05642 (PLBG)Address 51-360 QrAI; EI0
Address
Owner
Kelly - $irk
Mailing
Address P.O. Boot; 329
. Ra3ndw �ra� Zip 9 �7t?
Address 68315 K1.6l:,ey Ad.
P.O. BOX 1504
78-105 CALLE ESTADO
LA QUINTA, CALIFORNIA 92253
w . . i
69f45-5450 .
Cit Zip Tela
sthadral City 92234 619/3?? -71,747
State Lic. -City
& Classif. 2518 ' ` A Lic. # 194
Arch., Engr.,
Designer
Address Tel.
City1. Zip State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am lir:ensed yikW provisions of Chapter 9 (commencing with Section
7000) of Division 3 of the Businesg.` ind P)ofessions Code, and my license is in full force and
effect. f i„•>' +
.SIGNATURE DATE
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractors License law for the following
reason: (Sec. 7031.5,Business and Prons fessioCode. Any city or county which requires a
Permit to construct, after, rrprove, dernodish, or repa ' any structure, prior to its issuance also
requires the applicant for such permit to fie 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 PWessions Code, or that. he is exempt therefrom, and the basis
for the alleged exemption. Any viaolation of Section 7031.5 by -any applicant for a permit
subjects the applicant to a cfW penally of not more than five hundred dollars ($500).
❑ 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 Contractors 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
or Improvement is sold within one year of completion, the owner -budder will have the burden
of proving that he did not build of improve for the purpose of safe.)
❑ I, 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 lids of reproves thereon, and who contracts for
such projects with a contractor(s) lice used pursuant to the Contractors License Law.)
❑ 1 am exempt under Sec a, & 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
Worker's Compensation Insurance, or a certified copy ther&f. (Sec. 3800, Labor Code.)
Policy No. Company"fz'•�� /�-
❑ Copy is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed if the pend is for one hundred dollars ($100) valuation
or less.)
1 certify that in the performance of UV 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. q after nab this Cerbicate of Exemption you should become
subject to the workers' Compensation pnovisbris of the Labor Code, you must forthwith
comply with such provisions of this pend 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, Chd Code.)
Lenders Name
Lenders Address
This is a building permit when property filled out, signed and validated, and is subject to
expiration if work lhereunder is suspended for 180 days.
I certity 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
Signature of applicant Date
Mailing Address
City,. State, Zip
No. 05542
11LDING: TYPE CONST.• OCC: GRP.
P: Number 773-—W6
.Legal Description
Project Description
Silipa€ Pit
Sq. Ft.
Size
No.
Stories
No. Dw.
Units
New ❑ Add ❑ Alter ❑
Repair ❑ Demolition ❑
Estimated Valuation
$2,500.00
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
54..00
Mech.
Electrical
Plumbing
S.M.I.
.�
Grading
Driveway Enc.
Infrastructure
TOTAL
REMARKS
040TAL4-fit''4—Hy 54.21 rf
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 DATEINSPECTOR
4/14%89
Issued by: Date Permit
Validated by:
. Validation:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
PLUMBING FEES
1ST FL. SQ. FT. ® $
UNITS
r'
r
ROUGH PLUMB.
BONDING
YARD SPKLR SYSTEM
2ND FL SQ. FT.
FORMS
i
SEWER OR SE PlG -�
ROUGH WIRING.
MOBILEHOME SVC.
BAR SINK
POR. SQ. FT. ®
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
POWER OUTLET
ROOF DRAINS
GAR. SO. FT. ®
TEMP. POLE
GROUT
DRAINAGE PIPING
CAR P. SQ. FT. ®
FINAL INSP.
BOND BEAM
WATER SYSTEM
DRINKING FOUNTAIN.
WALL SQ. FT.
LUMBER GR..
FINAL INSP.
URINAL
SQ. FT.
ROOFING
ESTIMATED CONSTRUCTION VALUATION $
WATER PIPING
NOTE: Not to be used as property tax valuation
FLOOR DRAIN
MECHANICAL FEES
VENTILATION
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
FIREPLACE
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 I
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SQ. FT. RESID ® 1% c
SEWAGE DISPOSAL
SO.FT.GAR ® 3/ac
HOUSE SEWER
CERT. OCC.
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
i
SEWER OR SE PlG -�
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.
FRAMING
FINAL INSP.
ROOFING
REMARKS:
VENTILATION
FIRE ZONE ROOFING'
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATIONISOUND
FINISH GRADING
M INAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATOR=SIINITIALS
• GARDEN WALL FINAL
'7 t .� a'�s•ty_�>:i'._ ... � i#' 0.°'''a '+-�"';�'3 -4 '.£�. i;, n'ic � ,t' s .r mow_ "+:,,� .vim, �y Y"' =-,.!F pa"41
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COUNTY.,OF RIVERSIDE DEPARTMENT OF HEALTH°'"Or° NO'
ENVIRONMENTAL HEALTH SERVICES ' 77.E70eq _ 004
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. il
VERIFY .ITEMS IN SECTION A FROM BUILDING & SAFETY -APPLICATION BUILDING DEPARTMENT APPLICATION LOG'*
t Contractor, Contact Person
1b7-
Phone
72
Address & Phone _
rG r/Scy W L
J
OwnerPhone
.
Mailing Address
/'n
City .. ,
i State
Zip
Job Property Address
Legal Description Prop. (PM, Tract, Lot
U F
Sr Wt.,& cAr w. r 6i/I.-UAY
Lot Size° Watef�r AgencyaWl
Use of Permit� P/P, CU, etc. p (a%c c ,
Other
C
I l y15%
So a
�r
X (�
�- o;Iing�
MH Site Prep, et .�LZ t:..•^
. uyr✓c�Yr . f""'Y
Date :4
Signature of Applicant
CATEGORY: REV CODE FEE
CATEGORY: REV CODE FEE
.
Ol"SUBSURFACE DISPOSAL 4238 500
❑ SITE EVALUATION UPON REQUEST 7349 $42.00' `,.':
❑ MULTIPLE PARCELS WITHIN SAME
•
(NO PLOT PLAN)
LAND DIVISION ",
❑ SEWER/SEPTIC VERIFICATION 7348;1 $11.00
a 1st 4 Parcels (Each) 1238 $45.00.
(Less than 1 year),
b. Each Parcel "after 4 7344 $16.00
❑ PRELIMINARY ELECTIVE 7352, $45.00', ,
❑ Rereview, (2nd review same parcel) 7344 $16.00
EVALUATION (Attach DOH SAN 53) ,- =`' j'
❑ Site Evaluation in Conjunction with 1
❑ .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
i rlIINITII!AL DATE
Holding Tank Agreements Completed '' ❑ Yes G '/ �" S
Certification of Existing S.D. System Required ❑ Yes l�N�o'1
WOCB Clearance required. (Attach Form O Yes FJ'N0
DOH SAN 007, Santa Ana Region Only)
Solis Percolation Report Required. ❑Yes 0'No
Special FeaslbUlty Boring Report Required. ❑ Yes 12 N/
Detailed Contour Plot Plans Required (1 to 5 ft. interval) . ❑ Yes a /NNo�
Other ❑ Yes Q'Nd/
Staff Specialist Lot Inspection Required ❑ Yes D1 NoLot
Inspection Date
Soils boring report byPrmmoject # Date
Sorts Map Page Sort Type Approved by rA,,, /Cal" Data
No. of Systema
Type of System(s).
No. Dwelling Unita (/)
(1) Septic Tank
Soil Rate
.GresserUnd
!r X 1 S F
❑ Holding Tank ❑ Existing
Bedroom/a,
�- X�fT.
Intcp
1 `
❑ New ❑ Replacement
(lig
'(24,Leach Line Sq. Ft.
Sidewall allowance
Uns(s) It. low loft wide with
NLch Bed sq. R
Bottkiii h area
ft. rock/ sq. ft.
per running it.
min. below drainlines or
of area
Vs
lE1/, fVA
Leachlines/bed'spec� for sb
(3)'PR 66r"r' y
No: Pits
PitBetim
''L -, Seepage Pit Totel'Depth.
W16 `
Inlet BI
1
/
N/A Ll Overburden factor
r- R t/
j✓=+.t
c.y'
Max. Allowable Depth F
T r,
u
No. 2 System A11/A_ l3�r
REMARKS: �> ¢ y, y:Lu. 7`dsr O yr,c,.," ..�ir G /f ✓ w o,� pe�,Q d.
..:A:.c�(�a:/ 3-�a>C.iA:.Ga:..a. ,�• � � . B l -P "e+ir.o. ' .I,vJ i/..
�� //�-a.-.s
Ale"11 1-1) C2v'.vt�/L/n.�... /.-?^�.q..rE�"' d.l A ^./ /IPJ... i .� r �.Y/�.l�aLt-.. .t .mss." •.
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This application 'los PROVED _EMI for the category checked in SECTION B above, regarding the design of a subsurface disposal system as indicated
on the accompanQ-1516t-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.
(1) Septic tank and sewer lines must be 50' meq yrp,frem awy wells
(2) Leach lines mus 00 minimum from any wells, including expansion area
(} Seepage pits must be 150' minimum from any wells, including expansion area -1/0
j!
/"Il.�� ll.J Y_/fe
Signature of Health Official''L`�` Date �(
mss;
1-
1-V
/< 7�1�i t fit.• �u e.' r /a/J �y G
RECEIPT,NO. S�� Issued By 5AK Date
i
DISTRICT:',*7 ❑ ` Riverside,Indio ❑ Hemet 'C7, Perris 0. Rancho Calif. 0 Blythe
t� '
! DOH SAN 122 (Rev. 5/88) DISTRIBUTION: WHITE - Office file YELLOW - Applicant . PINK - Bldg. Dept' GOLDENROD - Plans/Records
Post Office Box U Cathedral City, CA 92234 e (619) 328-1747
License .#256154-n
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HENDRICKSON CONSTRUCTION, INC;.
General Engineering Contractor •Underground Specialists
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Post Office Box U Cathedral City, CA 92234 e (619) 328-1747
License .#256154-n
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