0692 (AR)1
' PEflM1T APPLICATION
City of La Ouinta
• Department of Building and Safety -.
BOK
PAG
x 'This'permit becomes void if work'not commenced. within 180 days from date of
issuance, -OR, if -work has been suspended or abandoned for a period of 180 days. '
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section neednot be completed if' .. ;
LICENSED CONTRACTORS DECLARATION: I ;herebyaffirm that :f am licensed under provisions of Chapter 9 .
the-permitis for one.hundred ($100) o;'less. I certify that in the.performance of the work for which this permit is '
' (commencing with Section 7000).of Division 3 of the Business'and Professiohs Code; and my license is in full force
.. " issued, I shall not employ any person in anymanner,so as to become subject to the Workers'Compensation Laws of .. -.
and effect.
California.
License Class. Lic. Number
Date Applicant -
Date ' Contractor -
:. NOTICE TO APPLICANT: if, alter making. this. Certificate of Exemption, you should become subject to the Workers -
OWNER -BUILDER DECLARATION: 'Thereby affirm that I am exempt from the Contractor's License Law for the
Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall
be deemed revoked.
• . following reason (Sec. 7031,5: Business and Professions Code:. Any city or county which requires a permit to . .
ADDRESS
construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
such.permit to file a signed statement thal,he is licensed pursuant to the provisions of the Contractor.'s License Law ..
YO 1 hereby certify thafno excavation five (5) or more feet in depth into which a person is required'to descend, will be •= • '
..,(Chapter 9 (commencing with section 7000) of Division.3 of the Business and, Professions Code) or that he is exempt•
made in connection with work authorized by thi's permit, and that no building structure, scaffolding, false vork; dr
therefrom and the basis for the alleged exemption. -Any violation of Section 7031.5 by any applicant for i permit . -
demolition or dismantling thereof !J/ill be more than thirty -.six (36) feet high. (Chap 3.2,.Grp 2, Art 2, Sec341,-Title 8,
subjects the applicant to a civil penalty of not more than five hundred dollars ($500.):
-C.A.C.) V"'•' •'• ' '
O I. as owner of the properly, or,my employees with wages as their sole compensation, will do,the work, and.the,'
0 As owner -budder, I will:not employ anyone to do work which would require a permit from the Division of. .
structure is not intended or offered for sale (Sec. 7044: Business and Professions Code: The Contractor's License-
Industrial Safety; as *noted above, unless such person has a permit to do such work" from that division..
Law does not apply to an owner of property who builds, or improves thereon, avid who does such work himself orr
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through his own employees, provided that such improvements are.not intended or offered for sale. If, however,,the
O Division of Industrial SafetyPermit No.'
- building or improvemnt jAspld w.ithin one. year of completion, the owner-builderwill havethe burden of proving that.
Date Applicant'
he did not build or improve for -the, purpose of sale.).
CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the pertormance '
O I, as owner of the property, am exculsively contracting with licensed contractors.to construct the project•(Sec:•
.'• of the work -for which this permit is issued (Sec. 3097, Civ: C.).
• 7044.,Business and Professions Code: The Contractor's License Law does not apply.to an owner of property,who .
Lender's'Name
builds or improves thereon, and who contracts for such projects with a contractor(s) licensed pursuant to.lhe +
Contractor's License Law.). _.•.
Lender's Address -
•.
O.f am exempt under. -Sec. f' ..B. 8 P.C..(Attached Certificate)..
I certify that I have read`this applicatian,and state that the above intormation.is correct. I agree.to comply.with all
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Date 1.l Owner ���'� l.7 •�%%��% -r l'`-'' tii/��i
cit and count
Y y ordinances and state laws relating4o building construction, and hereby authorize representatives
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of this county to enter upon the above-mentioned property for inspection purposes.
WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of:consent to self -insure, or a '
certificate of Workers' Compensation Insurance ..or a certified copy thereof -(Sev3800.'Lab. Cr).^
Signature'ot Applicant or Agent Date''
Policy No, Company
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRiJ certify l have read this application and state that
❑ Certified copy is hereby furnished.
the information given is correct. I agree to comply with'.all state laws and county ordinances relating to buidling
O Certified copy is filed with the City Building Inspection Department or City Department.
construction, and authorize a' representative of the City of La Ouinta Department of Building and Safety to enter
upon the property for which I have applied for this permit for the purpose of making inspections.
Date Applicant
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Signature of Applicant or Agent Date
CANT NAM (L; F. MI \ "• ,
'CITY/COMMUNITY/STATE/ZIP - • '\f.
JOB SITE ADDRESS/SPACE :
CITY/COMMUNITY/STATE/ZIP- +.
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TRACT NAME
OWNER NAME (L, F. MI) - - -.
CONTRACTOR -FIRM NAME - ..
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ADDRESS
CITY/COMMUNITY/STATE/ZIP ,
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LICNC II-
ARC/ENG FIRM NAME• ..
ADDRESS -•
CITY/COMMUNITY/STATE/ZIP
PHONE •
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USE OF PERMIT
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END
SIDE .
Print Applicant/Agent Name
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M AN - 41984
City Of La Qui..,a
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TOTAL
FEE •
• VALUATION �/�
BLDG. DEPT.
I111111iiP
NO.
OPERATION DATE
INSPECTOR
NO.
OPERATION DATE PNSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
1
Set Back
33
Ventilation System
2
Ftgs & Frms
34.
Plenums & Ducts
2A
Slab Grade
35
Furnace Compart.
3
Steel
36
Inlets & Outlets
4
Grout Blocks
37
Combustion Air
5
Bond Beams
38
Compressor
6
Roof Deck
39
Appl. Clearance
7
Framing
40
Fire Damper
8
Vents
41
Smoke Detection Device
9
Garage Fire Wall
42
Commercial Hood
10
Fireplace P. L.
❑
43
Final
10A
Fireplace T.O.
❑
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ADDITIONAL INFORMATION
SEWAGE SYSTEM -SIZE & LOCATION
11 Exterior Lath
12 Internal Lath
12A Drywall ,Z
13 Finish Grade
INSULATION Thick R
Value
7A Walls (Batts)
12B Ceiling (Batts)
12C Ceiling (Blown)
14 Final
PLUMBING APPROVALS
15 Ground Plumb
16 Water Piping
17 Rough Plumb
18 Vents
19 Sewage Disposal
20 Sewer
21 Water Heater
22 Water Softener
23 Water Service
24 Gas Test
25 Final
Tank Pit L. Line
ELECTRIC APPROVALS
REAR OF PROPERTY LINE
P P)
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final
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773 2,2 -3 -Doi
RIVERSIDE COUNTY DEPARTMENT OF HEALTH
PERMIT APPLICATION FOR A SUBSURFACE DISPOSAL SYSTEM
Applicant: Submit this form with three copies'of a scaled plot plan drawn to county specifications required on the
attached check list. A non refundable filing fee of $15 is required when the application is submitted. Check must be
made payable to County of Riverside.
Name
EV L Nn SoV
Mailing Address
L) VA k- 7
( _7 1"
City
State
Zip Code
Phone
�'•
CALtt
i r
4 IS
*Property Address
A A) FI
1*0ty orC-emmun"
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*Legal Description of Property (Lot, Parcel,yMap, Tract)
"~ 4J l 1 ( l / 1,— ez r-I�.. = G�J> LG svFi" V
*Assessors Parcel No.
Water Serving Property From
Lot size
M - 4j
Signature of Applicant Date { .
*The above information must be verified from Building Application
Staff Use — Do Not Write Below This Line
Initial Date
WQCB Clearance required Yes ❑ No�
Soils feasibility report required Yes ❑ No
Detailed boring report required Yes ElN.o
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Detailed contour plot required Yes ❑ No +
Comments:
Soils or boring report by Date
Approved by e a� ,�ell, 4 /U
�e U�
Soils Map Page Soil Type t Tract File No. her
Number of Bedrooms
IDUJT1134 On/GY
�3gpn
Septic Tank Size (gallons)
/�
Rate Required
4f
y9 /� c
Type of System
New /Add❑ition Replacement
/(�OAvxf /!��77i ACi4+At A.
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Leach line sq. ft. of bottom area trench
Leach bed (sq. ft. of bottom area bed)
Seepage Pit Diameter.%w
Number of Pits
Seepage.Pit Depth B.I. /
Total Depth of Pit C
Location of qystem
Additional RequiremenQJ_t 1�Q1/�_(. 1�.�.tC..yj ��,,..�,,, , iU e-,,
6 �a'i'�2��//'�!
-.r,� i f' �° 1 ;,y^.- 7`�i 11 G'.xrlir,.l1 /.1�s�fr7tPP.lt'.9.:^• tr
A permit is aapptoved./d.era:ied forthe design of�`afsubsurface dls'posal system as mdlcate�d on the a�ccompanledsplo pl9n
using the requirements set forth in Section B above. A building permit is necessary for the installation of the above
designed system.
Signature of Health Official / Date
��-Receipt No. 5 F4 Issued By
District: Riverside ❑ Indio .LTJ Hemet ❑ Date
DISTRIBUTION: WHITE - Office File YELLOW - Applicant
DOH SAN 122 (Rev 10/82)
PINK - Building Dept. GOLDENROD - Pending File