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0204-042 (PLBG)LICENSED CONTRACTOR DECLARATION I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and " Professionals Code, and my License is in full force and effect. ',4 - * License # Lic. Class Exp. Date 6541 +1157 AMC MOPI Date �f� f Signature of ContractorA✓%�^��'�p'�% OWNER -BUILDER DECLARATION I hereby affirm under penalty of perjury that I am exempt from the Contractor's License Law for the following reason: ( ) 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, Business & Professionals Code). ( ) I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business & Professionals Code). ( ) I am exempt under Section , B&P.C. for this reason Date, Signature of Owner �``Pi WORKER'S COMPENSATION DECLARATION r r' I hereby affirm under penalty of perjury one of the following declarations: ( ) I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. (,). I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation insurance carrier & policy no. are: Carrier , STATE MD .. Policy No. Dor-164003.02 _ (This section need not be completed if the permit valuation is for $100.00 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, and agree that if I should become subject to the workers' compensation provisions of Section 3700 of the Labor Code, I sh II fo hwith comply with hose pr vlslo • s., !` Date: Warning: Failure to secure Workers' Compensation coverage is unlawful and shall subject an employer to criminal penalties and civil fines up to $100,000, in addition to the cost of compensation, damages as provided for in Section 3706 of the Labor Code, interest and attorney's fees. IMPORTANT Application is hereby made to the Director of Building and Safety for a permit subject to the conditions and restrictions set forth on his application. 1. Each person upon whose behalf this application -is made & each person of whose request and for whose benefit work is performed under or pursuant to any permit issued as a result of this applicaton agrees to, & shall, indemnify & hold harmless the City of La Quinta, its officers, agents and employees. 2. Any permit issued as a result of this application becomes null and void if work is not commenced within 180 days from date of issuance of such permit, or cessation of work for 180 days will subject permit to cancellation. I certify that I have read this application and state that the above information is correct. I agree to comply with all City, and State laws relating to the building construction, and hereby authorize representatives of this City to enter upon the above-mentioned property for inspection purpose ; rAgent)'4 sr _`46Signature (OwneDate z�1 BUILDI NG PERMIT PERMIT/J 0204•:4: DATE VALUATION s.2,,s c LOT TRACT JOB SITE -4 APN ADDRESS 78472 CALLIUMERTA e OWNER CONTRACTOR / DESIGNER / EN INEER M1 11*11$1C7:[H kit ADltI.i,"KSON C: ft3W•SM.M't Olq 1A QTJR4TA CA 92253 CKMEDRAL CffT CA 922-34 ,(760)326-1747 QR140 194 USE OF PERMIT } VAk,i,7ATI01f ESUS►,Op 1 EsumAITI) COST OF, CONMUCICTOV MMM117M SUMMARY PlIVIMS3M ME 101-0004 1 �•VXJ 21 �5-'toTAL C"z71�t�i` vcT1:oiq,�i75 pi.t�, 4:r�� mx $60.00 -�- - 1E P*I' S $010151 APR 04 2002 MYOFLAQUINTA RECEIPT DATE :BY DATE FINALED INSPECTOR ti INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs Underground Ducts Forms & Footings Ducts - Slab Grade Return Air Steel Combustion Air Roof Deck Exhaust Fans O.K. to Wrap F.A.U. .Framing Compressor Insulation Vents Fireplace P.L. Grills Fireplace T.O. Fans & Controls Party Wall Insulation Condensate Lines Party Wall Firewall Exterior Lath Drywall - Int. Lath Final Final BLOCKWALL APPROVALS POOLS - SPAS Steel Set Backs Electric Bond Footings Main Drain Bond Beam Approval to Cover Equipment Location Underground Electric Underground Plbg. Test Final I Gas Piping PLUMBING APPRO�."ALS Gas Test Electric Final Waste Lines _ _ Heater Final Water Piping Plumbing Final Plumbing Top Out Equipment Enclosure ,Shower Pans O.K. for Finish Plaster Sewer Lateral .Sewer Connection =y'- Z Pool Cover Encapsulation Gas Piping. Gas Test Appliances Final Final —(7 ILI Utility Notice (Gas) ELECTRICAL A/F)PROVALS Temp. Power Pole Underground Conduit Rough Wiring Low Voltage Wiring Fixtures Main Service Sub Panels, Exterior Receptacles G.F.I. Smoke Detectors Temp. Use of Power Final Utility Notice (Perm) COMMENTS: COUNTY OF RIVERSIDE COMMUNITY HEALTH AGENCY ASSESSOR'S PARCEL NUMBER DEPARTMENT V6 JA OBD OF ENVIRONMENTAL HEALTH — — .APPLICATION FOR WASTE WATER DISPOSAL APPROVAL APPLICANT: Submit this form with four copies of a SCALED plot plan (1"=20' to V=40' SCALE) drawn to County specifications as indicated on the attached check list. A non-refundable filing fee 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 payment. LLMS,l- C'�`%� of LA M -17-A A e t Contractor, Contact Person gAJenv-IGtC�s0A)(OttJ1,_T Address City State Zip 6 )f 37 Ali4 , � �'. (.. i5;,lux3f! Telephone Zel 7 Q Owner '` �j�[ Addrees�s r / �f Ciry,�/ / �� State Zip / /' / /7 i 2�/ i / iT r Jl q / /�i/✓ i7 /d c.I 6%• q.1- G, Telephone OJob o Property Ad11ess r}�, City/ �.�- / i7 V7o�.1/� 1� r7G/✓r ! l�. 't h !�f.4 t s / Esc Zip, �En d1+ u Lot Size `Nater Agenc ell /'ylt7jvb �� C14 t a Ac. r/� Use of Permit /P, au ��%iG�. i /?� Tv �,- Legal Legal Descriptio / �,�� %d /QCT DBX1 .'� S`c"/ a 14ri'/L Del'QIGr Dw4in�Pltki�it"e.P,tep�:etc.Syl7� Signature of ApLpljcI- t t6/ '�'�'f a jrjq/t Date 41 e FOR OFFICE USE ONLY CHECK BOX IF REQUIRED If any box is checked, this application shall be considered rejected until the ❑ Detailed Contour Plot Plans Required (1 to 5 foot interval) information is provided and the fee paid. Resubmittals later than 90 days after date noted below may require repayment of fees. ❑ Other CIStaff Specialist Lot Inspection Required Z❑ Holding Tank Agreements Completed ❑ Certification of Existing S.D. System Required Thomas Bros. Page Grid . W ❑ WQCB Clearance Required ❑ Date Lot Inspection Completed: Initials U) (Attach for DOH -SAN -007, Santa Ana Region Only) ❑ Soils Percolation Report Required Remarks: ❑ Special Feasibility vBoring Report Required ❑ Maintenance Booklet Provided ❑� Rereview Required Initials Dattt�e,,�� .,,, ❑ Final Inspection by Department of Environmental Health is required. call 24 hours PRIOR to inspection. f,Pleasse (Tmrrj T W/ .E•/42'PSoils Percolation Boring Report By E/ri Lic/Project # Date Soils Map Page Soil Type Approved By Date No. of Systems If T 11V6 Type of System(s) (JHolding Tank ❑ Replacement No. Dwelling Units(/fNAy•(1 Bedrooms, Fixture Septic Tank Soil Rate Gr se/Sand ❑ New �ddittiop, TO unitsl`Nf i/. ��/44/t•M. % .1 r�'lm''wc 7,S"0 �, Greas- tcp/Lint Trap / ❑r -Existing w , EhConneci to §e,,.w,eef Mt�k' G4 Gal. S\. Ft. t3ot om Area T .fal�L'inear " Ft. Sidewall Allowance ft. rock/ sq. ft. running ft. Inlet Tested a t�h O N/A �`_AZ Ygrry Install NL'ne(s) ft. long ft. wide with min. inches rock below drainlines Leach Bed sq. ft. of Bottom Area �•, U Proposed Bottom E�i� or Z 0 Leach lines/bed special design for slope: Applicable (3) Pit Diameter N(5. its Z., k�� Pit Below Inlet (B1) 1# Seepage Pit Total Depth Maximum Allowable Other: U t-' ,..--•- 7 K � T *V/Gf Depth N/A Overburden Factor 'Or5" 6' � �S•- U)�– Well Review Approved: SIGNATURE Date: Well Drilling Permit# � � • - /// Grading Plan Approved: Date: SIGNATURE !+� Plan Check Only Approved: Date: . d REMARKS: t /�fR.t`�' Y�l '► f. iCf fig" c eI% y j ' v This appli atlon i APP ROVEDdBEMED,fo,* tye a?egur-checleed-rn -SEC:FtON*Bwa'6-o a regarding i'he design of a disposal system as indicated on the accompanied plot plan, using the requirements set forth in SECTION C above. A building permit is necessary for the installation of the above- % Revenue Code 573! 2 �% Fee $ 02. �. r� r=/ designed system. No construction is permitted in the reouir d reserved 100% expansion area. Check # (1) Septic Tank must be 100' minimum from any wells. •�; 0 -! (2) Leach lines must be 100' minimum from any wells, including lexpansion r Date "' 7' Z 0 area. Initials W(3 Sewer lines must be 50' minimum from any wells. 4� Seepage pii�ts�must bee/1�!`1 5�0'' minimum from any, wells includ�expa/� n RIVERSIDE: , area. C, /o• R't �/1�P n 909-955-8980 �G�eZ./%f�r�- ��� INDIO: 760-863-7000 .��� /• SOUTHWEST- 909-600-6180 �,G1 Signature �j✓'" Qd'Z,, Date /V0 7r�.,oar "" % O �'i P C t'%La/d DEH -SAN -122 fRav Ainii ••. .. ---v roc, . ­Lwv—. Ppucanr, rlrvn—flag. uep[.; UULULNROD—Plans/Records N COUNTY OF RIVEFSIDE HEALTH SERVICES AGENC . DEPARTMENT OF EM/IRONMENTAL HEALTH Food Sewage Disposal 126-M Trailer Park 1, Septic Tank ( 7SO 64 �� Motel, Apt., H tel ao,,,,.) Sq. Ft. f Leach Line r Dwelling ?Xln'(aivWPX, ADD /— No. � PDia�BI —le TD�S MD Seepage Pi- %N/t�( /I/, -- I �✓ Commercial Building Connection to Sewer = %�/1T/L/ D67T�o�✓Qol Swimming Pool Connect to Existing S.S.D.S.� _X_No on-site regenerating water softening devices may be discharged into the individual sewage disposal system herewith approved without clearance from the Water Ouality Control Board. %Water supply ser in hi rfn allation must be from an approved source fx/ST. All sewage dlspo�'�{i must conformwith requirementsofcurrent Uniform Plumbing Code. Any cing,gradingorfillin excess of two{2) fest will nuliifyy sewage disposal approval. _Approval has been obtained from the Regional Water Ouality Control Board for installation of the sewage disposal system. This is to certify that the Riverside County Environmental Health Servicesappr as th dace e go disposal plot plan to obtain building permit for i allation, constru . � 4 7�CT DATE ' Q,5?- BY IN MAINTAIN 100% EXPANSION AREA. MIN.= FRO A MIN- 1W FROM ANY E TREE OR WATER MAINNS iib IUrC y� 4112 l( 7� 69 FiFROM I�ENT OF PUBLIC HEAL -Approval of mese pians Dy 1Leparuneu� ut rue - Health of Riverside County does not relieve the Rn�it ID FOR ONE (1) YEM ear or Architect of the responsibility for the JhWibw ATE OF APPROVAL �e or Arehiteetural ieeiOL" CITY OF to QUINTA BUILDING & SAFETY DEPT. APPROVED FOR CONSTRUCTION DA ��A' BY 0`�/G�C�2Lj (=noN� Oni Jai E 'I - y �JRui�6f,j A RE -INSPECTION FEE"OF $30 WILL_BE CHARGED. IF THE APPROVED. -- PLANS AND 10B CARD_ ARE NOT ON THE SITE _fOR ' A _SCHEDULED INSPECTION. .NO EXCEPTIONSI .. -- ..3� yo - PIA). � � 9 A `/C7 � CT7 CITY OF LA QUINTA BUILDING A SAFETY DEPT, APPROVED FOR CONSTRUCTI BY :.