05044 (SFD)Building
Address
T 4b 0
4hf 4 4v a"
P.O. BOX 1504
78-105 CALLE ESTADO
LA QUINTA, CALIFORNIA 92253
Mailing
Address 81-715 Hinhway III A
City lZip ITel.
t 1 92201 1 342-61.66
City
State Lic. L:Ity
& Classif. (� O pZ Lic. #
Arch., Engr.,
Designer
Address
City ZipI State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
71100) of Division 3 of the Business and Professions Code, and my license is in full force and
effect.
SIGNATURE DATE
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 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, after, improve, demolish, or repair any structure. prior to its issuance also
requires the applicant for such Permit to life a signed statement that he is licensed pursuant to
the provisions of the Contractor's License Law, Chapter 9 (commencing with Section 7000) of
Division 3 of 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
subjects the applicant to a civil penalty of not more than five hundred dollars (5500).
❑ 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 appy to an owner of property who
buddy or improves thereon and who does such work himself or through his own employees,
provided that such improvements are not intended or offered for safe. ff, however, the building
or improvement is sold within one year of completion, the owner -builder wiz have the burden
of proving that he did not build or improve for the purpose of safe.)
❑ I, as owner of the property, am exclusively contracting with licensed contractors to con-
struct the project (Sec. 7044, Business and Professions Code: The Contractors 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.)
❑ 1 am exempt under Secz. B. & P.C. for this reason
Date Owner
WORKERS' COMPENSATION DECLARATION
1 hereby affirm that I have a certificate of consent to self -insure, or a certificate of
Worker's Compensation Insurance, or a certified copy thereof. fSec. 3800, Labor Code.)
Policy No Company - •+
❑ Copy is filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed i1 the permit is for one hundred dofts (5100) valuation
or lass.)
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 Exermlion 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.
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.)
Lender's Name
Lenders 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.
I certity that I have read this application and state that the above infornation 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
No.
LDING: TYPE CONST. OCC. GRP.;
P. Number 774-291-002
Description
t Description S.F.D.
45044
f
Sq. Ft,. 1652
Size
No.. No. DIN.
Stories Units
New ❑ Add ❑
Alter ❑ Repair ❑ Demolition ❑
Estimated Valuation
$$8-091
PERMIT
AMOUNT
Plan Chk. Dep.
C nA
Plan Chk. Bal.
? A A 4
Const.
Q
Mech.
I }
Electrical
115,
Plumbing
MO.
S.M.I.
6.23
Grading
7n A
Driveway Enc.
20, 00
Infrastructure
E 9A3 , fill)
S3.4I3.R3
TOTAL
REMARKS
i i"« `ilk}•7.. '+�' t, ��f''11 �t i ,i i �' �, ; -, } tl
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 113M i7nit
1125M
Validated by:
Validation:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL. SO. FT. ® $
UNITS
SLAB GRADE 2
2ND FL. Sp. FT.
BONDING
YARD SPKLR SYSTEM
STORAGE TANK
MOBILEHOME SVC.
BAR SINK
POR. gp, FT, ®
DUCT WORK
ROCK STORAGE
GAR. Sp. FT, ®
POWER OUTLET
ROOF DRAINS
HEATING (FINAL)
OTHER APPJEOUIP.
DRAINAGE PIPING
CAR P. Sp. FT. ®
TEMP. POLE
WALL Sp. FT.
GROUT
DRINKING FOUNTAIN.
SERVICE
FINAL INSP.
URINAL
SO FT ®
WATER SYSTEM
ESTIMATED CONSTRUCTION VALUATION $
=$
WATER PIPING
NOTE: Not to be used as property tax valuation
FINAL INSP.
FLOOR DRAIN
MECHANICAL FEES
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
LAUNDRYTRAY
AIR HANDLING UNIT CFM
FIRE ZONE ROOFING
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.
Sp. FT. ® c
BATH TUB
/J
6. LATHING
SO. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID ® 11/4 c
SEWAGE DISPOSAL
SO.FT.GAR ® 3/ac
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 PLUMB. FEE
STRUCTURE PLUMBING ELECTRICAL HEATING & AIR COND. SOLAR
1 SETBACK -
AROUND-PLUMBIF ,/
UNDERGROUND
A.C. UNIT
COLL. AREA
SLAB GRADE 2
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 APPJEOUIP.
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
C �) j�
tel/ 'ITCJ _
p /j
`/y�'j�
i
�/ ,4
e17< /7_/`.
If
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL I.
/J
6. LATHING
MESH
CINSULATION/SOUND�'�
FINISH GRADING
)NAL INSPECTIONW2
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESIINITIALS
GARDEN WALL FINAL
,
COACHELLA VALLEY WATER DISTRICT
,, CASH RECEIPT DETAIL
Received From: —0 ,,2 4 Z U L L �1L 1M ���/ Date:
Address: o � 1,$ AV' _ A1,A1/,4421 P_9 Lell ��lf/%Z21 5-'m' T 2 7 P //
Account No. Lot(s) p� .� Tract SC_ �i L K. 2 Z7
Service Address T — G.A. Code
❑ Meter(s) $
❑ Service(s)
❑ Backflow(s)
❑ House Lateral(s)
❑ DetectorCheck(s)
❑ Meter Surcharge
y ;
q,6161tati,. Capacity Charge /' � _ 5:7
�Z
O WS.B.F.C. .
O Tampoiety Conatikilon Meter
Tufn011Cflatpe , '�•ri s .7' i -�yi��.:� t 1 � 1<'t ',"'� •+ r:^ . '' '., •t �.•`.
f� Nafi/�� r w h.♦ .L$T M.(( rV% A�/erF�
Q Inepeotlon Fee Thtet 4 3t. _ > ;FtF� ." `T"p`,T.-�+'. 'y a,'. _ ` -• ` j jr i -'. L .y •d �+� .
.,F�—! t Y
»� -t. ;- . y aY�r•1
❑ Plan Check Fees Water/ Sewer-' '
Tract - '
❑ Bond Payment - A.D. - Bond
Assmt.
O Customer Deposit
❑ Other
iI?rgm
TOTAL
Remarks: [1/LLnfAI& A a rl-% , .4c ll Agra izA/A/C'
❑Copy to:
a '`r
Cash WaterServlce—1,461
;
Check
C1
Money Cashier /
Order
f �i , C 11189),
--..- �-..,..�..,a�,d.._"'i''`t1'�.:.:.'..-r."".`,w •i-`ti'T�'y�+'"t,C'."`s •c.r�ts"!,�t?ti 4--� �-�'ta+"..�,v..�y.[�,�....`�,r••-..�-.+'�a:.,�%'���.o:. �-✓c..-a.....-mss,--s i�;y�.�..: i:.r.:ii `_r'tl{�"^,:c.;!�,: ..
0
Z
0
` V G
COUNTY OF RIVERSIDE DEPARTMENT OF HEALTH Assessors Parte\ No.
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 checklist.
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. t
VERIFY ITEMS IN SECTION A FROM BUILDING 8 SAFETY APPLICATION BUILDING DEPARTMENT APPLICATION LOG' # —�
A"q Contractor, Contact Person
Phone
Address 8 Phone
Pall'—
OTaVL he -1 to
Phone
Mailing Address
_
State
Zip
Job Property Address
Legal escription•Prop-(PM,—Tract; lot) -
/YSr
2.3 6Lcs 2 Ury
Lot Size
Water Agency/Well
Use of Permit P/P, CU, etc.
_ Other
Dwelling, MH Site Prep, etc.
Date
Signature of Applicant
CATEGORY: REV CODECATEGORY:
REV CODE FEE
1C , 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 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/EXPERIMENTAL 7345 $13200 ;
❑ Site Evaluation Lot Less than
SYSTEM
10,000 Sq. Ft. 7347 $86.00
IN IL
Holding Tank Agreements Completed ❑Yes 4 No
Certification of Existing S.D. System Required ❑ Yes No 1
I
WQCB Clearanoe required. (Attach Form ❑ Yes ❑ No
DOH SAN 007, Santa Ana Region Only)
Soils Percolation Report Required. ❑ Yes ❑ No
Special Feasibility Boring Report Required. ❑ Yes ❑ No I
Detailed Contour Plot Plans Required (1 to 5 ft. interval) ❑ Yes No
Other ❑ Yes No
1 `
Staff Specialist Lot Inspection Required ❑ Yes No
Lot Inspection Date
Soils boring report by o ( Project # Date
Soils Map Page Soft Type Approved by Date
No. of Systema
Type of system(s)
❑ Holding Tank ❑ Existing
No. Dwelling Unita
Bedrooms, Fixture Units
(1) Septic Tank
Soil Rate
Greaseffld
G�eIneDncp
New ❑ Replacement
` t� n „
�. \�
4 /A/
V�QA
l
.Sm'
GAI
(2) Leach Line Sq!Ft
Sidewell allowance
install Line(s). ft wide with
Leach Bed . ft
Bottom trencherea
R rock/ sq. R
min. inchesroc)C below drainilnes r
.
of bottorh area
per running.ft!
/
❑ NA
Leachlines/bed special design for slo
(3) Pit Diameter
No. Pits
Pit BelowSeepage
Pit otal Depth
j I
Other
Applicable
\\//
Inlet(BI)
(
N/A Overburden factor
❑ 5 6` 6
' j
11
Max. Allowable Depth
No. 2 System
NBCA kI'l � UCS /n l�51u� Q VyC4-•
REMARKS: `J
r
This application isftPPR,0,),V/DENIED for the category checked in SECTION B above, regarding the design of a subsurface disposal system as indicated
on the accompani plan, 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 permitted in the required reserved 100% expansion area.
6? Septic tank and sewer lines must be 50' minimum from any wells
(2) Leach lines must be 100' minimum f om any wells, including expansion area W (tea (A it
'
3)'r page pits must 1 minima from an wells including expansion area t1
`
.I.
Signature of Health Official Date—
ate
rr ,
RECEIPT NO. , Issued By 4 Date
DISTRICT: ❑ Riverside, Indio ❑ Hemet ❑ Perris ❑ Rancho Calif. ❑. Blythe
DOH SAN 122 (Rev: 5/88) DISTRIBUTION: WHITE - Office{file YELLOW -Applicant PINK - Bldg. Dept. GOLDENROD - Plans/Records
Is
of I II,E or
nt;IIICUL I URAL CUMMISSIONOt
AN
WI:1611 IS bi MEASURES
UNFE M-7—PT
UEVEWPUR' S [WIE 1
AUDRESs r
49-(113 Ilwy 06, Oulte 11-I2
'Cvrrchellu, CA 92236
619-342-0291
E. LEON Stint;GY
Jn�lEs U WAUACE
ASSISIAM �7,'•I •uSSItl` r.0
CLEMEN1 VF.`vEhl5lE
Sl�1.tn
CASC IJU. / 2 I CA
v. fan/_Cl:o
�1P�LL•'1'11U1dCt � Gr 3 � Z - � � �8
/,o -f Z-3, I zSr /3L. lq
(dear Vevelopere
After reviewing your lanciscal,i.nc1 I,lans, Itll I,lont material listed is 'lot
n vE yuaralltine IM -45 c�uveining trial Valley. 1C suhstil:utions
violatio
do occur olid they differ [mull 111011tn}aterial listed, this office must be notified
bmlediately.
'1'I mik you for prutectLlg .a'Id Ilieservillg the Coachella Valley's fest-free em1mirlient.
Em
Agr3.c6itur8l Calnlissioder suffice
cc, Indio Haid 111verside office
'S'
C