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0202-043 (PLBG)
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 ani Professionals Code, and my License is in full force and effect. License # I Lic. Class Exp. Date 4,k32180 C21 CA 2- 7_ Date `' 6y�; 10044Signature of Contractor/ -_y �) T 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. r,) 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 STA.'Y1d KIND Policy No. 01'3340141 (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 3700 of the Labor Coderl'shall forthwith comply with those provisions. 'Date:.2 Trc•.1., 2A:il2 Applicant—/ I 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 inspection purposes. Signature (Owner/Agent) "`---•A M•rt/'•°5,•.b le" ���� DateSLal = BUILDING PERMIT- PERMIT# DATE VALUATION LOT 020i`0143 TRACT JOB SITE ADDRESS 7&-M .AGO APN K OWNER CONTRACTOR / DESIGNER / ENGINEER ZLA,Y W,1411NEW AWS t3 7�r;;i•` �FLC3$1` .'13 "a'3 15'i`. 7V-086 LWO DR .3 6. 1 QJ WiRA DRIVE LA Q007 TA CA 9272S3 VIATHEDRALMIT CA 922-34 (760)324.-1911 CB1,0 '769 USE OFPERMIT j '�y �+{'�'� *'y'y' �M' :.7L`riV MAt, 3�.7l.fiX9,cl 1 `L 61 X 40` SYAZPAQX PIT; SWER UNAs,+';A,ILABUTY CO`NIFIR e -D BY X91it'E 'i'AWN IM 09 CMD. VALUATION 4,500,00 LS F111191AAM COST OF 440,1�151.11t'4?a��.�J1K# qqgg y y y'�l v�•, /( ,{ PRIn .4� A R ` Oho .GFlnl'w:L 1'SsitMllSk O 111118. SEWE'l; IQ3+6t30.419-000 $30.00 .T 54 MY O 6 �S i i!�1,. � `j' I, �`+°�s ; 4. ANI P1'.A9Fv:�' LHISU F1WVPA7D IM -10 Moo TMAL rMUMM"138 ME, NOW 7 RECEIPT DATE j BY t""` i�; DATE FINALED INSPECTOR k;,, t 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 8 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: _ /} t: v t i1 ; 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) ALMS UNDERGROUND CONSTRUCTION 38703 VISTA DRIVE CATHEDRAL CITY, CA 92234 PH. (760)324-1911/FAX (760)324-9541 CA. LIC. #482180 1 CITY OF LA QUINTA' BUILDING & SAFETY DEPT. APPROVED FOR CONSTRUCTION E5, F ls4 rJ -s P+,' K saepmc'e P-.+ 0 cc) I d '- JT E. IV L __IAD Soopag Q - COUNTY OF RIVERSIDE COMMUNITY HEALTH AGENCY r 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 application shall remain valid for a period not to exceed one year from date of payment. LMS # City / State Ir -.1 Lf City f t ' State If., J, . 7 City •I:egal'Descnption ...`_`—Y (' - S FOR OFFICE USE ONLY CHECK BOX IF REQUIRED i If any box is checked, this application shall be considered rejected until the information is.provided and the fee paid. Resubmittals later than 90 days after date noted below may require repayment of fees. Z❑ Holding Tank Agreements Completed 0 ❑ Certification of Existing S.D. System Required WElWQCB Clearance Required (Attach for DOH -SAN -007, Santa Ana Region Only) ❑ Soils Percolation Report Required Zip - Telephone Zip Telephone Zip Date / z4o2 t ❑ Detailed Contour Plot Plans Required (1 to 5 foot interval) ❑ Other f. ❑ Staff Specialist Lott Inspection Required Thomas Bros. Pagte Grid ❑ Date Lot Inspection Completed: Initials Remarks: I Q Booklet ❑ Special Feasibility Boring Report Required Maintenance � ' Provided ❑ Final Inspection by Department of Environmental Health is required. ❑ Rereview Required Initials Date Please call 24 hours PRIOR to inspection. C/42 / Soils Percolation Boring Report By i Lic/Project # . Date } I Soils Map Page Soil Type 1' Approved By ! • h Date No. of Systems Type of System(s) i No. Dwelling Units (1) Septic Tank Soil Rate Grease/Sand ❑ Holding Tank ❑ Replacement Bedrooms, Fixture Units Grease Intcp/Lint Trap / ❑ New' ❑Addition iR�PY /'n _ 'Q Existing Q Connect to Sewer �. ,�'�; ,�� r � al, Gal. Sq. Ft. Total Linear Sidewall Allowance = Leach Bed sq. ft. Bottom Area Ft.ft. rock/ sq. ft. running ft. Install L ne(s) ft. long ft. wide of Bottom Area ' I Inlet Tested Depth ❑ N/A with min.inches rock below drainlines U Proposed Bottom Tested Depth or Z Leach lines/bed special design for slope: (3) Pit Diameter No. Pits Pit Below Inlet (131) Seepage Pit Maximum Other: ~ Applicable Total Depth Allowable P:i C) N/A Overburden Factor ❑ 5' j© 6' .' / TD 4' Depth �� U) Well Review Approved: Date: Well Drilling Permit# SIGNATURE Grading Plan Approved: Date: Plan Check Only Approved: _ REMARKS: r :! This application isftmt ED for the category checked in SECTION B above, .of a disposalsystem as 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 - designed system. No construction is permitted in the required reserved 100% expansion area. (1 Septic Tank must be 100' minimum from any wells. Z (2) Leach lines must be 100' minimum from any wells, including expansion 0 area. C) (3) Sewer lines must be 50' minimum from any wells. W-^� a (4) Seepage pits must be 150' minimum from any wells, including expansion area' SigFature f Date + )EH -SAN -122 (Rev 8/01) Distribution: WF Date: . / ,., " Revenue Code {�%5;��%i'",/.��� K� ./Fee $ ql Check # Date'" �" (!';,� . • Initial Mf77 2i • owl 3 y ,. RIVERSIDE: 4 909-955-8980 INDIO: { 760-863-7000 SOUTHWEST: 1909-600-6180 NK—Bldg. Dept.; taI