Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
PLBG (0401-159)
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 260%214 C42 MC pp OV -1118112 Date + ` L !� 1+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: ( ) 1, 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 issued. My workers' compensation insurance carrier & policy no. are: Carrier STATE FUND . Policy No. 045-001,1393-2003 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 3subject to the workers' compensation provisions of Section 3700 of the Labor ,.,,CoCode, I shall forthwith comply with -those, provisions. de, f /f l /L• ' Applicant • Warning:y 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 I 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) Date•+ •+° t /, +X''' • L is '. PERMIT # BUILDING PERMIT .DATE Qumnar VALUATION sur LOT TRACT JOB SITE r, ADDRESS 49.470 t�,Vii?.,D A9 ,1� OM.M.'Z .� APN (5-182-Wl OWNER CONTRACTOR / DESIGNER / EN (NEER A 1 CF8000C1, S}^",�t` ICI NIC 44-200'fOW 3' , MCM? WAY P. O. BOX 183 3.)AU/1:i CA, 92260 DFMTH.0TxPPJHGa CA 92240 (760)329.6875 CID110 0386 USE OF PERMIT' PLi.1W_'_ 1G 10014 WSTEM PER. HFA.1.,TH DDT APPRO M PLNKS. SEWER 40T .AiVAIIAB1X-VER]FIED WITH tufa rILI @ S:Vdtf'O. VALUATION 2,3ffl} o Tei WM. �i;M COS' Off+` COMMUCTTC}N PLUMBING FKK 101.000-419.000 USA M-TOT'lil:, CON3ii3 C TION AND P AV C114F.CK brb .OD ISS FRE-FArD MIS D JAN 1.4 100cl= OF 4 QUINTA �✓ RECEIPT ApJCE'.D 7 �DATEFINALED INSPECTOR 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 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 Sewer Connection Encapsulation Gas Piping Gas Test Appliances Final COMMENTS: Final Utility Notice (Gas) ELECTRICAL APPROVALS Temp. Power Pole Underground Conduit Rough Wiring Low Voldage Wiring Fixtures Main Service Sub Panels Exterior Receptacles G. F.I. Smoke Detectors Temp. Use of Power Final Utility Notice (Perm) COUNTY OF RIVERSIDE COMMUNITY HEALTH AGENCY ASSESSOR'S PARCEL NUMBER 4 IS 2- DEPARTMENT OF ENVIRONMENTAL HEALTH t19— — APPLICATION FOR WASTE WATER DISPOSAL APPROVAL APPLICANT: 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 /%..,,, Address City �^ State Zip �� lk Telephone 141 r .r 1ST s �v/fl /�{ y :�✓ .Ic., l ��" 5l `y Owner r Address City State Zip Telephone Q Nr �l �n o �ww.r P� ,�,r tv..,, ,q.,� ► ., ..sT`r`ery . 9xy1.a 7 OJob Property Address City " Zip P: Ay 970 4vel A-4, I-V a/'i .4 lam.. 472.1-r U Lot Size Water Agency/Well Use of Permit, P/P, SVP' PUP, etc. Legal Description DBA .j e La- - 24 -Tk 3 Dwelling, MH Site Prep., etc. qyb Signature of Applicant yam. Date FOR OFFICE USE. ONLY CHECK BOX IF REQUIRED _. If any box is checked, this application shall be considered rejected until the ❑ Detailed Contour Plot Plans Required (1 to 5 foot interval) information is provided and the fee paid. Resubmittals later than 90 days " wafter date noted below may require. repayment of fees. ❑ Other ❑ Staff Specialist Lot Inspection Required Z ❑ Holding Tank Agreements Completed ❑ Certification of Existing S.D. System Required Thomas Bros. Page Grid W❑ WQCB Clearance Required ❑ Date Lot Inspection Completed: • Initials U) (Attach for DOH -SAN -007, Santa Ana Region Only) ❑ Soils Percolation Report Required Remarks: ❑ Special Feasibility, Boring Report Required ❑ Maintenance Booklet Provided ❑ Final Inspection by Department of Environmental Health is required. ❑ Rerevievi'Required Initials Date Please call 24 hours PRIOR to inspection. C/42 / Soils Percolation Boring Report By Lic/Project # Date Soils Map Page Soil Type Approved By Date No. of Systems Type of System(s) No. Dwelling Units (1) Septic Tank Soil Rate Grease/Sand ❑ Holding Tank Replacement New ❑ Addition Bedrooms, Fixture Units Q U/ ) zS I'�,1�1. 't Grease Intcp/Lint Trap ❑ Existing [J Connect to Sewer 3 %.1 /d0© Gal. IOC Gal. Sq. Ft. Total Linear Sidewall Allowance Leach Bed sq. ft. Bottom Area Ft. ft. rock/ sq. ft. running ft. Install Line(s) ft. long ft. wide of Bottom Area Inlet Tested Depth ❑ N/A with min. inches rock below drainlines U Proposed Bottom Tested Depfh or Z 0 Leach lines/bed special design for slope: (3) Pit Diameter No. Pits Pit Below Inlet (131) Seepage Pit Maximum Other: FDe F/0 Applicable Total Depth llowable• Allowable- WN/A- Overburden Factor ❑ 5' 6' TD r t✓ th U) Well Review Approved: Date: Well Drilling Permit# - SIGNATURE Grading Plan Approved: Date: SIGNATURE Plan Check Only Date: ( t r MA REMARKS: /-1!#\w� 1A a I' � [alll:�li, ��Ac �> � �Qvlclrl��j o Uhel A^ This applicationyis APPROVED/DENIED for the category checked in SECTION B above, regarding the design of a disposal system as indicated on the accompanied -plot p al n, using the requirements set forth in SECTION C above. A building is for installation �3 / € permit necessary the of the above- Revenue Code Fee $ designed system. No construction is Permitted in the required reserved 100% expansion area. ' O!% Check # (1) Septic Tank must be 100' minimum from any wells. D Z (2) Leach lines must be 100' minimum from any wells, including expansion Date ' / l�./ Initial O ' area. ! () (3) Sewer lines must be 50' minimum from any wells. LU U) (47) 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 1000F`% 1 l � l �-1 N _ Date 144 kmG — i 1 ul5inouuon: vvmi I t—urtice rue; rtt_ww—Applicant; PINK—Bldg. Dept.; GOLDENROD—Plans/Records ;THIS APPROVAL GRANTED BY THE ; :DEPARTMENT OF ENVIRONMENTAL HEALM i :IS VALID FOR ONE (1) YEAR FROM DATE OF APPROVAL !C®I NTY OF'RIVERSI DE DEF'ARN!r OF E RON E NTAL Sewage Drspo 9 GW. Commercial .— k Vit. of Leach Line' ; -,� seepage FiteLLNo.Lha' BI Caiia�ee3 to Sewer —Connect t® EAsriUg SYSW a No On7site Wates s©ftening devices shall be discharged into th septic syste��e vritl�mut zle�arance Brom the Calm "KeAun ya water Quality control Baa2•d. .An se nage. dispos�el ira t39ia7i€;ya shQ i coref'orm fie the current upe q �r :d'o9 in .lye area Of twc ;za•op4iSed ieaCh lines sdrall re:geirc .,ate:_ 2 nem a fsProv l byto Ss Dept.tIr ih't i, 4 ;THIS APPROVAL GRANTED BY THE ; :DEPARTMENT OF ENVIRONMENTAL HEALM i :IS VALID FOR ONE (1) YEAR FROM DATE OF APPROVAL !C®I NTY OF'RIVERSI DE DEF'ARN!r OF E RON E NTAL Sewage Drspo 9 GW. Commercial .— k Vit. of Leach Line' ; -,� seepage FiteLLNo.Lha' BI Caiia�ee3 to Sewer —Connect t® EAsriUg SYSW a No On7site Wates s©ftening devices shall be discharged into th septic syste��e vritl�mut zle�arance Brom the Calm "KeAun ya water Quality control Baa2•d. .An se nage. dispos�el ira t39ia7i€;ya shQ i coref'orm fie the current upe q �r :d'o9 in .lye area Of twc ;za•op4iSed ieaCh lines sdrall re:geirc .,ate:_ 2 nem a fsProv l byto Ss Dept.tIr ih't