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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
Professional§ Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
Q. /26
1 C42 - �� 02/2812(
1" 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
ectlon 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.
STATE FUND 046-00-OMM
(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
subj � to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith comply with those provisions.
rQa�te: 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
cons ruction, and hereby authorize representatives of this City to enter upon
the bove-mentioned property for inspection purposes.
1
ignature (Owner/Agent) Date l
BUILDING PERMIT PERMIT#
DATE VALUATION LOT. ,ti 2-19x. TRACT
JOB SITE APN
ADDRESS 49-770 WMAUA CMCLF
OWNER CONTRACTOR/DESIGNER/ENGINEER
WIILUAM 9DMMONS A -I C'}:MPOOL SERVICK INC
4269 COUNTRY RY CLUD DR I'. C), BOX 183
LONG BILACH CA 90907 nIIR`YfiJ?'Ii HOT SPRING1 CA 92240
?60)324•6S75 CRL# 0386
USE OF PERMIT
PLUMBING
NFW Sf:FWA.CIF PIT. APPROVALS ATTACH((),
VALUATION
1.8m.00 M
1fS'ytldMIND CUS1' OF (:bNSTRUG". 101'?
PLUM14040 FRE 10) -0(9,'-4) 9.000 �37.4a
q
F'
80%-W)TAL CONITMIJIMION AND T111 -W OJECK
IMS PRE, PAID I+"�.1:3
9,899.00
$1-7.so
$U00
A n` 'FO'IAL FER:1ITY 1+'.IMS 1)13.F..4OW S37,50
pEC 012000 N1 J
RECENI I ATE/ r �, BY DATE FINALED INSPECTOR
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 Wali Firewall
Exterior Lath
Drywall - Int. Lath
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Hacks
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
Heater Final
Water Piping.
Plumbing Final
Plumbing Top Out
Equipment Enclosure
Shower Pans
O.K for Finish Plaster
Sewer Lateral
Sewer Connection
Pool Cover
Encapsulation
Gas Piping
Gas Test
Appliances .
Final
COMMENTS:
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)
'Y
COUNTY OF RIVERSIDE HEALTH SERVICES AGENCY AssEssoR's PARCEL NUMBER
' — v — D
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 tothe County of Riverside. Approval of this applica-
tion shall remain valid for period not to exceed one year from date of payment.
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C.� ! T'/ fIdl/1,�'t4
LMs # cif
Agent, Contractor, Contact Pers/oon
Address City State Zip
Telephone
Q
Owner
Ut. rL�I �;,:,n • i.•r i,. �+.r j
Address ` `City / State Zip
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Job Property Address A
City r
Zip
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(n
Lot Size
Water Agenc%INalrep 1; /N4
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Use of Permit, P/P, SUP PUP, etc. 1
OIAfCIrR' Nl .s 1 T/rid .: c [ : ,I ?
Legal Description
� R p . t o", 19 A Ai -O f 6 T � ��+�� % 7f [ 3
` f , / �'! s . i Y� ='
f.✓ 5/'n<C
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Dwelling, HWS1te.Brep+etc. r
Signature of Applican"i tvF4 irr, P -54W/806' roA.P, [ - pu
Date
CHECK BOX IF REQUIRED
If any 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 Inspection Required
ca
❑ Holding Tank Agreements Completed
Thomas Bros. Page Grid
Z
❑ Certification of Existing S.D. System Required
❑ Date Lot Inspection Completed: Initials
Clearance Required
LULlWQCB
(Attach for DOH -SAN -007, Santa Ana Region Only)
Remarks:
❑ Soils Percolation Report Required
e
❑ Maintenance Booklet Provided
❑ Special Feasibility Boring Report Required�tal"Health
L)Final Inspection by Department of Environmeis required.
❑ Rereview Required Initials Date
Please call 24 hours PRIOR to inspection.
C/42 / Soils Percolation Boring Report by Lic/Project # Date
/�/%
1 C / Soil 0
Soils Map Page Type /'lid Approved By Date
ra
No of Systems
Type of System(s)
U Holding Tank Q Replacement
No. Dwelling Units( �),114 *
Bedrooms, F-ixterreyUnits-[45)(/1**
(1) Septic Tank
rk/ 4lintG
Soil Rate
Grease/Sand
Grease Intcp/Lint Trap
r
Q New ❑ Addition
❑ Existing
!!r� / 3�nM�
C3 (
(il G{. Gal
7 Q
rte'/ Gal.
(,
�
r •r
r jc
Sq. Ft.
Total Linear
Sidewall Allowancer
L%U l2�M+/N7
Leach Bed sq. ft. of
Bottom_ Area
Ft.
rock/ sq. ft. running ft.
Inlet Tested Depth [31 NA
Install._ Line(s) ft. long ft. wide with
min. inches r,�ock below drainlines or
Bottom Area
0
Proposed Bottom Tested Depth
Z
Leach lines/bed special design for slope:
(3) Pit Diameter
No. Pits
Pit Below Inlet (BI)
Seepage Pit
Maximum
Other:
UApplicable
%,�:'P�4t
7c ,
/
�Q
Total Depth
I
Allowable
Depth
LU
N/A Overburden Factor
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❑ S S
o7
TD
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(P.0 Poll P617 11-211-001
/
Well Review Approved: Date: Well Drilling Permit #
SIGNATURE v'1
Grading Plan Approved:1 Date:
f%�„�,
Sewer
Verification Approved: Date:
Plan Check Only Date/,,
//Approved:
//
REMARKS: /A VI T•! �'1 /Itn7s .� �1✓t.�'1 f.� La f�/�� / " / / ` �7 /i >f G/ • ! �. %'1 G/t�.cfiYr /7
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%lttJ /ZGE Olkf AJ
This application is APPROVEDIDENIEDzfor the'rcategoryscheckedsin•SECTIONIB
FOR OFFICE USE ONLY
•above, regarding the dam' esi' g of a subsurface disposal system as indicated on the
acompanied plot plan, using the requirements set forth in SECTION C above. A build-
ing installation
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permit is necessary for the of the above -designed system. No con.
struction Is permitted in the required reserved 100% expansion area.
Revenue code Fee $
(1) Septic Tank must be 100' minimum from any wells.
0 Check/ #
(2) Leach lines must be loo' minimum from any wells, including expansion area.
`/,
Date / " 7 ►/ t/ Initial
0
(3) Sewer lines must be 50' minimum from any wells.
T o r i O l
Z....•
0
minimumfrom any wells, including expansion area.
(9 Seepage pits must be 150' minimum
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11&4rE4 *AIVrw
T
E -INSPECTION FEE OFa3 CITY OF LA QUINT
WI
Q��� l
L BE CHARGED IF THE APPROV BUILDING & SAFETY DE
�'• P
NS AND JOB CARD ARE NOT 0
Signature of Health Official THE
SITE FOR A SCHEDULE APPROVE
IN
PECTION. FOR CONSTRUCTI
Date
NO D(CEPTIONS!
DATE _
DEH -SAN -122 (Rev 9/98) Distribution: WHITE—Office File; YELLOW—Applicant; PINK—Bldg. Dept.; GOLDENROL—Plans/Records
I
COUNTY OF RIVERSIDE'HEALTH SERVICES AGIwtiCY
DEPARTMENT OF ENVIRONMENTAL HEALTH
Food Sewage Deposal �T0 /1EnNa,
'frailer Park Al : . Septic Tank / 000 6,a,%
Mo sl Hotel 3M1 Sq. Ft. of Leach�.ine
D� ( EXIs marc / _ �, b' Dia a0 BI ^'o?YlU o�MD Seepage P>r 7U &1"-A� CXisTi'�c
Co rciaf Build'mg Connection to Sower . L'0 a gPJ�D f,EEPAG`
swimming Pool Connect to Existing.S.S.D.S.
lz-Ldaon-site regenerating water softening devices may be discharged Into the Individual sewage disposal
/stem herewith approved without clearance from the Water Qual' Control Board.
/K Water supply serv�i�n� is ��v dation must be from an apprd, ' e E)OS ri✓4 (C VOW
=All sewage dispos`�dl'i1t 'aliat must oonform with. requirements' of current Undorm Pluri►bing Code.
Any cutting, gradinbr filling in excess of two(2) feet will nullify sewage disposal approval.
,:"
Approval has been obtained from thd..legional Water Quality Control Board for installation of the sewage
disposal system. ;; ° `
This is to certify that the Riverside County &ronmental H.Qahh Services approves the subsurface sewage
disposal plot plan to obtain building permit for llation. constr 0
PATE __ fol ` - BY ,C__�WXV Qvv Z1,,,11111
MAINTAIN 100% � AREA. MIN. _.�./I"#C9M ANY WEL1
MIN, 1W FROM ANY TREE OR WAT"
All
• . , . 3 . a� a . , �P �,�'`����=x�`�I til-' Y���+;:�i^� �
G - A
DEPARTMENT OF PUBLIC HEALT '�m w � PAW by UW i".1u near of rob,,
IS YALIO FOR ONE (1� YEAR . ,� of Ri"�' Conah 4m °'t ram t6 �
an or Arciit.ac 09 tt+e reopomdbWy for the Room,
FROM- DATE OF APPIIOVAL �• ara►ta e.�.
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PLANS AND JOB CARD ARE NOT O - -_ ----
BUILDINGSAFETY-_DEPT
THE SITE FOR A SCHEDULE
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INSPECTION.
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APPROVES
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�y.�'�...:=...-:'�.4-,1V�rti�w��A�S`i12Y'�C�k:'rs.:.i"l S�hr ...w.+►.-.._r.i _^dw-4�.v++7.%•..aY`�''�ti� �i�
A-1 Cesspool Service, Inc.
P.O. Bo: 183, Desert Hof Springs, CA. 92240 JOB INVOICE,
`Since 1959'
(760)329-6875 Fax(760)251-3405
State Lic. #265214 Customer order No. Date ordered
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www.alcesspool.coro I order Taken By Dale"Promised
161
SERVICE ❑ PUMP SEPTIC TANK HAS SEPTIC TANK BEEN DUG UP7 13 Yee 0 No ❑ PMT. ON SITE
RECUESTED ❑ PUMP SEEPAGE PIT AT ITS RISER ❑ OFFICE BILLING
UAN . DESCRIPTION OF PRICE AMOUNT
p p"D
Pumping Fee per 1000 Gallons (or fraction)
fq)
Waste Discharge Fee per 1000 Gallons
Locating and Opening Fee (Ihr. Min.)
Out of Area Fee
TECHNICIAN REMARKS/COMMENTS:
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VA <�-
71
A SERVICE CHARGE OF S22 WILL BE DUE
ON ALL RETRUNED CHECKS.
A FINANCE CHARGE OF 11/2% PER MONTK IST. PER YEAR WELL BE
CHARGED ON PAST DUE ACCOUNTS OVER 30 DAYS
rF PAYMENT IS BY CHECK
DRIVERS LIG M STATE
1 hereby acknowledge the .atis1wtory eompledw of the above described work:
SIGNATIIRE
Total
Due
NOTICE TO OWNER
Under the California Mechanics Lien Law any contractor, subcontractor,
laborer, supplier, or other person who helps to Improve your property,
but is not paid for his/her work or hearing, your property could be sold
by' a court officer and the proceeds of the sale used to satisfy the
indebtedness. This can happen even if you have paid your contractor
in full if the subcontractors, laborers, or suppliers remain unpaid.
To preserve their right to file a claim or lien against your property,
certain claimants such as subcontractor or material suppliers are
required to provide you with a document entitled "Preliminary Notice":
A Preliminary notice is not a lien against your property. Its purpose is
to notify you of persons who may have a right to file a lien against
your property if they are not paid. Generally, the maximum time allowed
for filing a claim or lien against your property is ninety (90) Days after
the completion of your project.
TO INSURE EXTRA PROTECTION FOR YOURSELF AND YOUR
PROPERTY, YOU MAY WISH TO TAKE ONE OR MORE OF THE
FOLLOWING STEPS:
1) Require that payments be made directly to subcontractors and
material suppliers through a joint control. Any joint control agreement
should include the addendum approved by the Registrar of Contractors.
2) Issue joint checks for payment, made out to both your contractor
and subcontractors or material suppliers involved in the project. This
will insure that all persons due payment are actually made.
3) After UPON making payment on any completed phase of the project,
and before making any further payments, require your contractor to
provide you with unconditional lien releases signed by each material
suppliers, subcontractor and laborer involved in that portion of the
work for which payment was made. On projects involving
improvements to a single family residence or a duplex owned by
individuals, the persons signing these releases lose the right to file a
claim against your property. In other types of construction this
protection may still be important, but may be as complete. TO PROTECT
YOURSELF UNDER THIS OPTION YOU MUST BE CERTAIN THAT ALL
MATERIAL SUPPLIERS, SUBCONTRACTORS OR LABORERS HAVE
SIGNED.