9612-118 (PLBG)LICENSED CONTRACTOR DECLARATION
Cf) I hereby affirm under penalty of perjury that I am licensed under provisions of
1-- Chapter 9 (commencing with Section 7000) of 1=ivision 3 of the Business and
N W Professionals Code, and my License is in full force andeftct.
p : License # Lic. Class Exp. Date
W iA 3�kK��)R i_'i2 C34l; i2 Sr �ii97
r r- - r+l..-,f.
6 Z r- /Date Signature of Contractor,
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OWNER -BUILDER DECLARATION
W CD I hereby affirm under penalty of perjury that I am exempt from the Contractor's
U) License Law for the following reason:
Z_ ( ) 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).
co () I am exempt under Section , B&P.C. for this reason
LO
N Date Signature of Owner
ON
Q WORKER'S COMPENSATION DECLARATION
p Cc I hereby affirm under penalty of perjury one of the following declarations:
Lo FZ O () 1 have and will maintain a certificate of consent to self -insure for workers'
X W �= compensation, as provided for by Section 3700 of the Labor Code, for the
O � Q performance of the work for which this permit is issued.
CD Q U ( I have and will maintain workers' compensation insurance, as required by
O U Q Section 3700 of the Labor Code, for the performance of the work for which this
LO li rn H permit is issued. My workers' compensation insurance carrier & policy no. are:
v Z Carrier Policy No.
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Q (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' compensation provisions of Sdction 3700 of the Labor
ode, I shall forthwith comply wit those pro�/isigns. ff
t/Date: r APPlicant��V . -,L Ab
i.71
Rb 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
1 of the Labor Code, interest and attorney's fees.
4 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
construction, and hereby authorize representatives of this City to enter uponfi
the above` -mentioned prope y for inspection purRosest
ignature (Owner/Agent) + w Dat -� `
BUILDING PERMIT PERMIT���Itix CONTROL#
4520
DATE VALUATION LOT TRACT
1 Z/i'�/�1fi S2,IrfNi.tN1
ADDRESS 7 S CALLE, k��;i.IPE JOB
APN
OWNER
CONTRACTOR / DESIGNER / ENGINEER
I1II.1, PENNY
DA'ITI.AND CONMRUM ION
7f.40 CALLG FEWIT
5()305 HW Y I I 1
LAQUINFA CA U2253
C0A('1lfii•I.A CA Q23b
USE OF PERMIT
NI,I tIt3
iN.11r LL t'-XI'ANNION i.f.A(,t.i,II I
VALVATIGN A,(01 00 I's
..ti`4'Iiisri,�t11.0 coni. or. cxl) i1'i:Ilt"i'�l.aN
2,iH.t3.ttif
Erf,tzMIT FIFA, s>ir;tMIr>,R%
PLL INH itNo 11,Iilr.R3 1'(Ii•t)(�► �11w (i(� S<:! itt
P >; Al, -ANI'.) PLAN f"'}ii;t'it`
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'"P900
DEC 19 1996 "'011 -All, VEIIIIIII I' VEFN »>!W.NOW
SUM
CITY OF LA QUINTAL
/ _�_-'
RECEIPT
DATE
BY i
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
I 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
I
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
I
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
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
T /
0
Final
Final p
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:
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COUNTY OF RIVERSIDE HEALTH SERVICES AGENCY
DEPARTMENT OF ENVIRONMENTAL HEALTH
Food Sewage Disposal
Trailer Park Gal. Septic Tank
Motei, Apt., Hotel Sq. Ft. of Leach Line
_Dwelling _No. Dia ALO BI 42TD qL/�D Seepage Pit
Commercial Building Connection to Server
Swimming'Pool Connect to Existing S.S.D.S.
too on-site regenerating water softening devices may be discharged into the individual sewage disposal
system herewith approved without clearance from the Water Quality Control Board.
L"wa{ter supply serving this installation must be from an.approved source
_jZklt swage disposal installation must conform 0h requirements of carni Uniform Plumbing Cada.
Any qutting, 4rading or filling in excess o: two(2) fest wisi nlllify sewage d!iposal approval.
Approval has been owtained from the P.egicnal Water Quaiity Control Board for installation of the sewage
disposal system.
This is to c artify 'm t thf? Rivorsds County En•:ironmr-nta9 Hearth Services approves the subsurface sewage
disposal piot plan to obtain building pea mit for ins laiton, construction.
PATIT� Z < °l6� BY
TF
SeP6c tank and ec aq5•.^
be
DEPARTMENT OF PUBL6 HEALTH frOM any we7's, lnClWfing, expansio.a areas.
IS VALID FOR, ONE (1) YEAR Leh linea mini ba 100 ft. minimum and
FROM DATE OF APPROVAL. Seepage pits must be 150 ft. minimum from
any wells.
MAINTAIN joeqzo -, /
>.. MIN. 10' FROM AHY qtr -AE TAE—F.0 ��A`�io� MAK OM ANY W' ELL'-- :
COUNTY OF RIVERSIDE HEALTH SERVICES AGENCY AssEssoR's PARCEL NUMBER
—
I �
DEPARTMENT OF ENVIRONMENTAL HEALTH 70
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 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.
LOG #
Agent, Contractor, Contact Person
Address City State Zip
Telephone
&M &.w.&fl mj AAI'ra
.so•7o-1 GW P.236
'1139IF5 S_VV
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Owner
!,l /i�
Address City State Zip
NX65 k E Fit! /,Or k Gl2��alr�a 4s f1 S 3
Telephone
7
Z
OF
Job Property Address P
78 V S e-44 '
City
44 PlAl a,
Zip
'-r41P,*'-
-4 .
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Lot Size
Water Agency/Well
Use of Permit, P/P, SUP, PUP, etc.
Legal Description
U)
C Vw d
Dwelling, MH Site Prep., etc.
ature of pplicant
Date
/? /9 /
.CHECK BOX IF REQUIRED
❑ Holding Tank Agreements Completed
❑ Detailed Contour Plot Plans Required (1 to 5 foot interval)
❑ Certification of Existing S.D. System Required
❑ Grading Handout Provided
m
❑ WQCB Clearance Required
❑ Staff Specialist Lot Inspection Required
Z
0
(Attach For DOH -SAN -007, Santa Ana Region Only
❑ Lot Inspection
U❑
Soils Percolation Report Required
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U)
❑ Special Feasibility Boring Report Required
❑ Date Lot Inspection Completed: Initials
Remarks:
❑ Maintenance Booklet Provided
Initials Date
❑ Final Inspection by Department of Environmental Health is required.
C/42 / Soils Percolation Boring Report by i•/ e Lio/Project # Date
Soils Map Page Soil Type Approved By Date
No of Systems
Type of System(s)
❑ Holding Tank 716 Replacement
No. Dwelling Units
Bedrooms, Fixture Units
(1) Septic Tank
Soil Rate
Grease/Sand
Grease Intop/Unt Trap
❑New ❑ Addition
ElExisting
Gal.
Gal.
Sq. Ft.
Total Linear
Sidewall Allowance
Leach Bed sq. ft. of
Bottom Area
Ft.
Bottom Area
ft. rock/ sq. ft. running ft.
Install Lines) ft. long ft. wide with
Inlet Tested Depth ❑ NA
min. Inches rock below drainlines or
U
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:
O
Total Depth
Allowable
I,_
U
Applicable
Q �U
LLA/ 4
U
Depth
W
to
N/AOverburden Factor
5' 6'
TD
Well Review Approved: Date: Well Drilling Permit #
SIGNATURE
Grading Plan Approved: Date:
SIGNATURE
Sewer Verification Approved: Date:
REMARKS: 7 P �/f�iiv✓ti
/-S /�,° eo as
2al �? /
This application Is PPRO EV D DENIED for the category checked in SECTION B
FOR OFFICE USE ONLY
above, regarding tiie deslgnpra subsurface disposal system as Indicated on the
acompanied pbt plan, fn a requirements set forth In SECTION C above. A build-
/ O
ing permit is necessary for the installation of the above -designed system. No construc.
Revenue code Fee $
tion is permitted in the required reserved 100% expansion area.
( Septic Tank must be 100' minimum from any wells.
❑ Check #
(2) Leach lines must be 100' minimum from any wells, including expansion area.
Date Initial
0
(3) Sewer lines must be 50' minimum from any wells.
Z
O_
(4) Seepage pits must be 150' minimum from any wells, including expansion area.
H
U
W
U)
Signature of Health Offidal
ly !9 96
Date
DO -SAN 122 (Rev 9/93) Distribution: WHITE—Office File; YELLOW—Applicant; PINK -510g. Uept.; GULUtNHUL—PlanS/Hecoros