9904-027 (RC)LICENSED CONTRACTOR. DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
LChapter 9 (commencing with Section 7000) of Division 3 of the Business and
�_Pso ss.onals Code, and my License is in full force and effect.
` `License # i Lic.`Class ' Exp. Date''
,/'409020 21MOO
)Ate " f 4 Signature of Contractor
OWNER -BUILDER DECLARATION '
I hereby affirm under penalty of perjury that I am ex.empt from the Contract • is
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 '
contfactors to construct the project (Sec.'7044;; Business & Professionals
Code).
O 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•
corripensation,'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,,forthe performance of the work for which this
permit is issued. My workers''comperisation insurance carrier & policy no. are:
CarrierPolicy. No.
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(This section need not be completed.if the permit valuation is for $100.00 or less).
(-,).1 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.1 should become
subtectlo the workers' compensation, provisions of Section 3700 of. the Labor
Code .I shall forthwith comply with those provisions.
Date— ..f / / Applicant
Warning: Failure to secure Workers' Compensation coverageis 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 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 per issued as a result of this applicaton agrees to, & shall, -indemnify
& hold harmless the Cityof La Quinta, its. off agents, and- employe es.
2. Any permit issued as a result of this application become's 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
tw..
NScorrect. 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.
SignI ature (Owner/Agent) Date
BUILDING PERMIT PERMIT#
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r
DATE VALUATION LOT TRACT
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416/"JOB
SITE
ADDRESS 50-9,29 WX SYRNG � ON. STR. C g
APN QDa�=dD�QI-�4,�9
OWNER .
CONTRACTOR / DESIGNER / ENGINEER
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G- °`'ti+i IZ �S.T1! 1'C
"'' k AT[0.'T T{ try
1.10\JA%/,1I,r JY\. Sl./'S.i f1 1: C
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5913 AVE ENCT I`i AS �;M -100
522 AA-1T(:�C�S .Y R
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CA:F tSBAD - C_ A 920Jf 8
R.E DLA:N OS CA 92375
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USE OF PERMIT
COMMERCIAL RRMODEL
EL '
RAM3 CROC.011y S'I O.i .E - 'W:iVOR REMODEL
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PLAN CHI-,'/;.KP07 5122,85
101-0P-411 f,41041
R ,1 C EiYfC.'.AP. C iiE31:,80
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SMO NO MfDT(ON FEE'- t:r:/fVN 100--CF-e241"i)()Cl $178
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454: 3
MIT MES DUE NO'VV'
S542.0
a”
RE+C�EIIPJT
DATE
BY fj �¢//�/
DATE FINALED
INSPECTOR t
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
OX 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
Gas Piping
PLUMBING APPROVALS
Gas Test
Electric Final
Waste Lines
Neater 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
Final
Utility Notice (Perm) -
COMMENTS:
y'!�r,(�"`•"'t'�"°i?i'aF-a^au'3nr,V"i�'r�d+"s'�Yas�:T`&T yrriLr�llit<`t�5"'..;::�..bv.,.isY+..�'ir'`�'dc�'M,aiji,F«'�w.yc•a:,n.-.�,,.-i"-r-T•- •• ^-rr r��'w.-� rr.r-�y+.�+I^I. �i'',,,—•,td�tFa--'^'i.sM-":.rv+-la..�l....7el,.ars+{Z�'r"''r"� +.+.OM1
ASSESSOR'S PARCEL NUMBER
COUNTY OF RIVERSIDE HEALTH SERVICES AGENCY
DEPARTMENT OF ENVIRONMENTAL HEALTH
PERMIT APPLICATION FOR A SUBSURFACE SEWAGE DISPOSAL SYSTEM �a
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.
LMS #
Agent, Contractor, Contac,�arson ,
'Ad
'Address City State ' Zip
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Telephones Gd)
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Owner i
Ri�I G/2(i'C/�•/ v •
City State Zip .
Address!/Z?. �d�'I197Z�N,
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Telephone
9 In
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ti(� /I 1'I A L iq. �?� 0 �
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Z
Job Property Address ,
City
Zip
W
Lot Size
ater Agency a t.XtIP1
Use of Permit, P/P, SUP, PUP, etc.
oc
Legal Description
�!/�
�IALcEy
%LF % �.
,��s t ��6�is:�rit/G1�lTlr3t.t.
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wellieg�Ml Site P.reprrleta.(D. ° . /f .
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Signature of pelican, 2i `^
D to
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y��
CHECy B • IF REQUIRED',. Y
If'apsi box is checked, this application shall be considered rejected until,
❑ Detailed Contour Plot Plans Required (1 to 5 foot interval) .
the information is provided and the fee.paid. Resubmittals later than 90
days after date noted below may require repayment of fees. -
❑ Staff Specialist Lot In Required
m
❑ Holding Tank Agreements Completed
Z
Thomas Bros. Page Grid
O
L] Certification of Existing S.D. System Required
,
U❑
WQCB Clearance Required.
❑ Date Lot Inspection Completed: Initials
LU
(Attach for DOH -SAN -007; Santa Ana Region Only)
Remarks:
❑ Maintenance'Booklet Provided
❑ Soils Percolation Report Required
❑ Special Feasibility Boring. Fleport Required
❑ Rereview Required Initials ^ --bite-
❑ Final Inspection. by Department of Environmental Health is required.
Please:call 24 hours PRIOR to inspection.
C/42 / Soils Percolation Boring Report by Uc/Project # Date
'Soils Map Page Soil Type Approved By Date
No of Systems
Tx pe of System(s)
U Holding Tank ❑ Replacement.
No. Dwelling Units.
Bedrooms, Fixture Units
(1) Septic Tank
Soil Rate .
-:
GreUQ/S_ and-,
Grease Iritc`pJunt Trap
❑ New ❑ Addition.
❑ Existing-
{•
-Gal.
L%w V%rq r4t,&)
Gal.
4
Sq. Ft.
Bottom Area
Total Linear
Ft.
Sidewall Allowance
Leach Bed sq. ft. of
_•-_�r._tf..n.,nn:..n_H�-11..n•nll
___-. 1_:..../..\_—M_I..�.- �_..��__._.v�_
Bottom Area
- "
TYPE OF INSPECTION DATE INSP.
FOUNDATION & SETBACK
FOOTING STEEL
MAIN GROUND SYSTEM
GROUND PLUMBING - -
PRE-GUNITE
DO NOT POUR CONCRETE UNTIL ALL ABOVE HAS BEEN SIGNED
CONCRETE SLAB
JOISTS & GIRDERS
ELECTRICAL GROUND WORK
DO NOT POUR CONCRETE UNTIL ALL ABOVE HAS BEEN SIGNED
ROUGH ELECTRIC
ROUGH PLUMBING
ROUGH GAS & GAS TEST
HEATING & VENT- A/C
FIREPLACE
ROOF
BOND BEAM
O.K. TO WRAP
GROUT ❑ 4' ❑ 8'
FRAMING
INSULATION
PRE -ROOF
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED
UNTWALL IIVlr_MlVr1
CYTC0I1`I0 I ATW -- -
btWtH JtYIIL; IANK I I
r11VA
ELECTRICAL
PLUMBING
FINAL GAS TEST
HEATING - A/C
HOUSE NUMBERS
JOB COMPLETED
TEMP POWER
ABOVE APPROVALS DO NOT INCLUDE RIGHT TO
Tl ImKI -1 1 fru 1-^ '....tea..+- el III n1A11