09253 (AR)H
Building
Address
Owner
Mailing
Address
City
'f' n
Contractor
Address
- •�4
P.O. BOX 1504 N o .
78-105 CALLE ESTADO
49-885 Laao Drive LA QUINTA, CALIFORNIA 92253
& Classif. C42
Arch:, Engr.,
Designer
Address
Zip jTel.
Zip
astruct
Tela
Cit
Lic. #
Tel
BUILDING: TYPE CONST. OCC: GRP.
P. Number
al Description
Project Description
Sq. Ft.
Size
No.
09253
No. Dw.
Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
City
Zip
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.. /moij /l •g C' f e 1
~�Y
SIGNATURE `� � {„•!" a — I � 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
Estimated Valuation
,permit to construct, atter, 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).
❑ 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
PERMIT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
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
Mech.
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.)
Electrical
❑ 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
Plumbing
does not apply to an owner of property who builds or improves thereon, and who contracts for
S.M.I.
such projects with a contractors) licensed pursuant to the Contractor's License Law.)
❑ I am exempt under Sec. B. & P.C. for this reason
Grading
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
19 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.)
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 o/ 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 if 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
ateMailing Address
City, State, Zip
Driveway Enc. -
Infrastructure
TOTAL
REMARKS
0.
AMOUNT
72.00
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:—
Validated by:
Validation:
Date Permit
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
IST FL. SQ. FT. ® $
2ND FL. SQ. FT.
POR. SQ• FT. ®
GAR. SQ. FT. ®
CAR P. SQ. FT.
WALL SO. FT. ®
SO FT ®
ESTIMATED CONSTRUCTION VALUATION $
UNITS
MOBILEHOME SVC.
POWER OUTLET
"
YARD SPKLR SYSTEM
BAR SINK
ROOF DRAINS
DRAINAGE PIPING
DRINKING FOUNTAIN.
URINAL
WAl ER PIPING
NOTE: Not to be used as property tax valuation
BONDING
FLOOR DRAIN
MECHANICAL FEES
FORMS
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
GAS (ROUGH)
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
OTHER APPJEQUIP.
LAUNDRY TRAY
AIR HANDLING UNIT CFM
TE . OLE
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
SO. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID ® 1114 c
SEWAGE DISPOSAL
[Leo
SQ.FT.GAR ® 3/4c
HOUSE SEWER
REMARKS:
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 APPJEQUIP.
REINF. STEEL
GAS (FINAL)
TE . OLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
BOND BEAM
WATER SYSTEM
GRADING
cu. yd.
$ -plus-x$_
_$
LUMBER GR.
FINAL INSP.
FRAMING
FINAL I
ROOFING
[Leo
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATIONISOUND
FINISH GRADING
FINAL INSPECTIO
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURES11NITIALS
GARDEN WALL FINAL
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, �,.� '""+` "'!�'" ^'r n,.E �'-�•"fori'4i'F,ti>rw>r.�,.•�v-•7--,�li�r.Y�,�..!-^' .
COUNTY OF RIVERSIDE DEPARTMENT OF HEALTH Assasam Parcel tom
ENVIRONMENTAL SERVICES DIVISION 1,01 - 4/00 - 02/ -1
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 speculations as Indicated on the attached check Ilat
A non-refundable filing fee (see below) is required when the application is submitted. Check must be made payable to the County of
6601 ?0n&V&g;s,'hde. Npr9_-vaE(§J this application shall remain valid for a period not to exceed one year from date of approval.
`Q" as C
VERIFY ITEMS&SECTIONN A FROM BUILDING
& SAFETY APPLICATION BUILDING DEPARTMENT APPLICATION LOG #
AW1, (ntractor, Contact}j/reo
�b+S rrriftrdua� .c�
Phone
�2�/-
Address & Firm
'3 '- 3 V.
U)
Owner
Lr-<
Phone
Mailing Address
99J`
City /
State
Zip
Job Property Address /
Description Prop. (PM, Track Lot)
g2Z53
,y$3 5
Lot Size
Water Agency/Well
Use of Permit P/P, CU, etc.,
% �Q(p
Other
/
V C,� *
()
p,'t��t f Cdr• 0, y�%l��F; ,f:
"(INC'
/!' � FX('%{�fLl'% ((
(.
Dwelling, H Site Prep, etc.
Signature of Applicant
Date
CATEGORY: REV CODE FEE
CATEGORY: REV CODE FEE
SUBSURFACE DISPOSAL 1238
❑ SITE EVALUATION UPON REQUEST 7349 $ 43.00
CD
❑ MULTIPLE PARCELS WITHIN SAME �9'�
(NO PLOT PLAN)
LAND DIVISION
❑ SEWER/SEPTIC VERIFICATION 7348 $ 17.00
Z
O
a. 1 st 4 Parcels (Each) 1238 $ 57.00
(Less than 1 year)
b. Each Parcel after 4 7344 $ 24.00
❑ PRELIMINARY ELECTIVE 7352 $ 23.00
UJ
O Rereview (2nd review same parcel) 7344 $ 24.00
EVALUATION (Attach DOH SAN 53)
U)
❑ Site Evaluation in Conjunction with
❑ HOLDING TANK 7351 $ 47.00
Critical Ares 7348 $111.00
❑ ALTERNATIVE/EXPERIMENTAL 7345 $222.00
O She Evaluation Lot Less than
SYSTEM
10,000 Sq. Ft. 7347 $ 87.00
INITIAL DATE
Holding Tank Agreements Completed ❑ Yes No 9
Certification of Existing S.D. System Required ❑ Yes No
WQCB Clearance required. (Attach Form ❑ Yes No
DOH SAN 007, Santa Ana Region Only)
Soils Percolation Report Required. ❑ Yes No
Special Feasiblitty Boring Report Required. ❑ Yes No
Detailed Contour Plot Plans Required. (1 to 5 fL interval) ❑ Yes No
Olfher ❑Yes No
'Staff Specialist Lot Inspection Required al; ❑Yes , No f -
1
Lot Inspection Date
Soils boring report by PrOjec # Date
Soils Map Page Sol Type Approved by �,%Q Daft C5i"
tJ
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No. of Syslsme
Type of Systeme)
Ow ellirhg Un ffs
(1) Septic Tank
Soil Rate
Grease/Se►�/'
O
O Holding Tank ❑ Existing
O New ' ReplBoenMrrrt
Bedrooms xture Unhs
�,
QK) Sy✓� {n
it
/�
3 r'7
/Gr/_",
U(2)
Leach Line Sq. Ft
Bottom IB�e ^
Sidewell el
It sq. it
per cunni
Install Lirre(s) /R (t wide
min. inches bebw� drahilines or
Leech Bed sq,tC
of b m�a►ea
/i
❑ NA
Leachlines/bed special des' n for slope:
(3) Pit Diameter
No. Pits
Pit Below
Seepage PH Total Depth
Other.
Applicable
❑ 5 6
Inlet (BI)
/
(TD) a g ,
Max. Allowable Depth
N/A rden factor
No. 2 System
REMARKS:
.vt � Q �// < �
>� I'Ui�/'iJ� •, 7� d F /✓i �C /`
-
d r
This application iAPPROV /DENIED for the category checked in SECTION B above, regarding the design of a subsurface disposal system as indicated
on the accompan t plan, using the requirements set forth in SECTION C above. A building permit is necessary for the installation of the
Z
above -designed system. No construction is permitted in the required reserved 100% expansion area.
0
(1) Septic tank and sewer lines must be 50' minimum from any wells
(2) leach lines must be 100' minimum from any wells, including expansion area
UJ
i(3)� Seepage pits must be 150' minimum from any wells, including expansion area
U)
6 I �.�"y���
Signature of Health Official MVIZ 01
RECEIPT NO. Issued By �,�/"\ Date
DISTRICT: • ❑ Riverside, ` r di ' ❑ Hemet O Perris ❑. Rancho Calif. ❑ Blythe
DOH -SAN -122 (Rev. also) DISTRIBUTION: WHITE - Office file YELLOW - Applicant PINK - Bldg. Dept GOLDENROD - Plans/Records
L6 rx m.i n
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