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0003-079 (PLBG)LICENSED CONTRACTOR DECLARATION I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professionals Code, and my License is in full force and effect. License # Lic. Class Exp., Date i.JfQ3t3�L4 CIZ, C-34, C. .21 Date 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 Signature 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. (\)/I have and will maintain workers' compensation insurance, as required by Se tion 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. (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 subject to the workers' compensation provisions of Section 3700 of the Labor Code,I shall forthwith comply with!those provilons. ! /# �.-� ate: e � v d Applicant v �=<t W' i y� �j 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 property for inspection purposes. r VSignature (Owner/Agent) ' in te BUILDING PERMIT PERMIT# 000-079 DATE VALUATION $�ti.w� LOT TRACT JOB SITE r.... .. a.. �., , � ., , t . ,,^� APN ADDRESS fix^iL�U tytiLl�4+i 1131V3i$4 iJ - OWNER CONTRACTOR DESIGNER/ENGINEER ROB 8 T G \aA SV*ARD iiIgILAI.1D CO."!SllNZ l "'Ar11 N 78120 C ALLIi'i AMPIC0 50305 HWY 111, Lr1 QUIN'IA CA 92253 C'0ACF(EI LA C.A. 922311 (760)398-5544 CBTI# .14.1 USE OF PERMIT Pti�1P1L►lVi� 5�k i1tiiflktiilVTJCl1V GREASE IN—M—RC010R INSTALL Nl"t' Gi0_A SEWI:R 0114 S, U l 10 'ST INVUED COST OF CONSTRUCTION PFRti!eIT PIE3F, STAI NARV PLUM131NIJ VEE -- 3hwER 101-OW419-000 $:30.0) �:I jR-'I�Y7"�1. t`'�FJ�TR1 k'"T°It1A( Al�;i) .I>4,Aiti f"`6ifC''iC LESS i'i'•.F PAID FEI S "3'M'. L PERMIT Fi!;08DFI1",1V()W RECEIPTI DATE I BY I�/ f I DATE FINALED I INSPECTOR r 10,409.E On S30100 INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs Underground Ducts Forms & Footings Ducts Slab 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 Wail Insulation Condensate Lines Party Wail Firewall Exterior Lath Drywall - Int. Lath Final Final POOLS - SPAS BLOCKWALL APPROVALS steel Set Backs Electric Bond Footings Main Drain Bond Beam Approval to Cover Equipment Location Underground Electric Underground Plbg. Test Final 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 Final COMMENTS: r.i ,S�2y,���-154J oto / ' �Z —d ' Final Utility Notice (Gas) ELECTRICAL 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) ' COACHELLA VALLEY WATER DISTRICT w� CASH RECEIPT DETAIL Received From: %Pf//°3 �e!%'i• i UNI Iz. 5���✓!7We �/ / 6.. Date' Address: 0 ` Account No. _ Lot(s) Tract — Service Address%f '' e G.A. Code O Meter(s) — ^ $ E❑ Service(s) ❑ Backflow(s) r _ ❑ House Lateral(s), `t ❑ DetectorCheck(s) 1 ❑ Meter Surcharge Ml,,§anitation Capacity Charge f ' /` �u y `ry n!, /91 ❑ W.S.B. F.C. f+��G!✓ t Jr .� l %U • GS!�J S Q Temporary Construction Meter ' i "` ° 4 ❑ Turn on Charge` F ❑ Uncollected Account - Name F v � 4 • i �f' fG Inspection Fee; Tract- Fee - w 1 ❑ Plan Check Fees Water, ! Sewer - Tract - * Yu ❑ Bond Payment A.D. Bond ; D Customer Deposit '' ' a� y•Yz Yt. G other_ I _ � ,•,'`' -' .t'` > TOTAL $' � Rernarks: r'•� w 4/l - [ ).,,r �,Mopy to: WaterServlce r 1 Cash 1 ` • 1 ArGi t Check ,•„tri a:. • H -..'' ►� r IOrder CVWD 4381111891` �,.. r � a'r!'k.�rf�`f;Fr 1:?i..rY, .if.•<'}� Kai %�..�fi ��-•}�'�%>~t�' ,t Y; '., ri ;•• ,+:+ •?.}'t � � •� •1 !' • r 1 jj R EfEl.jf, t. FAli` �I', , Pr; ,( t ,,�•84�r i + r '4� � � T, tl r.:.•d�('u r ✓j 1 j, 1?� , f5,rd t '('ly��t ��� 1 ��{,i� q '( ? • Y ' aly�,Y r`'�; r' s� �)"1 r��, �` b� :< tr '� tw.. k9 •5 �r 4 p. � �jY t. I I n( trry -ir ttt `tanf R. t T'�,1 ^ z'ty.r+St,., i-x+`;��Ji• 44. ,srl+ti"i x I1; - ' { it Iter k' n i +i f If tea^ � )S t i•''�+ �,`s 1 .," .. ( I IF+7i J'Sb 1, r F t f F�.�,s, ,r .S; k I•{ 'P, i1,y� �!^ Ij H � :�r�r; , r. if 1 � }err t � ,, � 1'� �•. �'pr. w z .•. • I �rfyl, ;+ll G,.��1 +.1 �1�•yr�Myl1 i -MALAY 1 -,.fit � •rr 4• I,.r �. A HAMMER PUMPING INC. -HAMMER PUMPING INC. JOB INVOICE JOB INVOICE, 'P.O. Box 2448P.O. Box .2448 -CATHEDRAL CITY, CALIFORNIA 92235-244-8 CATHEDRAL aT,6 CALIFORNIA 92235-2448 (7601360-7448 (760)360--'7448 (760)321-7448. CUSTOMER'S ORDER NO. DATE ORDERED ORDER TAKEN BY DATE PROMISED 0 A.M:- , O.P.M. BILL TO PHONE ADDRESS MF CITY HELPER JOB NAME ANDON Cr6AY WORK �_T k-- (3 CONTRACT. .DESCRIPTION OF ORK F C_ �J It G F, T f7. ADDRESSM -QUANT. DESI Al USED RIPTION OF MATERIAL PRICE AMOUNT HELPER. Gallons Pumping Fee per 1000 gal. DO. . .. ... �: 0. V: Dumping Fee per 1.000 gal. DESCRIPTION OFORK. 3wtr­" . Out of Area Fee q. CTL Locating /.Opening Fee (per hour) r r Size System:. A SERVICE CHARGE OF $20 WILL BE DUE ON ALL RETURNED CHECKS .18% PER YEAR WILL BE CHARGED ON PAST DUE ACCOUNTS OVER 30 DAYS. - HOURS A SERVICE CHARGE OF $20 WILL* BE -DUE ON. ALL RETURNED CHECKS. TOTAL MATERIALS MECHANICS @ 18% PER YEAR WILL BE CHARGED ON PAST DUE ACCOUNTS OVER 30 DAYS. TOTAL LABOR HOURS LABOR AMOUNT TOTAL MATERIALS, I hereby acknowledge the satisfactory T TSL LABOR completion of the abQue descr*d work, TAX MECHANICS @ TOTAL LABOR DATE COMPLETED TOTAL HELPERS @ 1I hereby. acknowledge the satisfactory TOTAL LABOR comp. -of the above described work: TAX SIGN RE DATE COMPLETED r (11 La 710 I (760)321-7448 DESCRIPTION OF MATERIAL USED CUSTOMER'S ORDER NO. DATE ORDERED. 'ORDER TAKEN BY DATE PROMISED .O.A-M­ 0,P.M.". BILL'TO PHONE ADDRESSM I - E IC i HELPER. Dumping Fee per 1000 gal. _Ij0q, INA< AN LO TION 6_4 t � V: O:CONTRACT!-,�. OEkTRA' DESCRIPTION OFORK. . Locating J Ope.ning Fee ((per hour) 4 q. QUANT. DESCRIPTION OF MATERIAL USED PRICE ..AMOUNT 0 Gallon*s Pumping Fee per 1000 gal. J, t 0000 Dumping Fee per 1000 gal. V: Out of Area Fee. Locating J Ope.ning Fee ((per hour) 4 q. CTL Size System: A SERVICE CHARGE OF $20 WILL BE DUE ON ALL RETURNED CHECKS .18% PER YEAR WILL BE CHARGED ON PAST DUE ACCOUNTS OVER 30 DAYS. - HOURS LABOR AMOUNT TOTAL MATERIALS MECHANICS @ HELPERS @ TOTAL LABOR I hereby acknowledge the satisfactory T TSL LABOR completion of the abQue descr*d work, TAX NATURE DATE COMPLETED TOTAL RIF )11 yc1'-C.14..1. , t ---I---"--%1. '_' ' — "'- �_ ASSESSOR'S PARCEL NUMBER COUNTY OF RIVERSIDE HEALTH SERVICES AGENCY DEPARTMENT OF ENVIRONMENTAL HEALTH 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 specifications as indicated on the attached check list. A non-refundable filing fee is required when the application is submitted. Check must be made payable to the County of Riverside. Approval of this applica- tion shall remain valid for a period not to exceed one year from date of payme it. LMS # (emp -17Y OF `A 0""'An Agent, Contractor, Contact Person Address City State Zip Telephone Owner t 4c r,T �J ►Y /l Address / �^ City/ State Zip r © Yr Z (� Cis C k.f l ^! I Telephone .t_0 J ZZJob Property Address 7, -iso c.14 %,����o City CQ Qy�Nra Zip 9aas _. WLot Size, r (5t',fY �i(•19 afar Agenc ' .ell s(/ fr,w/ use of Permit, P/P, SUP, PUP, eta Legal Description /�VACµIt<tVA(try¢a4V4lST71(Cf DNr® rte dap etc�'rppD f'f t•rrllulln�T l7�A•; ! tIM�rtDt a911 Signature of Applica t uCAjAiA� &21 rj.Date CHECK BOX IF REQUIRED If any box is checked, this application shall be considered rejected until ❑ Detailed Contour Plot Plans Required (1 to 5 foot interval) the information is provided and the fee paid. Resubmittals later than 90 days after date noted below may require repayment of fees. ❑ Staff Specialist Lot Inspection Required m ❑ Holding Tank Agreements Completed Thomas Bros. Page Grid Z � ❑Certification of Existing S.D. System Required l'– ❑Date Lot Inspection Completed: Initials ❑ WOCB Clearance Required W N (Attach for DOH -SAN -007, Santa Ana Region Only) Remarks: ❑ Soils Percolation Report Required ❑Maintenance Booklet Provided _ ❑ Special Feasibility Boring Report Required ❑ Final Inspection by Department of Environmental Health is required. ❑ Rereview Required Initials Date Please call 24 hours PRIOR to inspection. C/42 / Soils Percolation Boring Report by Lic/Project # Date Soils Map Page Soil Type Appr.Dved By Date No of Systems T f� of System(s) 8 Hold' g Tank ❑Replacement No. fgtNlttfl�Yc,� Units (l)Y Bedroo= wits[ Ek`r' (1) optic Tank oil Rate 6fieasemand AI Grease Intcp/L•irrt•Fra�' ❑ New ❑Addition st47A16 V /y) V (! [ a4f' 7d� ❑ Existing , Gal. i Gal. Sq. Ft. Bottom Area Total Linear Ft. Sidewall Allowance r u f r r UE ^ Leach Bed sq. It or om Are ft. rock/ sq. ft. running ft. Install Line(s) ft. long ft. wide wl h G C✓40 Inlet Tested De = ❑ NA min. inches rock below drainlines or U Proposed Bottom Taste epth Z Q Leach lines/bed special design for slope: (3) Pit Diameter No. Pits Pit 3elow Inlet (BI) Seepage Pit Total Depth Maximum Allowable Other: •''— 1- Applicable N/A Overburden Fa ❑ 5' S ` TD epth F N rte_ t Well Review Approved: Data: Well Drilling Permit # SIGNATURE Grading Plan Approved:Dae: slF i --6-0,0� t/ 1,4/ ,�/J�4�G(!Li Sewer Verification Approved: I/Zme: 3 (l r�iso 7 -6.04 Plan Check Only Approved: Date: 64lai nlw REMARKS: i - � abovapp kation Is•JkPp a sw I sca e h 'dic ®N.B. above regarding t e sign of a su . , ac'e„disp©sal system as indicated on the WE 'W __ ��� FOR OF IC ONLY acompanied plot plan, using the requirements set forth In SECTION C above. A build- ing is for installation No t� �/• d Revenue C-/ '71 j 1/r Q 1 permit necessary the of the above -designed system. con- code e $stiruction In permitted In the required reserved 100% expansion �A-(OrYP 1) Sep be�ji inimum from any �0 �" "` ` F�'� a4.0 !J ❑' Check # /V 01 ......+..� ust wells.,/ (2) Leach lines must be 100' minimum from any wells, including expansion area. Date Initial 3) 'Sewer lines must be 50' minimum from any wells" i / ,v1 r - •'e'l • ti t*471_.4 (, IC . T• O � Z L,'Ve ; •/ is `M - w� (4) Seepage pits must be 150' minimum from any wells, including expansion area. rylq p�/ U fa U k j Signature of Health Official 3- 6 - dd Date DEH -SAN -122 (Rev 9/98) Distribution: WHITE—Unice File; YELLUW—Applicant; PINK—I log. Uept.; GULUENHUL—PIanS/Hecores , . ... . ..... .............. D E AR1 tv3ENT MENTAL HEALTH 1�1 ON v,-1go -Dispos Trailer ark Ft. of Leach Line IVID S -J)weliing No. 1 -ba —Bt..,,—. I TD GcirQrnercial B, uilding -(M 4 �,-.to poction to Snw��rd,,V(-y —.--ecrnriect-to-Existirg-S-.S-.D.-S-. Tc� �p Wimm n o ragopera.ting watur sottening device s [Wiy'Wdischar' discharged into the ift No ari-Sil systam Q:A'C@R4FB'-z7=Uc -�e \AWOr �X`wawrtvpply ser g/�is nst 11 t'cn m I bafrom an appr L' S'7- ,qla i . us X:1 C LI (AI.D All sawag -iffiakla A- of -current Uniforrin Plumbing. Code. fig must conlOrm with requircimp fTiW—cuRFg—grAdiffgor11111,1g-ln-exrssc;-.t-iwol2)-feat-Wit-rkjiIlffy-sawage-disposalapprova . -�—-- fli /Approval has.boon obtained from the Regional W6ter QUIINy-C60.al Board for installation othe seWzgq ii i R D: ♦i `' �.p•' C�r� �pf AS x.30. V/ • -b • ( +� _�.---..._...._... �,,; v G, IIA topu Cp Uu APIO -$'G .. 1 _... _ ._...._-.__.__._._.....____..._._..__._...__.._. lS7il�6 �WCn/lQ�� COW1�~` "` �ia (. c`�' �l /A'/✓� �/ C D ' Yl'�4 ink° . . : 0-� 'r �•., .. _. , ._, _ \d. ,tib-�:�, ,,� - V'1• _ '�'`�'"'�'Q" X"I 71 I Or vv ,. `4 COACHELLA VALLEY WATER :UIS'LK] C'1' . I•; K,.l;u.l.:►t.lun:: ltcg:►rdinL Itinct:cc•pCot;:/:icpaLaCot':: (excerpt) • a Th c. Cu•ir.lt,:,]."].a Valley Water lll:Lt:ict require:: Cltat a.l.]. pJ.au:: and spccl.l: l.r.:►t:i.on:: for Lhe l.nsLailatiun of interceptor::/:;eparat'ut :: nl►aiJ. r b"c :;u ).,,,ULud to the dl, ict it advance of con Kruction and no con:cl:1:,,.,:e:.l.un ;:ltal.l. ::tart "until 10-a"a and specifl.catioti:: have been approv,:,l by the disLr:l;cL. The propu::cel di:.charger. hall cump.l.(,.tc an " appllcacion" artcl submit"iL with approved plumbing, plans and wVcc.ifications (where applic:.tblc) at: :1.t::, lteadcluarc:cr:: In Coach,: I There •I.:, cu►:rerttly no change for the filial;, of t tl:; application. No in:uyl:ceptor/separa't'or shall be itis L'alIe(I without prior. approval of Lh, r."lll.:crict. - Applicant ;, shall notify the disLirict 110' 1'Aiuur : p"rlor to Lite: ::tart: of Ins tallaLion and all installation shall be . inspected by d1.::t.t:1.cL personucl.. ` There I:: ct►rrently no. charge. for Lhis inspection. If yon" .have any clucSt_ions or desire additional information, please call Joe Barham llcmatid L'valuation Specialist, (6 19 3911=2661 L'xtcw; I.on 536. BKC:1tlt