001057 (PLBG)PERMIT APPLICATION
City of La Ouinta
Department of Building and Safety
This permit becomes void if work not commenced within 180 days from date of issuance,.OR, if work has been suspended or abandoned for a period of 180 days.
r1, .
LICENSED CONTRACTORS DECLARATION: I 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.
License Class Lic: Number
Date ' • Contractor,/',�— r
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 Contra ctor''sLicense 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 ($500):
Q 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 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 offereddor sale. If, however, the
building or improvemnt 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.). t
O I, as owner of the property, am exculsively contracting with licensed contractors to construct 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.).
O 1 am exempt under. Sec. B. 8 P.C. (Attached Certificate).
Date' Owner
WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to self -insure, or a
certificate of Workers' Compensation Insurance , or a certified copy thereof (Sec. 3800. Lab. C.).
Policy No. Company
O Certified copy is hereby, furnished.
O Certified copy is filed with the City Building Inspection Department or City Department.
Date - Applicant
APPLICANT NAME (L•; F. MI) Inc •
Econo Sewer Const.
ADDRESS '
68-415 Perez Road-
CITY/COMMUNITY/STATE/ZIP
Cathedral City, CA 92234
JOB SITE ADDRESS/SPACE
78-563 Avenida Buena Ben'
CITY/COMMUNITY/STATE/ZIP '
La Quinta, CA 92253
BOK
769
PAG
084
PRC
002
C
TWN
RNG
SE
S
TRACT
LOTMOD
SB
TRACT NAME '
OWNER NAME (L. F. MI)
La Quinta Realty
CONTRACTOR -FIRM NAME
Applicant
ADDRESS '
above
CITY/COMMUNITY/STATE/ZIP
above
PHO
LINELI45CNc•
8232
C-42
ARC/ENG FIRM NAME
ADDRESS -
CITY/COMMUNITY/STATE/ZIP
PHONE a
TOTAL'
FEE
LICNC- •
-
USE OF PERMIT
Septic System
BL
ZON
FSB
I SSB
SSB
RSB
OFC ,
' ZONE ORD A
LOT SZ
END
SIDE
:ur
I
CERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE: This section need not be completed if
the permit is for one hundred ($100) o, 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 Applicant
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.
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
O thereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be
made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or
demolition or dismantling thereof, will be more than thirty-six (36) feet high %Kap 3.2. Grp 2, Art 2, Sec 341• Title 8.
C.A.C.)
O As owner -builder. 1 will not employ anyone to do work which would require a permit from the Division of
Industrial Safety,'as noted above, unless such person has a permit to do such work from that division.
0 Division of Industrial Safety Permit.No.
Date Applicant
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, Civ. C.p.
Lender's Name
Lender's Address
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 county to enter upon the above-mentioned property for inspection purposes. -
Signature of Applicant or Agent Date
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify I have read this application and state that
the information given is correct. I agree to comply with all state laws and county ordinances relating to buidling
construction, and authorize a' representative of the City of La Ouinta Department of Building and Safety to enter
upon tthe.e.p�rope/Ay.ff or which I have applied for this permit for the purpose of making inspections.
a- '1 _. 1 I` _ -
Signature of Applicant or Agent Date
Print Applicant/Agent Name
APPL/PRMT/lx—E28—$4
Plumbing
Permit to install new Dist. Box
3 and seepage pit
for septic system.
As per approved
plans.
16 NOW
TOTAL'
FEE
30.00
BILOG. DEPT
VALUATION (J �%0 r �.
A
NO.
OPERATION DATE INSPECTOR
NO. OPERATION DATE INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
1
Set Back
33 Ventilation System
2
Ftgs & Frms
34 Plenums & Ducts
2A
Slab Grade
35 Furnace Compart.
3
Steel
36 Inlets & Outlets
4
Grout Blocks
37 Combustion Air
5
Bond Beams
38 Compressor
6
Roof Deck
39 Appl. Clearance
7
Framing
40 Fire Damper
8
Vents
41 Smoke Detection Device
9
Garage Fire Wall
42 Commercial Hood
10
Fireplace P.L.
❑
43 1 Final
10A
Fireplace T.O.
❑
NON ADDITIONAL INFORMATION
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
12 Internal Lath
12A Drywall
13 Finish Grade
INSULATION Thick R
Value
7A Walls (Batts)
128 Ceiling (Batts)
12C Ceiling (Blown)
14 Final
PLUMBING APPROVALS
15 Ground Plumb
16 Water Piping
17 Rough Plumb
18 Vents
19 Sewage Disposal
20 Sewer
21 Water Heater
22 Water Softener
23 Water Service
24 Gas Test
25 Final
Tank Pit L. Line
ELECTRIC APPROVALS
REAR OF PROPERTY LINE
PSL P/1
STREET NAME
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
298 Bonding
30 Fixtures
31 Service
32 Final
RIVERSIDE COUNTY DEPARTMENT OF HEALTH
PERMIT APPLICATION FOR A SUBSURFACE DISPOSAL SYSTEM
Applicant: Submit this form with three copies of a scaled plot plan drawn to county specifications required on the
attached check list. A non refundable filing fee of $15 is required when the application is submitted. Check must be
made payable to County of Riverside.
Name Mailing Address
Q
City
State
Zip Code Phone
Z
O
_.
~
V
*Legal Description of Property (Lot, Parcel Map, Tract)
'Property Address
'City ar• (aDmir (unity
W
+
*Assessors Parcel No.
Water Serving Property From
Lot size
Signature of Applicant Date
*The above information must be verified from Building Application
Staff Use — Do Not Write Below This Line
Initial Date
WQCB Clearance required Yes ❑ No Q
Soils feasibility report required Yes ❑ No (3
Detailed boring report required Yes ❑ No
Detailed contour plot required Yes ❑ No
Comments:
as
Z
O
Soils or boring report by �`z"-� Date
Approved by '� Date
w
y
Soils Map Page Soil Type Tract File No. Other
NtJsWberof-Bedrooms Septic Tank Size (gallons)
Rate Required Type of System
New Addition Replacement
❑ ❑ ❑
Leach line sq. ft. of bottom area trench
Leach bed (sq. ft. of bottom area bed)
Seepage Pit Diameter
Number of Pits j�1
Seepage Pit Depth 3M.
Total Depth of Pit
6' ❑
5
Location of System
Additional Requirements
V A permit is approved/deniedfor the design o'l asub$urface disposal system as indicated on the accompanied plot plan
Zusing the requirements set forth in Section B above. A building permit is necessary for the installation of the above
O designed system.
ySignature of Health Official Date
Receipt No.
District: Riverside ❑
DISTRIBUTION: WHITE - Office File
Indio ❑ Hemet ❑
YELLOW - Applicant
Issued By
Date
PINK - Building Dept. GOLDENROD - Pending File
DOH SAN 122 (Rev 10/82)