05555 (PLBG)A,11,1 ng 52-940 9ALLWO-
t.t�o
Ti -tit 4.4 Qul�&
P.O. BOX 1504
78-105 CALLE ESTADO
LA QUINTA, CALIFORNIA 92253
Owner
MIMIC IINC
Mailing
Address SAU
ME
City Zip Tel.
LA QUINTA 92253 `
Contractor
RMRZCKSON CONST.
Address
68-315 KEBUY RD
City Zip Tel.
CIAIVWRAT. CITY 92234 328-1747
State Lic. City
& Classif. 235184 Lic. # 194
Arch., Engr.,
Designer
Address Tel.
City I Zip I State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
7000) of Division 3 of the Business �a.-nsd,Professions Code, and my license is in full force and
SIGNATURE "' ♦. "t DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the following
reason: (Sec. 7031.5,Business and Professions Code: Any city or county which requires a
permit to construct, after, improve, demolish, or repair any structure, prior to its issuance also
requires the applicant for such permit to rile 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 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 applicant to a ciw7 penalty of not more than rive 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 Contractor's License Law does not apply to an owner of property who
builds or 'reproves 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
orimprovement is sold wither one year of completion, the owner -builder will have the burden
of proving that he did not build or improve for the purpose of sale.)
❑ 1, 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 builds or improves thereon, and who contracts for
such projects with a contractor(s) licensed pursuant to the Contractor's License Law.)
❑ I am exempt under Sec B. & 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, there 3800, Labor Code.)
Policy No Company \ £ t
❑ 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 permit is for one hundred dollars (8100) 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 APPLICANT: ft, after making this Certificate of Exemption you should become
subject to the workers' Compensation provisions of the Labor Code, you must forthwith
comply with such provisions or this permit she!/ 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, Civil Code.)
Lenders Name
Lenders Address
This is a building permit when properly filled out, signed and validated, and is subject to
expiration it work thereunder is suspended for 180 days.
I certify that I have read this application and state that the above information is correct.
Iagree 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. 45555
11L"DING: TYPE CONST..00C,. .00C: GRP.
P. Number 773-324-010
:gal Description
oject Description SACS FIT
Sq. Ft.
Size
New ❑
No.
Stories
Add ❑ Alter ❑
IEstimated valuation 12,00
PERMIT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
S.M.I.
Grading
Driveway Enc.
No. Dw.
Units
Repair ❑
Demolition ❑
AMOUNT
Infrastructure
TOTAL
4,
REMARKS
.<��R,-..� .� 'T
VV" 1: t n nlf 5,' .ir- + t: • `r i a x < + -
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 DATE INSPECTOR
Issued by: Date 3127/89 Permit
Validated by:
Validation:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
IST FL. SO. FT. ® $
UNITS
SLAB GRADE
ROUGH PLUMB.
BONDING
YARD SPKLR SYSTEM
2ND FL SO. FT.
FORMS
SEWER OR SEPTIC TANK
ROUGH WIRING
MOBILEHOME SVC.
BAR SINK
POR. SO, FT. ®
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
POWER OUTLET
ROOF DRAINS
GAR. SO. FT. ®
TEMP. POLE
GROUT
DRAINAGE PIPING
CAR P. SO. FT. ®
FINAL INSP.
WALL SD. FT.
WATER SYSTEM
DRINKING FOUNTAIN.
GRADING
Cu. yd.
$ -Plus-X$-=$
URINAL
SO FT ®
FINAL INSP.
FRAMING
ESTIMATED CONSTRUCTION VALUATION $
WATER PIPING
NOTE: Not to be used as property tax valuation
FLOOR DRAIN
MECHANICAL FEES
WATER SOFTENER
VENT SYSTEM FAN EVAP.000L HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
FIRE ZONE ROOFING '
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
FIREPLACE
LAUNDRYTRAY
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 ® 1% c
SEWAGE DISPOSAL
SO.FT.GAR ® V4c
HOUSE SEWER
FINAL INSPECTION
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
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.
FRAMING
FINAL INSP.
ROOFING
REMARKS:
VENTILATION
FIRE ZONE ROOFING '
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATIONISOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESIINRIALS
GARDEN WALL FINAL
AVkM
WAN, ►s 'c'�' t"''a T'1 t_�'�' 4 �}�.. t`-- � Jr,�; cj,
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COUNTY OF RIVERSIDE DEPARTMENT OF HEALTH Assessors Parcel No.
ENVIRONMENTAL HEALTH SERVICES 7 -3d V `- 0/0 -
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.
VERIFY ITEMS IN'SECTION-A FROM BUILDING d SAFETY APPLICATION BUILDING DEPARTMENT APPLICATION LOG'*
Agent, Contractor, Contact Person/nom
Phone
Address &Phone r
(+
^.. G lA T
1-7
q
/n F, I1 1
Owner
Phone .
Mailing Address
j
1 i en
City
State
[OAL
Zip
Job Property Address
Legal Desciption� Prop,. M, Tract Lot)
Q. %
rr I z:� P r A
T/ �� tr
Lot Sizer
c ter A CWelI
Use of Permit P/P, CU, etc.
Other /
l
f
V X/00
S
.c Ay. -h) ��r.�'.
.��.,Ty gip_
✓
�' ' a
llm
DweH ,Site. Prep, etc.
Date
Signature of Applicant s
CATEGORY: REV CODE FEE_
SUBSURFACE
CATEGORY: REV CODE FEE; ;-
�' DISPOSAL 1238 $45 00
❑ SITE EVALUATION UPON REQUEST 7349 $42.00
❑ , MULTIPLE PARCELS WITHIN SAME
(NO PLOT PLAN)
LAND DIVISION
❑ SEWER/SEPTIC VERIFICATION 7348 $11.00
a. 1 at 4 Parcels (Each) 1238 $45.00
(Lass 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)
(1- Stte Evaluation in Conjunction with
❑ HOLDING TANK 7351 $45.00
Crttk:al Area 7346 $86.00
❑ ' ALTERNATIVE/EXPERIMENTAL 7345 $13200
❑ Site Evaluation Lot Less than
SYSTEM
10,000 Sq. Ft. J 7347 $86.00 ,
�/ //,,INITIAL DATE
{��1-
Holding Tank Agreements Completed ❑ Yes • 12 No r; 3 — 7
Certification" of Existing S.D. System Required ❑ Yes oo
WOCB Clearance required. (Attach Form• ❑ Yes C , No ,
DOH SAN 007, Santa Ana Region Only)
Soils Percolation Report Required_ ❑ Yes No' S
Special Feasibility Boring Report Required. ❑ Yes ID No
Detailed Contour Plot Plans Required (1 to 5 R interval), ❑ Yes 040
❑ Yes
Other'
Staff Specialist Lot Inspection Required ❑ Yes Q No
Lot Inspection Date
Soils boring report by' # Date
/Project
Soils Map Page '/ Solt Type Approved by /k-(� ,12 • Dame
No. of Systems'
Typu of Systems)
Tank 0Existi
No. Dwelling Units; T7
Bedroom��Un
r (1) Septic Tank
Soil Rate
Greae/Send
�ra<p
Oming
t
0 Replacement
E X l sr �QOA4j- 41Aik
(! aoo
^ /dam
n
Gal
7.
Gel
•
(2� Line Sq. Ft
Sidewall allowance
Ir sWP---- Line(s) ft long ft wide with
L� Bed sq. tL
rq�h area
R rook/ sq. R
min. irx r�i�&10below drainihes or
of bottom,area
per running ft
IRNA
ADS
Leschlines/bed special design for slope:
(3) Pit Diameter
No. Pits
Seepage Pit Total Depth "
Other.
Applicable
/
1Max.
Fn('B
�Q r
Allowable Depih
N/A Overburden factor
-0805 L1✓6
No. 2 System 7
REMARKS: $ ,m 7
..„ n �✓le.r.e,. .n ..,•.nom :..rr t
This application' APPRNtEI) for the category checked in SECTION B above, regarding the design of a subsurface disposal system as indicated
on the accompanied plo pan, 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' minimum from any wells
Leach lines must be 100' minimum from any wells, including expansion area
(3) Seepage pits must be 150' minimum from any,,.welis, including expansion areacJ j p y. 7r o 4k sem-
G¢-�e�..�.f /,%% '✓;;'3 • 3. � ��'
�o�
Signature of Health Official !� �G,: [ �Dete %%c.• ^ c G+D.
RECEIPT NO. Issued By Date S-'' �• 3 ".�%� �'''�
DISTRICT: ❑ Riverside, El-lndio ❑ Hemet Q Perris ❑ Rancho Calif. ❑ Blythe l ;:•:
DOH SAN 122 (Rev. 5/68) DISTRIBUTION: WHITE - Office file j, ; YELLOW - Applicant • PINK: Bldg. Dept GOLDENROD - Plans/Records
f�
tj 112 i c2 rJ C_
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HENDRICKSON CONSTRUCTION, INIG.
General Engineering Contractor Undergroond Specialis?s
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Post Office Box U e Cathedral City, CA 92234 (619) 328-1747
J
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DIVISM"m OXF
Tra-!'er Park
Vutd, Apt., Ha*,cl
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This Is to m -thy t,,,at ts., 'v r6rn-;,-1 C4
InsWilation the bu.W dw&M C. sra.
Data 3-
MAIMAINIOMWMSIMMARMI./S-O/ . .
Mli*41.10'FPtCMAWggftgM-=.M;VATM —FWMMYMAII-�
10
ot
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not nnlia-;-k� t},.
I'm Cr Architect
Tier
H N T, j-� for the bc jDaer-lar.
OJ V11i P, -R (1) YEAR
D
-ROVAL
FROM DAT -E ff APP