0771 (PLBG)PERMIT APPLICATION
City of La Duinta
Department of Building and Safety -
This permit becomes void it work not commenced within 180 days from date of issuance. OR, if work has been suspended or abandoned for a period'of'180 days.. a:•
ADDRESS
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed if
LICENSED .CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9
the permit is for one hundred ($100)•o; less. l certify that in the'pertormance 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 mannerso asto become subject to the Workers'CompensationLaws of
and effect.
California.
License Class -Lic. Number
Date Applicant
Date Contractor.
NOTICE -TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers' '.
OWNER -BUILDER DECLARATION: .I herebyaflirm.that I 'am exempi from the Contractor's License Law for the.
Compensation, provisions of the Labor Cade, you must forthwith comply.with such provisions or this permit shall
be deemed redoked.,
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
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
such permit to file asignedstatement that he,islicensed pursuanttotheprovisionsofthe Contractor's License Law
p 1hereby certify that noexcavation five (5)ormore feet indepth into which aperson isrequired todescend, 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
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 than'five hundred dollars (55011.):
C:A:`C)'
❑ Las owner of the property, or my employees with wages as their sole compensation, will do the work: and the
'❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division 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 -
CITY/COMMUNITY/STATE/ZIP ••
' through his own employees. provided that such improvements are not intended or offered for sale. If, however, the
O.Division of Industrial Safety Permit No.
.,building orimprovemntissoldwithinoneyearofcompletion,theowner-builderwillhavetheburdenofprovingthat
Date Applicant
he did not build or improve for the purpose of sale.).
CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance
a 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.).' • . . .
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
I am'ex��e•rnpt under Seo. f f � 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
/
�ia.-/��i f� - �'.• moi'.``_ Mr. yj',�j"j�.y.,;,�
Date �' Owners' g
city and county ordinances and state laws relating to building construction, and hereby authorize representatives
' V ' ✓
of this county to enter upon the above-mentioned property for inspection purposes.
WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have abertificate of consent to self -insure, or a
END, '
'certificate of Workers' Compensation Insurance , or a certified copy'lhereof (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
❑ Certified copy is hereby furnished. i.
the information given is correct. I -agree to comply with all state laws and county ordinances relating to buidling
O Certified'copy'is filed with the City Building Inspection Department or City Department.
construction, and authorize a'rgpresentative•of the City of La Ouinta Department of Building and Safety to enter. '
upon the property for which I have applied for this permii for the purpose of making inspections. .
Date Applicant
Signature of Applicant or Agent Date
APPLIC/�'�F, MI) �
ADDRESS
CITY/COMMUNITY/STATE/ZIP
44 (�)WA17A
JOB SITE AOORESS/SPACE '
CITY/COMMUNITY/STATE/ZIP • i. -
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LOT
" TOTAL'
FEE
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TRACT NAME
OWNER NAME (L. F, MI ..
CONTRACTOR -FIRM NAME ..
ADDRESS
.CITY/COMMUNITY/STATE/ZIP -
PHONE •
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.
ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP ••
PHONE II
UCNC 11
USE OF PERMIT
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END, '
SIDE
Print Applicant/Agent Name
APPL/PRMT� � 71 OA
,017- XtS
IPIAIAW41101 FSE /v ora
" TOTAL'
FEE
VALUATION /lOD
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.
❑
NPON
ADDITIONAL INFORMATION
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
t2 Internal Lath
12A Drywall
13 Finish Grade
INSULATION Thick R
Value
7A Walls (Batts)
12B 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
PI PiI
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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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
Mailing Address
( /�
L.� 1 A %0 i2 .� - i C� ��
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City
State
Zip Code
Phone
��
%�
- ->
'Property Address `
=City or Eol: munity
'Legal Description of Property (.Lot, Parcel Map, Tract),�,,O // -40,4 k
SA'Nrrf•(4r44A V2rxl 1AUv, jr4
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'Assessors Parcel No.
Water Serving Property From Lot size
Sigiature of Applicant
'The above information must be verified from Building Application
Sta`f Use — Do Not Write Below This Line
Initial Date
WQCB Clearance required Yes ❑ No ❑��
Soils feasibility report required, Yes El., No Eb
Detailed boring report required Yes ❑ No
Detailed contour plot required Yes ❑ No
Comments:
Soils or boring report by el--,_ Date
Approved by "rI i �► �,f�Date
Soils Map Page Soil Type ` Tract File No. (=..• �Qe+-^Gther
Number of Bedrooms
i e �� n
Septic Tank Size (gallons)
[��•�S�
Rate Required
C`. G��
Type of System
New Addition Replacement,
r
El
Leach line sq. ft. of bottom area trench
Leach bed (sq. ft/of'bottom area bed)
Seepage Pit Diameter
Number of Pits
ge.Pit
SeepaDepth B.I.
Total Depth of Pit
Location of System
Additio'lRequirements ' �, G �^,� �G• �.��a-+ -2
A permit is-approved/tde.fed forthe 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'syste^m.i,
Signature of Health Official Date
Receipt No. T/
1� /
Issued By
District: Riverside ❑
Indio ❑�
Hemet ❑ Date
DISTRIBUTION: WHITE - Office File YELLOW - Applicant PINK - Building Dept. GOLDENROD - Pending File
DOH SAN 122 (Rev 10/82)