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9510-013 (BLCK)
LICENSED CONTRACTOR DECLARATION 1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing with cli W ' Section 7000) of Division 3 of the Business and Professionals Code, and my ( o^ to License is in f6,li>.95c��)and effect. 551Alli r- W License #_ Lic. Classes Exp. Date ' Z Date ,I r_� SignatureofContractor c'o 0 o� OWNER -BUILDER DECLARATION J w I hereby affirm that I am exempt from the Contractor's License Law for the CL following reason: cA ( ) I, as owner of the property, or my employees with wages as their sole Z 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 Signatureof Owner N O rn WORKER'S COMPENSATION DECLARATION aQ I hereby affirm under penalty of perjury one of the following declarations: 2 Z () I have and will maintain a certificate of consent to self -insure for workers' LO H cc O compensation, as provided for by Section 3700 of the Labor Code, for the X W LL. performance of the work for which this permit is issued. p J Q ( ) I have and will maintain workers' compensation insurance, as required by C0 Q U Section 3700 of the Labor Code; for the performance of the work for which this O (-), permit is issued. My workers' compensation insurance carrier & policy no. are: W LO Carrier i.:nS..•7-t-•mixt Policy No. i=arwn:e-:�• 1 (This section need not be completed if the permit valuation is'for 100.00 or less). I0 j r a F () 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 ® Code, I shall forthwith comply with those provisions. } Date: Applicant 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 I of the Labor Code, interest and attorney's fees. 1 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 44 whose request and for whose benefit work is performed under or pursuant to any permit issued as a result of this application agrees to, & shall, indemnify & hold harmless the City of Indian Wells, 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 rpermit, 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 priiperty'for inspec on purposes. ignature (Owner/Agent) !i ,'; t �r Date ALC>f BUILDING PERMIT PERMIT9 J0-113 DATE .1014195 VALUATION ',51,9; ,(%{ LOT , TRACT JOB SITE ADDRESS 74-739X63"� 1C.6��S'aii)Sa;7 APN OWNER CONTRACTOR r1qq�'(�1¢q��1 �p0S Cy ONi4y"?'RI.tRKTION J / A p ) 78=735 )3OITi.;Ei RUSH LA, QU1NTA CA 92253 LA QU1.NTA. CA, 97253 (619)77-2-4024 DESIGNERIENGINEER USE OF PERMIT l4Ui[..11_i i FEE DESCRIPTION FEES 4:FT. WALL 40.00 U 571'. WALL 60.00 !.'h° CONS't'R.UC110WI Fi:'F 101-000-418-000 $450i DCT t 0 4 1995 By— YSUB- SUB-7VrAL LONSTi3:(.TC" ON AND PLAN CREC LESS PRE -PIVD PEES $0.00 TMAL PERAUT FEES ME NOW $43.00 TOTAL- PROJECT PEIRPWII T FEE S 45.00 RECEIPT DATE BY 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 Footings A Main Drain Bond Beam 4 Approval to Cover Equipment Location Underground Electric Underground Plbg. Test . Final Gas Piping PLUMBING APOROVAXS 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: DESERT SANDS UNIFIED SCHOOL DISTRICT 82-879 Highway 111 NOTICE: Indio, CA 92201 Document Cannot Be Duplicated 619-775-3500 Date 6/16/95 1 Type of Permit I La Quinta No. 113507 Permit # Log Owner Name john Carper !=Q No. 78-745 Street Bottlebrush City La Quinta Zip 92253 Study Area 123 APN # Tract # Lot # 0 Square Footage 11877 Type of Development I Single Family Residence INo. of units 0 Comments At the present time, the Desert Sands Unified School District does not collect fees on garages/carports, covered patios/walkways, residential additions under 500 square feet, detached accessory structures or replacement mobilehomes. It has been determined the above-named owner is exempt from paying school fees at this time due to the following reason: EXEMPTION NOT APPLICABLE This certifies that school facility fees imposed pursuant to Government Code 53080 in the amount of 1.72 X 1877 or $ 3,228.44 have been paid to D.S.U.S.D. for the property listed above and that building permits and/or Certificates of Occupancy for this square footage in this proposed project may now be issued. Fees Paid By John L., Carper Name on the check By Dolores A. Ballesteros Superintendent TeNph`one �'�= `r Fee collected /exempted by Mary Lou Lopez �. : �, d Payment Receive , Signature Check No. 472 Collector: Attach a co of county or city plan checkication form to district copy for all waivers. Embossed Original- Building Dept. /Applicant Copy - Applicant/Receipt Copy - Accounting ASSESSOR'S PARCEL NUMBER BOUNTY OF RIVERSIDE HEALTH SERVICES AGENCY G 3 Ia _ 4/ I. DEPARTMENT OF ENVIRONMENTAL HEALTH )ERMIT APPLICATION FOR A SUBSURFACE SEWAGE DISPOSAL SYSTEM PLICANT: 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. ion -refundable filing fee is required when the application is submitted. Check must be made payable to the County of Riverside. Approval of this applica- ,I shall remain valid for as period not to exceed one year from date of payment. iG# `rTs OF �Att�l./�„ii.� A ent, Contractor, Contact Person I Pot,l�uS Addr ss City State Zip �� talc X17 ? LYS IIvv Cpt Telephone Q er o�u GA�P� Address City State Zip � - L-A U I TAS' 12 z� 3 Telephone Z O Job Pro- �- 'V"IPf�Q L C ,44 (Ifs/ %/i City I A (),4i /n Zip i/ IU Lott Size rater Agencya%V 5jI AtNFCC� (/!1t(FV Use of Permit, P/P, SUP, PUP, etc. l� i�(�,✓c Gv/nrG� : 16 r Legal Description LOT %�� i�Erf2T�'t�c3/t'I�Ivo2TQ[r�F/ '',,,/ �A/It�c; p r f L/FrFOr� TG/. Fdrrt7 E'B iS Dwelling, MH Site Prep., etc. Signature of Applicant Date CHECK BOX IF REQUIRED ❑ Holding Tank Agreements Completed ❑ Detailed Contour Plot Plans Required (1 to 5 foot interval) ❑ Certification of Existing S.D. System Required ❑ Grading Handout Provided m ❑ WOCB Clearance Required ❑ Staff Specialist Lot Inspection Required Z 0 (Attach For DOH -SAN -007, Santa Ana Region Only ❑ Lot Inspection U❑ Soils Percolation Report Required Lu (n ❑ Special Feasibility Boring Report Required ❑ Date Lot Inspection Completed:_ Initials Remarks: ❑ Maintenance Booklet Provided Initials Date ❑ Final Inspection by Department of Environmental Health is required. C/42 / Soils Percolation BorinReport by UgProject # Date / / 1Q Soils Map Page Soil Type -4-j,4 Approved By Date No of Systems Type of System(s) ❑,Holding Tank ❑ Replacement No. Dwelling Units ( // Bedrooms, Fixtur"nits^ (1) Septic Tank Soil Rate Gcease/Sand ' Gr ea ntcp/Unt Trap © Newg ❑Addition El Existing 4,fdAA+• 364m NtA ,<' n700 Gal. . �:•� i ,r, a%t+� � Gal. Sq. Ft. • ttom Area Total Unear Ft Sidewall Allowance tt. rock/ sq. ft. running tt.Install e(s) tt. long ft. wide with Leach Bed sq. ft. of 'Bottom Area Inlet Tested Depth -- aNA min. inche cook below drainlines or U Proposed Bottom Tested Depth �� • ^•� Z Leach lines/bed special design for slope: (3) Pit Diameter No. Pits Pit Below Inlet (BI) Seepage Pit Maximum Other: O Total Depth Allowable Applicable '—� ' J [� Depth 1 W N/A uOverburden Factor "' '( L:1"V TD T 93 Well Review Approved: Date: Well Drilling Permit # ' SIGNATURE Grading Plan Approved: Date: SIGNATURE Sewer Verification Approved: Date: REMARKS: A C „/ �'"f�' -,4e -.<i r1..Q''.``riG' /� /�Q..�C�`� iUi•.:rt��i��..C�.Or �l�s, i � �yQ,.t..k�_i�� .0,.�� v D � This application is APPRO ENIED;for-*thescategory„checkedzinTSECP:I.OWB FOR OFFICE USE ONLY abof4; regarding the da.s gl of a subsurface disposal system as indicated on the acompantedlplot plan, using the requirements set forth in SECTION C above. A build- /6 a ing pr3rmit is necessary for the installation of the above -designed system. No construc- Revenue code 4,2 3 O Fee $ . U D tion is permitted in the required reserved 100% expansion area. 1) optic Tank must be 4 minimum from any wells.,/ ! 0 . f D -Check # # 36 (2) Leach lines must be 100' minimum from any wells, including expansion area. r Date "t7 "/ 1 f Initial 6 71 Sewer lines must be 50' minimum from any wells. i� (4) eepage pits must be 150' minimum from any wells, including expansion area. W D Co kA U) t n Signature of Health Official �} to H �j� D K/ - - ! if j� Date ph� yy IV W 0 3”` n� DOH -SAN 122 (Rev 9/93) Ulstributlon: WHITE—Uttice File; YELLUW—Applicant; FINK—Bldg. UepL: GU)L� NHUL—FlanS/Hecoras T vrS� 11"75 �� V,47--?Cr-.-J 7-L-1 C.Al,j /Zrf w f,6-- /F 1,2U,5� 771 C -)Ll- vrS� 11"75 �� V,47--?Cr-.-J 7-L-1 C.Al,j /Zrf w f,6-- /F