0009-078 (SFD)- ' 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
Professionals Code)and my License is in.full force and effect.
License
# Lic.'Class - psi 1 pExp. Date
31.911 9 '113 3/o I
It
D to %-4 Signature of Contractor z y�, `uw ,A,t1' 41A1�fi�
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 contrac°ing with licensed
contractors, to construct the project (Sec. 7044, Business &Professionals
Code). n
O I am exempt under Section B&P.C.-for this reason
Date Signature of. Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penaltyrof 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' compehsation 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.
S"t'AT9 FWD � fi��Y��•ffl3
(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,
1 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
sets ct to the workers' compensation provisions of Section 3700 of the Labor
C
f ode, I shall forthwith comply w thoseprovist
�S.
Date: w1 Applicant`s'.,, ;tiAt��
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 at
whose request and for whose benefit work is performed under or pursuant to' aY
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
" tie above-mentioned property for inspectio !purposes. \
Signature (Owner/Agent) �4, .k, . x h 21 - Date
BUILDING PERMIT -' PERMTJt
DATE VALUATION LOT (jt j TRACT -
y�'. 17
JOB SITE, - —" -' • .
ADDRESS
APN
&Q-94+ VWTA, 4"sA.Y.d_P
772-260-017
7
OWNER ?
CONTRACTOR / DESIGNER / EN INEER
.BR,PM NUSH11,41 I
'RICK, JO 930M C01`3'3.F"RUCIIfa W MC.
P () BOX 1 x 7 8
401490 t MUMr, €:'.RYEK,
Kati 10 CA 92102
FANC'.HO M9E AGE CA 92770
(760)776.1464- C BTA
r
USE OF PERMIT
Vii`!° 1'74'• SM - PE1401 DOn NOT IN(C'LrrtDE, 81A) °ke"WA.,i.o;, POOL,
DRIVEWAY APPROACH,
TUC T C^r1+iVIRUCTION N. 6,430.00 SR
POR,CHAVA`f'F0 1; ?9woo
"'giAC.#'M.b4.RPOWY ('3F) DA114184
(AD14TRACTAMOCt14'!' 1, 60.y0 LE
Myr or �.C?ilsMST+ r°,�' ON
`4�04.021.30
q; yelp �5y'�� p �y,� I,�9�1e'"�',�t��b,T
.Tj�.F.7. '.�k4.E 47�.L51.0.S.Vi, fty
_
CXKSTR.i,1CT190 PKE 1€), -000.418 -OW $1.707,00 '
><'11AN MCIC ltVIE 101_000_439_08 p,cm.02
l ft, `L3EP02119` 104 _000-459-31 8
t�4kL ldlllai:dCnF1I.II' ?� 101-000421^000
& C7s;10 i, FRE 101-000.420.000 5331.31
IFEE 101-000 -419-000 $334.175
YRICNG M fl10N tT Z - RESID 101 -OW -7414J00 $40,40
ORADI'NIQ 101-000-,423-4700 00
DEVELOPER Wi?.ACI:N' 1 �9s��Q0
P.RT Ftp: !13L11CPLACES - ;idas AE 01-000-25,5-000 �510.a
8"UB-1VTAL Cr+ RTiCT1'3:CK M0't AM a;<ikCK
T6,472.53
12M PRE -PAM RM
41,009,00,
rp`MP
g
A :A EM.1, FEESDUEMW
49'
JAN 11200.1:.
A
RECEIPT
DATE � / } BY
DAT INALED
INSPECTO
a
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING
APPROVALS
MECHANICAL APPROVALS
Set Backs
/_ /li .�
/ ( (��
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
`
Combustion Air
Roof Deck
Exhaust Fans
O.K. to Wrap
F.A.U.
Framing
C)
Compressor
Insulation
=�GfT6�-2
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
Waste Lines
2—1 �2
Electric Final
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
7 7 3
Final
COMMENTS:
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
2_
Utility Notice (Perm)
4 a pDesert°Sands Unified School District "
- _ s
47-950 Dune Palnis Road ,
Notice:. '' t •La Quinta, CA 92253
,
Document. Cannot Be Duplicated .760-771-8515
_ CERTIFICATE OF COMPLIANCE
' f f
Date 1/1'1/01 '" ;APN # 4 772-260-017
No. .:a 21465 Jurisdiction L`a Quutta `
Nussbaum `
Owner Name', Permit #
No. 80-940 Street:. Vista Galope - • , .� , Log'#
City ,La Quinta i ,f -Zip 92253 Study Area'
' Tract # 14104` k 'Lot ,# 17 Square Footage 6430 .
.,
e of Develo ment Strtx le Famil Residence y No'of'Units 1 •,
T 'p. p g Y , .,
4
At the present.time, the Desert ,Sands, Unified School District does not .collect- fees'on" -garages/carports;' covered-'
patios/walkways, residential additions under .500 square feet, detached accessory structures or replacement mobilehorries. It
has been determined the above-named owner is exempt from paying school fees at this time due to the following reason:
EXEMPTION NOT ,APPLICABLE~
This certifies that school facility, fees imposed pursuant to Government Code 53080 = in the amount of
. OYL
2.05 X 6,430 or $ 13,181.50. the property listed above and that`buildmg
permits and/or Certificates of Occupancy forthis.square footage in thissproposed project may now be -issued',
' Fees Paid B r �.
y CC - 1st"Bank -Laurie Johnson Tetephone '760-776-1464
Name`on the check
By 4 Dr. Doris Wilson +Fay`
_ Superintendent:
S
V' •
Fee collected '/e mpted by - Annette Barlow Payment Received: ;X'$13,181.50
'Check No. 58027
Signature.
' NOTICE: Pursuant of Assembly Bill 3081 (CHAP 549, -STATS. 1996) this will serve to notify you that the 90 -day approval period in.which you may protest the fees or other.payment identified
above will begin to fun from the date on which the building or installation permit for. this project is sssued or on which they are paid to the District(s) or to anotherpublidentity authorized to '
collect them on the Di§trict('s)(s') behalf; whichever is earlier.,
Collector •-Attach:a copy of.county or city. plan check application form to district copy for all waivers. ,
,.
Embossed Original- Building Dept./Applican3t Copy - Applicant/Receipt Copy - Accounting *.'
ASSESSOR'S PARCEL NUMBER
COUNTY OF RIVERSIDE HEALTH SERVICES AGENCY 2/_� _ 1'1
_ (40 11
1-7-72
DEPARTMENT OF ENVIRONMENTAL HEALTH
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-
tion shall remain valid for a period not to exceed one year from date of payment.
LMS # _
Agent, Contractor, Contact Person
, `e{J
Address City State Zip
74.6 t� VV *5' P4 -m li��
_
Telephone
� •VV3
Owner' `
� N�G��auM
AddressState . Zip
Aar --10) Maw 14 N''City A
A22a 1
Telephone
�4 ��
Q
(A
r
ZO
Job Properly v+dd ess
City
Aft -
Zip
WLot
Size
Water Agency/Well
Use of Permit, P/P, SUP, PUP, etc.
Legal Description it
� �
'i - -e
�z T \41 A-
MH
Dwelling, Site Prep etc.
Signature of Applicant C � � �
�
Dat w
/� +�
/
CHECK BOX IF REOUIRED�
If any box is checked, this application shall be considered rejected until
❑ Detailed Contour Plot Plans Required (1 to 5 foot interval)
the information is provided and the fee paid. Resubmittals later than 90
days after date noted below may require repayment of fees.
❑ Staff Specialist Lot Inspection Required
m
❑ Holding Tank Agreements Completed
Thomas Bros. Page Grid
Z
0
❑ Certification of Existing S.D. System Required
❑ Date Lot Inspection Completed: Initials
U❑
WOCB Clearance Required
W
(Attach for DOH -SAN -007, Santa Ana Region Only)
Remarks:
❑ Soils Percolation Report Required
❑ Maintenance Booklet Provided
❑ Special Feasibility Boring Report Required
❑ Final Inspection by Department of Environmental Health is required.
❑ Rereview Required Initials Date
Please call 24 hours PRIOR to inspection.
C/42 / Soils Percolation Boring Report by Lic/Project # Date
Soils Map Page Soil Type Approved By Date
No of Systems
T pe of System(s)
No. Dwelling Units
(1) Septic Tank
Soil Rate
Grease/Sand
Holding Tank ❑ Replacement
�] New ❑ Addition
Existing
Existing
Bedrooms, Fixture Units
(� 0 4 Gal.
IO (,
Grease Intcp/Lint Trap
Gal.
Sq. Ft.
Bottom Area
Total Linear
Ft.Bottom
Sidewall Allowance
Leach Bed sq. ft. of
Area
ft. rock/ 11-_ sq. ft. running ft.
Install Lines) ft. long ft. wide with
Inlet Tested Depth ❑ NA
min. inches rock below drai_nlines or
Proposed Bottom Tested Depth
Z
Leach lines/bed special design for slope:
(3) Pit Diameter
No. Pits
Pit Below Inlet (BI)
Seepage Pit
Maximum
Other:
Q
Total Depth
Allowable
U
Applicable _
%
" '
Q
)_ 4y
Depth
40
W
N/A Overburden Factor
❑ 5' 5
TD i
w
Well Review Approved: Date: Well Drilling Permit #
SIGNATURE
Grading Plan Approved: Date:
SIGNATURE
Sewer Verification Approved: Date:
Plan Check Only Approved: Date:
% � , f' �'r s , 00h:, )" c'A
�9 -'�r p tl
SREMARKS: y;�__..
This application is'APPROVED/DENIED for the in SECTION B
FOR OFFICE USE ONLY
category checked
above, regarding te`d`esignoa subsurface disposal system as indicated on the
acompanied plot plan, using the requirements set forth in SECTION C above. A build-
€ ) a 9
4 x
ing permit is necessary for the installation of the above -designed system. No can
Revenue code + Fee $ y
struction Is permitted In the required reserved 100% expansion area.
(
(1) Septic Tank must be 100' minimum from any wells.
heck #
Leach lines be 100' from
Dates 1 I# f5100 i f
(2) must minimum any wells, including expansion area.
initial
t7
(3) Sewer lines must be 50' minimum from any wells.
Z
O
(4) Seepage pits must be 150' minimum from any wells, including expansion area.
U
U)
Signature of Health Official
Date
DEH -SAN -122 (Rev 9/98) Distribution: WHITE—Office File; YELLOW—Applicant; PINK—Bldg. Dept.; GOLDENROL—Plans/Records
A
Fitch Engineers Inc.
January 24, 2001.
City of La Quinta
7� 495 Calle Tampico
La Quinta, Ca. 92,253
SU -Bi ECT: --8'o--64-6 VIt sta .Galope, La Quinta_
Gentle -Ten:
I hereby certify. this day that the pad elevation
onthe above referred to lot is set at 1CI.6. The
approved grading ,plan established the elevation at 101.5.
Resaectfully, '
WM, F. FITCH
R.C.E. 12571
1ESS10
EY
3 No. 12571
G.
SlOF CA�-�
f ,
Ci0L ENG1NEERlNG — PLANNING — SURVEYING
P.O. BOX 4551 PALM DESERT; CA'9226+
MOUNTAIN
ARCHITECTURE
ARCHITECTURE & ENGINEERING
BIG GEAR CITY AIRPORT • 5UITE A-1
P.O. BOX 6167 • BIG BEAR LAKE. CA 92315
(909)555o
John F. Acosta III; Architect, AIA
5/21/01
City of LaQuinta
Department of Building and Safety
La Quinta, CA
---RE. 80940,,Vista=Galope
La Quinta CA - -- -
Gentlemen:
This is to certify that a Structural Observation on the above referenced project has been
completed by me, or under my direction, and that the building is in compliance with the approved
plans.
c rely,
AIN ARCHITECTURE
111::111W AR
Jo F. Acosta, AIA
Lice sed Architect JOHN F, q
CWT, in ,
w AE1V 4.30 3
OF CA1.�F
CALIF. LICENSE #C24055 • ARIZONA LICENSE #28023 • CALIF. O.E.5. REGI5TERED EARTHQUAKE DAMAGE A55E550R #5A1373
Jan 19,01 03:48p Tri Star -Col S.
7603217798
7172!
REPORT OF- FIELD COMPACTION.TES
/ 7
RUR,�AE➢ORT NO. `� ! "' a, �� CLIENT:nTE
PROJECT:QL� V
p.2
NUCLEAR GAUGE INFORMATION AND
CALIBRATION
DAILY STANDARD .CALIBRATION NUMBERS
COUNTS FROM SHEETS
VARIATION, PEACENT,r I"
GAUGE ADJUSTMENT �% VARIATION FROM
LAST USE
GiUGE T`Y P&ROXCENPAmpe ELL
I MOISTURE: MOISTURE:.;
MOISTURE:
MOISTURE:
MODEL NO.: 3 3 d
DENSITY: DENSITY:
DENSITY:
OENSFfY:
PROC , OR INFORMATION
-
Ii
SOlL 10 VISUAL CLASSIFICATION OF SOIL I MAX. DRY DENSITY, PCF' OPTIMUM MOISTURE. %
COMPACTION I MOISTURE
REQUIREMENTS. % �' REQUIREMENTS,
GENERAL LOCATION:
EST
NO.
READING
QUOTIENT/
PCF
SOIL
ID N0.
TEST
DEPTH, IN
ELEVATION,
OF TEST
MOISTURE
CONTENT.
WETIDRY
DENSITY,
PERCENT
COMPACTION
COMMENTS
f
Ii
PCF
Kle 'I
1-4
�A
FfD-
n.
// e-4.
(
"
f
Ii
�A
FfD-
n.
/17. z-
(
"
f
�A
A'- S 103nSE O - MOLFTUnE IN EJCCFSf OF SP£C.ACATIONS
5 - SOIL CD.IE,VT E- momTURF BELOW SPECiF1CATIONS
6 OTTiEA
n.
/17. z-
f
A'- S 103nSE O - MOLFTUnE IN EJCCFSf OF SP£C.ACATIONS
5 - SOIL CD.IE,VT E- momTURF BELOW SPECiF1CATIONS
6 OTTiEA