9707-149 (PLBG)LICENSED CONTRACTOR DECLARATION
1 -hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section47000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class`, Exp. Date
Date M� Signature of Contractor-!)
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 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, Business & Professionals Code).
( ) I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business & Professionals
Code).
( ) I am exempt under Section B&P.C. for this reason
Date Sianature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
( ) I have and will maintain a certificate of consent to self -insure for workers'
compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
VI have and will maintain workers' compensation insurance„ as required by
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier Policy No.
a A°i ;1..' iJhfi} rt: 4-97.11N)V662
(This section need not be completed if the permit valuation is for $100.00 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, and agree that if I should become
94ect to the workers' compensationrprov isions of Section 3700 of the Labor
('ode, l' 21f_fbrt with+comply with thosel rovisions.
VDate: �l Applicant—
Warning:
Warning: Failure to secure Workers' Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned propelty`,`ffor Inspection purposes.
ICignature (Orme,/Ayer Il)( ` � }A �- : uate % `• t {� e
PERMIT #CONTROL #
BUILDING PERMIT 97147-149 .
7147 49. 5625
DATE -f129J9f I VALUATION .�� �; II� LOT TRACT
JOB SITE
ADDRESS 7 7555 t,M_1I9+. '1*AN-APN
OWNER
CONTRACTOR / DESIGNER / ENGINEER
VIA#,j ! \"7'j"170k- .yq A F.l S.'ji.Rt4 1rir1•� �t� .•�i� /"�('1'ArS.'Ial If"•'�'f{'s'a!
.. ."i{t•'}' tF,•l,..rL ,i. ,../s��.', t3f.v.,�l..+n�,_. 7....1c.I I \.4,11.16 i.._) /...FV
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(7601:179-1 7A.7 (,'61IX 14.E
USE OF PERMIT.
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A.t, &0,AJ4.IA-).
V a),t.17a►')1014
4,400,00 14*11
yiy� y�;�G y M 7�� �q j�,`.�`.sT'�.�°��1fED CANS' OF t�':31�1i�7'�:.(1�.`'. ION •..
rf
PLf•)NIt3iN014I.. 1014X)0-419-0( X)
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0 1997 LIESS k'& -R SID PS.I~S
t1 � f�Tt1AL .-FRt!4111 FE -FSS 0111i,1141(AV
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RECEIPT� I DATE I BY I DATE FINALED I INSPECTOR
4,040,€ 0
WOO
W CKI
545.00
' I
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Stab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. Test
Final I I
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances ,
t
Final
Final
Utility Notice (Gas) i follp,
ELECTRIC I APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final,
Utility Notice (Perm)
COMMENTS:
F
I ASSESSOR'S PARCEL NUMBER
COUNTY OF RIVERSIDE HEALTH SERVICES AGENCY '773 — 0 %f —
DEPARTMENT OF ENVIRONMENTAL HEALTH
PERMIT APPLICATION FOR A SUBSURFACE SEWAGE DISPOSAL SYSTEM
AI3PLICANT: Submit this form with four copies of a SCALED plot plan (1-20 SCALE) drawn to County specifications as indicated on the attached check list.
A non-refundable filing fee is required when the application is submitted. Cheek must be made payable to the County of Riverside. Approval of this applica-
tion shall remainvalid for a period not to exceed one year from date of payment.
01TV 1A 0ilf,NrA
LOG # f1/
Agent, Contractor, Contact Person
ZJcnci'��c�son/,1-o
Address City State Zip
16 ` Z,4 %.3'
Telephone
Owner
�'l l/,/�
Address City `State Zip
P� /may 4� Ct 4 t
Telephone
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Joti'Property Address
77- T
City
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Zip
15T*(P/'ro
U
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Lot Size
&ater Agen I Xf Si/�/!s
Use of Permit, P/P SUP, PUP, @tc.
t
Legal Description
U)
,/
CUA(NFt.^A J/At.Fy
A SCEP irM F �� T•
[ 0r �r� BtK. P.;; SAv7i1 rArMAI� ,-A A, W(f
Dwel log, to Prep., a c. ( 6 1�1
(it%AIV ,l1 S�1, c
LA %r✓4►r� U'J1r'"`/
Signature of Appli t _
Date 1�_VFA
CHECK BOX IF REQUIRED
❑ Holding Tank Agreements Completed
❑ Detailed Contour Plot Plans Required (1 to 5 foot interval)
❑ Certification of Existing S.D. System Required
❑ Grading Handout Provided
m
❑ WQCB Clearance Required
❑ Staff Specialist Lot Inspection Required
Z
O
(Attach For DOH -SAN -007, Santa Ana Region Only
❑ lot Inspection
U❑
Soils Percolation Report Required
W
❑ Date Lot Inspection Completed: Initials
W
❑ Special Feasibility Boring Report Required
Remarks:
❑ Maintenance Booklet Provided
Initials Date
❑ Final Inspection by Department of Environmental Health is required.
Q
Percolation Boring Report by 914EAA �AJ6/V1r_f.J! f L'IF/Project # ^' Date i -15-7f
�Jfi27'Soils
Soils Map Page Soil Type Approved By Al. A Date
No of Systems
Type of System(s)
No. QA4jW9 Unity)#r1sr
(1) Septic Tank
Soil Rate
Gf® Sand
G X t Sr
I] Holding Tank I] Replacement
O New &Addition •7V FXr1/
❑ SEWA61
Bedrooms, Fixture Units
b/ �i5.q
At��uj
E)(t ST,
,7f 40 Gal)
n 1
5 6Y A
Grease nt Trap
Gal
t 1/
Existing of 1Eh
t •
rr Awa w�
Sq. Ft.
�bttom Area
Total Linear
Si ewall Allowance
rock/ sq. ft. runniig ft.
Install ine(s) I. long I. wide with
Leach Bed sq. ft. of
om Area
Inlet Tested Depth ❑ NA
min. inc rock below drainlines or
U
Proposed Bottom Tested
Z
Leach lines/bed special design for slope:
(3) Pit Diameter
No. Pits
Pit Eelow Inlet (BI)
Seepage Pit
Maximum
Othe
O
'
Total Depth
Allowable
Applicable
(T4,4N
3 C
(f /j 1
TD / �
Depth
�(� 1
W
N/A Overburden Facttxa
NIA
U 6'
Spit
No r ci 1).r# /T 7v err
Well Review Approved: Date: Well Drilling Permit #
SIGNATURE '
Grading Plan Approved: Date:
SIGNATURE
Sewer Verification Approved: Date:
D
REMARKS: ^r
"*4,
.y- L j
e is applicaIio I . PROVE BNlig For-the-eategor�y�ehacked i .
FOR OFFICE USE ONLY
r
abovo—, regarding the design of a subsurface disposal system as indicated on the
acompanied plot plan, using the requirements set forth in SECTION C above. A build-
�a.7• Fee 07N oa
ing permit is necessary for the installation of the above -designed system. No construc-
Revenue code $
tion is permitted in the required reserved 100% expansion area.
/ �( 2
Yclheck /h 7 F •�'
(1) Septic Tank must be 100' minimum from any wells.
#
yn
7 Initial
7 - 9A�/
(2) Leach lines must be 100' minimum from any wells, including expansion, area.
Date /
0
(3) Sewer lines must be 50' minimum from any wells.
O_Seepage
(4) pi must a 150' minimum from any wells, including expansion area.
Imo- �^�-.
c .= r •, �:
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ax
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Signature of Health Official
C�l
K'k
�- 9-
dniy
I L
Date
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DOH -SAN 122 (Rev 9193) uislrIDUnon: vvrn I _ voice rite, 1 CLLVYY—MFlF 11R 1l, • ,-•_
' � � N
COUNP( OF RIVERSIDE HEALTH SERVICES AGENCY
DEPARTPvIENTOF iE- NVI RON IMENTAL 1 EALTH
_FoodX Sewage Disposal
_ _Trailer nark Cx►s'Gal. Scpiic Tan: iaS00 6a�) Cm
Mote!, Apt., Hotel So. Ft.pl LeachXiine I
_ ;:vei '}3 DA /" ht�. 6 pia_,3L_8l_ W Tp— NAD !Seepage Pit T41N -,6)(1 �Q
Cann arcia� Suming Exist ppFf1cE C,r'tr(3ctian to jU1Ver
86170.1 -off.
-- 1ii06. ��l?4X /1�Ttic DEPirr Of
Swirrtn:ino. Pool /6/`u•�tcrua� M��--�e°rinect to Existing S..S.D.S. P/r = v0'
_F.o iN}•�.jtr: PvIJ';t't6r::tSli j Sivatt;C Souaninrj. devictis maf be discharged into the individual sewage disposal
i app JV8d wril}oui cvarancG frorl the later Quality Control Board.
su rely :3r3rwn�°his inst ilatton rust be from an approved sourceE x/Sr. (C J W
All sewa, dssrus� iris►a?a1ion must conform wiih requirements of current Uniform Pluming Gexi®.
esattira ,gradin or filling in excess of tv�o{2) lost will nullify sewage disposal approval.
� ,al: rovai i}as 't;eor. !u twined from the Regional Water Quality Control Board for installation of the sewage
disposal System.
This is,to cartify that tt}n riverside County Environmental Health services apovee s a ,surface,sQwg /
disposal plot plan to oNain building permit for in Gatian; construction.BY 1A
��T �iv /S 7� a�s'J
CJ
MAINTAIN 100% EXPANSION ARS►. AKIN. /SO ' FRS ANY WELL
MIN. 10' PROM ANY : TREE OR WATERMAIN kL241 1
It
tlf11. UI1P11�1 j
DEPARTMENT OF PUDLIC NEALT®��, of t�eee p� D,the rtmeae oa< Pneo�
IS 'VALID FOR ONE (1) 'YEAR t�A;, of Riverside County does not relieve th® Emile.
FROM DATE OF APPROVAL. ; T_Architect of the responsibility for the En¢inee.,
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