05327 (SFD)Building
Address 54r-290 VE CC
P.O. BOX 1504
78-105 CALLE ESTADO
LA QUINTA,•CALIFORNIA 92253
CQUSU .A VALLEY UM
Mailing
Address 247 E. �a$Q�iTz �2
City Zip Tel.
AL3 SPRW(;S 32262 322-1420
Contractor STAqRR 6ti7iiUAN
R r
SAM
City ED I Tela
State Lic.I City W
& Classif. j -r�- 7 � 5 Y Lic. # !i 5'
Designer
Address Tel.
CityI Zip I State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am 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 J
SIGNATURE DATE
OWNEWBUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following
reason: (Sec. 7031.5,8usiness arid 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 such permit to file a signed statement that he is licensed pursuant to
the provisions of the Contractor's License Law, Chapter 9 (commencing with Section 7000) or
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
subjects the applicant to a civilpenally of not more than five hundred dollars (8500).
❑ 1, 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 are not intended or offered for sale. If, however, the building
orimprovement is sold within one year of completion, the owner -builder will have the burden
of proving that he did not build or improve for the purpose of sale.)
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to con-
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
such projects with a contractor(s) licensed pursuant to the Contractor's License Law.)
❑ 1 am exempt under Sec B. & P.C. for this reason
Date Owner
WORKERS' COMPENSATION DECLARATION f
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 _/-
Y LN+
❑ Copy is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed ff the permit Is for one hundred dollars ($100) valuation
or less.)
I certify that in the performance of thg 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
aliforniaDateOwner
NOTICE TO APPLICANT: ff. after making this Certificate of Exemption you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith
comply with such provisions or this pemrit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
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.)
Lender's Name
Lender's Address
This is abuilding permit when property 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.
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.
Signature of applicant Date
Mailing Address
City, state, Zip
No. 0-5327
BUILDING:'TYPE CONST. OCC: GRP.-
� t
A.P. Number' 774-252—W3
Legal Description LOT 3 BU 292 UNIT 27
Project Description SFD
Sq. Ft. 1403No. No. Dw.
Size - Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ -Demolition-0
ZONE:
BY:
Minimum Setback
Distances:
Front Setback from Center Line
Estimated Valuation
76,360
PERMIT
AMOUNT
Plan Chk. Dep.
25€1..00
Plan Chk. Bal.
E •-
Const.
1,j
Mech.
:0.
Electrical.
•
Y
Plumbing
157.50
S. M.I.
5.39
Grading
20.00
Driveway Enc.
20.00
Infrastructure
1a �•
TOTAL
41
REMARKS
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
2/7/83
Issued by:
Date Permit
Validated by:
Validation:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL. SQ. FT. ® $
UNITS
A.C. UNIT
COLL. AREA
6SLAB GRADE —�
YARD SPKLR SYSTEM
2ND FL. SD. FT. @
BONDING
HEATING (ROUGH)
MOBILEHOME SVC.
BAR SINK
POR. Sp, FT. ®
ROUGH WIRING.
GAR. SQ. FT. ®
POWER OUTLET
ROOF DRAINS
GAS (ROUGH)
DRAINAGE PIPING
CAR P. SO. FT. ®
HEATING (FINAL)
OTHER APPJEQUIP.
WALL SQ. FT.
GAS (FINAL)
DRINKING FOUNTAIN.
OXEMP. POLE %- -,f -J
URINAL
SQ FT ®
WATER HEATER
ESTIMATED CONSTRUCTION VALUATION $
WATER PIPING
NOTE: Not to be used as property tax valuation
BOND BEAM
FLOOR DRAIN
MECHANICAL FEES
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
FINAL INSP.
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, TEM/PERM
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 ® 11/4 c
SEWAGE DISPOSAL
GAR. FIREWALL
SQ.FT.GAR ® 3/ac
HOUSE SEWER
LATHING
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
6SLAB 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)
OXEMP. POLE %- -,f -J
GROUT
WATER HEATER
SERVICE
FINAL INSP.
BOND BEAM
WATER SYSTEM
GRADING
cu. yd.
$ plus x$
=$
LUMBER GR.
FINAL INSP.
FRAMING
FINAL INSP.
ROOFING C —G
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATION/SOUND
FINISH GRADING
INAL INSPECTIOH(4�5Y—�
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURES/INITIALS
GARDEN WALL FINAL
COUNTY OF RIVERSIDE DEPARTMENT OF HEALTH Assessors Paroel No.
77S% -.7
ENVIRONMENTAL HEALTH SERVICES S? — �3
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 list.
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.
VERIFY. ITEMS IN SECTION A FROM BUILDING & SAFETY APPLICATION BUILDING DEPARTMENT APPLICATION LOG' #
Agent, Contractor, Contact Person
5 7'A /d !2 @6 •cisT c/G r�e,c�
Phone
3Z2 -/.o
Address & Phone
�
Owner
Phone
Mailing Address* Z
OJ,4Y
�cjtr
State
9,4-
Zip
f r-Y4Z
Job Property Address w/G
1 .S./ X90 /'Et.�.s��
Legal Description Prop. (PM, Tract, Lot)
L 3 l�t.r: 2 9 z, GLvir
Lot Size ` '
Ater Agenc / all-�
<�
Use of Permit P/P, CU, etc. Qu
Other /`®
✓�/CaX
�
� Lc���• �`�-rc.yi-:/ o
/J����
Q
DOH SAN 122 (Rev. 5/88) ', DISTRIBUTION:
WHITE = Office file ` YELLOW - Applicant PINK - Bldg..Dept.'
1_w-, (ling H Site Prep, etc.
+: Signature of Applicant
pate
CATEGORY: REV CODE FEE
Ca' SUBSURFACE DISPOSAL 1238$45.00
_ CATEGORY: REV CODE FEE
❑ SRE EVALUATION UPO_ N 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
(Less than 1' Year)
.$45.00-
b. - Each Paroel after 4 7344 $16.00
❑ PRELIMINARY ELECTIVE 7352 $45.00
❑ Rereview (2nd review same parcel) r , 7344 $16.00
-EVALUATION (Attach DOH SAN 53) .
❑ ; Site Evaluation In. Conjunction with �_
❑ HOLDING TANK 7351 $45.00
Critical Area .. 7346 $86'00
❑, ALTERNATIVE/EXPERIMENTAL 7345 $132.00
❑ Site Evaluation Lot Less than . -
SYSTEM 't
10,000 Sq. Ft. > _ ,' 347 $86.00
ti ...
INITIAL DATE
Holding Tank Agreements Completed ❑Yes ❑N' o�
/
Certification of Existing S.D. System Required ❑ Yes ❑ N' o , �[
t
WQCB Clearance required. (Attach Form, ~0 Yes_ t !
DOH SAN 007, Santa Ana Region.Only) w
Soils_ Percolation Report Required. � ; __ 0 Yes No
_
Special Feasibility Boring Report Required.r 0. Yes O�NoNo%
Detailed Contour Plot Pians Required (1 to 5 ft interval) ❑Yes q�/
Offer ❑ Yes 121`7
Staff Specialist Lot Inspection Required ❑ E3 No
,Yes �r
Lot Inspection Date
Soils boring report by Project # Date
Solis Map Page �1 l ' Soil Type Approved .by""r Date
No. of Systema
Type/of System(a)
Na Dwelling Unig { /
(1) Septic Tank
Soil Rate
d-Nase/Sand
❑Holding Tank ❑ Existing
'New ❑ Replacement
aqS --.4V �'
/
7
Grease 1
�(2�Leach a Sq. Ft
B&tm_quench
Sidewall allowance
Install Une(s) It long ft wide with 'c
L,ach Baecd sq. ft
`
.F
�
ft rodV sq. R .
per running.fL ' d NA
- NA
min. i drainlirm or
b
•`
Leachlines/bed special design for slope:
(3) Pit Diameter
• No. Pits
Pit Below
Seepage h Tote) Depth ,
�,,
ApPliceblelnlQ
N/A � Ow wrden factor
•
0 6 /
,e
t'(B)
,L7L
Max{AIIQweble Depth
No. 2 System }/A.
ie
{r
REMARKS: � /L:r_. N .Qr e .r Gly r �LCJ` _ /III 0 �h- �/S.•
a
This application i AP RA O,iVEpD JEiEDD for the category checked in SECTION B above, regarding the design of a subsurface disposal system as indicated,.
on the accompanied 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.
Septic tank• --y-
/I U
(0 and sewer lines, must be 50' minimum from an wells
( Leach lines must•be 100'. minimum from any wells, including expansion area
Seepage pits must be)150' 'minimum fromtany wells, including expansion
//�'",.
of Health' Official�`-� (ii/L rr
—Signature Date_- X 1,
FA
RECEIPT NO � / /
e
-
1�
..
Iss(jed By
Date
DISTRICT: -•❑ Riverside, ❑; d
❑ Hemet ❑ Perris 0 Rancho Calif.
❑.,. Blythe t
DOH SAN 122 (Rev. 5/88) ', DISTRIBUTION:
WHITE = Office file ` YELLOW - Applicant PINK - Bldg..Dept.'
GOLDENROD - Plans/Records
s i
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+
.. _.�,..�-N•>..-c.'.,_..�. ._..� v. .. .. ... ..^ ..,_-... _-_ ._�.
.. ...._ ___._...__... .-._.. ..-. ._ _._ ,. ...--a+f_._�