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06717 (BLCK)4 P.O. BOX 1504 N o . 06 717 Building a d 78-105 CALLE ESTADO Address 53-960 Velasco LA QUINTA, CALIFORNIA 92253 Owner rY'$ Mailing' BUILDING: TYPE CONST. OCC: GRP. ` Address A.P. Number 774-145-010 City Zip Tel. _ La QuInta 92253 iLegal.Description Contractor Project Description 3t X LSflI re-Lai1T% wall Jack Clark Jr. Address P. 0. Bos 1371 City Zip Tel.: La Quints 92253 State Lic. City & Classif. 506657 Lic. # Arch., Engr., Designer Address Tel. CityI Zip I State Lic. # LICENSED CONTRACTOR'S DECLARATION I hereby affimn that I am licensed under,provisions of Chapter 9 (commencing with Sectidn 7000) of Division,3yof the usiness and Professions Code, and my license is in fulltforce and effect .... 7�f (VirCdr l't f Lr 4 :e SIGNATURE V DATE OWNE&BUILDER DECLARATION I hereby affirm that I am exempt from the Contractors License Law for the following reason: (Sec.. 7031.5,Bustness and Professions Code: Anycity or county which requires a permit to construct, after, improve, demolish, or repair any structure, prior to its issuance also requires the applicant for such PenmT to Ice a signed statement that he is licensed pursuant to the provisions of 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 viotaWn of Section 7031.5 by Any applicant for a permit subjects the applicant to a civil penalty of not more than five hundred dollars (E500). ❑ 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, Buisness and 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, provided that such improvements aro not intended or offered for safe. If, however, the building or improvement is sold within one year of completion, the owner -boder will have the burden 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- struct the project. (Sec. 7044, Business and Professions Code: The Contractors License Law does not apply to an owner of property who builds or improves thereon, and who contracts for such projects with a contractor(s) licensed pursuant to the Contractors License Law.) - O 1 am exempt under Sec. B. & P.C. for this reason Date Owner WORKERS' COMPENSATION DECLARATION I hereby affirm that 1 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. Company ❑ Copy is filed with the city. O Certified copy is hereby furnished. CERTIFICATE OF EXEMPTION FROM WORKERS COMPENSATION INSURANCE (This section need not be completed d the pemvt is for one hundred dollars (E100) valuation 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: H. after malting IMs Certificate of Exemption you should become subject to the Workers' Compensation provisiow of the Labor Code, you must forthwith comply with such provisions or this pemrtl shag be deemed revoked. CONSTRUCTION LENDING AGENCY Ihereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued. (Sec. 3097, Civil Code.) Lenders Name Lenders Address This is a building ly filled permit when property out, signed and validated, and is subject to expiration if work thereunder is suspended for 180 days. I certify that 1 have read this application and state that the above information is correct. 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 p . Signature of applicant Date M(iling Address City,State, Zip FINAL DATE INSPECTOR Issued by:Date12%6/`69 Permit Validated by: Validation: Sq. Ft. Size No. No. Dw. Stories Units New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑ Estimated Valuation PERMIT w AMOUNT Plan Chk. Dep. Plan Chk. Bal. Const: $54.00 Mech. Electrical Plumbing S.M.I. .21 Grading Driveway Enc. Infrastructure TOTAL REMARKS p g y { ZONE: BY: Minimum Setback Distances: Front Setback from Center Line Rear Setback from Rear Prop. Line Side Street Setback from Center Line Side Setback from Property Line FINAL DATE INSPECTOR Issued by:Date12%6/`69 Permit Validated by: Validation: CONSTRUCTION ESTIMATE NO. ELECTRICAL FEES NO. PLUMBING FEES 1ST FL. SQ. FT. ® $ UNITS COLL. AREA SLAB GRADE ROUGH PLUMB. YARD SPKLR SYSTEM 2ND FL. SQ. FT. @ HEATING (ROUGH) STORAGE TANK FORMS MOBILEHOME SVC. BAR SINK POR. $Q. FT. ® DUCT WORK ROCK STORAGE FOUND. REINF. POWER OUTLET ROOF DRAINS GAR. SQ. FT. ® HEATING (FINAL) OTHER APPJEQUIP. REINF. STEEL GAS (FINAL) DRAINAGE PIPING CARP. SQ. FT. ® WALL SQ. FT. WATER HEATER DRINKING FOUNTAIN. SERVICE FINAL INSP. URINAL SQ FT ® WATER SYSTEM ESTIMATED CONSTRUCTION VALUATION E GRADING cu. yd. $ plus xS 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(AUTOXDISH) APPLIANCE DRYER REMARKS: 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. SQ. FT. ® c BATH TUB SO. FT. ® c WATER HEATER MAX. HEATER OUTPUT, B.T.U. SO. FT. RESID ® 1+/4 c SEWAGE DISPOSAL MESH SQ.FT.GAR ® 3/4c HOUSE SEWER INSULATIONISOUND 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 FORMS SEWER OR SEPTIC TANK ROUGH WIRING DUCT WORK 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 xS =E LUMBER GR. FINAL INSP. FRAMING FINAL INSP. ROOFING C v�� //%� REMARKS: VENTILATION FIRE ZONE ROOFING ' FIREPLACE SPARK ARRESTOR GAR. FIREWALL LATHING MESH INSULATIONISOUND FINISH GRADING FINAL INSPECTION CERT. OCC. FENCE FINAL INSPECTOR'S SIGNATURESIINITIALS GARDEN WALL FINAL l 4 Y �z�P.O. BOX 1504 'APPLICATION ONLY Building { [ 78-105 CALLE ESTADO . Address Jr�'� �� 4 d •5 G v LA QUINTA, CALIFORNIA 922.,F 3 ,.. _. Owner _ 6 BUILDING: TYPE CONST. _: OCC_GRP. Mailing Address S (O �-0 w ¢-, \-i"1 �-l� , t A.P. Number -7 `"� ;- S C) C City Zip Tel. _ / 9p/� t�`C` Ci LZ(� D -7 -1 3 - -7 6. C Legal Description �v �. - CA1 2-3 5 2 z Contractor Project Description �- 1A6L LA IL J0 Address f -� 0 -3r?X t 37 Y CIZA Owl Al -fA ZIpq��3 Tel.�� State Lic.. City — & , _ & Classif. Lic. # Sq. Ft./_3�F� No. No. Dw. ' Size fCJ Stories Units Arch., Engr., Designer New Add ❑ Alter ❑ Repair ❑ Demolition ❑ Address Tel. City Zip State Lic. # _ • LICENSED CONTRACTOR'S D CLARATION' - I hereb, ffirm that I am li ens under provision ter 9 (commencing with Section ef000) of i 'sion 3 the �si an Pr�fessions%C c and my license is it I ani, SIGNA R (�� / DAT �" OWNER -BUILDER DECLARATION - Estimated ValuationI hereby affirm that 1 am exempt from the Contractor's License Law for the following 20 Z reason: (Sec. 7031:5,Business and Professions -Code: Any city or county which requires a Permit to -construct, atter, improve, demolish, or repair any • structure, prior to - its issuance also.. requires the applicant for such pem78 to fde a signed statement that he is licensed pursuant -to— PERMIT=-- - - - - AMOUNT- _ the provisions o/ the Contractor's License Law, Chapter 9 (commencing with Section 7000) of Division 3 o/ 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 o/not more than five Hundred dollars ($500). - ❑ 1, as owner of the property, or my employees with wages as their sole compensation, will Plan Chk. Bal. Z. p ` do the work, and the structure is not intended or offered for sale. (Sec. 7044, Buisness and CiOr1St. ' Professions Code:'The Contractor's License Law does not apply to an owner o/ property who ` 4L'-' •y -builds or improves thereon and who does such -work himself or through his own employees, Mech. - - 7 _ J�` v provided that such improvements are not intended or offered for sale. If, however, the building -'f or improvement is sold within one year of completion, the owner -builder will have the burden Electrical - of proving that he did-notbuild or improve. for. the purpose, of sale.)- ❑ 1, as owner of the property, am exclusively contracting with licensed contractors to con. Plumbing .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.I. ' - "" - ''-3- such projects with a contractor(s) licensed pursuant to the Contractor's License Law.) - - 'Grading O 1 am exempt under Sec. R. & P.C. for this ieason. Driveway Enc. Date Owner I�Inff rastructure _ WORKERS' COMPENSATION DECLARATION -I hereby affirm that 'I,have a certificate of consent,to.self-insure;, or.a-certificate of-. .y s r.,- . t ,� Worker's Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.) r `+ ... Policy No. - Company" ❑ Copy is filed with the city: ---0 Certified copy is hereby furnished. - c TOTAL 7 > o a CERTIFICATE OF EXEMPTION FROM REMARKS WORKERS' COMPENSATION INSURANCE �. V (This section need not be" completed if the - permit is for one hundred dollars ($100) valuation UVJ 1 if::.. 7.•U YY l Y 3 1 ' b'ti or less.) �. 1 certify that in the performance of the work for which this permit is issued, I shall not employ any person in any mannerso as to beco a subject to tWorkers' Compensation Laws of California. i �. 1 V - Date I ( Ii � Owner � "'/C'"�Xii i/LJ 1'N'� NOTICE TO APPLICANT:'If, after making this Certfflcate d 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 r Side Street Setback from Center Line Ihereby 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 Lenders 'Name lr - .� L.-L� 5 A,)div Gi &P—K, - Lender's Address I Q!S r -t -c -V' S'l LA -)-o t--021 ° 7 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. I certify that I have read this application and state that the above information is correct. Issued by: Date Permit 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 applican /G �U� Date (t b �� Mailing Address t o G Le rn1 / h I I hno. Validation: City, State, zip BUILDING DIVISION CONSTRUCTION ESTIMATE GROUND PLUMBING NO. ELECTRICAL FEES NO. PLUMBING FEES IST FL. SQ. FT. ® $ 74. UNITS BONDING HEATING (ROUGH) STORAGE TANK FORMS YARD SPKLR SYSTE . 2ND FL. SO. FT. DUCT WORK ROCK STORAGE FOUND. REINF. GAS (ROUGH) 1577 60 MOBILEHOME SVC. BAR 'NK POR. SQ. FT. ® Zv -7 Z 6 % POWER OUTLET ROOF DRAIN$ GAR.. SO. FT. ® GROUT WATER HEATER SERVICE FINAL INSP. BOND BEAM DRAINAGE PIPING CAR P. SQ. FT. ® GRADING cu. yd. $ plus x$ =$ LUMBER GR. WALL SQ. FT. ® V FRAMING DRINKING FOUNTAIN ROOFING URINAL SQ. FT. ® REMARKS: ESTIMATED CONSTRUCTION VALUATION $ VENTILATION WATER PIPING NOTE: Not to be used as property tax valuation FLOOR DRAIN MECHANICAL FEES WATER SOFTENER VENT SYSTEM FAN EVAP.000L HOOD SIGN WASHER(AUTO)(DISH) APPLIANCE DRYER LATHING GARBAGE DISPOSAL FURNACE UNIT WALL FLOOR SUSPENDED LAUNDRY TRAY AIR HANDLING UNIT CFM INSULATION/SOUND KITCHEN SINK ABSORPTION SYSTEM. B.T.U. FINISH GRADING TEMP USE PERMIT SVC WATER CLOSET COMPRESSOR HP POLE, TEM/PERM LAVATORY HEATING SYSTEM FORCED GRAVITY CERT. OCC. AMPERES SERV ENT SHOWER BOILER B.T.U. SO. FT. ® c BATH TUB SQ. FT. ®c WATER HEATER MAX. HEATER OUTPUT, B.T.U. SQ. FT. RESID ®1+/. c S-7 ZZ SEWAGE DISPOSAL SO.FT.GAR ® 3/ac I� 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 FORMS SEWER OR SEPTIC TANK ROUGH WIRING DUCT WORK 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 REMARKS: VENTILATION FIRE ZONE ROOFING FIREPLACE SPARK ARRESTOR GAR. FIREWALL LATHING MESH INSULATION/SOUND FINISH GRADING FINAL INSPECTION CERT. OCC. FENCE FINAL INSPECTOR'S SIGNATURESIINITIALS GARDEN WALL FINAL v RECEIPT NO. 4 / 6 / f Issued By / Date DISTRICT: ❑ Riverside, © Indio ❑ Hemet q Perris ❑ Rancho Calif. ❑ Blythe DOH -SAN -122 (Rev. 7/89) DISTRIBUTION: WHITE - Office file YELLOW - Applicant PINK - Bldg. Dept GOLDENROD - Plans/Records r'�F A. COUNTY OF RIVERSIDE ENVIRONMENTAL Aft"em PartoM Nm k-7 HEALTH SERVICES DIVISION — 1&5 — o)a .S— ,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. Check 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. Q / }� VERIFY ITEMS IN SECTION A FROM BUILDING & SAFETY APPLICATION BUILDING DEPARTMENT APPLICATION LOG # Cox • �a 0 Agent. Contractor, Contact Person M (N , t kc—, VU \l r+,q v Phone -7 -73 —cf4 f Li Address & Firm V 5' I o 1:� I a %'V 0.-, t ,11 Lee N H 1 , W c U Owner � fi 1 /� 2 c c t,U �-- / 't !-tti^ 4 P �c Mailing Address f. d C ,4r -f City State Zip Job8'ppe(tyf{ddr�ek Legal Description Prop. (PM, Tract, Lot) 7A1M -%->�'aLT C` g 12 bo lie l tom; c a Lot Size +rVVate geell" etc.'ZG 6 U c wf+c Use of Permit PPP,, Other yCU, ^1rfJ�(er�_ wellin H/Site Prep, etc.' r ' Signature of Applicant Date CATEGORY: REV CODE FEE CATEGORY: REV CODE FEE C SUBSURFACE DISPOSAL 1238 $ 57.00 ❑ SITE EVALUATION UPON REQUEST 7349 $ 43.00 m ❑ MULTIPLE PARCELS WITHIN SAME (NO PLOT PLAN) LAND DIVISION ❑ SEWER/SEPTIC VERIFICATION 7348 $ 17.00 Z O a. 1 at 4 Parcels (Each) 1238 $ 57.00 (Less than 1 year) b. Each Parcel after 4 7344 $ 24.00 ❑ PRELIMINARY ELECTIVE 7352 $ 23.00 W ❑ Rereview (2nd review same parcel) 7344 $ 24.00 EVALUATION (Attach DOH SAN 53) fns ❑ Site Evaluation in Conjunction with ❑ HOLDING TANK 7351 $ 47.00 Critical Area 7346 $111.00 ❑ ALTERNATIVEIEXPERIMENTAL 7345 $222.00 ❑ Site Evaluation lot Less than SYSTEM 10,000 Sq. Ft. 7347 $ 87.00 INITIAL DATE Holding Tank Agreements Completed ❑ Yes No Certification of Existing S.D. System Required ❑ Yes"0 WQCB Clearance required. (Attach Form O Yes fdeNo DOH SAN 007, Santa Ana Region Only) Soils Percolation Report Required. ❑ YesNo. ®�� Special Feasibility Boring Report Required. ❑ Yes tf'No Detailed Contour Plot Plans Required (1 to 5 ft interval) ❑ Yes Ca*Noi l -No Other ❑ Yes 21 Staff Specialist Lot Inspection Required ❑ Yes flNo Lot Inspection Date Soils boring report by Projed Date ` ��-� U Soils Map Page Sal Type ` Approved by Date No. of SystemaTY /of System(s) No. Dwelling Units C! % (1) Septi; Tank Soil Rate Grease/Sand Z rPJ Holding Tank ❑ Existing 3 -New ❑ Replacement�t Bedrooms. liklmFeAsintts /-Gal �1�f/i� j % fl�'r1 /f/j�}C• Y Gal U) �(�) leech Line Sq. Ft Sidewall allowance I I Line(s) R long ft wide with Leach Bed sq, ft Bbppn trench area _ ft rock/ sq. fl min. c below drainlines or of�"boltom arae per running It. Leachlines/bed special design for slope: (3) Pit Diameter No. Pits Pit Below Seepage PitTotal Depth !` Applicable / Inlet (BI)� (TD) �v/�" N/A L,I`t' Overburden factor Max. AllowableDepth No. 2 System REMARKS:( -ii L.l�C�l 0 This application is PPR'A ED for the category checked in SECTION B above, regarding the design of a subsurface disposal system as indicated on the accompan" n, using the requirements set forth in SECTION C above. A building permit is necessary for the installation of the Z above -designed system. No construction is permitted in the required reserved 100% expansion area. -' 0 Septic tank and sewer lines must be 50' minimum from any wells cY /ki pp �. U LU In (2 Leach lines must be 100' minimum from any wells, including expansK17 area (3) Seepage pits must be/150' minimum from any wells, including expans//bn area � �/I'y Si nature of Health Official ><-� `P�/� c Date T "1- j v RECEIPT NO. 4 / 6 / f Issued By / Date DISTRICT: ❑ Riverside, © Indio ❑ Hemet q Perris ❑ Rancho Calif. ❑ Blythe DOH -SAN -122 (Rev. 7/89) DISTRIBUTION: WHITE - Office file YELLOW - Applicant PINK - Bldg. Dept GOLDENROD - Plans/Records r'�F