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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 and
Professionals Code, and my -License is in full force and effect.
License # Lic. Class Exp. Date
396-698 x:12 c ,, °d �r �a}�
Date "�S_ 9 Signature of Contractor +��A��• ' ��'f�_
U' _
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).
( Y. I am. exempt under Section B&P.C. for this reason
Date Signature of Owner
i,
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 Policy No.
STATE; FU,` V ON 6- 725%1,93
(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
Code`, I shall forthwith comply with�t se ro yagion �(/}
Date: i evQ Applicant ��1
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 fj
application.
i 1. Each person upon whose behalf this application is made & each person ata'
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.
�o
/Signature (Owner/Agent)i Date "i �•
BUILDING PERMIT PERMIT#
DATE VALUATION LOT "+3469 TRACT
3/15/99 52.1oomo
JOB SITE Yg APN f
ADDRESS 78-390 E�.J��!X� O .D�i�UN S llkcE
OWNER CONTRACTOR/DESIGNER/ENGINEER
1.1184A MUSE L7ATf%i.AND CONtii72i_ft^T1ONY
78390 CAMEO DUNES P1. X30511«iY .t I I
LA t UINTA. CA 92753 C oACIREi.a A CA 9236
;,,° �itSEi�'398�5 �4�9 CT3I,1f . 31
USE OF PERMIT
PlIXAMiNo
SEPTiC KBANi ON. 89WEl2 COlv1 ECIF
VALUATION
2 100.00,LS
r
CST 1AIA:; I?. COST OF COMMUC TION �,8t3�.liG
PEr:RINOT .F FJ,- SUMN1r .RY
MUA031W 0CH -- SF'Wy..' t. 10 1 -01JO-419-000
x�
v c' �; A-' 1'A0, CON r'3'ttl.lf:: ION ANN) PLAN t".NECY
1,.ESc3 $0,00
MAR 16 199 9 -
G L.ft)A C J
DATE 'e I BY / ` %;'- I DATE FINALED I INSPECTOR
INSPECTION RECORD
OPERATION
DATE .
I 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
OX 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
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I I
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
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:
•
COACHELLA VALLEY WATER DISTRICT
i
CASH RECEIPT DETAIL
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S
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3-1 f C
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Received From:c�
Address: / ? �� v C)
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Date:
�� OIL/10--7.
`
Account No. -�
Lot(s)-
J _
Tract
Service Address r�,�_JtI
G.A. Code
❑ Meter(s)
$
i ❑ Service(s)
❑ Backflow(s)
❑ House Lateral(s)
❑ DetectorCheck(s)
❑ Meter Surcharge
%
/ ��
GVSanitationCapacity Charge
•,
❑ W.S.B.F.C.
❑ Temporary Construction Meter
' ❑ Turn on Charge
' ❑ Uncollected Account - Name
❑ Inspection Fee - Tract -
Fee -
❑ Plan Check Fees Water I Sewer -
' Tract -
_ '. .. rl Rnnd Pavmwnt - A_D - Rnnd
1
. V -moi'• '.
Receipt No. — Issued By
District: Riverside El❑
Indio./H117emet Date ? "
DISTRIBUTION: WHITE - Office File YELLOW - Applicant PINK - Building Dept. GOLDENROD - Pending File
DOH SAN 122 (Rev 10/82) - ,
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.
n� �I� PO fix c 73 7 d ;
_11 VA � o C-)
Name
Mailing Address
Q
CityStaten
Zip Code
Phone
U
W
'Property Address
'Cir ty & ommunity
'Legal Description of Property (Lot, Parcel Map, Tract)
L. 4 IN £ IJ, 33' ot- 13 Trt..i.f��u�l 3
UauK
i X17
'Assessors Parcel No.
Water Serving Property From
Lot size
�
ao, 000
Signature of Applicant Date '
'The above information must be verified from Building Application
Staff Use — Do Not Write Below This Line
Initial Date
WQCB Clearance required Yes ❑ No
Soils feasibility report required Yes ❑ No O
Detailed boring report required Yes ❑ No El
Detailed contour plot required Yes ❑ No ILI
Comments:
�i /� % I 3/7 L
�G
0
Soils or boring report by � 2�' • � '� - {� j Date
wApproved
� /�/
by U Date
N
Soils Map Page Soil Type __-- Tract File No. -ZaV 3 Other
Number of Bedrooms
3 100 4- _ fJ C/L09 c.
Septic Tank Size (gallons)
Rate Required
Type of System
New Addition Replacement
Leach line sq. ft. of bottom area trench
Leach bed (sq. ft. of bottom area bed)
Seepage Pit Diameter
'2--L'5 O 6'2--
Number of Pits
Seepage Pit Depth B.I.
Total Depth of Pit
ocation of System
Location
Additional Requirements�.',;;r ry o
U
A permit is approved/denied for the design of a subsurface disposal system as indicated on the accompanied plot plan
O
7.Z using the requirements set forth in Section B above. A building permit is necessary for the installation of the above
designed system. J `
U)
Signature of Health Official Date
Receipt No. — Issued By
District: Riverside El❑
Indio./H117emet Date ? "
DISTRIBUTION: WHITE - Office File YELLOW - Applicant PINK - Building Dept. GOLDENROD - Pending File
DOH SAN 122 (Rev 10/82) - ,