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9801-129 (PLBG)LICENSED CONTRACTOR DECLARATION I'hereby affirm under penalty of perjury that I am licensed under provisions,of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and DATE Professionals Code, and my License is in full force and effect. License # Lic. Class Exp. Date Signature of Contractor 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)., O I1am exempt under Section B& C for this reason Date %.Z ~�� �+* Signature of Owner_-^ WORKER'S COMPENSATION DECLARATION y, 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. ( ) 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: Cartier Policy No. (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 p vrovro is�ns of Section 3700 of the Labor Code, I shall forthwith.comply with'those,pr'ovislons. Date:Ri''i;'Z�Applicant —== Warning: Failure to secure Workers' Compensation coverage is unlawful and shall subject an employer to criminal penalties and civil fines Lip 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 applicators 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. sicorrect. I agree to comply with all City, and State laws relating to the buildif5g- construction, and hereby authorize representatives of this City to enter upon the above- mentioned•properry'for inspection purposes. 11 1 Signature (Owner/Agent)— -- Date— BUILDING PERMIT VALUATION LOT 112'2/98 54,000.00 JOB SITE ADDRESS 78-039 CALLS ESTADO OWNER MUMBIL 1'NC 78039 CALLE ESTA.DO UA QUINTA CA 92253 PERMIT # CONNTROOLc4 L #A 9801-129 TRACT 6 J Ei' { APN ar, ;z CONTRACTOR/DESIGNER/ENGINEER ONVNEWBUILD.ER, SUBLIST ATTACHED CBL# USE OF PERMIT EXPANSION SEPAGE PIS` 6%4(Y. DA t'aAND LIS'!W.) AS ` UP-CONT11MGTOR V.AL'OATION 4,000.00 LS `!'r I ESI'I1a1ATE8� COST OF C2:,1N.Vf.R@lC'lT0N ' . 4,010.08 PERMIT FEE SUMMARY PLUM MNG FU, 101-000419-000 539.:0 :SUIS -TOTAL CONS'R UMION AND PLAN C14FC K $37.N) LESS PIZE-PMD.IfXJS $0.00 TOTAL PERi1a. T ]FEES OVENOW $37.50 i RECEIPT DATE BY�t; / % . DATE FINALED INSPECTOR INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs Underground Ducts Forms & Footings Ducts Slab Grade Return Air Steel Combustion Air Roof Deck Exhaust Fans O.K. to Wrap F.A.U. Framing Compressor Insulation Vents Fireplace P.L. Grills Fireplace T.O. Fans & Controls Party Wall Insulation Condensate Lines Party Wall Firewall Exterior Lath Drywall - Int. Lath Final Final BLOCKWALL APPROVALS POOLS - SPAS Steel Set Backs Electric Bond Footings Main Drain Bond Beam Approval to Cover Equipment Location Underground Electric Underground Plbg. Test Final I I Gas Piping PLUMBING APPROVALS Gas Test Electric Final Waste Lines Heater Final Water Piping Plumbing Final Plumbing Top Out Equipment Enclosure Shower Pans O.K. for Finish Plaster Sewer Lateral Pool Cover Sewer Connection Encapsulation Gas Piping Gas Test Appliances Final Final Utility Notice (Gas) ELECTRICAL APPROVALS Temp. Power Pole Underground Conduit Rough Wiring Low Voltage Wiring Fixtures Main Service Sub Panels Exterior Receptacles G.F.I. Smoke Detectors Temp. Use of Power Final W ility Notice (Perm) COMMENTS: �1r SECTION D SECTION C SECTION B SECTION A o mJo tir>_ �w ,aZo3- V cy o Cw m"i l �d odsm ma ma w ym o� oa m co cn r o a 3< _mv O O n -� n ' m- a Zrn m m ya?g 17 o m 3T U O mm O _3<Al -Q CDw� c o m < m i D �o v o n o o m 4 o N CD N a > mv Dm O < CDo m0i 1 N x � a R 0 0 m m 3 0. 10 - y _w Zm TJ:V�l 3 v m m � N x3 w o o m > > pn� f �� � r QZ<O u ! T m cn w 0 m91 ywJ i m ° x 0 o m o lz CD N O2 33 - (mD m m IL f 7), N y M 1. ... U, o O C m ED [� OG a C O � j a 0 J aQ O O Q-0 UO m p _ m a m o Z '. ��mdo ° 7 y to '. oar 3 ' 3 o (A m� m m 7° fD oa ti •,-.. tJ Q7. f, C. 7' O �m • 3 3 C 3 C »1 �, N m H C Z O J o i (D C o V (n O / _ - 2 r 1 7 Z T Q i 3° 3 m o n wo i o o_o f$ Z m Ea 3 3 33 o aoomo- m X om � � m v o DD r- 31 0.a0 i Z f N m m x m o m m a D a O Cl i m m y rn 0 m 11 a?m m 7 N O s cJn p 3 o 3 F m m C o O a O •. - N - Q ,, a �� N m rn ti O C a < O J m N_ O� _ m m 7 O .Ji r J - E m m O. O. C ti Q d J D_ O m 7 d 3 m 0 1 m N Z` ` O 7 t0 (D IDJ m Vl N N O D ti. J m r m f0 •yyJ N= dN $2z m dX y3W C a I _j,i 3 a w z cozm a ° MID %zo . aoo � o a m T� a d m u N O aO ^mi d m °=�Z H C, - OO ., T m L ° .J-. w s A mHamm _� y 3�0 - O p - m Z o ti s mn c - N y ❑ ❑ ❑ ❑ ❑ Li ❑ v m o ` o Cn D 3 r ui p ❑ m _ S ? - m m m .. D m - 0 C t. - 0 o ^ 3 m a w. 7 c n x °o ° c�� y w� ° m m n n y m _ 4t a 2 r O O C) n o OLD o �� cr C _0 O '(a < r J O W -n D m N� �,.- w w o 3 m � 'f ,� r1 � Q n (D :E ro 3 n m o a N m . r m a w' m-n 3v n o. 3 � c o _w O m -0 J a En J p C. m y mm o w m m 0 1 ^� �� 77 a' O m �. O. m i ; O -n Z y CD 3 o -t w v�i o ,. [y a a D w f w oo Li rJ d !D o O 3 m 2 3• `�] U6 a .`l a aD s m 7 w mCD o m z 7 3 m m 7 m 5 N w _ _N -1 1 CD m ` w O I c m co r ° v a m p1 a m m a a - m m m 3 -0�' 7 n ccl _ 0 0 O • m o. -i n I m m- N N j N n m a a o a x J' O i k County of Riverside Health Services•Agency Department of Environmental Health 1737 Atlanta Avenue, #H 4 Riverside, CA 92507 ATTN: Land Use Section 7 1+ RECEIVED SIN 211999 1. Certification of Existing Subsurface Sewage Disposal System. Date of Inspeciion: / 9� 79- F) 3 9 C A 1 LE n LA QUID 17.A (Properly Address) / (Owner's Name) . 6J5SEif 7- CL04 amici' UNi7- / (Legal Description and APN) 7G9_ /0Z -6V'/-7 FAILURE TO PROVIDE ALL REQUIRED INFORMATION SHALL PREVENT OWNER FROM OBTAINING ENVIRONMENTAL HEALTH SERVICES APPROVAL. 2. Show design and location (1 " - 20' maximum scale) of the sewage disposal system in relation to attached dwellings, structures, wells, etc. on required plot plan (see Item 11 of memo RE: Existing Subsurface Sewage Disposal). 3. a. 1 examined the existing subsurface sewage disposal system at the above location on %9- 79 . date and determined that the septic tank capacity is I S"DO gallons and that there is- sq. ft. of leachline bottom area. fir,' I S _, g9,C Lo/tl5 b. There are leachline(s), each "' ft. long. c. There are ONE seepage pito, each i �_ in diameter, Q ft. deep. d. The leachbed is ft. by — ft., total sq. ft. of leachbed area. 4. a. Construction of septic tank (please check one of the following): 1,/concrete = fiberglass steel = other (explain): G.1, IS A LS O COAICA d 7E b. Internal dimensions of septic (length (-l' ft. , width �, depth Gf '+y�_/��► ft.) - J. N C. Condition of tank (please answer yes or no for each question) Yes No Inlet Tee present? Outlet Tee Present? Two compartments? _✓ Tank structure deteriorated?' _ Z✓ 'If yes, briefly.explain and indicate appropriate correction suggested: 5. a. While pumping the tank, did !effluent flow back into tank from the absorption system? ❑ Yes O No brt Prior to pumping, was the liquid level in the tank above the outlet tee? ❑ Yes 104o c. Was the area around the lids oxidized? ❑ Yes OAci d. Is design of system gravity feed? CKYes ❑, No e. Were well(s) observed on this or adjacent property? ❑ Yes 91- o If yes, indicate distance of well from: Septic Tank ft. Leachlines Seepage Pits I. Distance from springs, lakes Septic Tanks and natural drainage courses: Leachlines (circle appropriate item) . • Seepage Pits ft. g. Sewer is within 200 ft. of system and abuts property line. ❑ Yes ❑ No ADDITIONAL COMMENTS: 4 6. It is my opinion that the system appears to be in good working order and can be expected to function properly with proper maintenance. . Yes ❑ No ExISTlVG 6'X140' P/7" /S ra/L If there are any further questions, feel free to contact the undersigned at: 3 9�r-y� 44 spa • o _S /�. j! �!/ . COAG),I-/4A„ eA- g'r X 34 Telephone Number -' Address I certify under penalty of perjury that the foregoing is true and correct: Signature W C-42 State License Number xpiration Date RER1' IGW f5Rr: I ,, Print Name I —_ 11)#7r,44)V,6 CONS 1 RucT/oCIO. /A&,_ Name of Pumper Company and Receipt Number/Name of Compfny Holding C-42 License Address /-.2 1- 99 Date I — OEM -SAN -184 12/92) DISTRIBUTION: WHITE—Office PINK—Contractor YELLOW—Applicant I ON -LE E75 -AAO . � . - � ' _ � ... �. • GAS �'� � covER�.D . - - GRC -' SSD GAL - - 1.9-77L18-U_710� QoX, _ ._�------/ .. _ - �.. _ `_. iL . • �_ c / / -- .. — - ------ WI PJt'Sonc Cca�tacr w1) J ?-; = . SASH - p � � � Fnc. w. n•>� It1 i I i `;.�cqs-ir�dr r2af�ra.� �^ � e`er~ 1 rr2 /Yi, r1l • - c7a .�i�1)` � L -- ��►�c ' CX rsriN'C Lor �f� bwck 9 /%Fs✓LT Lure %2aci _ iWV/r AF RECEIVED JAN 211998 J_f -V 0 u s -r ( sp 4 rw6 : ) , GREgfE _rU1Z',VC/- ",4 5 -Or TraJ;faf Park k d Hotc-1 Ft./of Leaoii)e: in Aj, 1: V'TD V le Pt mluz -y APD 0 5eep�F &X B Ming' U (I rn..C, t, S.L.S. tei softening devicoa V., i) 'L Mved .v it h o ut -jh I& Clua'iiy Gu',4,ol Bs-urd. atu suix,!y surding this H t St be ~Dore© n a a ton mu IS (&,rq1sy1,,RKn muot conforni with of cul; �Ilurnbirq CA�fii, sewa -A mn! Uniform _�LA,)v ctq-,i.,jq acoroval. Qj-fij;inq in excess of lvev,)(2) feet., i . .;14 kr'd or instaflwkm of �i cp-rwAgo , n, If ifuva! h! ,z bf�arl ubia: m: from, lite Reg�qlppl Water OL -i -CvrlrW.b-,. N pisposa;.,. -,gtm. This istb cc;fs-.4>--al no Fijvrmd�, Goljn�! E-nvirownental d"Sposd pk/ po.m. t :'r I stallatl''p,51" 00,;L, MAWAIN 14' ','C% EXPANSIONMR. VIN.. FR,0M,jApY-,WEU -M 'MIN. 10' FROM ANY OR—R-GE'TREE OR WATER MAI h ala_ ZVl� 1.2-W No rE 3 0 F-; U -41t L 1) (1A f4 I tis H Y 1111, OF PUBLIC HEALTI, IS VAUD" FOR ONE (1) YEAR I U FROM! [JAIPE OF APPROVAL. %pprovau of tntsepia" DY We L)ep&rcrnent of pUr 4, 1"alth Of Riverside County does not relieve the Engig. Ow Or Or -Ayehitng, of the MPOftsibUity for the jk4ju blif AreWtee tmmW desiMm T, C0