PLBG (9607-057)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
2652111 2242 24W3/
Date Signature of Contractor f;•
lw>-
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 Jssueq.,. MY twBrkers' compensation insurance cggiee &�pplivy�wno. 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 shall not employ any person in any manner so as toy become subject to the
workers' compensation laws of California, and agreethatif I should become
subject to the workers' compensation,prowsions of Section 3700 of the Labor
,Code, I shall forthwith comply with those provisis.
:+ i
Date, r Applicant+^
Warning: Failure to secure Work 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 informationis
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
th,F above-mentioned property for inspection purpgses.
Signature (Owner/Agent)- •" ` "t 1.% Date i .. - 6/,
BUILDINGPERMIT PERMIT# CONTROL#
1 3726
DATE VALUATION LOT1%��;t
TRACT
7/22196 $4,500.011
JOB SITE
APN
ADDRESS 51-065IIW:N DA 1%fF,oiiX)Zrk
773-0U-007
OWNER
CONTRACTOR / DESIGNER / ENGINEER
IIA1,'.t.ik-r-K K & II!A` NI r,. WII' .tAtti '
A •j. CESSPOOL SERMCF, TRIC
31065 AVENII)A NIENT7OM
16819 LFII X? NIORONGO RU..
LA QUINTA CA 92253
FN1,Id.'I' HM' SPRING: C.R. 022,40
�ol�>j 29-e+475 O1li.0 WW
USE OF PERMIT
l�J.11h�f~tlNb;
N.)I) NI1W 25' SEEPAGE* I'll'
�.:i�Af A RAS; f Aiei<allty R 4.i�N} th! L.S
R.S' TIiNIA FA) COST O t.'O,NS.1'RU(:i ON
4,."r►'ii1.0f1
i"s1•;k2 f! IAllANN*
Y1I.11MIAW111."R 1A1.ON-1119.000 x3r).At)
St1 'iY?1:ti. Ct1N�"lftk'Cilc)!d AND PLAN c iJ CI,:
$?!
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOFr�
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
Final
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)
COMMENTS:
N�
ASSESSOR'S PARCEL NUMBER
COUNTY OF RIVERSIDE HEALTH'SERVICES AGENCY
DEPARTMENT OF ENVIRONMENTAL HEALTH
PERMIT APPLICATION FOR A SUBSURFACE SEWAGE DISPOSAL SYSTEM
APPLICANT: Submit this form with four copies of a SCALED plot plan (1-20 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 applica-
tion shall remain valid for a period. not to exceed one year from date of payment.
LOG # t>- I T • y yr CA N / A/M
Agent, Contractor, Contact Person
ee5
Address ` City Slate Zip
9,
Telephone ��"I
sc/L)
,Owner
Address City State Zip
MTelephone y
Q
1
6e Al -/I YV /`1/4m -s
S)- 7,9
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Job Property Address
City
Zip
U
N
Lot Size
ter gen eir
Use of Permit, P/P, SUP., PUPetc.
i
Fi s�rPri.Tr
Legal Description ^
n4ra Ff174-144,� �/`�«
C04 io ttiq 114
.7
tvdll F Vfi�ii
ew
i
1577- c
ea
L4 04,,,vr1 ilT.Dwelliog'MH
Signature o0Applicant
Date
A
CHECK BOX IF REQUIRED v
❑ Holding Tank Agreements Completed
❑ Detailed Contour Plot Plans Required (1 to 5 foot interval)
❑ Certification of Existing S.D. System Required'
❑ Grading Handout Provided
In
❑ WQCB Clearance Required
❑ Staff Specialist Lot Inspection Required
Z
(Attach For DOH -SAN -007, Santa Ana Region Only
❑ Lot Inspection
U❑
Soils Percolation Report Required
w
❑ Date Lot Inspection Completed: Initials
0
❑ Special Feasibility Boring.Report Required
Remarks:
Y
❑ Maintenance Booklet Provided
Initials Date
❑ Final Inspection by Department of Environmental Health is required.
/I
�a��' 9'/ Date
Cr=j. Soils Percolation Boring Report by AA< 0 Ac7tNy1oc F,1l6 dvtal'aOwul,&4 roject # C��7�
/7�j3
Soils Map Page Soil Type Approved By �•kCi�ti+ W 1.�Jiv Date �- 'A�-
No of. Systems
irlJ%i�'
Type of System(s)No.
13
Dwelling Units)EX ,J/
Fixture
(1) Septic Tank.
Soil Rate
Grease/Sand
Grease Int�cp/Lint
Ct
Holding Tank ll Replacement
El New . Addition
13 Existing '
Bedrooms UrGts
E X1 S %• i7f�rALF Y
4eAa.
F Xl S,A,,f
SSD Gal
3440 ��
Trap
t...,...
Gal.
� � . _ � �rbr�, �
,r
Sq. Ft.
Total Linear
Sidewall Allowance
Leach Bed sq. ft. of
Bb om Area
F
rock/ sq. ft. running ft.
Inlet Tested Depth ❑ NA
\
Install \Une(s) ft. long ft. wide with .
min. inches r� ock below drainlines or
Bottom Area
h•
U
Proposed Bottom Tested Dep
Z
Leach lines/bed special design for slope:
(3) Pit Diameter
No. Pits
Pit Below Inlet (BI)
Seepage Pit
Maximum
Other:
p
Total Depth
Allowable
I`
Applicable
6
/
Depth
W
N/A ✓Overburden Factor
9145', (
J
TDr
Well Review Approved: Date: Well Drilling Permit If
SIGNATURE
Grading Plan Approved: Date:
SIGNATURE
Sewer Verification Approved: Date: /, p
REMARKS:
• .
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y
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i (.a lK..I.�r./� /�..Sv 4�„L/�iTw�[.[Au ,.�'J7 R^WM �!N ,.ciY•"� L� / iw� � IAC.OH.. .Y`Ivc'aq�a R.s- �• V��
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This application is(APPROVE D/DENIED=for=the-categoryxchecked in SECTION B
FOR OFFICE USE ONLY
above, regarding the des" gn o(a subsurface disposal system as Indicated on the
aoompanied plot plan, using the requirements set forth in SECTION C above. A build-
a 16 a• o
ing permit is necessary for the installation of the above -designed system. No construc-
Revenue code Fee $ r/
tion is permitted in the required reserved 100% expansion area.
(1) Septic Tank must be 100' minimum from any wells.
//tt
0 Cheek # /KSS/y
(2) Leach lines must be 100 minimum from any wells, including expansion area.
•�) ItGr,W �-
D/ajt�e- /� ' % 6 Initial
C E/r T N4 ° `sV
0
(3) Sewer lines must be 50' minimum from any wells.
/�
Z
O_
(4) Seepage pits be 150' minimum from any wells, including expansion area.
-moi
/must
10
LU
lei
Signature of Health Official
'7-
Date
5■�
r--�
T� r�J FSA
DOH -SAN 122 (Rev 9/93) Distribution: WHITE—Office File; YELLOW—Applicant; PINK—Bldg. Dept% GOLDENROL—Plans/Records
fZipip, ._! H S. -i -s . iCES AGE:NCY
_ y
l'r,.:r` �X/s'. �.c,.::•::cl n�70A-//ilJi.�/
-
_x l;:�b' sBa AcnA, ('1p: L^a;;h Line
-- ...._.._ : i:�j �F3Az • v7`n/ �_i �j_ : .2S -8'' 9 TD -3a MD Seep ige ?it
Gt'iiLklSaf
. •:t :;:: C to t, s- i v{- yui
x :�a L ::ii'i fl, ljii:.i';i nOr'iS.iii:r� Pal &`:.: BS; i'.�i (2) 7ii:a'cli: �1 (.? "r} } }�. ?Jc...
P,.r.1 rov % has Jain obtainted from the Regional ir4wer Qual;-q'Cantrol Board for installawn ct the sswage
This is tia cealify 'tt:ai the Riverside County Environmental Heaith Services approves th.9 GUbsur;aca sewag a
disposii plot play; to obiain building permit fo; i aGabon, construelion. 3,--?
Ae-
P • C.
T
MAIINT,' 00% ExPANra A. MIN. �LLOL FROM ANY WEUEE OR WATER MAIN-�60 h
DEf AEtTl?i;_N a OF PUBLIC IC HEALTi ,approva of casae lens o
IS �'�AUD FOR ON (1) YEAR Health of Riverside Count p of reli ,vete runes.
or Architect of the resp does not for t e th�Hi . .
FRC(v?DATE 0APPROVAL. '" or Architects de,:i um9 � for th®
. �La T' 3 ;JCOC/<
/� �-S�r�.�iln�nu,ra
��r l�c�' ��Qu�:✓.,4
GlNir#!fes
773.-D'73 - 0o7= .�
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A-1: CESSPOOL SERVICE, INC.
P.O. Box 183
Desert Hot Springs, CA 92240
'Since 1959'
.(619) 329-6875
State Lic. #265214
f
'BILL TO -4--v
ADDRESS
CITY
JOB INVOICE
HELPER
qb' A . L (' O DAV WORK
/+O CONTRACT
' "'t'i 4-'c':•.L' t`i: ,.1 O EXTRA
OUANT
CUSTOMERS'S ORDER NO.
DATE ORDERED
C
Gallons
ORDER TAKEN BY
DATE PR 21,
�
\ ••
PHONE
HELPER
qb' A . L (' O DAV WORK
/+O CONTRACT
' "'t'i 4-'c':•.L' t`i: ,.1 O EXTRA
OUANT
DESCRIPTION OF WORK -
PRICE AMOUNT
C
Gallons
'' '
CLOW
Pumping Fee per 1000 gal.
Dumping Fee per 1000 gal.
Out of Area Fee
Locating / Opening Fee (per hour)
Size System:
A SERVICE CHARGE OF $20 WILL BE DUE
ON ALL RETURNED CHECKS.
A FINANCE CHARGE OF 11/2% PER MONTH, 18% PER YEAR WILL BE
CHARGED ON PAST DUE ACCOUNTS OVER 30 DAYS.
OUANT.
LABOR AMOUNT
TOTAL -
MATERIALS
MECHANICS @
TOTAL
LABOR
HELPERS @
I hereby ackoMod a the salislec TOTAL LAB R
com Ietlon of rh a v n work, -
-
TAX
SIGNATURE
COMP D/171
,f/.rr—
TOTAL
Under the California Mechanics Lien Law any contractor, subcontractor,
laborer, supplier, or other person who helps to improve your property, but
is not paid for his/her work or hearing, your property could be sold by a
court officer and the proceeds of the sale used to satisfy the indebtedness.
This can happen even if you have paid your contractor in full if the
subcontractors, laborers, or suppliers remain unpaid.
To preserve their right to file a claim or lien against your property, certain
claimants such as subcontractors or material suppliers are required to
provide you with a document entitled "Preliminary Notice". A Preliminary
Notice is not a lien against your property. Its purpose is to notify you of
persons who may have a right to file a lien against your property if they are
not paid. Generally, the maximum time allowed for filing a claim or lien
against your property is ninety (90) Days after the completion of your project.
TO INSURE EXTRA PROTECTION FOR YOURSELF AND YOUR PROPERTY,
YOU MAY WISH TO TAKE ONE OR MOREOF THE FOLLOWING STEPS:
1) Require that payments be made directly to subcontractors and material
suppliers through a joint control. Any, joint control agreement should include
the addendum approved by the Registrar of Contractors.
2) Issue joint checks for payment, made out to both your contractor and
subcontractors or material suppliers involved in the project. This will insure
that all persons due payment are actually made.
3) After UPON making payment on any completed phase of the project,
and before making any further payments, require your contractor to provide
you with unconditional lien releases signed by each material suppliers,
subcontractor and laborer involved in that portion of the work for which
payment was made. On projects involving improvements to a single family
residence or a duplex owned by individuals, the persons signing these
releases lose the right to file a claim against your property. In other types
of construction this protection may still be important, but may be as
complete. TO PROTECT YOURSELF UNDER THIS OPTION YOU MUST BE
CERTAIN THAT ALL MATERIAL SUPPLIERS, SUBCONTRACTORS OR
LABORERS HAVE SIGNED.