05794 (SFD)I
05794 P.O. BOX 1504 No.
Building 78-105 CALLE ESTADO
Address 53-600 iTE'"SCO LA QUINTA, CALIFORNIA 92253
Owner
DAVE GRIVIMT
Mailing TYPE CONST. OCC: GRP.
- ' � - ,�.
Address 43-675 CARMELA-P. Number
CIR= 77774-125—M
City Zip Tel.
-PALH DESERT 92260 345-5440 _ Legal Description LM 5
Contractor Project Description F. D.
D.G= t' NSTRUCTICNI
Address
SAME T
City Zip Tel:'
M r
State Lic. City
& Classif. 317340 Lic. #655 Sq. Ft. 1570 No. No. Dw.
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 atm licensed under provisions of Chapter 9 (commencing with Section
7000) of Division 3 of the Business and Professions Code,and my license is in full force and
effect. i !' 1.
SIGNATURE - DATE
OWNER -BUILDER DECLARATION Estimated Valuation 3
I hereby affirm that I am exempt from the Contractor's License Law for the following $ *3 R • �Q
reason: (Sec. 7031.5,Business and Professions Code: Any City or county which requires a
permit to construct, after, improve, demolish, or repair any structure, prior to its issuance also AMOUNT
requires the applicant for such permit to fife a signed statement that he is licensed pursuant to PERMIT
the provisions or 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
for the alleged exemption. Any violation of Section 7031.5 by -any applicant for a permit Plan Chk. Dep. •
subjects the applicant to a civil penalty of not more than five hundred dollars ($500)-
0 I, as owner of the property, or my employees with wages as their sole compensation, will Plan Chk. Bal. 242.24
do the work, and the structure is not intended or offered for sale. (Sec. 7044, Buisness and Const. .±1 . U
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, Mech. •-X)
provided that such Improvements are not intended or offered for sale. 11, however, the building
or improvement is sold within one year of completion, the owner -builder will have the burden Electrical -2.0.5
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- Plumbing 1-54.50
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 S -M.1. 1 Z • 15
such projects with a contractor(s) licensed pursuant to the Contractor's License Law.)
Grading ZLi• lyi
O I am exempt under Sec B. & P.C. for this reason
Driveway Enc. 2t *00
Date Owner Infrastructure s�
ki 6f3 tl AN 25. UV
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I 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
❑ Copy is filed with the city- ❑ Certified copy is hereby furnished.
TOTAL
CERTIFICATE OF EXEMPTION FROM REMARKS
WORKERS' COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars (S 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
Date Owner
NOTICE TO APPLICANT: ff, after making this Certificate of Exemption you should become ZONE: BY:
subject to the Workers' Compensation provisions of the labor code, you must forthwith Minimum Setback Distances:
comply with such provisions or this permit shall be deemed revoked.
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
Lender's Name
Lender's Address FINAL DATE INSPECTOR
This is a building permit when properly filled out, signed and validated, and is subject to
expiration if work thereunder is suspended for 180 days. a /19/80+
1 certify that I have read this application and state that the above information is correct- Issued by: Date J!yPermit
I 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 Validation:
City, State, Zip
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL. SQ. FT. ® $
UNITS
COLL. AREA
r4ffGRAD
YARD SPKLR SYSTEM
2ND FL SQ. Fr.
HEATING (ROUGH)
STORAGE TANK
FORMS IF
MOBILEHOME SVC.
BAR SINK
FOR. SQ. FT. ®
DUCT WORK
ROCK STORAGE
FOUND. REI 1/L
POWER OUTLET
ROOF DRAINS
GAR. SQ. FT. ®
HEATING (FINAL)
OTHER APPJEQUIP.
REINF. STEEL
DRAINAGE PIPING
CAR P. SQ. FT. @
WALL SQ. FT.
DRINKING FOUNTAIN.
SERVICE
FINAL INSP.
URINAL
SQ FT ®
7/4
WATER SYSTEM
ESTIMATED CONSTRUCTION VALUATION $
GRADING
Cu. yd.
$ plus x$
WATER PIPING
NOTE: Not to be used as property tax valuation
FLOOR DRAIN
MECHANICAL FEES
FINAL INSP.
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL \ HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
LAUNDRY TRAY
AIR HANDLING UNIT CFM
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
SQ. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID ® 1 Vi c
SEWAGE DISPOSAL
SQ.FT.GAR ® 3/ac
HOUSE SEWER
INSULATION/SOON ` U-1
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
ROUND PLU I
UNDERGROUND
A.C. UNIT
COLL. AREA
r4ffGRAD
ROUGH PLUMB.
BONDING
HEATING (ROUGH)
STORAGE TANK
FORMS IF
SEWER OR SEPTIC TANK
ROUGH WIRING
DUCT WORK
ROCK STORAGE
FOUND. REI 1/L
/
�o
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APPJEQUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
4�OND BEAM
7/4
WATER SYSTEM
GRADING
Cu. yd.
$ plus x$
_$
LUMBER GR.
FINAL INSP.
MING '
FINAL INSP.
ROOFING YI
[
p
REMARKS:
VENTILATION
FIRE ZONE ROOFING -
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATION/SOON ` U-1
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURES/INITIALS
GARDEN WALL FINAL
C
If
m
Z
O
W
'A
Z
C
U
W
0
i
COUNTY OF RIVERSIDE DEPARTMENT OF HEALTH Assessors Parcel No.
ENVIRONMENTAL HEALTH SERVICES
PERMIT APPLICATION FOR A SUBSURFACE SEWAGE DISPOSAL SYSTEM
Applicant: Submit this form with four copies of a scaled plot plan (1-20 scale) drawn to County speculations as indicated on the attached check IisL
A non-refundable filing fee (see below) is required when the application is submitted. Cheri( must be made payable to the County of
Riverside. Approval of this application shall remain valid for a period not to exceed one year from date of approval.
VERIFY ITEMS IN SECTION A FROM BUILDING A SAFETY APPLICATION BUILDING DEPARTMENT APPLICATION LOG.*
Agent, Contractor, Contact Person
1I , U/'o.
Phone
3 ys-5f,(a
Address 8 Phone
F i d t,,1k-4 .e L (f let 4 e
.Owner y 1,
e
Mailing Address -
v i
�
City. y�
•'' l�Se�7
State
L �`
Zip
2�
Job Property Address A.
?4020
legal Description Prop. (PM, Tract Lot) eL/
2z M4 ,.
Lot'Size
ester Agent I-
Use of Permit P/P, CU, etc.Za
Other a Q
'
K10 (d'
�Dwelling, MH, e Prep,
etc
C#
Signature of Applicant
Data
CATEGORY: REV CODE FEE
CATEGORY:: REV CODE FEE.
E1" SUBSURFACE DISPOSALi 1236 $45.00
❑ SITE EVALUATION UPON REQUEST 7349 $42:00
❑ •MULTIPLE PARCELS WITHIN SAME
(NO PLOT PLAN)
LAND DIVISION
❑ SEWER/SEPTIC VERIFICATION „7348 $11.00
a. 1 at 4 Parcels (Each) 1238 $45.00
(Less than 1 year)
b. Each Parcel after 4 7344 $16.00
❑ PRELIMINARY ELECTIVE 7352 $45.00
,, ❑ Rereview (2nd review same parcel) .7344 $16.00
EVALUATION (Attach DOH SAN 53)
,%,o 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
� INITIAL DATEp
Holding Tank Agreements Completed. 13Yes p� l 7 a
Certification of Existing S.D. System Required ❑Yes No
WQCB Clearance required. (Attach Form 11 Yes
DOH SAN 007, Santa Ana Region Only)
Soils Percolation Report Required. i ❑ Yes,
/N�.
Special Feasibility Boring Report Required. ❑ Yes t� No
Detailed Contour Plot Plans Required (1 to 5 ft interval) ❑ Yes
/Np:
Odw ❑ Yes E
/No
Staff Specialist Lot Inspection Required ❑ Yes
1 1 Lot Inspection Date
Sills boring report by' l :4 Z Project # -,Date
Sills Map PageSoA Type Approved'Date<':5=/o O�
No. of Systems
Tily of Sywei")
No. Dwelling Units
(1) Septic Tank
Soil Rate
Gresse/Sand
F�ding Tank ❑ Existing
O Replacement
Bedrooms, F•ixpnile
6D&M . 444X
�y
"'°'Grease Intop
(2) Leach Line Sq. Ft
Sidewall allowance
InstallQ _ Lines) ft long It wide with x.
"LeachBed sq. ft.
irernctn area
ft rock/ sq. ft:
min. inches dreinlQnes or k
of area
b+.
�
per running R .
Leachlines%bed special design for slope:.
(3) Pit Diameter
No. Pita
Pit Below
Seepage PR Depth
V;Vr
Otho_ r.
Applicable
/
- /
,�
Inlet (7)'
I
Max. AI(p Is Depth
N/A Overburden factor
—.L—
i
r6
No. 2 System
REMARKS:a� r�
~ This appiicat' s AP O D Mfor the category checked in SECTION B above, regarding the design of a subsurface disposal system as indicated
on the accompan plot plan, •using' the requirements set forth in SECTION C above. A' building permit is necessary for the installation of the
above -designed system. No construction is permitted in. the. required reserved 100%' expansion area.
(1 Septic tank and sewer lines must be 50' minimum from any well �c
Leact lines must be 100' minimum from any wells, including expansion a i
(3) Seepage pits must be*150' minimum from any wells, including expansion areal /p
W
MW
Signature of Heafffi Official�s-�d O 1 Date
`SDC -.- _-.. .
to To ' Issued By ��--";
RECEIPT NO. Date
DISTRICT: ❑ Riverside, C1 -'I dio ❑ Hemet q Perris ❑ �'tancho Calif. - ❑ Blythe
DOH SAN 122 (Rev. 5/88) DISTRIBUTION: WHITE -'Office file YELLOW - Applicant PINK - Bldg. Dept GOLDENROD - Plans/Records
1)I I I1,E U�
AGRICUL I URAL C;UMM155K)l' t
AND
W1:1611 I S L'. MEASURES
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53-600 VELASCO
_ D.G. CONSTRUCTION
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