9709-041 (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
Professionals Code, and my License is, in full force and effect.
cense # Lic. Class Exp. Date
Vate f r': ° 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).
( ) I am exempt under Section , B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
,( ) [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.
1 have and will maintain workers' compensation insurance, as required by
S ction 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.
(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 jshall 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 Section 3700 -of the Labor
Code, I shall forthwith comply with those provisions. j
v'Date:!�-- �yy Applicant-
7-
Warning:
pplicant dWarning: 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
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
t�the above-mentioned property for inspection purposes.
Signature (Owner/Agent) �+ �" '"� Date"'
PERMIT #CONTROL #
BUILDING PERMIT .,;►�Eb. 5
DATE ''f,0/4 VALUATION - , j.�`( j� # LOT TRACT ^'876
y
S•;
JOB SITE
ADDRESS 80-10,55 "VI 1i"a A GRANDEAPN
I OWNER,
NOTAXNEAUX,
80105111Fri% C;if0N1Ert;
USE OF PERMIT
CONTRACTOR/DESIGNER/ENGINEER
ELL
4.1,775 s>�,,'tia •LUlS t� l V
€'t1;.M L :SERI CA 42261.
($3()}321-48(w r_nLt; 01
MN) SESa73F1.Ci,U NIC 4`1 hWNC .S S A AU
JAWr I.S.
f;n�i �`i4L.a 4.�!•�d COST 01.0 q:.F��.6��.t,;�wiis.,•.A6R�.�
fz°uflklfn P4017fm 9oI;•ffxu)-4 �).w"x) $ f.§0
ti
ft'Y NOW
.49 -TOTAL tT10141. NN`04%
0
RECEIPT I DATE I BY/ I DATE FINALED I INSPECTOR
1460,000
%37 () -
Mot)
$37.50
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
Steel.
POOLS - SPAS
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
/(v
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
r
Final
Utilitootice (Perm)
COMMENTS:
/
K
��(lam'
I 2
ASSESSOR'S PARCEL NUMBER
—,,j-UWTY OF RIVERSIDE HEALTH SERVICES AGENCY
DEPARTMENT OF ENVIRONMENTAL
MENTAL 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 nun-lohindtiblu filing feo t:; iotljjij(,(l wile', the application is submitted. Check must be made payable to the County of Riverside. A 'roval of lhis�-,pp I
,19 pp p"
lion shall remain valid for a period not to exceed one year from date of payment. — 9 7
_.t��38
23
`7 -T
LOG # I r 15. 1.4 QUI' $214. 0
0 Q�v Ora 9, A
A C acw� � 4,v Qf'
,g.ajointr, cUilact Person Address ress city State Zip "Telephone"
L
Own.,
L� / / _ Address city State ip Telephorle
Z
OZip
Job Property Address
City
C)
W
0
Lot Size �i��aterAgenEX/Jf7.%/j UseofPermit, P/P sup, PUP, etc. Legal Description
113 414 L L& f/ PchAa 1640 11NE i4init A16 -1d
ZOT
Ty.?l elfin
�nature of Applica!h�v.-I-I I �1� Date
.
CHECK BOX IF REQUIRED
C3 Holding Tank Agreements 'Completed
0 Detailed Contour Plot Plans Required (1 to 5 toot interval)
C3 Certification of Existing S.D. System Required
0 Grading Handout Provided
co
Z
C3 W6CB Clearance Required
❑ Staff Specialist Lot Inspection Required
(Attach For DOH -SAN -007, Santa Ana Region Only
Soils Percolation Report Required
❑ Lot Inspection
W
(n
0 Special Feasibility Boring Report Req'uired
❑ Date Lot inspection Completed: Initials
Remarks:
0 Maintenance Booklet Provided
Initials Date
❑ Final Inspection by Department of Environmental Health is required.
C/42 / Soils Percolation Boring Report by LiciProject # Date
CSoils Map Page -Soil Type ljo
Approved By
.44
Date
No of Systems 0.
E� ( S'r'
1Vpe of System(s)
0 Holding Tank 01R.placement
No. Dwelling UnitI')r--ytjT7- (1)Septic Tank
Bedrooms, RildnowtUtus k 15ii-V-6
Soil Rate G ase/Sand
G
0 Now 0 Addition
0 Exisling
r. EJ 6-0"� _0 C) 0 0 G
n[cp/Lint Trap
C,
Gal,
q. Ft.
m Area
Total Linear
f.
Sidewall Allowance
_ttom
ft. rock/ _sq. it. running
unn�
g it.
IntelTested NA
Install a(s)—_It. long It. wide with
�in.hock 1b.11
min. inch ock below drainlines or
Leach Bed sq: It. of
Area
0
Proposed B
BottomT87
s D !Pth__
Z
0
Leach lines/bed, special design for slope:
(3) 1011 Diameter
No. Pits
Pit Below Inlet (BI)
Seepage Pit
Maximum
Of
Applicable
Total Depth
Allowable
Depth
W
U)
N/A Over ur
_Overbur actor
6
TD__Lq__
Well Review Approved: Date:
SIGNATURE Well Drilling Permit If
Grading Plan Approved-
IGNATIM—Date:
E
sewer Ver' ion Approved:
RE ARKS: 4
/V
lo r
-v,, "40d
y7 r7 4ht All
"W It'.,
k."I. - Z
C
V94
This application is R6d-WFGl!6+I9N--B-
abiwe,'regarding the design of a subsurface disposal system as Indicated on the
FOR OFFICE USE ON9
acompanied plot plan,,using the requirements set forth InSECTION C above. A build -
Ing permit is necessary for the installation of the above -designed system. No construe-
is
Revenue code /'2 31? $ �2 (2
tion permitted in the required reserved 100% expansion area
_Fee
(1) Septic Tank must be 100' minimum from any wells.
R"C`heck #
(2) Leach lines must be 106 minimum from any wells. Including expansion area.
Date —initial
(3) Sewer lines must be 50' minimum from any wells.
A—C Alp - -02,393.
Z
O(4)
Seepage Seepage pits usI be 150' minimum from any wells, Including expansion area.
Q1 to
0
W
U)
o J !�
Signature
of Health Official
1-2 -97
Dale
lX)H•SAN
122 (Rev 91931
—wm1itt
Cru r. TcLL
Jor": OW—Appicani; PINK—Bldg. Dept.: GOLDENROL—Plans/Records