9802-038 (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.
License # Lic. Class Exp. Date
42180 C21 C42 31199
ate •.p _`4r ,/,',!; Signature of Contractor
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
WORKER'S COMPENSATION DECLARATION
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 Policy No.
S rA E FUiart7 ;sryl.
(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 shall forthwith comply with those provisions.
Applicant._
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 at
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 purposes.
,Signature (Owner/Agent)/ 4 �% T Date 7
PERM'Tf
BUILDING PERMIT CONTROLN
'
DATE /ms VALUATION $I,,( LOT TRACT G 8 ® 6
JOB SITE ADDRESS Ota-.i35e ��.3r�.�`)!r•tii�.b�7QN APN `
OWNER CONTRA(CT*OR / [DESSI gGNER)/�E±NGINEER jy / p7
� i i j. i, 1►i 44Jif.♦7 , Afl ,&1 Vll'IDI-.1tCTg �� �i1 Y iflli VlM
4633; jKl- ERSON S7` . 8703 V.(w`+'3: 1)It1Vt:
LA, QjAthi'M CA 91253 C ATHl?iJ2Ai. C'i7'Y CA 9''1.x34
-1911. J10,11 70
USE OF PERMIT
6.121 ALL !wX?ANSK)N G S 1W St:€ Pili E Pit P -MR ITfsr xii DUAT PLAN.
J4' P13' RLD.OW iNLEM'. tLvMSTfi:.'rA.'I'1.ON lr,X M.V0%.0) tt.)?t.WCi3. 9
STNItTE-3)W1114PF~R IT
?C)± -0(k -42.30M
PAID
FEB 13 1998
• ').
CITY OF Qui I ;
S1CC)N�i,TCChnPLANCRECK at $75,1311
LXES,�S PRETAID FEES $0.00
Ti.3'i'r`1t NCA
RECEIPT DATE BY f I DATE FIN ALED I' INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
TINSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
0.K to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wail insulation
Condensate Lines
Party Wail 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 Pibg. Test
Final
Gas Piping
PLUMBING APPROVALS
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
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICAL APPROVALS
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
t �
Ck
Final
Utility Notice (Perm)
COMMENTS:
`
-
No
s
ASSESSOR'S PARCEL NUMBER
COUNTY OF RIVERSIDE HEALTH SERVICES AGENCY
1 6 Y9 7
DEPARTMENT OF ENVIRONMENTAL HEALTH
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 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 applica-
tion shall remain valid for a period not to exceed one year from date of payment. w +
r•t r,. ,
L
c- ry of A Q��
LOG #
Agent, Contractor, Contact Personr
IYV%.r Cl CQiq
Address City State Zip
' 3 S 703 l(;,,1, C±j l
Telephone
32V-1.911
14 he fr rvtird 54
A6.4.I . 9a23y
Q
Owner J
/� aly- 'A90/riS
Address / City State Zip
`/I'335 ,JerFpr3wK Z� W;AT �
Telephone
Z
Job Property Address
y 6 - 33 S_TEFF,�ro,-) Sr
CityZip
A 04e �
W
Lot Size
�N7'aFe� '. II yl fries
a c ��
Use of Permit, P/P, SU PUP, etc.
SE /
Legal Description
C�AC'1 tCA r
DD , ac /rr•
Lo r a� T/IgcTai90
tDwe In H Sit Prep., etc. 71.sT
A' W f3pa Rn
r~r
Sign ur of Appi r-/3-�j� XrJ�
Date
-
i 3 Fwd • /998
CHECK BOX REQUIRED
❑ Holding Tank Agreements Completed r
❑ Detailed Contour'Plot Plans- ,Required '(1 to 5 foot interval)
❑ Certification of Existing S.D. System Required-
❑ Grading Handout Provided
m
❑ WQCB Clearance Required
❑ Staff Specialist Lot Inspection Required
Z
O
(Attach For DOH -SAN -007, Santa Ana Region Only
❑ Lot Inspection
U❑
Soils Percolation Report Required
W
U)
❑ Special Feasibility Boring Report Required
❑ Date Lot Inspection Completed: Initials
Remarks:
❑ Maintenance Booklet Provided
Initials Date
❑ Final Inspection by Department of Environmental Health is required.
C/42 / Soils Percolation Boring Report by UgProject # Date
/14/1
Soils Map Page Soil Type Approved By Date
No of Systems
Type of System(s)
No. Dwelling Units
(1) Septic Tank
Soil Rate
Grease/Sand
E-)(157-
❑ Holding Tank O Replacement
0 New Ey rir
Bedrooms, ,Fixtt7(WnIfS
t�X / fT I Ja 6/J /V
l
Grease ntccpp�/Unt Trap
"1Gal.
I'
�O�Additionro
I]•Existing(%&AA4i� S&V4t6 SYfr[
/
U00 Gal
i
Sq. Ft.
Bottom Area
Totil Linear
Ft.
Sidewall Allowance
rock/ sq. ft. running ft.
Eulfr (Fitt/( , /
Install Une(S long) ft. wide�th
Leach Bed sq. ft. of
Bott Area
/
% f
�7
Inlet Tested Depth 0'NA
min. �a inches rock below drainlines or
U
\��
l
Proposed Bottom Tested Depth
e�f MGt ,w/ 1'
Z
Leach lines/bed special design for slope.
(3) Pit Diameter
No"Pits
Pit Below Inlet (BI)
Seepage Pit
Maximum
Other:
O
,�_
Total Depth
Allowable
UApplicable1
65'
T 2u
/ r
/
/
—/,f�ar
Depth
W
N/A ✓ Overburden Factor
l.� 6'/Sr.
QO
TD
U)
Well Review Approved: Date: Well Drilling Permit #
SIGNATURE
Grading Plan Approved: Date: C
SIGNATURE
Sewer Verification A-pprov'ed-:� Date:
REMARKS:
��✓ ct /.i'L:�'t" noa``� Q��r��( Ger l�w,�
This application i�,AP ROVED/D NIED-for-the-category-cheeked-in-SECTION B
the des disposal
FOR OFFICE USE ONLY
above, regarding gn of a subsurface system as Indicated on the
acompanled plot plan, using the requirements set forth In SECTION C above. A build-
ing permit is necessary for the Installation of the above -designed system. No construc-
Revenue code Fee 3 0�� 0 0
tion is permitted to the required reserved 100% expansion area...-
t3
.,
(1) Septic Tank must be 100' minimum from any wells:
❑ Check #
(2) Leach Imes must be 100' minimum from any including
`
Date �3 `
� - 9�
0
wells, expansion area.
r \
(3) Sewer lines must be 50' minimum from any wells.
initial
�1 P
` • /C •T �O Q3
Z
O(4)
Seepage pits must be 150' minimum from any wells, including expansion area.
I
�?
Dd Cu-
/ ,
4
ra
Signature of Health Official
a-/3-5�
,+.y
Date
Io
DOH -SAN 122 (Rev 9/93) Distribution: WHITE—Office File; YELLOW—Applicant; PINK—BIdg :Dejikk GOLDENROL—Plans/Records
��i:j�8
ALMS UNDERGROUND CONSTRUCTION
38703 VISTA DRIVE
CATHEDRAL CITY, CA 92234 '
fr- (760)324-1911.FAX(760)324-9541 '
CA. LIC. #482180
41
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COUNTY OF RIVERSIDE HEALTH SERVICES AGENCY.
DEPARTMENT OF ENVIRONMENTAL HEALTH
FoodSewage Disposal
V/S G
Trailer Park al. Septic Tank 6 off ca c
Motel, Apt.,, Hotel 2111 -Sq. Ft. of Leach ine is a� �� ��I�
_.,Dwelling EXisr.(38yM4k ADD /-No. 6'Di4/- B�� TD Ld' ci
Commercial Building Connection to Sewe� MD Seepage , � �i ,A✓� Qo
Swimming Pool Connect to Existing S.S.D.S.
No on-site regenerating water softening devices may be discharged into the individual sewage disposal
system herewith approved without clearance from the Water Quality control Bqard.
Water supply sere hi tallation must be from an a
g posX lgr approved source Ea(i S'T (c V W D/
All sewa a dis s I ins a on must conform with requirements of current Uniform Plumbing Code.
�C Any cutting, gradin�or filling in excess of tw0(2) feet will nullify sewage disposal approval.
Approval has been obtained from the Regional Water Quality Control Board for installation of the sewage
disposal system.
This Is to certify that the Riverside County Environmental Health Services approves thG subsurface sewag@
disposal plot plan to obtain building permit for ' statfati6n, const W1 .
Q4 -- .2 - �3 — 9� _ BY [mac)
MA1NTAiN 100% IEXPANSIAN.AREA. MIN., IS -d /FROM ANY WELL ✓/�`'�
MIN. 10' FROM ANY 'it s-1 TREE OR WATER MAIN -4-
AA
1 Y�
3.
THIV YH
',pproVar of One puaae by Lite i/epartment oI rubs.
DEPARTMENT OF PUBLIC HEALT B" of Riverside County does net relieve the �
IS VALID FOR ONE (1) YEAR *a or Arebi+ect of the responsiwlity for tW Maimw
FROM DATE OF APPROVAL %to or AraMbe0tmW damilm-