0101-109 (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. Clas�sv'Exp. Date
A 6
,,"bate L&;- Signature Signature of Contract��orr, ✓
OWN ER -B LIILDER�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:
Carriert' Policy No.
STATYUND
(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' compens�11n provisions of Section 3700 of the Labor
el Code, I shall forthwith comply wi ti ose provisio
Datel-- 0 ` Applicant I F +
Warning: Failure to secure W�p'�kers' 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 condit ons 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, indemnir/
& 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 propQ for inspec ion purposes.
Signature (Owner/Agent) � A4&4 ` Date �-tv
-
BUILDING PERMIT PERMIT#
DATE VALUATION LOT j'�Q�_ TRACT
=2.(I&VJ
JOB SITE
APN
ADDRESS
OWNER
CONTRACTOR/DESIGNER/EN (NEER
DAVID CH"Y" & AM 001
I.)0_1,.0)'4 Lat,3NS"1Ri;fC'.i3.ON OLIMPANY"
78.;4495 C'£71VMe QNNY4)N COURT
65 ; t."0WIW-RC.:WL ROAD 01.
QUINTA CA 92253
PAILM 411>1104GS 04% 92262
(760)325-8626 C:I Alt< 5265
USE OF PERMIT
Yf,LtMSINO ONLY -MR. R. xNSP&.—, t1 X ixf TFCi�ti3`
P LAPIS ONDER 11KR.dl#i f 0t0J-1.10
VALUATION Le
Xxi.RAIATM) COb1'3'' C}':9:+' CONSTRUCTION FYI€i:V
2.2;131 MOD
Fir ''t;�1�k3�t�?9;4 X1:4?: t 0y , �'i00T•� 3 �..f71�0 �t l4,Qi1
fi
r
SUB -TOTAL G&Mi�J�".'t' ON AND PIAKCY. ECK,.
I: FROW FRE-P-4101T�,F.�
$0.00
&Q -TAU YMMH 1110.1i DUE NOW
JAN 112001 .
)f l y Ut- LA
RECEIPT
v
DATE
BY
DATE FINALED
INSPECTOR
-a'
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
O.K. 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 l P
BLOCKWALL APPROVALS
Steel
POOLS - SPAS
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Plbg. Test
Final I IGas
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
h
Encapsulation
Gas Piping
Gas Test
Appliances
J---�-�-� ljL
Final O -�
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)
Final
COMMENTS:
CdUNTY*OF RIVERSIDE HEALTH SERVICES AGENCY AssessoR's PARCEL NUMBER
1
DEPARTMENT OF ENVIRONMENTAL HEALTH —
APPLICATION FOR WASTE WATER DISPOSAL APPROVAL
APPLICANT: Submit this form with four copies of a SCALED plot plan (1"=20' to 1"=40' 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
application shall remain valid for a period not to exceed one year from date of payment.
LMS #
Agent, Contractor, Contact Person
Address City State Zip
Telephone
C\ n,.._ \ems .y l l"""
�P� t r C' C) 1 \ ('^ti.rt.r IF
Owner
Address City State Zip
Telephone
Z
Job Property l T
City
Zip
gAddress
U
Lot Size
Water Agency/W\\ell
Use of Permit,. P/P, PUP, etc.
Description
DBA
LU
VSUP,
[Legal
Dwelling, MH Site Prep., etc.
Signatuprat Applicant
Date
FOR OFFICE
USE ONLY
CH CK BOX IF REQUIRED
If any box is checked, this application shall be considered rejected until the
(3 Detailed Contour Plot Plans Required (1 to 5 foot interval)
information is provided and the fee paid. Resubmittals later than 90 days
after date noted below may require repayment of fees.
❑ Other
C)Staff Specialist Lot Inspection Required
m
❑ Holding Tank Agreements Completed
Z
❑ Certification of Existing S.D. System Required
Thomas Bros. Page Grid
W
❑ WQCB Clearance Required
❑ Date Lot Inspection Completed: Initials
co
(Attach for DOH -SAN -007, Santa Ana Region Only)
Remarks:
❑ Soils Percolation Report Required
❑ Maintenance Booklet Provided
❑ Special Feasibility Boring Report Required
❑ Final Inspection by Department of Environmental Health is required.
❑ Rereview Required Initials Date
Please call 24 hours PRIOR to inspection.
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)
No. Dwelling Units
(1) Septic Tank
Soil Rate
&5asd lb llr.�?1
❑ Holding Tank ❑ Replacement
Bedrooms, Fixture Units
Grease Intcp/trap r'
{
New ❑ Addition
l
❑ Existing Connect to Sewer
Gal.
1-1500 Gal.
Sq. Ft.
Total Linear
Sidewall Allowance
Leach Bed sq. ft.
Bottom Area
Ft.
ft. rock/ sq. ft. running ft.
Install Lines) ft. long ft. wide
of Bottom Area
Inlet Tested Depth ❑ N/A
with min. inches rock below drainlines
U
Proposed Bottom Tested Depth
or
Z
Leach lines/bed special design for slope:
(3) Pit Diameter
No. Pits
Pit Below Inlet (131)
Seepage Pit
Maximum
Other:
O
Applicable
pp
Total Depth
Allowable
H
Depth
W
N/A Overburden Factor
❑ 5' ❑ 6'
TD
0
Well Review Approved: Date: Well Drilling Permit#
SIGNATURE
Grading Plan Approved: Date:
SIGNATURE QI! C V St"a
Plan Check Only Approved: Date:
REMARKS: Cyti _£'� :h1'1r a4('e rl..C. C%! n, e—\e'ki t� 4♦. i-le^.'f!1 It cc i! t Cri �. f•. .
` t 1 i j
1
f ,�.-. 1. l/ t. 1 1. %1
/\ t l t'n11 ,. � w.T'. Or ►!� s � { \11•..� IC .�\ 'i/, / , I(YZr.r� i.!^.f .1
j.� /
�
CI
This application is APPROVED6DENIED for the category checked in
SECTION B above, regarding F e design of a disposal system as indicated
on the accompanied plot plan, using the requirements set forth in SECTION
i–
r
C above. A building permit is necessary for the installation of the above-
Revenue Code _ . Fee $ 1
designed system. No construction is permitted in the required reserved
100% expansion area.
r
Check #
(1) Septic Tank must be 100' minimum from any wells.
Z
(2) Leach lines must be 100' minimum from any wells, including expansion
Date i Initial . J 1,
area.
7 c'
F-
()
(3) Sewer lines must be 50' minimum from any wells.
LU
U)
(4) Seepage pits must be 150' minimum from any wells, including expansion
RIVERSIDE: 909-955$980
area.
INDIO: 760-863-7000
SOUTHWEST: 909-600-6180
Signature `
Date
DEH -SAN -122 (Rev 10100) Distribution: WHITE—Office File; YELLOW—Applicant; PINK—Bldg. Dept.; GOLDENROD—Plans/Records
DIST. # - - COUNTY OF RIVERSIDE HEALTH SERVICES AGENCY
DEPARTMENT OF ENVIRONMENTAL HEALTH
PLAN CORRECTION
Plan Check # Date
DBA Address
Plans Submitted by Phone
Owner Address e ` Phone
The plans are now approved subject to the conditions listed below and the attached compliance sheet.
C, C i
i
• 4
a
C • �'
CONSTRUCTION INSPECTIONS: Contact the Plan Checker for a Preliminary Inspection when construction is approx-
imately 80% complete, with plumbing, rough ventilation, and rough equipment installed. Request for inspection should be
made at least five (5) working days in advance.
A FINAL INSPECTION MUST be made upon completion of ALL work including finished details. APPROVAL to operate shall
not be granted, or remodeled areas approved to operate, until the facility has passed the FINAL INSPECTION, and
"APPLICATION TO OPERATE" has been completed and PERMIT FEES have been paid.
Request for inspection should be made at least five (5) working days in advance.
I
PLANS CHECKED BY l ` ' Phone -
I acknowledge the corrections noted herein and as indicated on the plans and agree to incorporate them during construction:
71 - "'0",
Date / ~�
DOH -SAN -178 (Rev 1/92) W -OFFICE — Y -APPLICANT — P -BLDG. DEPT.
COMMUNITY DEVELOPMENT
PUBLIC WORKS
FILE COPY
C ity I. of La Quinta
Developers Project Approval Form
Prior to the issuance of Building Permits for the project listed below, the following Departmental
clearances must be obtained. Please return this form to the Building and Safety Department only
after approval. Contact applicant for resolution of conditions preventing or delaying approval.
Project: 50-949 WASHINGTON STREET
CHAPELLIS RESTAURANT
Applicant Contact: JOHN REYNOLDS (760)564-8723
Application / Circulation Date:
Community Development Department
Christine di Iorio, Planning Manager
Public Works Departme
c
teve Speer, Senior Engjneer
Building and Safety Department
Greg Butler, Building and Safety Department Manager
Health Department
Fire Department
Schools Fees Paid
Date
Date .
Date
1/08/2001 JGJ
Date
Date
ate
Date
OL COMMUNITY DEVELOPMENT
PUBLIC WORKS
_G FILE COPY
Ci of La Quinta
Developers Project Approval Form
Prior to the issuance of Building Permits for the project listed below, the following Departmental
clearances must be obtained. Please return this form to the Building and Safety Department only
after approval. Contact applicant for resolution of conditions preventing or delaying approval.
Project: 50-949 WASHINGTON STREET
CHAPELLIS RESTAURANT
Applicant Contact: JOHN REYNOLDS (760)564-8723
Application / Circulation Date: 1/08/2001 JGJ
Date
Community Development Department _ -/ w
/vo4 / e� eCd "c�-t7o-�o
J.
Christine di Iorio, Planning Manager Date
Public Works Department
Steve Speer, Senior Engineer Date
Building and Safety Department
Greg Butler, Building and Safety Department Manager Date
Health Department
Date
Fire Department
Date
Schools Fees Paid
Date
. CO)
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