9702-003 (PLBG)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
F- Chapter9. (commencing with Section 7000) of Division 3 of the Business and
CV W Professionals Code, and my.License is in full force and effect.
p Ch License # Lic. Class Exp. Date
t� (jL
f\
A 13
d) Z n ate Signature of Contractor.
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OWNER -BUILDER DECLARATION
CD
LU LU I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ � 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).
M O I am exempt under Section B&P.C. forthis reason
N Date Signature of Owner
0 N
U Q WORKER'S COMPENSATION DECLARATION -
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.
have and will maintain workers' compensation insurance, as required by
Sraction 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.
STATE 171
(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,
l .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'Sec_ tion 3700 of the Labor
Cede, I h fo by th comply with.those pro slop
ate: Applicant' s1 c 9 (" Al
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
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 att
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
Zt5ove-mentioned property for,inspec9on purposes.
ure (Owner/Agent) 44 f C� `' "" ` Date
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BUILDING PERMIT PERk# y ;,. .. CONTROL#
4665
DATE 3%rf 9 VALUATION LOT TRACT
JOB SITE
APN
ADDRESS 46473 OU�4E PA11,j�lgi'OM) -
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OWNER
CONTRACTOR / DESIGNER / ENGINEER
rI l;l1'!? c �t:5rlZ�11_.1s :
TK.' S I AK t:,f.)NSTIOU('`T'ION
44C-178 OUNE f%ALMS
311 M) CAN EA, Mi 4343 117
LA Qj1 1 N A "'A V126531,
t:"A'f"4iii'1:►iZAI: 01'1' CA 42"34
USE OF PERMIT
4':.,11_0013
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0;iiU'➢`KIAC.r ANk'trfdl' :,lNKi.t ) {„:
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11AIN031id.) FEE, - SEWf-ift 1(fl-( xf-,419-f}tkl
`r li1.11YJ''�Al, CrIMST?I ti._"110 �lNb l�t.niv'yTfIT?tX
4+;3f) 00
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RECEIPT
DATE
ABY
v ..
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
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
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment:Location
Underground Electric
Underground Plbg. 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
O.K for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:
�/1— iP'(/OdJI/��l'OJ�J� 2��7
Final
Utility Notice (Gas)�dq4
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
FBdures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
-Utility Notice (Perm)
All
COUNTY OF RIVERSIDE HEALTH SERVICES AGENCY ASSESSOR'S PARCEL NUMBER
14"
DEPARTMENT OF ENVIRONMENTAL HEALTH
PERMIT APPLICATION FOR A SUBSURFACE SEWAGE DISPOSAL SYSTEM
APPLICANT: Submit this form with four copies of a SCALED plot pian (1-20 SCALE) drawn to County tspecifications as Indicated on the attached check Ust.
A. non-refundable filing fee is required when the appikladon Is submitted. Check must be made payable to the Coun of,Rive kle. 0 ,roval of this app -lice -
bon shall remain valid for a period not to exceed one year from date of navmertL �' Fi
fj / $ 14A
� i OF 6)Ifr,jrA
LOG # t y C A i ' �' ��+211 4 $ D�
Agent, Contractor, Contact.Persom
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rasa CUYL) Siete Q 97jp
Q 1 '7( 6-41 Z
Telephone
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Address city 911119 Zip
Telephone
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Job Propeny.A7dd ss
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Zip
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Lot Size.
Water A X /J rA/E use of Permit, PIP, SUP, PUP, etc.
Legal Description
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Atn,cc,��q �ittryX Qt�CC l"PSIPQ6+ W A�6w
j%itPti� 6! t{grtF re
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Si!na�w Applica 3-3- `�T - t
Date
CMECBOX IF REOUI €D
�❑ Holding Tank Agreements Completed
❑ Detailed Contour Plot Plans. Required (1 to 5 foot interval)
❑ Certification of Existing S.D. System Required'
0 Grading Handout Provided
Z❑
WQCB Clearance Required
LI 'Staff SpeciMst Lot Inspection Required
0
(Attach For. DOH -SAN -007, Santa Ana Region Only
❑ Lot Inspection
U❑
Soils Percolation Report Required
W
❑ Date Lot Inspection Completed: :Initials
0)
❑ Special Feasibility Boring Report Required
Remarks:
❑ Maintenance Booklet Provided
Initials Date
❑ Final Inspection by Department of Environmental Health Is required.
C/42 / Solis Percolation Boring Report by UdProjers # Date
Solis Map Page 6 l ` Soil Type By Date
Is
No of Systems
Type oTSystem(s),f
Q Holding Tank eplaoentent
No. Dwelling Unite We) if r'
Bedrooms, -
(1)
Soil Rate
Grease/Sand
intcp/Lird Trap
❑ New O Addition
13Existingk
i 1 • � Q ��
rj
i) Gal.
'�'+ 1 4i%l
i
Gel.
Sq. FL
om Area
Total Linear
Sidewall Allowance
mcWsG, tt: running n:
Insta (p) ff. long fL wide with
Leach Bed sq. ft. of
Bo Am
Inlet TestedNA
min. below drainlines or
U
Proposed Bottom TestsOepth
Z
Leach Ilnes/bed special design for slope:
(3) PR Diameter
No. 06
Pit Below Inlet .(EN)
Seepage Pit
Maximum
Other:
p
f
Total Depth
Allowable
W
Appli
W «e cior
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/
TD „I Y i
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co
Well Review Approved: Date; Well Drilling Penult #f
61GNATURE '
Grading Plan Approved: tete:
. SIGNATURE
Sewer Verification Approved: pate:
REMARKS: t 49. a 1`0 C .
D
Y
�IUvr/.a-3-�
t olco .fes N
This application Is ROVE n ION B
FOR OFFICE USE ONLY
ebovill regarding the es of a subsurface disposal system as Indicated on the
aoompanled plot plan, using the requirements set forth In SECTION C above. A bulk[-
Ing 19 recsSSWY for i installation the°above designed No
Revenue %�,. I ! Fae tj r y- QL
permit of system. construe
Bode
tion Is, oermkled in the required reserved .100% exoenelo/n.�aro/1a._
(1) Septic Tank must be 100' minimum from any welld f 0 /l •/ l" f `�
,�, C iyr,
t_YCMok fl /
(2) Leach lines must be tib' minimum from any wells, IndVuding44expansbn area.
?6
Date � ? — l In1del 7A 1
Arc F� Ivo. I -/ !L -
(3) Sewer Imes must. be 50' minimum from any wells:
Z
_O
{4) Seepage pita must be 150' minimum from any wk including expansion area.
U
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Signature of Health Official
Data
DOH -SAN 122 (Rev 9/93) Distribution: WHITE=Office File; YELLOW—Applkant; PINK—Bldg. Dept.; GOLDENROL—Pians/Records
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