9705-113 (PLBG)LICENSED CONTRACTOR DECLARATION
C6 <' I I hr Mby affirm under penalty of perjury that I am licensed under provisions of
a H,.Chapter9 (commencing with Section 7000) of Division 3 of the Business and
WProfessionals Code, and my License is in full force and effect.
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413153 A iOf-Al!97
/Date f Signature of Contractor -^ .,F
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.
X) 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:
Carrier Policy No.
STA` 4 !•'C IND
I 15 1451 .•��� �
(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 Section 3700 of the Labor
Code, I shalltforthwith comply with those -provisions.
Date: t_ ✓ Applicant—
Warning: Failure to secure Worke, " 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
construction, and hereby authorize representatives of this City to enter upon
the above-mentioned property for inspection purposes.
Signature (Owner/Agent) f Date '" /x
BUILDINGPERMIT PERMIT#
CONTROL#
5177
DATE °5/2119'7 VALUATION 'S7,ii4)OW LOT TRACT
JOB SITE
ADDRESS 77 -81.8 CAiAX, HIDAL GO
APN 773-0934KN
.QWN9�1`t
CONTRACTOR / DESIGNER / ENGINEER
K) 60%, 1260
874-5 VIA NIELODIA
LA QIANTA CA 92253
PALM D SFRT C!A
02200
(619)564-244.
Cv131.#
1.185 .
USE OF PERMIT
PLUMB
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RECEIPT
DATE
BY
DATE FINALED
INSPECTOR
OPERATION,
DATE
INSPECTOR OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
A 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
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
. Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground Pibg. 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
OX for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
Final
Utility Notice (Gas)
ELECTRICA PROVALS
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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ONDI 'IO.NA.LLY
ACCEPT D FOR COU •
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SUBJECT 0 iiv' � LLAi ION AS PER f r'
AVD A L APPLICABLE CODES
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.#",% t ASSESSOR'S PARCEL NUMBER
COUNTY OF RIVERSIDE HEALTH SERVICES AGENCY -7.73 _ 3 _ pad
DEPARTMENT OF ENVIRONMENTAL HEALTH 0_q
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-
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tion shall remain valid for a period not to exceed one year from date of payment.
{21
1238 $214.L
LOG # CHK $214 M (30
Agent, Contractor, Contact Person
�ti4"..L Gyle
Address C State Zip
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Telephone
2-/Q/1. 5
Owner �C
Address City State Zip
Telephone
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Job Property Address/�
i ?61''/e/- /Lid /�' O
City/ �
!j Q & t/! yr -4
Zip
191 z
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Lot Size
Water Agency/Well
Use of Permit, P/P, SUP, PUP, etc.
Legal Description
U)
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7 91k 137 5"0.,IA
Dwelling, MH Site Prep., etc.
�Gr���, l -
Signature of Applican
Date
CHECK BOX IF RE IRED
❑ Holding Tank Agreements Completed
❑ Detailed Contour Plot Plans Required (1 to 5 foot interval)
❑ Certification of Existing S.D. System Required
❑ Grading Handout Provided
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❑ WOCB Clearance Required
❑ Staff Specialist Lot Inspection Required
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(Attach For DOH -SAN -007, Santa Ana Region Only
❑ Lot Inspection
U❑
Soils Percolation Report Required
LU
❑ Date Lot Inspection Completed: Initials
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❑ Special Feasibility Boring Report Required
Remarks:
❑ Maintenance Booklet Provided
Initials Date
❑ Final Inspection by Department of Environmental Health is required.
f
C/42 / Soils Percolation Boring Report by^I I 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
Grease/Sand
❑ Holding Tank Replacement
O New ❑ Addition
El Existing
Bedrooms, Fixture Units
/
3 d d�-r►^ 2 ha rq A
/ U f✓ v Gal.
Grease Intcp/Lint Trap
Gal.
Sq. Ft.
Total Linear
Sidewall Allowance
ti
Leach Bed sq. ft. of
Bottom Area
Ft.
��
Bottom Area
h. rock/ sq -ft. running ft.
Install Line(s) ft. to 9 ft. wide with
Inlet Tested Depth ❑ NA
min. ibes• ock below drainlines or
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Proposed Botto ested Depth
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Leach lines/bed special design for slope:
(3) Pit Diameter
No. Pits
Pit Below Inlet (61)
Seepage Pit
Maximum
Other:
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Total Depth
Allowable
1
Applicable/
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tIts/
Depth
W
N/A Overburden Factor
Q 5' 6'
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Well Review Approved: Date: Well Drilling Permit #
SIGNATURE
Grading Plan Approved: Date:
SIGNATURE
Sewer Verification Approved: Date: 1 /
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REMARKS: ( /! t e i,t e 7 t/ f� t V1� r� S ! 4 T r/iEt,� �tat� 7f!'i� !I
rariP►-�t� ab'f ►.deA 0l cess 'ea® .
If
This application is{APPROVE /DENIED for the category checked in SECTION B
FOR OFFICE USE ONLY
above, regarding thhg deli of a subsurface disposal system as Indicated on the
acompanied plot plan, using the requirements set forth in SECTION C above. A build-
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ing permit is necessary for the Installation of the above -designed system. No construc-
Revenue code .l b Fee $
tion is permitted in the required reserved 100% expansion area.
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(- ,
Tank be 100'
4/3 L/
optic must minimum from any wells.
(�
/ Cheek #
(2) Leach lines must be 100' minimum from any wells, including expansion area.
Date Initial
°C'
(3) Sewer lines must be 50' minimum from any wells.
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seepage pits must be 150' minimum from any wells, including expansion area.
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Sig rlai� of Health Official
Moll -7
Date
DOFiSAN 122 (Rev 9/93) Distribution: WHI I L—Ultiee r -Ile; YLLLUW—Appneam; I -INK -0109. uepi.; UVLutrvntJL—rianslnecuiuw
CA (:LTi/ rN1:D, , DTRE =k'i e
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COUNTY OF RIVERSIDE HEALTH SERVICES AGENCY
DEPARTMENT OF ENVIRONMENTAL HEALTH
Food Sewage Disposal
Trailer Park ). OUO Gal. Septic Tank
-Motel, Apt. Hotel Sq. Ft. of Leach Line
1,1 Dwelling 2hAR, _L—No. b Dia � BI1�TD �$ MD :seepage Pit
Commercial Building Connection to Sewer
Swimming Pool Connect to Existing S.S.D.S.
_f/' z•<;�^' regenerating water softening devices maybe discharged into the individual sewage d'isv? ssal
'herewith approved without clearanca fror:t the Water Quality Control Board,
serving this installation most be from, a.-oproved source
'-%0 zawaQ. dssposal installation must conformwith requirements of current Uniform Plumbing C4• ;=.
vAny cutting, grading or filling in excess of two(2) -feet will nullKy sewage dssposal approval.
=_ATrpr;,val has been obtained from the Regional !Nater Quality Control Board for installation of th_> c_ a=ag9
Cl+"� Oi -as 5ys!err4.
This is to w,-.ifyt 0'at t ,e Rivarside County EnvironmentAl Health Services approves the subsurtace sewage
disposal plot plan to obtain building permit for installation, construction.
DATE 2f.% BY
Septic tank and sewer tines must be 50 ft. 15
from any wells, including expansion areas. -
Leach lines must be 100 ft. minimum and DEPARTMENT OF PUBLIC HEALTI-
seepage pits must be 150 ft. minimum from IS VALID FOR ONE (1) YEAR
any wells. FROM DATE OF APPROVAL.
MAINTAIN 100% EXPANSION AREA, MIN. -1-2. FROM ANY WELL
MIN. 10' FROM ANY LARGE TREE OR WATER MAIN. S ;�j