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21-0164 (PLBG)LICENSED CONTRACTOR DECLARATION I hereby affirm under penalty of perjury that I am licensed under provi; jor_1f_, 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 29-661118 C12 C 4 011-.2 -� rmsr 1Z �Si'`>•��/ i 7.•c- 1. 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 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 STTATF, FJJ)gD Policy No. 046-02009725101 (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 Section 370. of the Labor Code, I shall forthwith comply with,those provisions. ..-Date: Applicant P i t, ` �- j 01 ' • I �'f..� f l C. d, Warning: Failure to secure Workers' Compensation coverage is unlawful and shall subject an employer to criminal penalties and civil fines up to $100,000, in addition to the cost of compensation, damages as provided for in Section 3706 of the Labor Code, interest and attorney's fees. IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the conditions and restrictions set forth on his application. 1. Each person upon whose behalf this application.is made & each person at whose request and for whose benefit work is performed under or pursuant to any permit issued as a result of this applicaton agrees to, & shall, indemnify & hold harmless the City of La Quinta, its officers, agents and employees. 2. Any permit issued as a result of this application becomes null and void i work is not commenced within 180 days from date of issuance of suc permit, or cessation of work for 180 days will subject permit to cancellatio I certify that I have read this application and state that the above information i correct. I agree to comply with all City, and State laws relating to the buildin construction, and hereby authorize representatives of this City to enter upon the above-mentioned property for inspection -pur poses.,, ,-Signature (Owner/Agent)f t aji Date ; °< BUILDING PER PERMIT# tMtb-134 DATE '•" VALUATION P�yQn+i+d.� LOT TRACT JOB SITE y�r ♦�A➢ �V ADDRESS 7S.4�8 1.t.l�✓', 3, ri 1i�.6 III APN �. OWNER CONTRACTOR/ DESIGNER/ EN6 INEER �r BrKER :>LIUNTim D.A.M, LAW C01V r.f Rt7P rT'(4iS 7Po-4831wXEM:HWAY 111 50305 FIVY 1 11 LA. QU€N'1 A C:fa 92253 t ACIff+rs:I1 x. CA 9223310 (76rJp9i;, 5m4- CZ -19, 31 USE OF, PERMIT ai Il?iC3 ASAJ40CAN AD00 tint (:VN ORFA.SE 1WTFkz:XM'C1RM-1S9'A.LL 101?_r 60M 0AL aid t"3p.�4�AE, NA TEdtt;UTOR HP APPROVE -D PLANS. VAU XsATIt3N ' il,l}Dt1,9N' Lo".•' H�,"TAW.0 D COST' aF 4"(D,I`iSa'":��.s.. TMION 201M).00 :Pi �i'1�: i�'i`I14flftlL�S,$#ll' 1 . C 13M-•1'OTAL C:C;►NS'TT U .t `T. ON AMD PLA114 CIM 17K $27.00 g 4 •ti, LEMS �''k2&F tD Ff- d TOTAL PMMIT Jim,: 8 ID uz 140W $0.00 $2_7100 OC !- l � CITY OF�TA FINANCE DEPT. RECEIPT DATE BYE DATE FINALED 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 BLOCKWALL APPROVALS POOLS - SPAS Steel Set Backs Electric Bond D D Footings Main Drain Bond B am Approval to Cover Equipment Location Underground Electric Underground Plbg. Test Final Gas Piping PLUMBING APPROVALS Gas Test Electric Final Waste Lines Heater Ficial 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 s�/�,,� — Final Utility Notice (Gas) I7 OL S 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) Final COMMENTS: C.66NTY OF RIVERSIDE COMMUNITY HEALTH AGENCY ASSESSOR'S PARCEL NUMBER DEPARTMENT OF ENVIRONMENTAL HEALTH — — 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 applicationsshall remain valid for a period not to one year exceed LMS # 1 t 7r V 41-"' /4 Agent, Contracto 'Contact Person p�l1 •� 1. 11#A Address City �. tate Zip '�,�' 4' j I FN(�t/�4 � /�/ L Q �ur.✓�-:�` - c Telephone ���, r- ��c r 14V ASN/�ff'c �'� `yr.a-alY"-T'i�f Owner ! L,aii�p ess City State Zip Telephone Q �lAl�it y ('c ro,r1�i%<«- 7 6 t q �,/�rA4.s�� �,� s OJob Property Addres's A City / Zip Q Lot Size 'ter Age W ell EyjS%!L ('�, ,� c cFy>r�' Permit, PIP, SUP PUP, etc. G�JJri!1� ��'� � nF �V1Gi Legal Description. �CE'PfD� DBA ''�jEE� flu 7�'R 1 1-41, rat r ST/1/C7 e04P. rvP g lylFhSitetPrep etc. G/�P/y- • P �I�� �C%1!!( Signature of Applidant"- 6"�°.�}; 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 after date noted below may require repayment of fees. ❑ Other l; ❑ Staff Specialist Lot Inspection Required ZQ Holding Tank Agreements Completed ❑ Certification of Existing S.D. System Required Thomas Bros. Page Grid W Q WQCB Clearance Required Q 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 ❑ Rereview Required Initials Date ❑ Final Inspection by Department of Environmental Health is required. 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),40P l fAJr r<Fo ❑ Holding Tank g ©Replacement ❑ New ❑ A IditionF ,,No `Dwelling-Units�(s) /N�l, .Bedrooms Ftxtere•Units �1'' SER>rP>/6; /S9 M�iy' (1) Septic Tank %• Soil Rate Grease%Saod N�4 Grease Intc /L•int Tia • &P(4 ."n"p ''� ❑ Existing OsConnect to Sewer �1Jr,w) r ' 1 4 �_ A *A' I. //p (�, Q(/(/ Gal. - w Sq. Ft. Bottom Area Total Linear Ft. Sldewalj'48' ance ft. rock/ sq. ft. running ft. rcebrrPajrr.'Leach Pfdwide Install Lines) ft. long ft. Bedasq. ft.- of Bottom Area Inlet Tested De th. ❑ N/A � /44N1h� with min. inches rock below drainlines � C't/�/,c U Proposed Bottom Testy ted%Depth or Z 0 Leach lines/bed special design for slope: (3) Pit Diameter No. Pits Pit Below Inlet (61) Seepage Pit Maximum Other: W. Applicable- N/A Overburden, l / \ ❑ 5' ❑"6' i�40 Total Depth STD Allowable Depth ^ U) _ .�lWYr vd.•:.rY71 41 i,!✓N r-yrj~ VY�4��. �ML'��a -__1� K•� • ��/IW i1040 V_: P' �•Xr(( Gi c1�116-t�f Well Review Approved: Date: W.elliDrillrhTIP Tmit# ! (/(1 �'1 / �Y>�s/1 Jt 7 SIGNATURE Grading Plan Approved: ` Date: t/ SIGNATURE ' Plan Check OnllyAp/proved:/ Date: REMARKS: //.1r l�ia ,- SGC AY (%/�>1.0 .v,jt��LC �C a'1�dvDy �i'GGe7-. /1ilPic •f' W -/4 zf ..y. � %>�.d�_ /�'7`1�:.�/�r��%' ,C�11'4� • llC.�•!1' �'`�� �,,,�G x+19 h.l��,�l% .�1/�,,.�'/.,.,,rD / ,'�^ JJ%.�:II� /.y;�l.�.�lU��!,�1'�:h. •. 4:�^�...[��•1,/ iJ�..�P�.�/�•r ,oC�.�t+�� �t.['..d' ,,fir-F� / .,�-'r+x'�.� tyThis application IslAPPROVED/DENI;ED4for,�the categoryicheckedain -B -above, slgnr'of a dispos I system as •SECTION reg ardingIthe d indicated on the accompanied plot plan, using the requirements set forth in SECTION C above. A building permit is necessary for the installation of the above- Revenue Code D (� r 3t'/ r ? J41J Fee $ Ila. r a i/ designed system. No construction, is permitted in the required reserved' 100%`expansion'area: •_, - , _ ,; �p -- - - - y - -- Check # �� A (1) Septic -Tank must be 10.0' minimum from any wells. Z (2) Leach lines must be 100' minimum from any wells, includingexansion - Date / 3 r �" Initial O (~j area. (3) Sewer lines must be 50' minimum from any wells.G' ! n^ P ^'' �� 0'r•' • �• �""""" " LU U) (4) Seepage pits must be 150' minimum from any wells, including expansion RIVERSIDE: 909-955-8980 area. / / 4d , / A, (y(/ /a"'L r � INDIO: 760-863-7000 SOUTHWEST- 909-600-6180 Signature Date vlsalouuon: wnl I E—Omce rue; YELLUw—Applicant; PINK—Bldg. Dept.; GOLDENROD—Plans/Records RIVERSIDE HEALTH %0%5��_:RVICES AGENC. COUNTY OF ,,,P,�-PRTMENT OF E=NVIR011VZ-- NN'FALH r%LTH jjc'60116 . IS Fcod okas;siwaoo D;,.-,posal Traitor P rk Gai. Suptic Tank _ Motel, Apt., Hotel __.Sq. Ft. of Leach Line Dwelling Nt:' Cala _Cil _TD_m0 Seepage Conr!,:-,6,-jn to Sewer C.oromr..?rcial Building _ Swimming; wim. minConncrct to Existing AC Ae Ito g, Pool No on-site regenerating water softening devices mad - - — systervi herewith approved without ciearam.o) from me Water supply*his in�staoation mus,, t..& -from an approveu Mrc irofni�nl ;I oi - cu ' i ' re-nt iiiurm Plumbing Code. sorA kaz M s _LXn ro,,st comorn, �P,-;th rk.?-,tj' ur ll smagi- dispos ;nS Any cutting,7 radintpur filling in szcess of leot '.'rill'.'rillrikill:Ir" olsnos-a! app Oval. . I 'd Wi�'(G.'QL .11, 1 0 i, C�ojyji oi Board for installation of the sewag _Approval has bean cbtalned itom I� e Regi:;: .1 disposal systern. This is to certity that the Riverside County En\;'!'�t fk en -1 Health Services approves the Eur r dispavai-plot plan to obtain building permit to stalla(i-0 C/7- n, consgruct DATE__Lj By AI,CCJ aP14,CEMFJVr A gallon gr7ejejn1tergeptSpr,,shal1 be installe ust be an a r v e L CI grease ""'Q _)r.properly lo I �jr' a$p pursued e'd m an �.'l P auffplina box it U1 2 Itz u -• 1 -11 "T" in"er-captor inCT;'U'H:i dish a -er, -tures (on-ly) --t receiving fix b io any garbage area; ut, It P0416/3-compurtme5t1m op sirt' /-;°` '� grindert. .: ri-1- A-_ C d il J), n 44eA )III fid 7 -� Gtr ; �� 001- 77LO 7 A�FRWAI GRAWOED IM" of these plans by at M�m � 1 DEPARTMENT Of PUBLIC H RmIth of Riverside County does not relieve the BD40W IS� L *or or Architect of the responsibilIV kor the 41saftfd1p. IS VALID FOR ONE (1) YEAR 1mg or Architectural desiffn.7 Frr'r, m r ROM DATE OF APPROVAJ. ­ — - � l WE —�'� .:�C 'Ire.. ..'��. �^ 4�' •�� •��' 7a . � -. 'r, (Tp g��u •_' ' •�l♦�:. N6cJ / . EGt,/QI1E �. , •• Ott ' • .. ' +N GI2�� S d .i• , 1nrMRCr— •: , -. PRo�.os�o 6,000 1 Lu CzAi-WN G E PV 4w Z ev UE2f cur,,J! ' • V7, TM4 yl MIj I CITY ®F LA 0Ui, , I � BUILDING & SAFETY DE," APPROVED cn ' N .• • ' FOR CONST) i iUN ' � ,.. i•�i ��I Circ - .,��_•_ _ 4. �. i J 1 :. ti 04,0 W. e 0 a COACHELLA VALLEY WATER DISTRICT Regulations Regarding Interceptors/Separators (Gaccrpt) ' The Coachella Valley Water District i.equires that all plans and specifications for the installation ol' irltercentors/separat6rs shall be submitted to the district in advance of construction and no cotlstrUctloll shall startuntil 1)lans and speclflcations have becll approved by the district. The proposed discharger shall Complete an "interceptor application" and submit It With approval plUmbing plans and speclhcatlollS "s (wllcrc aPhlicablc) at it's headquarters in Coachella. There is currently no charge for the filing of this application. a No intcrccptor/separator shall be installed .vrithout prior approval of the district. /Applicants shall notil.y the district 48 hours prior to thc.start of installation'and all installation shall lie inspected by district personnel. There is currently no ehargc for this inspection. If you 1MVC any ducstions or desire additional information, please call Joe Barham, Demand Evaluation Specialist, at (760) 398-2651.