001206 (PLBG)PERMIT APPLICATION
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` City of La Ouinta
LICENSED CONTRACTORS DECLARATION: I hereby affirm that 1 am licensed under provisions of Chapter 9." .'
Department of Building and Safety
(commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force
This permit becomes void if work not commenced within 180 days from date of issuance. OR, if work has been suspended or abandoned for a period of 180 days. ,
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CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATIONINSURANCE: This section need not be completed if
LICENSED CONTRACTORS DECLARATION: I hereby affirm that 1 am licensed under provisions of Chapter 9." .'
the permit is for one hundred ($100) o, less. I certify that in the performance of the work for which this permit is
(commencing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force
: issued, I shall not employ any person inany mannersoasto become subject to the Workers'CompensationLaws of
and effect. 112 -
California.
License Class Lic. Number
Date Applicant
v
Date Contractor'' , Ute' ..NOTICE TO.APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers'
J
OWNER-BUILDER DECLARATION: I hereby atfirm'that I am exempt from the Contractor's License Law for the .
LCompensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall
be deemed revoked.
following reason (Sec. 7031.5. Business and Professions Code: Any city or county which requires a permit to
II
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construct; alter, improve. demolish, or repair any structure, prior to its issuance, also requires the applicant for
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
such permit to file a signed statement that he is licensed pursuant to the provisions of the Contra.ctor's License Law
0 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be .
(Chapter 9(commencing with section 7000) of Division 3 of the Business and Professions Code)or.that he is exempt. ,
made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or
therefrom and the basis for the alleged.eXemption..Any violation.of Section 7031.5 by any applicant for a permit „fir
demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap 3.2, Grp 2, Art 2. Sec341, Title B:
subjects the applicant to a civil penalty of not more thanfive hundred dollars ($500.): a•yr;
. C:A.C.)
0 1. as owner of the property, or my employees with wages as their sole compensation, will do the work, and the
0 As owner -builder, I will not employ anyone to do work which would require a permit from thevOivision of
structure is not. intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License
Industrial Safety, as noted above, unless such person has a permit to do such work from that division.
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, provided that such improvements are not intended or offered for sale. 11, however,.the
O Division.of Industrial Safety Permit No.
building or improvemnt is sold within one year of completion. the owner -builder will have the burden of proving that
Date Applicant
he did not build or.improve for the purpose of sale.).
CONSTRUCTION LENDING AGENCY: I hereby affirm that there la a construction lending agency for the performance
0 I, as owner of the property, am exculsively contracting with licensed contractors to construct the project (Sec:
of the work for which this permit is issued (Sec.. 3097, Civ. C.). k -
7044. Business and Professions Code: The Contractor's License Law does not apply to an owner of property who
Lender's Name
' builds or improves'thereon, and who contracts for such projects with a contractor(s) licensed pursuant to the.
SSB
Contractor's License Law.).
Lender's Address
0 1 am exempt under Sec: B. 8 P.C. (Attached Certificate).
I certify that I have read this application and state that the above information is correct.I agree to comply with all.
Date "` Owner
city and county ordinances and state laws relating to building construction, and hereby authorize representatives ,
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of this county to enter upon the above mentioned property for inspection purposes. ^
WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to self -insure, or a . .
END
certificate of Workers' Compensation Insurance„ or a certified copy thereof (Sec. 3800. Lab. C.). .
Signature of Applicant or Agent Date
Policy No. Company.
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify I have read this application and state that
0 Certified copy is hereby furnished.
the information given is correct. I agree to comply with all state laws and county ordinances relating to buidling
0 Certified copy is filed with the City. Building Inspection Department or City Department.
construction, and authorize a'representative of the City of La Ouinta Department of Building and Safety to enter
upon the property'for which I love applied for this permit for the purpose of making inspections.
Date Applicant
F
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- Signature of Applicant or Agent Date
Print Applicant/Agent Name
APPL/PRMT n o ! 7w . DATE Plumbi ntj
ADD:ESV. BM 1255 .
cIYY&0.--MUNIT•Y SU21' C 92260 •
JO�AdaITEaESS�7S.l AC'E� Sands P lace
a coMM �tr�Jrs�rwTE /zCA 92253
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TRACT NAME
OWNER NAME (L, F. MI) ,
COMM AtSTTO=MZppliCMt ,• .
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ADDRESS
CITY/COMMUNITY/STATE/ZIP '
P LOEO.6718
L.3SU813
ARC/ENG FIRM NAME
ADDRESS '
CITY/COMMUNITY/STATE/ZIP
PHONE M
LICNC••
US_FE 01>`RMLT System
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END
- SIDE
Print Applicant/Agent Name
APPL/PRMT n o ! 7w . DATE Plumbi ntj
Pewit to install septic system as per
approved plans and applicable codes and
ordinances,
1
TOTAL :$�
FEE .
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�}.51500.00
• VALUATION
BLDG. DEPT.
NO.
OPERATION DATE
INSPECTOR
NO. OPERATION DATE INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
1
Set Back
33 Ventilation System
2
Ftgs & Frms
34 Plenums & Ducts
2A
Slab Grade
35 Furnace Compart.
3
Steel
36 Inlets & Outlets °
4
Grout Blocks
37 Combustion Air
5
Bond Beams
38 Compressor
6
Roof. Deck
39 Appl. Clearance
7
Framing
40 Fire Damper
8
Vents
41 Smoke Detection Device
9
Garage Fire Wall
42 Commercial Hood
10
Fireplace P. L.
❑
43 Final
10A
fireplace T.O.
❑
NON ADDITIONAL INFORMATION
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SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
12 Internal Lath
12A Drywall
13 Finish Grade
INSULATION Thick R
Value
7A Walls (Batts)
128 Ceiling (Batts)
12C Ceiling (Blown)
14 Final
PLUMBING APPROVALS
15 Ground Plumb
16 Water Piping
17 Rough Plumb
18 Vents
19 Sewage Disposal
20 Sewer
21 Water Heater
22 Water Softener
23 Water Service
24 Gas Test
25 Final
Tank Pit L. Line
ELECTRIC APPROVALS
REAR OF PROPERTY LINE
p�L P)
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final
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is Vi -t! ID FO YE
O:YE (1) AR
FROM DATE OF APPRO111.
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1�/vc1,�IDIVk- ON IOF ENVIRONMENTAL
XScwaoe Disposal
Food Establishment r-�Gcl. c--ptic Tank(tooc 6,1-1
Trailer Park Sq. FF�y9f Leach LLinc
Motel, Apt Hotel
: 3 /�D/L�. M4k. 4D� x J&? Seepage Pit
Dwelling Conncc?.icn to Sewer
Commercial Building
Swimming PCol
` -_ .. _-ft-:• •_ -_ into '.�;c individual sewage
1 .1t `, -r :nn c'_v: cs r..=; be cib nA. _ ad
No en -site rcg�r. l•_;;a;ity ' dial Boa u.
.-..1 : I. ; i °....:• otn ti.2 \•'J.'.er L
system I :re•.:i:. r: :. :.:; .:^r:rv..: s_ 4�.
Vdat r su :.! s : 9j0,f ' eni' ' r ifor•,i Plumbing C.`,'
All se _ _ ;C:.._rm c::;h raqu:ral _^.:S'.. I.
�, of f: ur (4) f --et \Yil: f/ :'�; -gc dispcszl approval.
An; cue. •• "' ;;;�i Board for instal'.ation of i''
Rcc.:onal Watcr Quality Cc.
'hpp:ovat n1' the:: l:•t;:rsby the L'ep::r:mc "utrLo
ilea!ih of Ri-,csille County does not relieve'w.
ger or Architc-ct of the responsibility for thO L•8int"'
tue or Architectural desim"
ane C.
i5 is is c-:'tt:y t:••. -.t tf;e (:iversi e
C.::nty Department of
ila'.i.n tn•z ilem(s) chcck_d zbcvc.
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Iblic Health �p oves for occupancy, n;sru
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Receipt No., A 6 Q/ / tU
District: Riverside ❑ Indio ❑""-- Hemet ❑
DISTRIBUTION: WHITE - Office File YELLOW - Applicant
DOH SAN 122 (Rev 10/84)
Issued By
Date
/ -- 2 3-6 1
PINK - Building Dept. GOLDENROD - Pending File
COUNTY OF RIVERSIDE, 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.
t('-'
Name k
Mailing Address
City
State
Zip Code
Phone
*Propert/ty�Addd�reess C1 . t%�%�
;City7or Comm/unity
/
'Legal Description of Property (Lot, Parcel Map, Tract)
// 2
, T Kt�h /1Cu�t�`/r .
// (C� ,, . y'
A( � fid �S L'� L/O
'Assessors Parcel No.
6 -o63- v/9
Water Serving Property From
!1
Lot size
f7
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 El
Soils feasibility report required Yes ❑ No ❑►
Detailed boring report required Yes ❑ No ED
Detailed contour plot required Yes ❑ No ED
Comments:
i�
J t ``� �`���` 't`���� Date
Soils or -boring report by -
Approved by ! `� Date
' 1 �
Soils Map Page Soil Type Tract File No.Other
Number of Bedrooms
Septic Tank Size (gallons)
/► p t f
6604
Rate Required
,
3 �r �'
Type of System
New Addition Replacement
�j %'i�l;Y
flf C/ .. `.% � !
. 1i? 7 d'1 "r
7
❑ ®,./�� ❑
Leach line sq. ft. of bottom area trench ✓ I 1 ' " '
Leach bed (sq.'ft. of bottom area bed)
Seepage Pit Diameter(
5_M O 6 r a
Number of Pits �C'�/ r,?yam/FJ
y 1 /
Seepage Pit jDepth
��1B.I:
tr 7 ( ^ -c .�i CcJ.lty'
Total Depth of Pit �
Location of System ;
Additional Requirements f/ r'i'Uit `/•/��h .���,j"(j. /./,'t—t' �. Q.. u' GC'L�', �°
A permit is approved%denieciyfor 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.
Signature of Health Official l Date
Receipt No., A 6 Q/ / tU
District: Riverside ❑ Indio ❑""-- Hemet ❑
DISTRIBUTION: WHITE - Office File YELLOW - Applicant
DOH SAN 122 (Rev 10/84)
Issued By
Date
/ -- 2 3-6 1
PINK - Building Dept. GOLDENROD - Pending File