05377 (SFD)P.O. BOX 1504 N o .
Building 78-105 CALLE ESTADO
Address r%A-1109 VATTPTA LA QUINTA, CALIFORNIA 92253
Owner
LUXURY HOKES INC
Mailing
Address P.O. BOX 2401
City Zip Tel.
PALL DESERT 92260 346-4614
Contractor
SAME
Zip
State Lic. I City
& Classif. 352211 Lic. #
Arch., Engr.,"
Designer
Address I Tel.
CityZip 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 and Professions Code, and my license is in full force and
effect. ° +
W e 4 ..-� d,/. gr
SIGNATURE "•~.T^ :- DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt frAm the Contractor's 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) or
Division 3 of the Business and Professions Code, or Mat. 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 five hundred dollars (8500).
❑ 1, 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. It, however, the building
or improvement is sold within 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.)
O 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 or property who builds or improves thereon, and who contracts for
such projects with a contractor(s) licensed pursuant to the Contractor's License Law.)
❑ 1 am exempt under Sec B. & P.C. for this reason
Date Owner
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. (Sec. 3800, Labor Code.)
Policy No. Company
❑ Copy is filed with the city. O Certified opy 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. If, after making this Certificate of Exemption you should become
subject to the Workers' Compensation provisions or the labor Code, you must forthwith
comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 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
Lender's 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. .
1 certity that I 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
BUILDING: TYPE CONST. OCC: GRP.
A.P. Number 774-212-020
Legal Description
Project Description SIM
05377
Sq. Ft. No. No. Dw.
Size IAM Stories Units
New ❑ Add ❑ Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation
PERMIT
AMOUNT
Plan Chk. Dep.
250.00
Plan Chk. Bal.
260.81
Const.
594. 50
Mech.
5-3.50
Electrical
1 4�
Plumbing
157 .50
S.M.I.
Grading
10.00
Driveway Enc.
20,01)
Infrastructure
I.984.54
TOTAL
i0t)' iW-)%t�L 3 45r7 €� ' *217 I 's rz� 1".42
REMARKS
�. _
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 2/22j89 Permit
Validated by:
Validation:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL. SO. FT. ® $
UNITS
COLL. AREA
o%�d_LAB GRADE
ROUGH PLUMB.
YARD SPKLR SYSTEM
2ND FL. SO. FT.
HEATING (ROUGH)
STORAGE TANK
FORMS
MOBILEHOME SVC.
BAR SINK
POR. SQ. FT. ®
DUCT WORK
ROCK STORAGE
FOUND. REINF.
POWER OUTLET
ROOF DRAINS
GAR. SQ. FT. ®
HEATING (FINAL)
OTHER APPJEQUIP.
REINF. STEEL
GAS (FINAL)
DRAINAGE PIPING
CAR P. SO. FT. ®
GROUT
WATER HEATER
DRINKING FOUNTAIN
WALL SO. FT. ®
FINAL INSP.
BOND BEAM
WATER SYSTEM
URINAL
SQ. FT. @
GRADING
cu. yd.
plus x$
_$
ESTIMATED CONSTRUCTION VALUATION $
WATER PIPING
NOTE: Not to be used as property tax valuation
FINAL INSP.
FLOOR DRAIN
MECHANICAL FEES
nREMARKS:
' _ ) 77-�
Oji 7 ��
2L
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WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTONDISH)
APPLIANCE DRYER
VENTILATION
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
FIRE ZONE ROOFING
LAUNDRY TRAY
AIR HANDLING UNIT CFM
FIREPLACE
KITCHEN SINK
ABSORPTION SYSTEM B.T.U.
TEMP USE PERMIT SVC
WATER CLOSET
COMPRESSOR HP
POLE, TEM/PERM
LAVATORY
HEATING SYSTEM FORCED GRAVITY
AMPERES SERV ENT
SHOWER
BOILER B.T.U.
SQ. FT. ® c
BATH TUB
SO. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SQ. Fr. RESID ® 11/. c
SEWAGE DISPOSAL
SO.FT.GAR ® 3/,c
HOUSE SEWER
GAS PIPING
PERMIT FEE
PERMIT FEE
PERMIT FEE
DBL
TOTAL FEES
MICRO FEE
MECH.FEE PL.CK.FEE
CONST. FEE ELECT. FEE
SMI FEE I PLUMB. FEE
STRUCTURE PLUMBING ELECTRICAL HEATING & AIR COND. SOLAR
ETBACK - - v
GROUND PLUMBING
UNDERGROUND
A.C. UNIT
COLL. AREA
o%�d_LAB 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.
FRAMING
FINAL INSP.
JJ _
OOFING
�LA�-
nREMARKS:
' _ ) 77-�
Oji 7 ��
2L
i
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J
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
/ LATHING ( J�' —6
MESH
PfNSULATIONISOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURES/INITIALS
GARDEN WALL FINAL
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COUNTY OF RIVERSIDE DEPARTMENT OF HEALTH Assessors Parcel No.
7
ENVIRONMENTAL HEALTH SERVICES
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 & SAFETY APPLICATION BUILDING DEPARTMENT APPLICATION LOG'*
t recior Peso /
(IVB
, hp � /
4 8 P
_:50
a g rasa
` ►
to
Zi
Job Property dress
- / lh1o��
l egarDescription Prop. PM, T ) U
1�` ul
Lot Size f
wale Age_ y . I
of rmit P CU, etc. (A Q (A 1 "
:�elli'gH
r ��91
Site Prep
etc.
Data
lure of Applicant
CATE6We REV CODE FEE
CATEGORY: REV CODE FEE
❑_,SUBSURFACE 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
(Less than 1 year)
b. Each Parcel after 4 40; 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/EXPEhIMENTAL 7345 $13200
❑ Site Evaluation Lot Less than
SYSTEM
10,000 Sq. Ft. 7347 $86.00
INrnk DA7
"�M� a l u
Holding Tank Agreements Completed ❑ Yes No
Certification of Existing S.D. System Required ❑ Yes No f I
WOCB Clearance required. (Attach Form ❑ Yes No
DOH SAN 007, Santa Ana Region Only)
Sills Percolation Report Required. ❑ Yes I I No
Special Feasibility Boring Report Required. Q Yes I I No
Detailed Contour Plot Plans Required (1 to 5 ft interval) ❑ Yes I I No
Other 0 Yes . No
Staff Specialist. Lot Inspection Required 0 Yes No
Lot Inspection Date ,
�J
Sills boring report by G ' Project # Date
Sills Map Page Sol Type Approved by Data
No. of Systems
Type of System(s)
No. Dwelling Unita
(1) Septic Tank
Soil Rate
Greaser Eiand
❑ Holding Tank ❑ Existing
9 New O Replacement
Bedrooms, Fixture Units
` /'
Greaei Inicp
/
1
In N 2.,Q•„ M d
00
`` S c -1
_)i<1
Gail
(2) Leach Line Sc Ft
Bottom trench area
Sidewall allowance
/sq.
Install Lines) R long ft wide with
Leach Bed eo. to
/
R rock/ _/
R
per running It. /
min. Inches rods drefnlines or
of bottom
❑ :NA
—
Leachlines/bed special design foo slope:
(3) Pit Diameter
No. Pita
PR Below
Seepage PR Total Depth
Other:
Applicable
Inlet (BI)
t g
/
N/A Overburden factor
,},�
❑ 5 % 6
t
1 r
Max. Allowable Depth
No. 2 System
REMARKS: (\,A `l 14, k AVO /• t X('O r $ ' G••� Q V.O �
�I. ISS
This application i APPROV. D/DENIED for the category checked in SECTION B above, regarding the design of a subsurface disposal system as indicated
on the accompan' plot plan, using the requirements set forth in SECTION C above. A building permit is necessary for the installation of the
abg.Tesigned system. No construction is permitted in the required reserved 100% expansion area.
/-(f)> Septic tank and sewer lines must be 50' minimum from any wells
(� Leach lines must be 100' minimum from any wells, including expansion area r�
3 Seepage pits must be 1 0' minimum from ncluding expansion area r l^^ ` � k O ` wA`i Q \1 .11, C1111 I
V
anywells
C (�S / 10
Si nature of Heaffh Offical Date
RECEIPT NO.Issued By Date 2-1�
DISTRICT: ❑ Riverside, ,� Indio ❑ Hemet 4 Perris ❑ Rancho Calif. ❑ Blythe
DOH'SAN 122 (Rev. 5/88) DISTRIBUTION: WHITE - Office file YELLOW - Applicant PINK - Bldg. Dept GOLDENROD - Plans/Records
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