06491 (SFD)Building 53_925 Vallejo
Address
Owner
Max Reefer
Mailing
Address P&Aa&xc Mt r
City ,. _:: Zip
Contractor
c;64
4
P.O. BOX 1504 No.
78-105 CALLE ESTADO
--LA QUINTA, CALIFORNIA 92253
Gallant C.oustauction.
Address
. 52-$23 Bermudas
City r lZip
"State Lic.
5 & Classif. 220017
Arch., Engr.,
Designer
Tel.
323-$235
Tela
b64-4470
City
Lic. # . 1448
Tel.
City Zip State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed unde,-provii&ons.of Chapter 9 (commencing with Section
7000) of Division 3 o the Business amdtiKfessions;'C,ode, and my license is in full force and
effect. + � t' � r •- Yx�}�_ ` r �.r?t`i� .
l
SIGNATURE DATE
OWNER -BUILDER DECLARATION
I her affirm that 1 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
le , 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
• -Di'vision 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 civil 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 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
orimprovement is sold within one year of completion, the owner -bulkier 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.)
O 1 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
Workers Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy No. Company
❑ Copy is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM.
WORKERS' COMPENSATION INSURANCE
(This section need riot be completed If the permit is for one hundred dollars ($100) 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 mannerso as to become subject to the Workers' Compensation
Laws of California.
Date Owner
NOTICE TO APPLICANT. N, 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 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, Civil Code.)
Lenders Name
Lenders Address
This is a building permit when properly filled out, signed and validated, and is subject to
expiration if work thereunder is suspended for 180 days. .
I cerlity that I. have read this application and state thatthe 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
06491'
BUILDING: TYPE CONST: OCC. GRP.
A.P. Number 774-162-022
Legal Description
Project Description STM
Sq. Ft. 1495 No. No. Dw.
Size Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
a
Estimated Valuation
$82,236
PERMIT
-
Plan Chk. Dep.
$250.0
Plan Chk. Bal.
Const.
Mech.
Electrical
INSPECTOR
Plumbing
S.M.I.
Grading
Date Permit
Driveway Enc.
Infrastructure
Validation:
TOTAL
$3.232.
REMARKS
AMOUNT
LJf aJV
2€3.010
20.00
3,831.20
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 Permit
Validated by:
Validation:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL. SO. FT. ® $
UNITS
SLAB GRADE
ROUGH PLUMB.
BONDING
YARD SPKLR SYSTEM
2ND FL SQ. FT. ®
FORMS
SEWER OR SEPTIC TANK
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
CARP. SQ. FT. ®
FINAL INSP.
BOND BEAM
WATER SYSTEM
DRINKING FOUNTAIN
WALL SO. FT. ®
_$
LUMBER GR.
FINAL INSP. Z �7
URINAL
SQ. FT.
ROOFING4(�(,i
ESTIMATED CONSTRUCTION VALUATION $
WATER PIPING
NOTE: Not to be used as property tax valuation
FLOOR DRAIN
MECHANICAL FEES
VENTILATION
I WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
FIREPLACE
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
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.
SQ. FT. ® c
BATH TUB
SQ. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SQ. FT. RESID ® 1Vi c
SEWAGE DISPOSAL
SQ.FT.GAR ® V4c
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�
MBIN i
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 APPJEQUIP.
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. Z �7
FRAMING / Qn
FINAL INSP.
ROOFING4(�(,i
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING TOWN
MESH
INSULATIONISOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURES/INITIALS
GARDEN WALL FINAL
t)1 t u,E ur E. EEOII SPnt;r,Y
co.fn�,ur.tn
AGIUCUL I URAL CONIMISSI(OILat )ANiES o v:nLVA(:
niVUUUMEyI [tF.NVEhIS1E•
bi MEASURE'S SLAM
r' �� ��i'j•
/ — 116 Iltt[te 11-12
tog-613 61 J 1 IW Y
".C',tile 1 In o CA 92236
619-.342-0291
J
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d
1�UUhES5 t .cam. � � 9/
war Developers
v eAls our landsc[Ip lq 11101 s� ttll lliftllt nyterlal list Cdsu�stitutsivlts
1►[ ter re i y YC.ac.
1
violotiou o[ yuat'311 Ile 1[rttult�laittlnylelri 1 listed l,,iseo[[lce must he rsotlEied
do occur mid they dl[[er 1
ismp-diately.
u Lor �rvtectllly 011d p,eservljq the Coachella Valiey's ,est -tree envirolrl>esslr.
Thank you I
nycultutal %ani ssiierl s ul [ ice
ccs Indio and Itiverside.U[[Ice /
(1_,A+ U. L Z-c9� /h V L Y R L LTJ
e) p lel
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COUNTY OF RIVERSIDE DEPARTMENT OF HEALTH Assessors Parcel No.
ENVIRONMENTAL HEALTH SERVICES ��'� — 0 2'
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 checklist.
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 8 SAFETY APPLICATION BUILDING DEPARTMENT APPLICATION LOG #
Agent, Contractor, Contact Person
taJ CLl"
Phone
317'
Address & Phone
St-
t.Own�o
1 I,
61470
er _
Owner
Phone
Mailing Address'
City
RA Fly, l rr
State
��
Zip
�zz7v
Job Property Address
( a ,
Legal Description Prop. (PM, Tract, Lot>�aT /! 646
�� A rac
Lot Size
r,A, gency II
Use of Permit P/P, CU, etc..X0 !c.y' `
o�G
Other �0. � P. L � QV !�✓?
r r
�
ViV1T Z
elling ILIV p, etc-
% Signature of Applicant
Date
��,��-� CATEGORY: '.I REV CODE FEE
CATEGORY: REV CODE FEE
Q"1SUBSURFACE DISPOSAL 12387
0 SITE EVALUATION UPON REQUEST 7349 $42.00
❑ MULTIPLE PARCELS WITHIN SAME
(NO PLOT PLAN)
LAND DIVISION
❑ SEWER/SEPTIC VERIFICATION 7348 $11.00
a. 1 st 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)
❑ Site Evaluation in Conjunction with
❑ 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
INITIAL DATE
Holding Tank Agreements Completed ❑ Yes V<o t d"
Certification of Existing S.D..System Required ❑ Yesto
WQCB Clearance required. (Attach Form - ❑ YesNO
DOH SAN 007, Santa Ana Region Only)
Soils Percolation Report Required. ❑ YesNo
Special Feasibility Boring Report Required. ❑ YesNB" o
Detailed Contour Plot Plans Required (1 to 5 ft. interval) ❑ Yes
Other ❑ Yes %
Staff Specialist Lot Inspection Required ❑ Yes �Io
_ Lot Inspection Date
Soils boring report by Projekt # Date
�+
Soils Map Page Soil Type C Approved by Date
No. of Systems
T;9 of System(s)
Holding Tank ❑ Existing
No. Dwelling Units t
Bedrooms, Rodarmb'ni fs'
(1) Septic Tank
Soil Rate
Great s%
a Intcp
ew ❑Replacement
/i¢y) al
rG
Gal
(2)� each Line Sq. Ft.
Sidewall allowance
Install_ Line(s) fL long ft wide with
Leach Bed sq. ft.
Botto ench area
fL rock/ sq. ft.
min."aa i�nch�.reck below drainlines or
o£trotto y areFA, �a
per running ft.
Leachlines/bed special design for slope:
(3) Pit Diameter
No. Pits
Pit Below
Seepage Pit/Total Depth
�T
er:
Applicable
k
/�/f
0=5.a"
!
Inlet (BI)
%CL
Maooyable Depth
N/A Overburden factor
No. 2 System NI.A
REMARKS ~• L�K1/f L�"'���� � ��r✓/0 ��s"�e-�'�- E^-�it..��.e,...
-�-. /7.�`f �
p.�
This application is(APPROVED/ EMED"for the category checked in SECTION B above, regarding the design of a subsurface disposal system as indicated
on the accompanied p o an, 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.
PSeptic tank and sewer lines must be 50' minimum from any wells
2)Leach lines must be 100' minimum from any wells, including expansion rea
_
3) Seepage pits must be�150' minimum from any wells?including expansior5 area!at
Si nature of Health Official .- Gc„�.fw!r( �(/. fJ kf"' /3
RECEIPT NO. (� Issued By le Date n -la - 2
DISTRICT, .❑. Riverside, ❑.fodI dio ❑ Hemet ❑ Perris ❑ Rancho Calif. 0 Blythe
i. DOH SAN 1.22 (Rev. 5/88) DISTRIBUTION: WHITE - Office file YELLOW -Applicant PINK -.Bldg. Dept. GOLDENROD - Plans/Records
,G'04
COACHELLA VALLEY WATER DISTRICT
c CASH RECEIPT DETAIL. Y X8"33
Receh-ad F `� Date
Addms3: p
Aocount No: U* o s) ;Tract
_ R
SeMceAddress. ' ,
3 G.A. Code
aF ` Meter(s) .' / t S,
O Backflow(s)
O Houee Laterals)
O DetectorCheck(s)
O MeterSurcharge ,
Sanitation Capacity Charge
O WS.B.F.C.
+ O Temporary Construction Meter
❑ Tum on Charge; J -
❑ Uncollected Account - Name
OflnspectionFee Tract-'
H
. • FN - ��Y�r •
O Plan Check Fees Water /Sewer -
Tract -
O Bond Payment - A.D. Bond
. 'Assmt-
O Customer Deposit '
D Other
r r,� TOTAL S
Remarks: a 1
OCopy to:
Cash r f i t t w ��,.r ,':a Water Service
w.. Check
"'. Money `if ! z Cashler, zy sk
+{. Ofder. _ ' jr.�Lr � tr+� � t � ' Y '• ' i . a j. r"�Y ti
s ' ,� ' S' • � 4 1 ', �-a
if