 6.S U? 6' BL XK W.AI , PLIR CITY S9'A:.NDItRID SOUTH SIDEYAR,13 A11- 2001 CDC:, 6 FT. WALL 63,00 LF ESTI MIKID COSIr 01' CONSTRUMON 10625.00 PJ3'RJ. I, FEE, Stiff m1Wi;4ky CONSTRUCTION M 103-000-418-000 $39.00 CITY OF LA QUINTA FINANCE DEPT. °1t.M-A r'AI, C034a`"OrPIJ'eTIONAND ;t` 1..,P,W CHECK $39.00 JZSS PRE -PAM FKI".S $0,00 RECEIPT DATE BY---,-­_ D?FIyA INSP 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 steed Set Backs Electric Bond Footings l Main Drain Bond Beam Zz`d 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 Final Final UU14 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) COMMENTS: OWNER / BUILDER INFORMATION Dear Property Owner: An application for a building permit has been submitted in your name listing yourself as the builder of the property improvements specified. For your protection you should be aware that as "Owner/ Builder" you are the responsible party of record on such a permit. Building permits are not required to be signed by property owners unless they are personally performing their own work. If your work is being performed by someone other than yourself, you may protect yourself from possible A liability if that person applies for the proper permit in his or her name. Contractors are required by law to be licensed and bonded by the State of California and to have a business license from the City or County. They are also required by law' to put their license number on all permits for which they apply. If you plan to do your own work, with the exception of various trades that you plan to subcontract, you should be aware of the following information for your benefit and protection: If you employ or otherwise engage any persons other than your immediate family, and the work (including materials and other costs) is $200.00 or more for the entire project, and such persons are not licensed as contractors or subcontractors, then you may be an employer. If you are an employer, you must register with the State and Federal Government as an employer and you are subject to several obligations including State and Federal income tax withholding, federal social security taxes, worker's compensation insurance, disability insurance costs and unemployment compensation contributions. There may be financial risks for you if you do not carry out these obligations, and these risks are especially serious with respect to worker's compensation insurance. For more specific information about your obligations under Federal Law, contact the Internal Revenue Service (and, if you wish, the U.S. Small Business Adminstration). For more specific information about your obligations under Stare Law, contact the Department of Benefit Payments and the Division of Industrial Accidents. If the structure is intended for sale, property owners who are not licensed contractors are allowed to perform their work personally or through their own employees, without a licensed contractor or subcontractor, only under limited conditions. A frequent practice of unlicensed persons professing to be contractors is to secure an "Owner/ Builder" building permit, erroneously implying that the property owner is providing his or her own labor and material personally. Building permits are not required to be signed by property owners unless they are performing their own work personally. Information about licensed contractors may be obtained by contacting the Contractors' State License Board in your community or at 1020 N. Street, Sacramento, California 95814. Please complete and return the enclosed owner -builder verification form so that we can confirm that you are aware of these matters. The building permit will not be issued until the verification is returned. Very truly yours, CITY OF LA QUINTA DEPT. OF BUILDING AND SAFETY 78-495 Calle Tampico La Quinta, CA 92253 (760) 777-7012 FAX: (760) 777-7011 WNER'S SIGNATURE/DATE PROPERTY ADDRESS VyN_030 •PERMIT NUMBER(s) -w 1• P.O. BOX 1504 Building'. , 78-105 CALLE ESTADO Address .. $.3-925 Martinez LA QUINTA, CALIFORNIA_ 92253 Owner :• , , ^ Wach£>:lla Valley Lang BUILDING: TYPE CONST. OCC. GRP. Mailin Address 247 9., Tahquitz Way02 } 774-17 ►-006 , -- A.P. Number- - City t Zip Tel. Palvisspr 92262 322-1020 Legal Description Contractor Project Description • • • Starr 1Conistruction Address - Same City Zip Tel. State Lic. City & Classif. 387934 Lic. #..095 . _ . c Sq. Ft. . No.- _ No. Dw. Arch., Engr., Size Stories Units Designer New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑ Address Tel. 428' Gaac$ge City Zip State 4136 61 'Fence Lic. # LICENSED CONTRACTOR'S DECLARATION I hereby affirm that I 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. - /F i- /7 . -.,* -Z 11t_ 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, after, 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 Division 3 of the Business and Professions Code, or that. he is exempt therefrom, and the basis for the alleged exemption. Any violation of Section 7031.5 by 'any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars ($500). O 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, Buisness and Professions Code: The Contractor's License Law does not apply to an owner of property who builds 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 of proving that he did not build or improve for the purpose of sale.) O I, as ownir 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 of property who builds or Improves thereon, and who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's License Law.) O 1 am exempt under Sec. B. & P.C. for this reason Date Owner WORKERS' COMPENSATION DECLARATION `tf I hereby affirm that I have a certificate of consent to self-insure,for a -certificate of Worker's Compensation Insurance, or a certified copy thereof c. 380oi%6abor Code.) Policy No. Company O Copy is filed with the city. O Certified copy is hereby furnished. r CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars (E 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., If, after making this Certificate of Exemption you should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY 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.) Lender's Name Lender's Address This is a building permit when properly filled out, signed and validated, and is subject to expiration it work thereunder is suspended for 180 days. I certify that I have read this application and state that the above Information is correct. I 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. :timated Valuation y t Zt l7 5 1 5'iJ $75,505 PERMIT AMOUNT Plan Chk. Dep." Plan Chk. Bal.' Const. :364 «tICJ Mech. :33 .Gtt) Electrical 7467.7 Plumbing x05.00 S.M.I. ".,I' • 36 Grading a () . 0 U Driveway Enc.# Infrastructure 140 ib" .. tlf r TOTAL REMARKS A4,5414"t if, AA ­0541A 14 i ZONE: BY: Minimum Setback Distances: Front Setback from Center Line Rear Setback from Rear Prop. Line Side Street Setback from Center Line Side Setback from Property Line FINAL DATE —INS EC OR Issued by: Date Permit mentioned property for inspection purposes. Validated by: Signature of applicant Date Mailing Address Validation: City, State, Zip I WHITE - FINANCE, PINK - APPLICANT, GREEN - BUILDING, GOLDENROD - ASSESSOR'S OFFICE, HARD COPY - FILE CONSTRUCTION ESTIMATE NO. ELECTRICAL FEES NO. PLUMBING FEES $ UNITS A.C. UNIT IST FL SO FT (a �fLLA GRADE C _ ROUGH PLUMB BONDING YARD SPKLR SYSTEM 2ND FL SO FT. a STORAGE TANK FORMS SEWER OR SEPTIC TANK MOBILEHOME SVC. BAR SINK POR SO FT. a ROCK STORAGE FOUND. REINF. GAS (ROUGH) POWER OUTLET ROOF DRAINS GAR SO. FT. et HEATING (FINAL) OTHER APP.IEOUIP. REINF. STEEL GAS (FINAL) DRAINAGE PIPING CAR P. SO FT. 6 GROUT DRINKING FOUNTAIN WALL SO. FT. Q SERVICE FINAL INSP. URINAL SO. FT. 0 ESTIMATED CONSTRUCTION VALUATION $ GRADING cu. yd. _plus—x$ WATER PIPING NOTE: Not to be used as property tax valuation FLOOR DRAIN MECHANICAL FEES FINAL INSP. WATER SOFTENER VENT SYSTEM FAN EVAP.COOL HOOD SIGN WASHER(AUTO)(DISH) APPLIANCE DRYER REMARKS: GARBAGE DISPOSAL FURNACE UNIT WALL FLOOR SUSPENDED LAUNDRYTRAY 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. SO. FT. ®c BATH TUB SO. FT. @ c WATER HEATER MAX. HEATER OUTPUT, B.T.U. SO. FT. RESID ( I'A c SEWAGE DISPOSAL MESH SO.FT.GAR Ig 3/4c HOUSE SEWER INSULATIONISOU N D 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 8 AIR COND. SOLAR PETBACK % GROUND PLUMBING UNDERGROUND A.C. UNIT COLL. AREA �fLLA GRADE C _ 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 APP.IEOUIP. REINF. STEEL GAS (FINAL) TEMP. POLE GROUT WATER HEATER SERVICE FINAL INSP. BOND BEAM WATER SYSTEM j GRADING cu. yd. _plus—x$ _$ LUMBER GR. FINAL INSP. &FRAMING / 0� FINAL INSP. j6OOFING / A _ ��! D (/ T6 L W k/it�`/� p [ /�. REMARKS: VENTILATION FIRE ZONE ROOFING FIREPLACE SPARK ARRESTOR GAR. FIREWALL MESH INSULATIONISOU N D FINISH GRADING // NAL INSPECTION — /_ - r ' CERT. OCC. FENCE FINAL INSPECTOR'S SIGNATURESlINITIALS GARDEN WALL FINAL -!Y� 4 4 Q" P.O. BOX 1504 APPLICATION ONLY Building 1 78-105 CALLE ESTADO Address z - /".4 A 7-1NEZ LA QUINTA, CALIFORNIA 92253 Owner e malting I Addresses �7 �-,� 0 7- /�� U -4-4 21 City lZip ITel. -2- L z I 3 z Z --/o z.o 14V # L'ITy up I el.. P�%LJ?iJ .3 2 2- State State Lic. City & Classif. g 7 y+3� Lic. # 89S Arch., Engr., Designer Address I Tel. City( Zip I State Lic. # LICENSED CONTRACTOR'S DECLARATION I hereby affirm that I 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,Business and Professions Code: Any city or county which requires a permit to construct, 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 the provisions of 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 of Section 7031.5 by 'any applicant for a permit subjects the applicant to a civil penalty of not more than rive hundred dollars ($500). ❑ 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, Bulsness and Professions Code: The Contractor's License Law does not apply to an owner of property who builds 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 or completion, the owner -builder will have the burden of proving that he did not build or Improve for the purpose of sale.) ❑ I, 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 of property -who builds or Improves thereon, and who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's License Law.) ❑ 1 am exempt under Sec. B. & P.C. for this reason Date Owner 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 ❑ Copy is filed with the city. ❑ Certified copy is hereby furnished. CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed If the permit Is for one hundred dollars ($100) valuation or less.) 1 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., If, alter making this Certificate of Exemption you should become subject to the Workers' Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY 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.) Lender's 'Name Lender's Address This is a building permit when properly filled out, signed and validated, and is subject to expiration it work thereunder is suspended for 180 days. I certify that I have read this application and state that the above information is correct. I 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— Date Mailing Address City, State, Zip BUILDING DIVISION BUILDING: TYPE CONST. OCC. GRP. A.P. Number 9 7 4-- Legal Description Lv7^ y QeA-f2 15/7 Project Description Sq. Ft. Size New,1D imated No. No. Dw. Stories / Units /5� Add ❑ Alter ❑ Repair ❑ Demolition ❑ PERMIT Plan Chk. Dep. Plan Chk. Bal. Const. Mech. Electrical Plumbing S.M.I. Grading Driveway Enc. Infrastructure TOTAL on AMOUNT REMARKS 005 i A? 10 1 135 07 -?7 -RR 1 3 1U GASH i IUTAL 1 ;401Q;i ZONE: BY: Minimum Setback Distances: Front Setback from Center Line Rear Setback from Rear Prop. Line Side Street Setback from Center Line Side Setback from Property Line FINAL DATE INSPECTOR Issued by: Date Permit Validated by: Validation: CONSTRUCTION ESTIMATE NO. ELECTRICAL FEES NO. PLUMBING FEES 1ST FL. SO. FT. @ $ UNITS SLAB GRADE ROUGH PLUMB. BONDING YARD SPKLR SYSTEM 2ND FL. SQ. FT. FORMS SEWER OR SEPTIC TANK ROUGH WIRING MOBILEHOME SVC. BAR SINK POR. SO. FT. @ GAS (ROUGH) METER LOOP GAR. SQ. FT. @ POWER OUTLET ROOF DRAINS GAS (FINAL) TEMP. POLE DRAINAGE PIPING CAR P. I SQ. FT. @ GROUT WATER HEATER WALL SQ. FT. @ FINAL INSP. DRINKING FOUNTAIN SQ. FT. @ WATER SYSTEM URINAL ESTIMATED CONSTRUCTION VALUATION $ WATER PIPING NOTE: Not to be used as property tax valuation FINAL INSP. FLOOR DRAIN MECHANICAL FEES WATER SOFTENER VENT SYSTEM FAN EVAP.COOL HOOD SIGN WASHER(AUTO)(DISH) APPLIANCE DRYER GARBAGE DISPOSAL FURNACE UNIT WALL FLOOR SUSPENDED LAUNDRY TRAY AIR HANDLING UNIT CFM FIRE ZONE ROOFING 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 LATHING SQ. FT. @ c WATER HEATER MAX. HEATER OUTPUT, B.T.U. SQ. FT. RESID @ 1 % c SEWAGE DISPOSAL SO.FT.GAR @ 3/ec HOUSE SEWER FINISH GRADING 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 APP./EQUIP. 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 INSULATION/SOUND FINISH GRADING FINAL INSPECTION CERT. OCC. FENCE FINAL INSPECTOR'S SIGNATURES11NITIALS. GARDEN WALL FINAL Desert Sands Unified School District CERTIFICATION OF PAYMENT NOTICE: THIS DOCUMENT CAWTFof ACILITY FEES BE ®UPUCATED. TO: City of La Quinta DATE: Department of Community Development 78-105 Calle Estado La Quinta, CA 92253 X 0-7, Iq 8 �� This is to-ertify that f . developer of Pa yrhich is located at 3 r,��iti2iin/� this District, has paid school facility fees imposed pursuanf to the aut.t�or�y ener(te by'G vernment Code Sect'ol 53080 in the amo nt of $ UU T11 covering a total of quare feet of( ) resid tial or ( ) industrial/commercial development and that buil in/'g permits for this footage in this development may now be issued by your jurisdiction. 51 /IV/D# ' I �W IM11-1 for DESERT SA DS UNIFIED SCHOOL DISTRICT White - Building Department • Yellow - Facilities Planning • Pink - Accounting i Gold - Developer (10)-37 Pq z 0 H H W t COUNTY OF RIVERSIDE, ENVIRONMENTAL HEALTH SERVICES DIVISION PERMIT APPLICATION FOR A SUBSURFACE SEWAGE DISPOSAL SYSTEM 1-7 7 -/ 7/ icant: Submit this form with four copies of a scaled plot plan (1-20 scale) drawn to ty specifications required on the attached check list. A non-refundable filing fee of is required when the application is submitted. Check must be made payable to the ty of Riverside Building Department Application Log # Name (Owner, Agent, Contractor, Etc.) Mailing Address I 7';q Ae .e eo,u s�-.�.u.� T. o AJ -;z `✓ 7 E -r a 14 Q u. i City State Date Zip Code Telephone from Building -&A I moi' 2 2, 4 -Z__ �G ��) _-? 2 Z - ,, a Z � *Job Property Address- /��� * ityI or .C�nreunktTy *Legal Description of Prpty _Lot„, PM, .TR,). —5 ,z A.�7iMa F_-_. �a 61i urA Lcr /3t C 2 yy t/ v.r 2.3 *Assessor's Parcel No. CY4 er Agennccyi Use of Permit t1it,,.v06!, //It(,. ? r Lot Size 7 741- 7/ - e /4. Ot-'Well t'.lJ sue+ �� .� SFD, MH Site Prep Etc-. co Planning Case # / G x /GG No L4</ Ia k WQCB Clearance reqd. Yes[ _-e_1 cam_ Signature of Applicant Date *The above information must be verified from Building Application STAFF USE - DO NOT WRITE BELOW THIS LINE Initial Date Certification of Existing S.D. System reqd. Yes[ I No L4</ Ia k WQCB Clearance reqd. Yes[ ] No Cr' ./Iff Soils feasibility report reqd. Yes[ ] No[ I I ri Detailed boring report reqd. Yes[ ] No[' f Detailed contour plot plans reqd. Yes[ ] No[ ] _ Staff Specialist approval reqd. Yes[ 7 Nor I Lot Inspection Date Soils/boring re ort by ,ZII& Proj. # Date Soils Map PaOWN Soil TA (�d� Approved by Date•V %� 7 Type of System: No. of Bedrooms) (1) Septic Tank Soil Rate Required Existing New Addition Replacement i / Gals. (2)'L\Leach line sq. ft. Sidewall allowance Install Line(s) Leach bed (Both trench area) ft. rock/ Sq. Ft. Ft. Lon Ft. wide Sq. Ft. of n� per running ft. with Min.nches rock bottom ']� N/A CLbelow drain lines area Leach lines/bed-special design (3) Pit Diameter No. Pit Seepage it total depth for slope: Applicable '7[ii} 61[L]� Pits BI i / N/A ✓ Overburden factor / Max. allowable depth "y ✓1 7_;, r,.;. - i7. _•^ 3 f 1 / �v �r , : ��.�� r Lam..,.. f�� 1 v/4 r �` This application is Ca rove ` �e.-rcd for the design of a subsurface disposal s; -stem 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. Septic tank and sewer lines must be 50� from any wells{' S?) Leach lines must be 100' min. from any wells including expansion area Seepage pits must. be 150' min. from any wells including expansion area Signature of Health Official r ` Date RECEIPT N0. _-5 '6 -/ U Issued by a /( Date / -, 7 /4 jr - t J District: Riverside C I Indio [ -I- Hemet [ I Perris [ ] Rancho Calif.0 I Blythe [ ] Distribution: WHITE -Office file YELLOW -Applicant PINK -Bldg. Dept. GOLDENROD -Fending File DOH SAN 122 (Rev. 2/86) Of R� p � o @11 7 OFFICE OF AGRICULTURAL CONIMISSIONER AND WEIGHTS & MEASURES 49-613 liwy 86, Suite B-12 'Coachella, CA 92236 619-342-8291 E. LEON SPAUGY COSI W ISSIO`E R JAMES 0 WALLACE ASSIStA�t COMMISSIONER. CLEMENT 6E`VENISTE SEALER DATE ` ' S9 CASE No . �¢� �'{ 0.7:2--% — . DEVELOPER'S NAME: S 1 i\ Py" ADDRESS: �. ' ��1� u r 2 PP, TELEPHONE: Dear Developer: p After reviewing your landscaping plans, all plant material listed is not in violation of quarantine laws governing the Coachella Valley. If substitutions do occur and they differ.frcm plant material listed, this office must be notified immediately. Thank you for protecting and preserving the Coachella Valley's pest -free environment. ' C_SijY1 Agricultural C ssioner's Office cc: Indio and Riverside Office n: 44-1 A42 -TME Z Al is