06072 (SFD)T4ht . 4 4Qui &
P.O. BOX 1504
Building , , 78-105 CALLE ESTADO
Address 51-645 Eisenhower LA QUINTA, CALIFORNIA 92253
William Tribble
Mailing "
Address 80-655 Ave 43
City Zip Tel.
India 1 92201. 1
Contractor
Sam
City Zip Tela
i
State Lic. City
& Classif. 484957 $-1 Lic. #
Arch., Engr.,
Designer
'Address , Tel.
City Zip State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that 1 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
E"th, 'effect.
SIGNATURE DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the following
reason: (Sec. 7031.5,Bushness and Professions Gbde: Any City or county which requires a
Permit to Construct, after, improve, demolish, or repair arty structure, prior to its issuance also
requires the applicant for such permit to Ida a signed statement that he is licensed pursuant to
the provisions of the Contractor's License Law, Chapter 9 (commencing with Section 7000) of
Diviston 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 civilpenalty of not more than five hundred dollars ($500).
' ❑ 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, Suisness and
Professions Code: The Contractor's License Law does not apply to an owner of property who
i 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. ff, however, the building
or improvement is sold within one year of completion, the owner -budder wig have the burden
of proving that he did not build or knprove for the purpose of safe.)
❑ I, as owner of the property, am exclusively contracting with licensed contractors to con-
struct the project. (Sec. 7044, Business and Profession Code: The Contractor's License Law
does not apply to an owner or property who builds of improves thereon, and who contracts for
such projects with a contractors) licensed pursuant to the Contractor's License Law.)
❑ 1 am exempt under Sec. IR S 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, ora certified cow -thereof. (Sec -3800, Labor Code.)
Policy No Company / -4il
❑ 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: It, after makig this Certificate of Exemption you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith
Cmply 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, Civi Code.)
Lenders Name
Lender's Address
This is abuilding permit when property filled out, signed and validated, and is subject to
expiration if work thereunder is suspended for 100 days.
I certity 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.
11LDING: TYPE CONST. OCC: GRP.:
P. Number i73-134-018
Legal Description Lot 06 Block 115
Project Description S.F.D.
06072 `
Sq. Ft. 1565 No. No. DIN.
Size Stories Units
NeWT-M Add ❑ Alter ❑ Repair ❑ Demolition ❑
3timated Valuation
891855.00
PERMIT
AMOUNT
Plan Chk. Dep.
250.00
Plan Chk. Bal.
248.48
Const.
594.50
"
Mech.
47.00-'v
Electrical
112.10
Plumbing
165.50
S.M.I.
6.30
Grading
20.00
Driveway Enc.
20.00
Infrastructure
1988.49
TOTAL
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
t'
FINAL DATE
INSPECTOR
7-7-89
Issued by:
Date Permit
Validated by:
Validation:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
1ST FL. SQ. FT. ® $
UNITS
-LAB GRADEROUGH
PLUMB.
BONDING
YARD SPKLR SYSTEM
2ND FL. SQ. FT.
FORMS
V4,16EWER OR SEPTI
ROUGH WIRING
MOBILEHOME SVC.
BAR SINK
POR. SQ, Fr. ®
GAS (ROUGH)
METER LOOP
GAR. SO. Fr. ®
POWER OUTLET
ROOF DRAINS
GAS (FINAL)
TEMP. POLE
DRAINAGE PIPING
CAR P. I SO. Fr. ®
GROUT
WATER HEATER
WALL SQ. FT.
FINAL INSP.
DRINKING FOUNTAIN.
SQ FT ®
WATER SYSTEM
URINAL
ESTIMATED CONSTRUCTION VALUATION $
WATER PIPING
NOTE: Not to be used as property tax valuation
FRAMING - ��/
FLOOR DRAIN
MECHANICAL FEES
/ tJ :
I�S/
0 �
�x7 (. _
V
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.
SQ. FT. ® c
BATH TUB
SO. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID ® 11/4 c
SEWAGE DISPOSAL
INSULATION/SOON
SQ.FT.GAR ® V4c
HOUSE SEWER
FINISH GRADING
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
CSETBACK . 6F�/ ' I
D PLUMBINJ— 7�7'
UNDERGROUND
A.C. UNIT
COLL. AREA
-LAB GRADEROUGH
PLUMB.
BONDING
HEATING (ROUGH)
STORAGE TANK
FORMS
V4,16EWER OR SEPTI
ROUGH WIRING
DUCT WORK
ROCK STORAGE
FOUND. REINF.
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APPJEOUIP.
REINF. STEEL _ b
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
BOND BEAM
WATER SYSTEM
GRADING
cu. yd.
$ —Plus—X$—=$
LUMBER GR.
F AL INSP.
FRAMING - ��/
AL INSP. 6`
ROOFING�• _ /� _
/ tJ :
I�S/
0 �
�x7 (. _
V
% _ �� !/ J,/
�FO)�/
GP J
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING — 6-d
MESH
INSULATION/SOON
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURES/INITIALS
GARDEN WALL FINAL
Z
Z
O
U
W
I)
m
Z
O
U
W
W
Z
O
U
W
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Ad
0
0
✓' W
COUNTY OF RIVERSIDE DEPARTMENT OF HEALTH Assessors Parcel No.
—0/9
ENVIRONMENTAL HEALTH SERVICES ri 3�
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 list
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 d SAFETY APPLICATION BUILDING DEPARTMENT APPLICATION LOG'
Agent, Contractor, Contact Person . -
Phone
Address & Phone
Owner/ 1 `
Phone .
Mailing Address
city
State
Zip
Job Property Address
Legal Description Prop. (PM, Tract, Lot)
`
Lot Size
'ter`A nc /Well t
fIe Y
Use of Permit PP, CU, -etc.
�+ )< [
i
/t�"',�
Mr, etC.
nor aG c e !.
����.r•�•„-;;;.w.
.
Dwe�9,.
�F.1!
Date
Signature of Applicant
CATEGORY: REV CODE FEE
CATEGORY: REV CODE FEE'
SUBSURFACE DISPOSAL 1238 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)
❑ She Evaluation in Conjunction with
❑ HOLDING TANK 7351 $45.00
Critical Area 7346 $86.00.
❑ ALTERNATIVE/EXPERIMENTAL 7345 $13200
❑ She Evaluation Lot Less than
SYSTEM
10,000 Sq. Ft. 7347 $86.00
;
INITIAL DATE
Holding Tank Agreements Completed ❑ Yes !
Certification of Existing S.D. System Required ❑ Yes Bjo
WQCB Clearance required. (Attach Form r ❑ Yes O
DOH SAN 007, Santa Ana Region Only)
Soils Percolation Report Required. ❑ Yes 1❑
i
Special Feasibility Boring Report Required. ❑ Yes
Detailed Contour Plot Plans Required (1 to 5,ft. interval) ❑ Yes Q No
Other ❑ Yes
a
Staff Specialist Lot Inspection Required ❑ Yes ❑"No
Lot Inspection Date
Soils boring report by r� �project !k Data
Soils Map Page % Sol Type 61 U by /f��l���— DateP
�. ,approved :_
No. of Systems
Ty a of System(.)
❑ Holding Tank ❑ Existing
No. Dwelling Units( 1 }
Bedrooms, F))Mure lanifs
(1) Septic Tank
Soil Rats
Grease/Send
'aftase intcp
❑ ReplaoeReplacement!'�°`�A0),4ew
'
% s r /
)
i�®DF% Gal
i
Gal
2) Leach Line Sq. Ft
Sidewall allowance
a
install , - une(s) it long —ft wide with,
�LeBctr Bed sq. ft
Bbttom trench area
t
It. r fin.
per running ft
�ir° below dralnl'mes or'oflk"_
mxtear
area
Leachlines/bed special design for slope:
(3) Pit Diameter
-No. Pits
Pit Below
Seepage Pit Total Depth
r
ApplicableIrileN(Bir
r
4442
N/A !9!-!!!�Overtwrden factor t
0395 d18
J—
Max. Allowable Depth
4,4n'
No. 2 Systeme
REMARKS:
�� / L.'L,t t•�"i'' Q' _< ,../ft.'i.. y -,_ /�1'.•y., p''� %`: �'t�ti3..t-s� G��+t
( �,f `l`%�,iCa
.Ct QrFrria He 4 !1a r.a '� /ate
fa.I'.:..i .f%� • �..,� YY°.-G�^' .� i"',1i.� ?��-..�.� .e, /,.a i�i4/J.�',%fC>�.c., .� sem..
���fd[�ryi% f
��//+?_.�
/nL //.t�..!et
.�i � d.P f �-� I i �t r. � R .LQA�i. � �'��t�� ..I A'%..'3..�// if'LS.P.i 4I�r (✓.-/ro P ..FY. --a
This application is SAP ROVED ^g-NIED for the category checked SECTION B above, regarding the design of a subsurface disposal system as indicated
on the accompanied plot plan, using the requirements set forth in SECTION 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.
1 Septic tank and sewer lines must be 50' minimum from any wells/mac-fay,
2 ` Leach lines must be 100' minimum from any wells, including expansio ares
3) Seepage pits must. be 150' minimum from any wells, including expans n area
�. '. f
t¢��/,Q �
� 1f �y✓'/�_ IJR /` (�lal..yrJ�-ry-., Gc.'Z�� •%i�,�-' ,-a`-
Frr� rr+� v�LYN �[
Si nature of Health Officio � r+2✓, a, c� 1 . -, P� /o it
RECEIPT NO. 6 ,. Issued By L-. Date 12 a)
1�
DISTRICT: ❑ Riverside, Q�ndio ❑ Hemet q Perris ❑ Rancho Calif. ❑ Blythe
DOH SAN 122 (Rev. 5/88) DISTRIBUTION: WHITE - Office file YELLOW - Applicant PINK - Bldg. Dept GOLDENROD - Plans/Records
E
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4
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