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05613 (SFD)Building 53-,825 1�EBA Artrtrocc P.O. BOX 1504 78-105 CALLE ESTADO LA QUINTA, CALIFORNIA 92253 Owner I Coachella Valley Land Mailing Address 2417 B. Tabiquitz Way #2 City Zip Tel. Palm Springs 92262 1 619/322-1020 Contractor Address Construct ion , P State Lic. City & Classif. 387934 Lic. # 895 Arch., Engr., Designer Address Tel. CityI Zip I State Lic. # LICENSED CONTRACTOR'S DECLARATION I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 70pp) 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. 7031.5,8usiness and Professions Code: Any city or county which requires a permit to construct, after. Improve, demolish, or repair any structure, prior to its issuance also requires the apoficant for such Penni to ire 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 viofafion of Section 7031.5 by 'any applicant for a permit subjects the applicant to a civi perry of not more than rive hundred dollars ($500). ❑ 1, 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 buikls or improves thereon and who does such work himself or through his own employees, provided that such improvements are not intended or offered for safe. It, however, the building orimprovement is sokf witlur 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, Busrress 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 Date Owner 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- O 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 ($100) 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. ff, after mabg 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 Drs 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 Lenders Address This is abuilding permit when property filled out, signed and validated, and is subject to expiration if work thereunder is suspended for 160 days. I car ity 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 Date Mailing Address City, State, Zip No. BUILDING: TYPE CONST. OCC: GRP.; A.P. Number 775--163-016 Legal Description Lot 4 Blk 237 Project Description_ SFD 05513 Unit 22 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 4/6/89 Validated by: Validation: Permit Sq- Ft. 1410 Size No. 1 No. Dw. Stories Units New EX Add ❑ Alter ❑ Repair ❑ Demolition ❑ 428 square foot garage 170 feet 6 -foot wood fence Estimated Valuation $76,360,00 PERMIT AMOUNT Plan Chk. Dep. L� U Plan Chk. Bal. �•� Const. • Mech. • Electrical • Plumbing • S.M.I. 3• Grading 20.00 Driveway Enc. •U Infrastructure a TOTAL REMARKS 1j iJ=n: t:*�-�et ir_iw ,• - . r -- 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 4/6/89 Validated by: Validation: Permit CONSTRUCTION ESTIMATE NO. ELECTRICAL FEES NO. PLUMBING FEES 1ST FL. SO. FT. @ $ UNITS SLAB GRAD ROUGH PLUMB. BONDING YARD SPKLR SYSTEM 2ND FL SO. FT. @ FORMS SEWER OR SEPI ROUGH WIRING MOBILEHOME SVC. BAR SINK POR. SO. FT. ® GAS (ROUGH) METER LOOP GAR. SO. FT. @ POWER OUTLET ROOF DRAINS GAS (FINAL) TEMP. POLE DRAINAGE PIPING CAR P. I SO. FT. GROUT WATER HEATER WALL SO. FT. FINAL INSP. DRINKING FOUNTAIN BOND BEAM WATER SYSTEM URINAL SO. FT. ® =$ LUMBER GR. ESTIMATED CONSTRUCTION VALUATION $ FINAL INSP. WATER PIPING NOTE: Not to be used as property tax valuation FLOOR DRAIN MECHANICAL FEES WATER SOFTENER VENT SYSTEM FAN EVAP.COOL HOOD SIGN WASHER(AUTO)(DISH) APPLIANCE DRYER GARBAGE DISPOSAL FURNACE UNIT WALL FLOOR SUSPENDED LAUNDRY TRAY AIR HANDLING UNIT CFM KITCHEN SINK ABSORPTION SYSTEM B.T.U. TEMP USE PERMIT SVC WATER CLOSET' COMPRESSOR HP POLE, TEMIPERM LAVATORY HEATING SYSTEM FORCED GRAVITY AMPERES SERV ENT SHOWER BOILER B.T.U. SO. FT. ® c BATH TUB MESH SO. FT. ® c WATER HEATER MAX. HEATER OUTPUT, B.T.U. SO. FT. RESID ® 1114 c SEWAGE DISPOSAL FINISH GRADING SO.FT.GAR ® V4c HOUSE SEWER i GAS PIPING PERMIT FEE 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 GRAD ROUGH PLUMB. BONDING HEATING (ROUGH) STORAGE TANK FORMS SEWER OR SEPI ROUGH WIRING DUCT WORK ROCK STORAGE FOUND. REINF. GAS (ROUGH) METER LOOP HEATING (FINAL) OTHER APPJEOUIP. 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 FINAL INSP. ROOFING VENTILATION ///// 1k/ 7.— . t a U REMARKS: FIRE ZONE ROOFING FIREPLACE SPARK ARRESTOR GAR. FIREWALL LATHING MESH INSULATIONISOUND FINISH GRADING i FINAL INSPECTION CERT. OCC. FENCE FINAL INSPECTOR'S SIGNATURESIINrT1ALS GARDEN WALL FINAL U Z O U W 0 M Z O U W fn X L 0 LU (n COUNTY OF RIVERSIDE DEPARTMENT OF HEALTHAsseamm Parcel No. ENVIRONMENTAL HEALTH SERVICES 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 speculations as indicated on the attached check IlsL A non-refundable filing fee (see below) 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 approval. ,,,. VERIFY ITEMS IN SECTION A FROM BUILDING Q SAFETY APPLICATION BUILDING DEPARTMENT APPLICATION LOG'* Agent, Contractor, Contact Person Phone Address 8 Phone S f2 ,Y- C 4)S 0-r 6..) z2 -/oz Owner Phone . Mailing Address o� S/ TA N 0 L/ i r Z vt/�1 y .Z/ City State Zip Job Property Address ;i6,,11,0 { Legal Description Prop. (PM, Tract, Lot) �AL 4-L 6382- /YI--QQ4IeA 6/ .l3Gw.2 3 Lot Sizeter Agenc ,l4tefF Use of Permit P/P, CU, etc. I A 7.74/ Ni'� j Other • ..•:.C�/J r.w. c T' DIH ng MH Siff Prep, etc. Signature of Applicant Date ��' CATEGORY: REV CODE FEE CATEGORY: REV CODE FEE bl SUBSURFACE DISPOSAL 1238 � 5.00 ❑ SITE EVALUATION UPON REQUEST . 7349 $42.00 ❑ MULTIPLE PARCELS WITHIN SAME (NO PLOT PLAN) LAND DIVISION ❑ SEWER/SEPTIC VERIFICATION 7348 $11.00 a. 1 at 4 Parcels (Each) 1238 $45.00 (Less than 1 year) b. Each Parcel after 4 7344 $16.00 ❑ PRELIMINARY ELECTIVE 7352 $45.00 ❑ Rereview (2nd review same parcel) 7344 $16.00 EVALUATION (Attach DOH SAN 53) ❑ Site Evaluation in Conjunction with ❑ HOLDING TANK 7351 $45.00 Critical Area 7346 $66.00 ❑ ALTERNATIVE/EXPERIMENTAL 7345 $13200 ❑ Site Evaluation Lot Less than SYSTEM 10,000 Sq. Ft. 7347 $86.00 '0, INITIAL DATE eot Holding Tank Agreements Completed 11Yes ,Q N' O Certification of Existing S.D. System Required ❑ Yes 0. r WOCB Clearance required. (Attach Form ❑ YesNo DOH SAN 007, Santa Ana Region Only) Soils Percolation Report Required. ❑. Yes �/ Special Feasibility Boring Report Required. ❑ Yes I. Detailed Contour Plot Plans Required (1 to 5 ft. interval) ❑ YesN0 Oti1er ❑ Yes l7 Nod Staff Specialist Lot Inspection Required ❑ Yes INO lot Inspection Date Sills boring report by projject # Date Soils Map Page Ar//SON Type fl Approved • by ,f �f �//� Date .30' n r No. of Systema T r of System(.) No. Dwelling Units(l) (1) Septic Tank Soil Rate Grease/Sand L- b Holding Tank ❑ Existing 'New ❑ Replacement BedroomarejUnils �D�'cM • 444k• Gal ,J GyG!/j 7l, Grease►rMcp Gal Y 1 (2. Leech Line Sq. Ft Sidewall allowance Irratell Line(s) n long R wide with Mach Bed sq. it. trench area It rock/ fi min. i "�todk,pe®bw�^d� fil'mes or of area per running n �NA t Leachlines/bed special design for slope: i (3) Pit Diameter No. Pita ' Pit Below Seepage PR Total Depth des / Applicable N/A Overburden factor r Inlet (BI) A/ ! Max. Allowable Depth r �Q No. 2 System ! VIA r REMARKS: / -�7 :%.tJ.� n� :� .� .•�r f� ,l�,.c.r7 .o'er nG-�i, ../_%7z / w This This application is,PPF RO D ,, IgD•for the category checked in SECTION B above, regarding the design of a subsurface disposal system as indicated on the accompanied plot plan, using the requirements set forth in hECTION C above. A building permit is necessary for the installation of the above -designed system. No construction is permitted in the required reserved,;100% expansion area. (i Septic tank and sewer lines must be 50' minimum from any wells /0 -. -{ -A--« Leach lines must be 100' minimum from any wells, including exnse rea (2pa a Q" Seepage pits must ��be 150' minimum from any wells, including expangion rea„I cis �P il% _ r .a8llo r/ ✓l LZ.�-r^ a i� rd �'3:J lt'—�� �•o, e�� Signature of Hearth Official 1T1JG Cit/ •C .GG�� ,� �. r A1 RECEIPT NO.U`�� Issued By =-' 02 Date DISTRICT: ❑ Riverside, ❑Indio ❑ Hemet q Perris ❑ Rancho Calif. ❑ Blythe DOH SAN 122 (Rev. 5/88) DISTRIBUTION: WHITE - Office file YELLOW - Applicant PINK - Bldg. Dept GOLDENROD - Plans/Records V- I� 4