001186 (SFD)PERMIT APPLICATION
City of La Ouinta
Department of Building and Safety
This permit becomes void if work not commenced within 180 days from date of issuance, OR;•if work has been suspended or abandoned for a period of 180 days.
LICENSED CONTRACTORS 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.
License Class Lic. Number
Date - Contractor
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 requires a permit to
construct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for
_ such permit to file a signed statement that he is licensed pursuant to thaprovisions of the Contractor's License Law
(Chapter 9 (commencing with section 7000) of Division 3 of the Business and Professions Code)orthat he is exempt
therefrom and the basis for the alleged exemption. Any violation of.Section 7031.5 by anyapplicant for permit;,
subjects the applicant to a civil penalty of not more than five.hundred dollars ($500.):
. O 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 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 or improvemnt 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.). i t
❑ I, as owner of the property, am exculsively contracting with licensed contractors to construct 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.).
❑ I am exempt underSec.�, " a ? _ :8 VCI(Atached
Date Owner ' a
WORKERS' COMPENSATION DECLARATION: I hereby affirm that l have a certificate of consent to self -insure, or a
certificate of Workers' Compensation Insurance , or a certified copy thereof (Sec. 3800..Lab. C.)" � -
Policy No. Company
❑ Certified copy is hereby furnished.
O Certified copy is filed with the City Building Inspection Department or City Department.
Date Applicant
APPLICANT NAME (L. F. MI) twian Y r
ADDRESS P.D. RM 040
CITY/COMMUNITY/STATE/ZIPTa Z
Aun�, CA 92253 ,
1533-58555
JOB SITE ADDRESS/SPACE
Avenida Diaz '
CITY/COMMUNITY/STATE/ZIPJa Quinta, . C' 92253
CA
801
K�4
220
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C
22.00 ,
Plan Check Fee
'FIND
SE
S
TRACT
I LOT
A
6.65
MOD
SB
Prop, DevpA, Fee
TRACT NAME iI we -
OWNER NAME IL. F. MI) Ai���t
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rj+ J
CONTRACTOR -FIRM NAME
%
ADDRESS P,O. B= 2288
CITY/COMMUNITY/STATE/ZIPT.Xlio, CA . 92202.
PHONE . 347-7171
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LSS Iri69
ARC/ENG FIRM NAME .
ADDRESS
CITY/COMMUNITY/STATE/ZIP '
PHONE .
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LICNC N
USE OF PERMIT single family INvt t in
BL
ZON
FSB
SSB:'
SSB
RSB
OFC .
ZONE ORD..
- LOT SZ i
END
- SIDE
CERTIFICATE OF. EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed if
the permit.is for one hundred ($100) o, 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 Applicant
NOTICE TO APPLICANT: If, 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.
DIVISION OF INDUSTRIAL SAFETY PERMIT,CERTIFICATION:
a 1 hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be
made iri connection with'work authorized by this permit, and that no building structure, scaffolding, falsework, or
demolition or dismantling thereof, will. be more than thirty-six (36) feet high. (Chap 3.2, Grp 2, Art 2, Sec 341, Title 8.
C.A.C.) a •..
❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of
Industrial Safety, as noted above,'unless such person has a permit to do such work from that division.
r O Division of Industrial Safety Permit No.
Date
Applicant
_CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance
of the work forwhich,this permit is issued (Sec. 3097, Civ: C.).
Lender's Name
Lender's Address
I certify 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 county to enter upon the above-mentioned property for inspection purposes.
Signature of Applicant or Agent Date
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify I have read this application and state that
the information given is correct. I agree to comply with all•state laws and county ordinances relating to buidling
construction, and authorize a'representative 5,t6e,City of La,Ouinta Department of Building and Safety to enter
upon the p[opHrty�lor which I tiave'applieed for/!Pis permit% orea purpose of making inspections.
S ^ Sigaaturelof Applicant•or Agent- �j�)/ I
Date
Print Applicant/Agent Name
APPUPRMT nfll 1 RG
Pmt to =u tryw.ct 1592 sq. ft. of
S. .D &,91
of 4:5U
�arid
garage as
sq. Lt• ogarage as � approved plans-
mech. ech. F+ee -
22.00 ,
Plan Check Fee
9166133.
Cbnst. Fee
4M*O( "a
Elect. Fee
43.1.3
SMI Fee
6.65
Plumbing Fee
50.50
Prop, DevpA, Fee
450.00Aft
7/
X250.00) PD 12 14
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TOTAL
FEE
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BLDG. DEFT.
VALUATION —�
NO.
OPERATION DATE
INSPECTOR
NO.
OPERATION DATE INSPECTOR
-71
BUILDING APPROVALS
MECHANICAL APPROVALS
1
Set Back
33
Ventilation.System
2
Ftgs & Frms
34
Plenums & Ducts
2A
Slab Grade
35
Furnace Compart.
3
Steel
36
Inlets & Outlets
4
Grout Blocks
37
Combustion Air
5
Bond Beams
f
38
Compressor
6
Roof Deck
39
Appl. Clearance
7
Framing
ci
40
Fire Damper
8
Vents
41
Smoke Detection Device
9
Garage Fire Wall
42
Commercial Hood
10
Fireplace P. L.
❑
43
Final
10A
Fireplace T.O.
❑
NON ADDITIONAL INFORMATION
%/�3/S; �' 1
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath Q� �-
12 Internal Lath
12A Drywall
13 Finish Grade
INSULATION Thick R..
Value
7A Walls (Batts)
12B Ceiling (Batts)
12C Ceiling (Blown)
14 Final
PLUMBING APPROV LS
15 Ground Plumb Q 5
16 Water Piping
17 Rough Plumb
18 Vents
19 Sewage Disposal
20 Sewer
21 Water Heater
22 Water Softener
23 Water Service
24 Gas Test
25 Final
Tank Pit L. Line
ELECTRIC APPROVAL'S
REAR:OF. PROPERTY LINE
`
PSL P/L
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final
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RIVERSIDE COUNTY DEPARTMENT OF HEALTH
PERMIT APPLICATION FOR A SUBSURFACE DISPOSAL SYSTEM
Applicant: Submit this form with three copies of a scaled plot plan drawn to county specifications required on the
attached check list. A non refundable filing fee of $15 is required when the application is submitted. Check must be
made payable to County of Riverside.
Name
Mailing Address
/�i�/ � �` c� .� ! Lel--- � r i � --�
�'• i K /l �/�
City
State
Zip Code
Phone
'Property Address
'City or Community
'Legal Description of Property (Lot, Parcel Map, Tract)
'Assessors Parcel No.
Water Serving Property From Lot size
Signature of Applicant Date
'The above information must be verified from Building Application
Staff Use — Do Not Write Below This Line
Initial Date
�� ���•
WQCB Clearance required Yes ❑ No Q -
Soils feasibility report required Yes ❑ No CD
Detailed boring report required Yes ❑ Nob
Detailed contour plot required Yes ❑ Not
Comments:
Soils or boring report by !ati1 Date
Approved by Date
Soils Map Page Soil Type Tract File No. Other
Number of Bedrooms
Septic Tank Size (gallons)
Rate Required
Type of System
New Addition Replacement
Leach line sq. ft. of bottom area trench
Leach bed (sq. ft. of bottom area bed)
Seepage Pit Diameter
Number of Pits
Seepage.Pit Depth B.I.
Total Depth of Pit
5r ❑ 6'
Location of System
j W. C�-�- OF .oto r.'% � G
Additional Requirements
r (A I, xCt'-, IVU(I E.0R��,�-1, ? -- r�t,t loja �! ?�--, n•� c�Pi f
A permit is pproye.d)denied for the design of a subsurface disposal system as indicated on the accompanied plot plan
using the requirements set forth in Section B above. A building permit is necessary for the installation of the above
designedJ,system.
Signature of Health Official Date
Receipt No. 4:9 D % / 9 Issued By
District: Riverside ❑ Indi0 Hemet ❑ Date
DISTRIBUTION: WHITE - Office File YELLOW - Applicant PINK - Building Dept. GOLDENROD - Pending File
DOH SAN 122 (Rev 10/82)