06103 (PLBG)I ,
4
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P.O. BOX 1504 No. 06103
Building 78-105 CALLE ESTADO
Address 51-820 Juarez LA QUINTA, CALIFORNIA 92253
Owner
Mailing'
Moafric Inc. BUILDING: TYPE CONST. OCC: GRP.
Address Same �" A.P. Number 773-155-003
CityZip Tel.
-La Quints 92253 +328-17$7 Legal Description
Contractor
Project Description seCvc1izt! nJI.$
Ttcndr ckson Con€itruetion Inc.
Address
618--.31,5 Kieley Road
City Zip Tel.'•
Cathedral Citi 92234 328--1447
State Lic. City
& Classif. Lic. # i � Sq. Ft. No. No. Dw.
�5�i$4
Arch., Engr., Size Stories Units
Designer New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
Address Tel.
City Zip State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
70pp) of Division 3 of the Business and Professions Code, and my license is in full force and
effect
SIGNATURE DATE
OWNER -BUILDER DECLARATION Estimated Valuation I hereby affirm that I am exempt from the Contractor's License Law for the following $2100101
reason: (Sec. 7031.5,13ushess and Professions Code: Any city or county which requires a
permit to construct, after, irprove, 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 PERMIT AMOUNT
the provisions of the Contractor's License Law, Chapter 9 (commencing with Section 7000) o/
Division 3 of the INisness and Professions Code, or that. he Is exempt therefrom, and the basis
for the alleged exemption. Any vi datiar of Section .7031.5 by 'any applicant for a permit Plan Chk. Dep.
subjects the appicant,to a civilpenally of not more than Fire hundred dollars ($500).
❑ I, as owner of the property, or my employees with wages as their sole compensation, will Plan Chk. Bal:
do the work, and the structure is not intended or offered for sale. (Sec. 7044, Buisness and COnSt
Professions Code: The Contractor's License Law does n.ot apply to an owner of property who (�
builds or knproves thereon and who does such work himself or through his own employees, Mech.
provided that such irprovements are not intended or offered for sale. If, however, the building
or Improvement is sold within one year of completion, the owner -builder will have the burden Electrical
of provng that he did not build or reprove for the purpose of sale.)
❑ 'I, as owner of the property, am exclusively contracting with licensed contractors to torr Plumbing
Strutt 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 S. M. j, `�
such pro#ects with a contractor(s) 8censed pursuant to the Contractor's License Law.)
Grading
11I am exempt under Sec. w- 8 P.C. for this reason
Driveway Enc.
Date Owner Infrastructure
WORKERS COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -insure, or a certificate of
Workers Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy No. Comfy
0, Copy is filed with the city. ❑ Certified copy is hereby furnished.
TOTAL
CERTIFICATE OF EXEMPTION FROM REMARKSren F -rct4
WORKERS' COMPENSATION INSURANCE
(This section need not be completed ff the permit is for one hundred dollars (5100) valuation tfV �!,tf Pit,
or less.)
I certify that in the performance of thip 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
Date Owner
NOTICE TO APPLICANT: ft, after making this Certificate of Exemption you should become ZONE: BY:
sutpect to the Workers' Compensation provisions of the Labor Code, you must forthwith
comply with such provsiorsorMPermit shall bedeemed revoked. Minimum Setback Distances:
Front Setback from Center Line
Rear Setback from Rear Prop. Line
CONSTRUCTION LENDING AGENCY Side Street Setback from Center Line
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.) Side Setback from Property Line
Lendees. Name
Lender's Address
This is a building permit when properly filled out, signed and validated, and is subject to FINAL DATE INSPECTOR
expiration if work thereunder is suspended for 180 days. - 7120/89
1 car ity that I have read this application and state that the above information is correct. - Issued by: Date Permit
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.
Validated by:
Signature of applicant Date
Mailing Address r Validation:
City, State, Zip
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL SQ. FT. ® $
UNITS
SLAB GRADE
ROUGH PLUMB.
BONDING
YARD SPKLR SYSTEM
2ND FL SQ. FT.
FORMSWER
OR SEPTIC,
ROUGH WIRING
MOBILEHOME SVC.
BAR SINK
POR. SQ. FT. ®
GAS (ROUGH)
METER LOOP
GAR. SO. FT. ®
POWER OUTLET
ROOF DRAINS
GAS (FINAL)
TEMP. POLE
DRAINAGE PIPING
CAR P. SQ. FT. @
GROUT
WATER HEATER
WALL SQ. FT.
FINAL INSP.
DRINKING FOUNTAIN
SO FT ®
WATER SYSTEM
URINAL
ESTIMATED CONSTRUCTION VALUATION $
=$
WATER PIPING
NOTE: Not to be used as property tax valuation
FINAL INSP.
FLOOR DRAIN
MECHANICAL FEES
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTONDISH)
APPLIANCE DRYER
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
VENTILATION
LAUNDRYTRAY
AIR HANDLING UNIT CFM
FIRE ZONE ROOFING
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.
SQ. FT. ® c
BATH TUB
LATHING
SQ. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SQ. FT. RESID ® 1% c
SEWAGE DISPOSAL
SQ.FT.GAR ® V4c
HOUSE SEWER
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
FORMSWER
OR SEPTIC,
ROUGH WIRING
DUCTWORK
ROCK STORAGE
FOUND. REINF.
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APPJEQUIP.
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.
ROOFING
A41/
Q� /
KI'
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATIONISOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESlINRIALS
GARDEN WALL FINAL
1
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RECEIPT NO. hr( 3 i Issued By Date—
DISTRICT:
ate DISTRICT: ❑ -_Riverside;" io ❑ Hemet q Perris ❑ Rancho Calif. ❑ Blythe
DOH SAN 122 (Rev. 5/88) DISTRIBUTION: WHITE - Office file YELLOW - Applicant PINK - Bldg. Dept GOLDENROD - Plans/Records
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COUNTY OF RIVERSIDE DEPARTMENT OF HEALTH A'°"Or° �' 110
ENVIRONMENTAL HEALTH SERVICES 773 - ls-r - D03 -
PERMIT APPLICATION FOR A SUBSURFACE SEWAGE DISP SYSTEM
Applicant: Submit this form with four copies of a scaled plot plan (1-2) scale) d o County speculations as indicated on the attached check list
A non-refundable filing fee (see below) is required when the appli on is submitted. Check must be made payable to the County of
Riverside. Approval of this application shall remain valid for a pe ' • not to exceed one year from date of approval.
Q
VERIFY ITEMS IN SECTION A FROM BUILDING & SAFETY APPLICATION BU ING DEPARTMENT APPLICATION LOG'*
Z
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t, Contractor, Contact Person /} Phone kn Address & Phone
WOwner
to
Phone' Mailing Address
TV
V3 wG 9 U.o vt �►
City
State
Zip pe Description Prop. (PM, Tractt Lot)
Lot Size
Water Agent , .
Use of P/P, CU, etc. ----o 0—" 006her Sa _'j
15-0 (R i 00
^
1. iQ j , W
A JG j.Q <.d J r. /er L�<ls�. J �/�
welling, H Site rep, etc. c a "",`
� FX,ft
1Z2,,IA9
Signature of Applicant
Date
/ CATEGORY: REV CODE FEE
CATEGORY: REV CODE FEE
011SUBSURFACE DISPOSAL 1238$45.00
❑ SITE EVALUATION UPON REQUEST 7349 $42.00
C0
❑ MULTIPLE PARCELS WITHIN SAME
(NO PLOT PLAN)
Z
LAND DIVISION
❑ SEWER/SEPTIC VERIFICATION 7348 $11.00
Q
a. 1 at 4 Parcels (Each) 1238 $45.00
(Less than 1 year)
H
b. Each Parcel after 4 7344 $16.00
❑ PRELIMINARY ELECTIVE 7352 $45.00
W
❑ Rereview (2nd review same parcel) 7344 $16.00
EVALUATION (Attach DOH SAN 53)
CO)
❑ Site Evaluation In Conjunction with
❑ HOLDING TANK 7351 $45.00
Critical Area 7346 $86.00
❑ ALTERNATIVE/EXPERIMENTAL 7345 $13200
❑ Site Evaluation Lot Less than
SYSTEM
10,000 Sq. Ft. 7347 $86.00
DATE
/I)[�,IT-IAjL
Holding Tank Agreements Completed ❑Yes N lu
VNo
Certification of Existing S.D. System Required ❑ Yes 1
WQCB Clearance required. (Attach Form ❑ Yes RrNo
DOH SAN 007, Santa Ana Region Only)
Soils Percolation Report Required. ❑ Yes
Special Feasibility Boring Report Required. ❑ Yes
Detailed Contour Plot Plans Required (1 to 5. it interval) ❑ Yes No
Other ❑ Yes¢/No
Staff Specialist Lot Inspection Required
❑ Yes IdNo
Lot Inspection Date
Soils boring report by Project # Date
//
Soils Map Page C-. " �''
Sol Type Approved by Date
rt
U
Pio. of Systems
T r of Systems)
No. Dwelling Uniti (I�
(1) Septic Tank
Soil Rate
Grease/Sand
O
EX r Ir
O Holding Tank O Exfati
Replacement
Bedrooms.+510 mA
x�f
Er'
Gre aA,latCp
Fxicr.(?A04,".MAn
(0
d•3 %q
�acT� Da,e+
d
sly
LU
2) Leech Line Sq. FL
Sidewall allowance1
/%
rrstalh-.�_�Line(s) it long ft wide with
Leach Bed aq. it
trench area
fl. rock/ sq. R
min. inches- drelnlhres or
"!bf;bo_ltomm area
per running ft
Leachlines/bed special design for slope:
Applicable
(3) Pit Diameter
No. Pits
Pit Below
Inlet (BI)
Seepage Pit Total Depth
' ow )?><
Max. Allowable�Depih
8 r
N/A Overburden factor
�((I
No. 2 System N /xI.
REMARKS:
O - Y 3 p✓_e". �%,.5� r ..�• _E�(:_f� r� � J.. i +... .t.�' � :� i ...!
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This application is APPROVED • EtsitED:for the category checked in SECTION B above, regarding the design of a subsurface disposal system as indicated
0
on the accompan' p o pan, using the requirements set forth in SECTION C above. A building permit is necessary for the installation of the
0
above -designed system. No construction is permitted in the required reserved 100% expansion area.
Septic tank and sewer lines must be 50' minimum from any wells
U
Leach lines must be 100' minimum from any wells, including expansion area
(3 Seepage pits must be 1150'' minimum any wells, Including expansion area / iS��-z,, t'.�(�p,OC/C�J� ✓I^
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I ` -" i tet/- /�� 1l ` 1f&
Signature of Health Officiay � 2 - pate t
RECEIPT NO. hr( 3 i Issued By Date—
DISTRICT:
ate DISTRICT: ❑ -_Riverside;" io ❑ Hemet q Perris ❑ Rancho Calif. ❑ Blythe
DOH SAN 122 (Rev. 5/88) DISTRIBUTION: WHITE - Office file YELLOW - Applicant PINK - Bldg. Dept GOLDENROD - Plans/Records
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RIVERSIDE COUNTY DEPARTMENT OF PUBLIC HEALTH
DIVISION OF MNVIRONMENTAL HEALTH
F -Edablilftwd
ood 3mmMs Dl2;xsmI
TrailAw Park Exp G.el, ST.,ft- TW* (/000 C-4 1-,J
';q rt C.4 I -W �-!i L '.,g
Dwelling Ex :s- r. API) 'x 4 9Z p �
Cmumarcial Bulldir4j 0.rutLn to !:,w:r «zzC,
S*Wtwna Pcol
No w4ft topeeraft water WjWqh3 eaviin jr.— tn 12', 7-?t.j the
system borowO apc,-zjnd v.%hqt
C*.Vj,-tl
Water guoply r 7- (�c
All. avmo
Or rtY,.V 13•
Approval has bK-a ob4�4- ""n. "tt" W)W%� Ltww'.1 cl tho ;-v-
disposal opton
This Is to co"- thd ft MvavMq-Cvq%j 04mttL,
MAWr
ft 0 lfp4tl VGVC3 tcr vloww. -truccilc
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f FRO Ml- DATE A?FR0 *a Architedt of tM MM*rA"*- ' 901 t'O,LAfl��
.IN't)SIJUS E.J1.820 AVE'NIDA .:J 1.
N0 '773-155-003-1
PAR(I
AF31%IT' I`-JE3R 773155003-:1.
T134) 020-017
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