002833 (PLBG)T4ht 4 4 Q"
Building 51-4185 Calle �, 8
Address
Owner
Mailing
Address P. r).
City Tel.
Ta ;��nta'ip 92253
Contractor
Address
50-305 My, U1
State LIC
& Classif
P.O. BOX 1504
78-105 CALLE ESTADO
LA QUINTA, CALIFORNIA 92253
NO. 002833
BUILDING: TYPE CONST. OCC. GRP.
A.P. Number 769""112—Orifi
Legal Description
Project Description
City
Lic. # - '
..,
Designer_..�
Address Tel.
City Zip State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section
7000).of Division 3 of the Business and Professions Code, and my license is in full force and
effect.
SIGNATURE DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I 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, alter, improve, demolish, or repair any structure, prior, to its issuance also
requires the applicant for such permit to file 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 (8500):
❑ 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, Buisness and
Professions Code: The Contractor's License Law does not apply to an owner of property who
builds or improves thereon and who does such work himself or through his own employees,
provided that such improvements are not intended or offered for. sale. If, however, the building
or improvement is.sold within one year of completion, the owner -builder will have the burden
of proving that he did not build or improve for the purpose of sale.)
❑ I, as owner of the property, am exclusively contracting with licensed contractors to con-
struct the project. (Sec. 7044, Business and Professions Code: The Contractor's 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 Sec. B. & P.C. for this reason
1
Date Owner '
ra
r
WORKERS' COMPENSATION DECLARATION
I 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. (Sec. 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 if the permit is for one hundred dollars (8100) valuation
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.
Date Owner
NOTICE TO APPLICANT. If, after making this Certificate of Exemption 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
I 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
Lender's 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 certify that I have read this application and state that the above information 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 A Date
Mailing Address n
City, State, Zip
HARD COPY
REMARKS
ZONE:
BY:
Minimum Setback Distances:
Front Setback from Center Line
Sq. Ft.
Size
No.
Stories
No. Dw.
Units
New C? Add ❑
Alter ❑
Repair ❑ Demolition ❑
FINAL DATE
INSPECTOR
Issued by:
Abad& t J.l9t .13IC aepil,6 and bLsl :A. >r1sw
systm
Validation:
A709b
1 12 2 00 U
Estimated Valuation
2+000.0
PERMIT
AMOUNT
Plan Chk. Dep -
ep-Plan
PI anChk. Bal.
Const.
Mech.
Electrical
Plumbing
75.i1b
S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTALS..
i�tl
REMARKS
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"`87 Permit
Validated by:
Validation:
A709b
1 12 2 00 U
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
IST FL. SO. FT. @ $
UNITS
SLAB GRADE
ROUGH PLUMB.
BONDING
YARD SPKLR SYSTEM
2ND FL. SD. FT. @
FORMS
AW&FfSEWER OR SEPTIC >
POR. SO. FT. @
MOBILEHOME SVC.
BAR SINK
GAR. SO. FT. @
POWER OOTLET
ROOF DRAINS
HEATING (FINAL)
OTHER APP.IEQUIP.
DRAINAGE PIPING
CAR P. I SO. FT. @
TEMP. POLE
WALL SO. FT. @
GROUT
DRINKING FOUNTAIN
SQ FT @
FINAL INSP.
URINAL
ESTIMATED CONSTRUCTION VALUATION $
WATER SYSTEM
WATER PIPING
NOTE: Not to be used as property tax valuation
=$
FLOOR DRAIN
MECHANICAL FEES
FINAL INSP.
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
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.
SQ. FT. @ c
BATH TUB
GAR. FIREWALL
SQ. FT. @ c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID @ 11/4 c
SEWAGE DISPOSAL
MESH
SQ.FT.GAR @ 3/ac
HOUSE SEWER
INSULATION/SOUND
GAS PIPING
PERMIT FEE
FINISH GRADING
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
SETBACK
GROUND PLUMBING
UNDERGROUND
A.C. UNIT
COLL. AREA
SLAB GRADE
ROUGH PLUMB.
BONDING
HEATING (ROUGH)
STORAGE TANK
FORMS
AW&FfSEWER OR SEPTIC >
ROUGH WIRING
DUCT WORK
ROCK STORAGE
FOUND. REINF.
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APP.IEQUIP.
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
INAL INSP. /
ROOFING
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATION/SOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURES/INITIALS,
GARDEN WALL FINAL
E
APPROVAL GRANTED 'Approval or these plans by the Lepartment o2 eublu
RTMENT OF PUBLIC HEALTH Health of Riverside County does not relieve the EnSEAR ver or Architect of the responsibility for the En 8�VALID FOR ONE (I) (ae or Architectural desien.,, DATE OF APPROVAL
VACANT PROPERTY
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END CALLE GUATEMALA
STREET
i SITE PLAN SCALE or 50 zoQ
�IV°:510N OF (EIiV°dEi:2(liMINAEFaTA L HEALTH
Estabijshroent --------------- -----— Sew ge Disposal
Trailer Park Gal. Septic Tank
Motel, Apt., Hotel Sq.'F,tJof Leach Line
— Dwelling 6X/Sr ���01(,N.Mgx) l— x ro Seepage Pit
Commercial Building Connection to Sewer =r
v Swimming Pool
No on-site regenerating water softening dovices may be discharged into the individual sewage dispose:
system herewith approved wi : c•ut c•.=:nr.:cce from tl•.e Watcr !.'.li:y Control Boar�jl•
Water supply servir�z V-' is 'sliF.i ? 3 r:: _!E L from an ap :c-, J so;<rce. F_X1Sr• (C Ll LU.
All sewage. dispc°�^`us'�G� m st ca:: c.r^ \V:ii rrc r..:�^r.a of current Uniform Plumbing Code.
Any cutting, .'grading, or fi::i .0 in ettc s> of fo;:r (r? ;:ij. ;.�Uiii` sawage disposal approval.
Approval has been cbtained frc•n the t egicn;l Water QL;Ziity C•.ntrol Board for installation of the sew
age disposal system.
This is to certify that the Riverside County Department of Public Heath approves for construction
or uu taklatim the item(s) checked above.
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COUNTY OF RIVERSIDE, ENVIRONMENTAL HEALTH SERVICES DIVISION -76
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 required on the attached check list.
A non-refundable filing fee of $37 is required wFien the application is submitted. Check must be made payable to the County of Riverside.
I - > ll > Building Department Application Log #
J ,4
1+. 7 /3,4
Name (Owner, Agent, Contractor, Etc.)
Mailing Address
City
/��'ti�v/,vr/�
State
CRL1
Zip Code
Telephone
Job Property Address
(,Ulf
/'City or Community--
Legal Description of Property. (Lot, PM, TR)
Y •7 S l ./I 7/4 /-LI/I
L /4 Y'" A !/-�'.1 . •r/ T /•F
o-rs z/7- �5 Ar- ST /•' % [ (//"3 711/i e- ,T'
'Assessor's Parcel No.
Water Agency or"Wel
F Y -f r•'
T), �/f
Use of Permit erre AV7 �'-t-�ryu Planning Case N
Lot Size
/ >-I X /i
7" / — 2 6
l
0-1
)
DMH Site Preparation Etc.
-A-4, t- / I/ L ! 7
Signature of Applicant Date
'The above information must be verflied from Building Application
STAFF USE — DO NOT WRITE BELOW THIS LINE
Initial Date
❑ Z N /
Certification of Existing S.D. System required. Yes
WQCB Clearance required. ❑ Yes ❑ Nom
Soils feasibility report recuired. ❑ Yes No'
Detailed boring report required. El Yes � Nom
Detailed contour plot plans required. ❑ Yes i No'
Staff Specialist approval required. ❑ Yes /0 No Lot Inspection Date
Soils/boring report by--��-- - Project # Date
Soils Map Page !I / Soil Typed TIE Approved by IL( a C- Date
Type of System:
No. of Bedrooms
(1) Septic Tank
1-240
Soil Rate Required
4
❑ Existing ❑ New ❑ Additional ❑fl~Replacement
{ WMA -14A
Gals.
f . - o-�.tJ Icr�
(2) Leach line sq. ft.
Sidewall allowance
Install- Lines) Ft. Long,
Leach bed Sq.
(Bottom trench area)
ft. rock/ Sq. Ft.
Ft. wicle-with min. inches
Ft. of bottom
per running ft. 0•1\1/4
rock below drain lines
area
Leach lines/bed-special design for slope_- '
'(3) Pit Diameter
No. Pits
Pit BI
Seepage Pit total depths
Applicable-(M:6,®'6�Q
—L --'Overburden facto r
r
Max. allowable depth �n
�N/A
/ / S
.� ./ L i;S+� !,;" la.... G:%t. �r'..?.l• .I. -*-r i .2 F��! i ,^rs �s n r,/ a � 1l_�I`-tea-� � � , t � ,is-�.t„c..izS��F�
�..i"n �� �/ �Li
�'Z-•.-s -1 /.�i`--f' .�i•Cif�(-N !/T/! f '47 sN�s-s1-. _ a -.� Ne
�P..r..,v_1 >��.f'c�...e+� �;r�.r YX�✓�(' /I.�t��17 ,�.A/� �r� s, 7'�� ,ate:. �: �'
This application is apprcved/denied-for the design of a subsurface disposal system as indicated on the accompanied plot plan using the requirements
set forth in Section B above A building permit is necessary for the installation of the above -designed system.
(1)7� Septic tank and sewer lines must be 50' from any wells
Leach lines must be 100' min. from any wells including expanslonlarea � � / • r
3)Seepagepits must/be X150' mir;from any wells including /expansion area./ /p 1,( � ,f�� &JM
�/ ' l,�fi'��i2..-E%+!-..P'(U,�•fi���Xt-G.�y.� .�:./
�:�-Y,l.� �C.fJ• �G
11 ..��•,.,, .�-�J
Signature of Health Official f Date
RECEIPT NO. 0 Issued by S� t Date—
District:
ate District: ❑Riverside ❑� ndio ❑ Hemet ❑ Perris ❑ Rancho Calif. ❑ Blythe
Distribution: WHITE—Office file YELLOW—Applicant PINK—Bldg. Dept. GOLDENROD—Pending File
DOH -SAN -122 (Rev. 6/86)
0