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14314 (PLBG)
4.4 P.O. BOX 1504 N o . 14 314 Building 78-411 Ave. Zia Fonda 78-495 CALLE TAMPICO Address LA QUINTA, CALIFORNIA 92253 Owner ES,zaro A2.ejo£3 Mailing Sa33II BUILDING: TYPE CONST. OCC. GRP. Address A.P. Number City Zip Tel. La .Quint1,. CA 92253. J Legal Description Contractor "Seepage • Pit Rendrickson Construe ib Project Description. ' Address .69373 kieley Rd. CLta'th*edra? ..Citi Zip CA 92234 TeI.'328-1747 State Ci & Classl fc. ... 6541-67 Lio # 194 Sq. Ft. No. No. Dw. ' Size Stories Units Arch., Engr.; Designer r New ❑ Add ❑ Alter ❑• Repair .❑ Demolition ❑ Address Tel. City Zip State Lic. # LICENSED CONTRACTOR'S DECLARATION I hereb affirrrp"that I am IicensL�:under pmvisions'of Chapter 9 (commencing with Section es 000) of�ivl/sifl�n oft a Busihe`ss and _,roffee`lbn"s Code,.and my license is in full force and �...�""� - « GfN'TU./y.(.J-�� DATE OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from, the Contractor's License Law for the following .-_ :.reason:• (Sec. 7031.5,Business and .Professions Code.. Any city or county which requiresa•' permit to construct, after, Improve, demolish, or repair any structure, prior to its issuance.also . requires the applicant for such permit to the 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 or 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 Estimated Valuation.. $3 D .000.00 - I PERMIT •. • - • AMOUNT - • 4 -' Plan Chk. Dep.' subjects the applicant to a civil penalty of not more than five hundred dollars (8500). ❑ 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 Plan Chk. Bal. COr1St. Mech. . y 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 Electrical ' 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.) + 1 .1 - Plumbing ❑ I, as owner of the property, am exclusively contracting with licensed contractors to torr 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 contractors) #caned pursuant to the Contractor's License Law.) • - - ❑ I am exempt under Sec. • B. 8 P.C. for this reason S.M.I.- Grading Driveway Enc. Date owner Infrastructure WORKERS' COMPENSATION DECLARATION I hereby 411irm that I have a certificate of consent to self -insure, or a certificate of Worker's Co 156nsation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.) Polis NoO .Company 40156py is filed with the city. O Certified copy is hereby furnished. TOTAL "� CERTIFICATE OF EXEMPTION.FROM WORKERS' COMPENSATION INSURANCE REMARKS (This section need -not be completed if the permit is for one, hundred dollars ($100) valuation or less.) - I certify that in the performance of thg 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 -Ow . ner NOTICE TO APPLICANT: ff, after making this Certificate or . 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 bedeemed revoked. - ZONE: • "BY: Minimum Setback Distances:.. _ Front Setback from C er Line Rear Setback from R ro • e WARNING: FAILURE TO SECUREWORKERS'COMPENSATIONCOVERAGE ISUNLAWFUL,'AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL. PENALTIES AND CIVIL FINES UP TO ONE -Side Street Setback Ce ne HUNDRED THOUSAND DOLLARS ($1150,000), IN ADDITION.T.O THE COST OF COMPENSATION, Side Setback from. erty Llne DAMAGES AS PROVIDED FOR IN 'SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. This is a building permit when properly filled out, signed and validated,.and is subject to expiration it work thereunder is supsppended for 180 days. 1 certif 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. FINAL DATE 17 ECTULi Issued -by: _P�rmit _ 7 Validated by - Signature of applicant Date Mailing Address Validation: ! City, State, Zip CONSTRUCTION ESTIMATE NO. ELECTRICAL FEES NO. PLUMBING FEES;, 1ST FL. SQ. FT. ® $ UNITS SLAB GRADE 2 ND FL. SQ. FT. p BONDING YARD SPKLR SYSTEM i POR. SQ. FT. ® MOBILEHOME SVC. BAR SINK GAR. SQ. FT, ® POWER OUTLET ROOF DRAINS CAR P. SO. FT. GAS (ROUGH) DRAINAGE PIPING WALL SQ. FT. ' DRINKING FOUNTAIN. SO. FT. ® TEMP. POLE URINAL ESTIMATED CONSTRUCTION VALUATION $ GROUT WATER PIPING NOTE: Not to be used as property tax valuation FINAL INSP. FLOOR DRAIN MECHANICAL FEES. WATER SYSTEM WATER'SOFTENER VENT SYSTEM FAN EVAP.COOL HOOD SIGN WASHER(AUTO)(DISH) APPLIANCE DRYER FINAL INSP. GARBAGE DISPOSAL FURNACE UNIT WALL FLOOR SUSPENDED LAUNDRY TRAY 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 SQ. FT. ® c WATER HEATER MAX. HEATER OUTPUT, B.T.U. SQ. FT. RESID ® 11/a c SEWAGE DISPOSAL GAR. FIREWALL SQ.FT.GAR ® :/ac HOUSE SEWER LATHING GAS PIPING PERMIT FEE ERMIT FEE PERMIT FEE DBL TOTAL FEES MICRO FEE MECH.FEE EPLCK.FEE CONST. FEE ELECT. FEE SMI FEE PLUMB. FEE - STRUCTURE PLUMBING I 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 EDUCT 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. ROOFING REMARKS: VENTILATION FIRE ZONE ROOFING FIREPLACE SPARK ARRESTOR ' GAR. FIREWALL LATHING MESH INSULATION/SOUND FINISH GRADING FINAL INSPECTION` CERT. OCC. FENCE FINAL INSPECTOR'S SIGNATURESIINITIALS GARDEN WALL FINAL r Q Z C U W (n m Z O U W 0 U Z U W 0 (/ ❑ CASH ®CHECRNO. 1 2-06 t RECEIPT NO. Issued By I r G /� ✓ Date I" DISTRICT- ❑ Riverside ❑ Indio ❑ Hemet ❑ Perris ❑ Rancho Calif. ❑ Blythe []Bermuda Dunes 0 � a.a DOH -SAN -122 (Rev 1/92) DISTRIBUTION: WHITE—Office file YELLOW—Applicant PINK—Bldg. Dept. GOLDENROD—Plarumeod:i i '3 COUNTY OF RIVERSIDE HEALTH SERVICES AGENCY Assessors Parcel No. DEPARTMENT OF ENVIRONMENTAL HEALTH - 7G� — —dna - /L ,( w 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. LOG # VERIFY ITEMS IN SECTION A FROM A NON -FEE BUILDING & SAFETY (goldenrod) APPLICATION Agent/contract r, ContactPerson Phone Address City State Zip % Sa Owner Phone Address City State Zip .o r 70-ty/j/S�7 Job Property Address 4CIty �, State Zip Legal Description Prop. (PM, Tract, Lot) /or/ R;, M—Al A{l.0 J, u w T P., . 420 -DB Lot Size 4 en ell Use of Permit PIP, CU, etc. ' Other C • V • LJ tz�, Dwelling, MH Site Prep, etc. � Date Signature of Arplicant CATEGORY REV CODE * CATEGORY REV CODE FEE /FEE-0 SUBSURFACE DISPOSAL (per system) 1238 $ S- 0 El/ SITE EVALUATION UPON REQUEST 7349 $� a ❑ MULTIPLE PARCELS WITHIN SAME LAND DIVISION pr /{p0• (NO PLOT PLAN) 904 ❑ SEWER/SEPTIC VERIFICATION a. 1st 4 Parcels (Each) 1238 00 7348 $ 840, ❑ PRELIMINARY ELECTIVE EVALUATION b. Each Parcel after 4 7344 $ (Attach DOH -SAN -53) 7352 $ $9:Ob cO ❑ REREVIEW (2nd review same parcel) 7344 $ Awil ❑ HOLDING TANK 7351 $16 ❑ SITE EVALUATION In Con)uction with Critical Area 7346 $ ❑ ALTERNATIVE EXPERIMENTAL SYSTEM 7345 $ CO //��QQ �•� 10,000 Sq. P.. 7347 $ ' ❑ GRADING PLAN REVIEW DETAILED 1238 $1A4f e ❑ SITE EVALUATION Lot Less than ❑ GRADING PLAN REVIEW CURSORY 1238 ❑ SECOND FIELD VISIT (SITE EVALUATION) 7348 $ AD $ _Wba El COPIES (LAND USE) 7786.81 $ 50 INITIAL DATE Holding Tank Agreements Completed ❑ Yes ❑ No Certification of Existing S.D. System Required ❑ Yes ❑ No WOCB Clearance Required ❑ Yes ❑ No (Attach Form DOH SAN 007, Santa Ana Region Only) Soils Percolation Report Required ❑ Yes ❑ No Special Feasibility Boring Report Required ❑ Yes ❑ No Detailed Contour Plot Plans Required (1 to 5 fl. interval) ❑ Yes ❑ No Grading Handout Provided ❑ Yes ❑ No Staff Specialist Lot Inspection Required ❑ Yes ❑ No Maintenance Booklet Provided ❑ Yes ❑ No Lot Inspection Date Initials C/42 / Soils Percolation Boring Report by Lic/Project # Date Soils Map Page Soil Type Approved By Date No. of Systems Type of System(s) ❑ Holding Tank j>(Replacement No. Dwelling Units (1) Septic Tank Soil Rate Grease/Sand Grease lntcp/Unt Trap fo Bedrooms Fi ure Units ey./S� ❑ New Addition❑ Existing/(I D Gal. Gal. Sq. Ft. Bottom Area Total Linear Ft. Sidewall Allowance n. rock/ eq. -n. running n. Install une(s) n. long n. wide•witn" _Leach Bed sq. ft. ,111*4 of Bottom Are Inlet Tested Depth ❑ NA min. inches rock below drelniines or Proposed B�dfom Tested Depth -~ Lsachlinea/bed special design for elope: Pec a (3) Pit Diameter No. Pits Pit Below Inlet Seepage Pit Total Depth (TD) 1- 3 / Other: Applicable ❑ 5 g' 6 (BI) I ' Max. Allowable/ Depth N/A Overburden Factor 1 t �o Well Review Approved: Signature Date Well Drilling Permit # Grading Plan Approved: Signature Date REMARKS: r L -W -a Q e Y 5/lyr-,n Sueh,^ ark, m a,,,, 44 xisL��n <C;►,>�r! 1411 / SAOA toe This application i APPROVEPIDENIED for the category checked in SECTION B above, regarding the design of a subsurface disposal system as indicated on the accompartilIdplotoen, 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 parmittad in the renuiaad reserved 1nnofi axpancinn area I (1) Septic tank must be 100' minimum from any wells (2) Leach lines must be 100' minimum from any wells, including expansion area I (3) Seepage pits must be 1150' minimum 'rom any wells, including expansion area co Signature of Health Official (/ ❑ CASH ®CHECRNO. 1 2-06 t RECEIPT NO. Issued By I r G /� ✓ Date I" DISTRICT- ❑ Riverside ❑ Indio ❑ Hemet ❑ Perris ❑ Rancho Calif. ❑ Blythe []Bermuda Dunes 0 � a.a DOH -SAN -122 (Rev 1/92) DISTRIBUTION: WHITE—Office file YELLOW—Applicant PINK—Bldg. Dept. GOLDENROD—Plarumeod:i i '3 ML2,' po-00�, A 0 4- t5-,9 ri Z A- C 76 L? HENDRICKSON CONSTRUCTION, INC. General Engineering Contractor * Underground Specialists .Post Office Box U 9 Cathedral City, CA 92234 * (619) 328-1747 License #256104-A WV'ER81DE COMWDEPARM EW CW PUBLIC ®9V181ON OF ENVIRONP MAL H&AL H Food Establishment Trail* Park al _L Sewage Dispo, Motel, Apt., Hotel Cal. Septic Tank —t°Yt 5A Dwelling >0 � Ft f Leach Line w` `` Ss2pege pit — P-' Coimmin'la! Building Connection to Sewer Swin�aning �! �l filo on-site reg®neratlAg neater softening deices May be discha system h8r0Mth n y into the fta7acisaal, se«aga disposal �^ posed without cl©aranee .corn the eater (parelity Cann?ro! Poa?d. Wmtaxr Supply ssrvi"S chis installation Must be from an a+ :o rad source. - t Al! Wwag-a disposal in;?all tion Mast celft7m Yr;th y a a U <",rrk n.s of cue rear: lir�iforM plamtsina _ An 2.Y3t` R80 aiiitls} ,; r .a. o fie. p. ' ,, has t, sn �z,�i.- rne_d ,�� t� �Ff fo¢r> (4) frit tNll nulliff .wrgat,� disco=,:l approval. A u?ro°. a.. u�, �� tea �gl Fater fD+�a!!. g dispo.-ql sy n. ' Cztnirot K• d .or in€tailaticn of the sewage This is tb c*rtite ts'I ttpa Rivf-75.169 County mpartrr.ent of public Hcalth a proves for owu nst+alia `,on flee ' i�; 6t t �yy ra. pp pansy, construction x In Wr"U"L EPAi T ENT OF PUBLIC HEAL Tg4 IS �°g,��!g ID FONR QpjE (I3 �`E��l� Septic thilk and sevjer i nes rrxsY b 900 . from any well, includinfl; expans,ca,n vrs as. Leach lines crust b,100 ft. rninimum and seepage -pits must be 150 ft. Milaimum from any wells. t ��IC-� �ib�+g5V i t�i �05�'�iE E/t�✓e+""c:.OHMEA.WIN. FROM ANY WF -Ln WtiN. 10' FROM ANY a9 P -A- GE TREE OR WA` ER MAIN. 5e-/s�l7 2 / ! 7—