05326 (SFD)P.O. BOX 1504
Building78-105 54-300 MUMC i LA QUINTAC
Address CALIFORNIA 92253
Owner CO LLA W." LEY LAND
Mailin
Address 247 E. TARQUITi #2
City Izip Tel.
PALM MIMS 92262 ,. 321-1020
Contractor
:STM CONSTRUCTION
Address
SME
State Lic. .-; to City
& Classif. :k Lic. # . .
Arch., Engr-,
Designer
Address Tel.
City Zip State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
affirm that 1 am licensed under provisions of Chapter 9 (commencing with Section
70)M of bivision 3 of the Business and Professions Code, and my license is in full force and
effect. - xl;rA1P9
R _SIGNATURE 1 - .0, DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following
reason (Sec. 7031.5,Busrtess and Professions Code: Any city or county which requires a
permit to construct. affer, improve. demolish, or repair any structure, prior to its issuance also
requires the applicant for such permd to Me a signed statement that he is licensed pursuant to
the prov mns of the Conbactor'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
subjects the appirant to a chd penally of not more than five hundred dollars ($500).
0.1, 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 Cade: The Cormactor's License Law does not apply to an owner of property who
brdlda 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
or hrprovemmd is sold Vidrir one year of completion. the, owner -builder will have the burden
of pmviV that he did not buil or improve for the purpose of sale.)
O I, as owner of the properly, am exclusively contracting with licensed contractors to con-
struct the project (Sec_ 7044, Bus6ress and Professions Code: The Contractor's License -Law
does not apply to an owner of property who builds or bnproves thereon, and who contracts for
such projects with a cordractor(s) ieensed pursuant to the Contractor's License Law.)
O 1 am exempt under Sec. -B. & P.C. for this reason
Date Owner
WORKERS COMPENSATION DECLARATION/
hereby affirm that I have a certificate of consent'to self -insure, or a certificate of
Workers Compensation Insurance, or a certified copy th'ereoN- (Sec` 3800, Labor Code.)
Policy No Company
❑ Copy is filed with the city_ ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be carrpteted if the permit is for one hundred dollars ($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 APPLKANT: f after makig this Certificate of Exemption you should become
subject to the ftrkers' Compensation provfsioris of the Labor Code, you must forthwith
campy with such provisions or mfrs Permit shag be deemed revoked. '
No. 05326
BUILDING: TYPE CONST: OCC: GRP_
A.P: Number - 774-•252—W4
Legal.Description WT 4 BLK 292 UNIT 27
Project Description $
V •
N' a] j
Sq. Ft. 1410 No.' No. Dw.
Size Stories'- Units
----------------
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
:timated Valuation
S
PERMIT
Plan Chk. Dep. -
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
76.360
2501.1
t
AMOUNT _
r.
1^.rw
x.5:7 •
17.50
.39
20.00 {
11,679A5
REMARKS'
•.i. 37 YWi 3 Y 1 V.7 [Yr' i.. ,t: X. ' ! �, a ..,' { '
ZONE: BY:
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. (sea 3097, Civil Code.) Side Setback from Property Line'
Lenders. Name ;
Lenders Aderess FINAL DATE INSPECTOR
'This is a building permit when property filled out, signed and validated, and is subject to ' j
expiration it work thereunder is suspended for 180 days-
1 certify that 1 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 Validation:
City. State, Zip
+
• - - . . _ ik 3,;,.r' yb„ .t. ;. f i .. ry Y(. _ '-_,, •k ,, •tf
4
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES,-
-1ST FL. SO. FT. @ $
UNITS
A.C. UNIT
COLL. AREA
e//�LAB GRADE (/� ,
YARD SPKLR SYSTEM
2ND FL Sp. FT. 0
BONDING
HEATING (ROUGH)
MOBILEHOME SVC.
BAR SINK
POR. Sp. FT. @.
SEWER OR SEPTIC TANK
ROUGH WIRING
POWER OUTLET
ROOF DRAINS
GAR. SO. FT. @
GAS (ROUGH)
METER LOOP
DRAINAGE PIPING
CAR P. SO. FT. Q
REINF. STEEL
WALL Sp. FT. Q
TEMP. POLE
DRINKING FOUNTAIN.
URINAL
SO FT (g-
WATER HEATER
SERVICE
ESTIMATED CONSTRUCTION VALUATION $
FINAL INSP.
WATER PIPING
NOTE: Not to be used as property tax valuation
FLOOR DRAIN
MECHANICAL FEES
$
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
916 AMING 5i
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
ROOFING
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
SO. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID ® 11/. c
SEWAGE DISPOSAL
SO.FT.GAR ® 3/ac
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 I/-- ) -r"WROUND
PLUMBINi;�3
UNDERGROUND
A.C. UNIT
COLL. AREA
e//�LAB 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 APPJEOUIP.
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.
916 AMING 5i
FINAL INSP.
ROOFING
yr �J
�
l/— 3 %C a /
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATIONISOUND
FINISH GRADING
�LtFINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURES/IVITIALS
GARDEN WALL FINAL
. r-.. � _ i,x. t,/"�' Y a! v.., �t - _,�. .•..••....-...•- k+��' !G•, oy+ .re-giy `-4'T57�'1-. �•iI`'."+.�•.�V- _ Rey'�'��+"'r'.'tsTr"o�::..'..7�+y�'�
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'1
ICOUNTY 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 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.
Q
VERIFY ITEMS IN SECTION A FROM BUILDING & SAFETY APPLICATION BUILDING DEPARTMENT APPLICATION LOG'*
z
0
Agent, Contractor, Contact Person
Phone
Address & Phone
AO Ca94)5 -rig 41aria4)
322 -�67d
W
Cl)7
Owner
Phone
Mailing Address
-f,4 tf cJ� r rL l tj Ail
`E�i�/ SPfL�c9 G s
State
,<2
Zip
9z 2 Gz
Job Property Address�,�,�
.8{ 3,00 f0A.3
Legal Description Prop. (PM, Tract, Lot)
.to -r .6L� 2-T7. LW
Lot Size
�VlTate= 1
Use of Permit P/P, CU, etc. � �1� yi`
Other '" ``�
ell
��!
welling;. MH Site Prep, etc.
/ ,31
Signature of Applicant
pat
/ CATEGORY: REV CODE FEE
CATEGORY: REV CODE FEE
Lit"` SUBSURFACE DISPOSAL 1238 5.00
❑ SITE EVALUATION UPON REQUEST 7349 $42.00
m
❑ MULTIPLE PARCELS WITHIN SAME
(NO PLOT PLAN)
z
LAND DIVISION
❑ SEWER/SEPTIC VERIFICATION 7348 $11.00
Q
a. 1 st 4 Parcels (Each) '1238 $45.00
(Less than 1 year)
U.
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)
❑ 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
10,000 Sq. Ft. 7347 $86.00
N;T
Holding Tank Agreements Completed ❑ Yes ��•
Certification of Existing S.D. System Required ❑ Yes ❑'Nom r
WQCB Clearance required. (Attach Form ❑ Yes 91No
DOH SAN 007, Santa Ana Region Only)
Soils Percolation Report Required. ❑Yes �'No'
Special Feasibility Boring Report Required. ❑ Yes a13 N�to-.
Detailed Contour Plot Plans Required (1 to 5 ft interval) ❑ Yes ❑!/No�'
Other ❑ Yes VIM t
Staff Specialist Lot Inspection Required ❑ Yes 0 No \ ti
Lot Inspection Date
Soils boring report by''Project # Date
cy
Sills Map Page J, j . Soil Type Approved by Al .4f/�_ — Date
U
z
No. of Systems
Type of Systems)
i7 Holding Tank ❑ Existing
- No. Dwelling Units t I A
Bedrooms, Fixture• lr -
(1) Septic Tank
Soil Rate
Grease/Sand
�(ar�ese Int
U❑Replacement
341044 �Z
��,,
p
W
-(2)Leach om trench area Line Sq. Ft
Sidewall allowance
Install`, Une(s) It kxig H wide with
Leach Bed sq. ft
R rock/ sq. R
per running R
min. inches`''r�ck belowdrainlines or
of button _area
Leachiines/bed special design for slope:
(3) Pit Diameter
No. Pits
Pit Below
Seepage Pit Total Depth
Other.
Applicable
.P
Inlet (BI).P=!&'�/
1
s?/
Max. Allowable Depth
N/A Overburden tactor
v
ell)
No. 2 System
REMARKS:-7'YLt,_� !'1" ez, Q� . �LG[ ./��� sL--<) /dAJfJ'-�-az
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�.G2-,��1'S�? ,tel n��iC.•'y,��E��GG��j��
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h�.lt/'e �!.�-f ,�tr
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This application isAPPROVED - ENIES for the category checked in SECTION B above, regarding the design of a subsurface disposal system as indicated
on the accompanied p o "plan, 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.
A
1) Septic tank lines Ti s
'
and sewer must be 50' minimum from any wellsey
/
a
( Leach lines must be 100' minimum from any wells, including exp(3
tml�
Seepage pits must be I ,� Xv ' minimum from any wells, including expansion area
Si nature of Health Official � a / Date � ' � _ � � f / � �P
RECEIPT NO. ryIssued By �C/1---" Date
DISTRICT: ❑ Riverside, t6]-1' Indio ❑ Hemet ❑ 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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