08821 (BLCK)P.O. BOX 1504
Building 78-105 CALLE ESTADO
Address 78-153 Avenida Bt3ena gentU±AQUINTA, CALIFORNIA 92253
Owner
Mailing
Address
City Zip Tel.
.
Contractor
Conklin Co.
73-612 Rwv Ill #7
City Zip Tela
Palm Desert 92260 346--8805
State Lic. City
& Classif. BX 316634 Lic. # 203
Arch., Engr.,
Designer
Address Tel.
CityI Zip I State I
Lic. #
LICENSED CONTRACT.OR:S_DECL-A'RATI'ON
I hereby affirm that I am licensed ynder prp sions of hapter•9 (commencing with Section
7000) of Division 3 of tbe-B'usiness-and rof8salons Co e, and"my license is in full force and
effect. .� r / f t ! i� se
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
permit to construct, alter, 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
I 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
builds or improves thereon and who does such work himself or through his own employees,
m: -provided that such improvements are not intended or offered for sale. If, however, the building
i t orimprovement 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.)
❑ 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
does not apply to an owner of property who builds or improves thereon, and who contracts for
such projects with a contractor(s) licensed pursuant to the Contractor's License Law.)
❑ 1 am exempt under Sec. B. & P.C. for this reason
Date Owner
WORKERS' COMPENSATION DECLARATION
I hereby affirm that 1 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 fir'• -f 1
QCopy 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 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.
r Date Owner
NOTICE TO APPLICANT: If, after making this Certificate of 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 it work thereunder is suspended for 180 days.
I certify that I have read this application and state that the above information is correct.
1 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 Address
City, State, Zip
t••
No. 08821
BUILDING: TYPE CONST. OCC: GRP.•
A.P. Number dn
Legal Description
Project Description 51 Alnrk Wall ArnxinA trAnh
Sq. Ft. 26 if No. No. Dw.
Size Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
mated Valuation
I PERMIT I I AMOUNT
Plan Chk. Dep
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL 2c; o7
REMARKS
, • y hAt,Y,t n.a
1011x� ^
x---
r �•i.ASA
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: Date
Validated by:
Validation:
Permit
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL. SO. FT. ® $
UNITS
COLL. AREA
SLAB GRADE
ROUGH PLUMB.
YARD SPKLR SYSTEM
2ND FL. SO. FT.
HEATING (ROUGH)
STORAGE TANK
POR. SO. FT. ®
MOBILEHOME SVC.
BAR SINK
GAR. SO. FT. ®
POWER OUTLET
ROOF DRAINS
CAR P. SO. FT.
GAS (ROUGH)
DRAINAGE PIPING
WALL SO. FT.
HEATING (FINAL)
DRINKING FOUNTAIN.
SO FT ®
GAS (FINAL)
URINAL
ESTIMATED CONSTRUCTION VALUATION $
WATER PIPING
NOTE: Not to be used as property tax valuation
WATER HEATER
FLOOR DRAIN
MECHANICAL FEES
FINAL INSP.
WATER SOFTENER
VENT SYSTEM FAN EVAP.000L HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
GRADING
cu. yd.
$ plus x$
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
LAUNDRYTRAY
AIR HANDLING UNIT CFM
FINAL INSP.
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.
SO. FT. ® c
BATH TUB
SO. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID ® 11/4 c
SEWAGE DISPOSAL
SO.FT.GAR ® 3/ac
HOUSE SEWER
GAR. FIREWALL
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 APPJEOUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
BOND BEAM
WATER SYSTEM
GRADING
cu. yd.
$ plus x$
_$
LUMBER GR.
FINAL INSP.
FRAMING
FINAL INSP.
ROOFINGREMARKS:
t6
y�nd gaq/l/--
-x ?Iqo 4j -)1q,6
/d, (7 GmrFIREPLACE(
VENTILATION
FIRE ZONE ROOFING
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATIONISOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESIINITIALS
GARDEN WALL FINAL
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761-Ufi -0oA-
RIVERSIDE COUNTY DEPARTMENT OF HEALTH
PERMIT APPLICATION FOR A SUBSURFACE DISPOSAL SYSTEM
Applicant: Submit this form with three copies of a scaled plot plan drawn to county specifications required on the
attached check list. A non refundable filing fee of $15 is required when the application is submitted. Check must be
made payable to County of Riverside.
Name /�
4" 7'-- Cf cD
�
Mailing Address
N ' , 'j l 'A /� -�:.
City//))
Z')
Sta/tee
Zip Code
Phone
06, rt%r
.-+sa /
'Property Addresst'`
It o CoIRMWFl)ty
'Legal Description of Property (Lot, Parcel Map, Tract)
9 lJ h�cl�a,vr-= 5 e rr
'
4
11A 4f07A
!V i`(c�
*Assessors ParcelNo.
Water ServingPropertyFrom '
Lot size
r � °' � f��Kr'
�•f'LI%: �V![!l.<'� �!%
V 1 /
L \ C��7`" r1 !. L:
Signature of Ao(cant Date
'The above information must be verified from Building Application
Staff Use — Do Not Write Below This Line
f Initial Date
WQCB Clearance required Yes C3 No -��"
Soils feasibility- report required Yes ❑ No
Detailed boring report required Yes ❑ No
Detailed contour plot required Yes ❑ No
Comments:
1 A
Soils or boring report by ��` �`"'e r�� v Date
Approved by Date
Soils Map Page Soil Type Tract File No. Other
NermbeF-155
X f ST • ti'u�r f r APAa-rmF;1)
Septic Tank Size (gallons) a
% EXE S r. (/ j�J O
Rate Required
3. f�
Type of System
New Addition Replacement
��l')
❑ 0' ❑
Leach line sq. ft. of bottom area trench
Leach bed (sq. ft. of bottom area bed)
Seepage Pit Diameter
'51296' 0
Number of Pitts
Seepage.Pit Depth EM.
Total Depth of Pit
L (ijIS7 66x)
Q
0
Loccaatmoo^n of Systems
Additional Requirements
� "� .2,1�• . ..� �.n.r-• GSL `^,.`"`�� ,�k
rJf
>' r cc r��. —c �/ .4
A permitlis appro� ved/•denied-{or the design of a subsurface disposal system as indicated on the accompanied plot plan
using the requirements set forth in Section B above. A building permit is necessary for the installation of the above
designed system. r � � .
A?
Signature of Health Official Date
Receipt No.
District: Riverside ❑ Indio LJ Hemet ❑
DISTRIBUTION: WHITE - Office File YELLOW - Applicant
DOH SAN 122 (Rev 10/82)
Issued By 4dilL
Date
PINK - Building Dept. GOLDENROD - Pending File
1