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9607-055 (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 cel W Professionals Code, and my License is in full force and effect. 7) co License # Lic. Class Exp. Date LO Z r- Date Signature of Contractor F ` s' / ✓�' � �Ot- (0 �Z °) OWNER -BUILDER DECLARATION W 1 hereby affirm under penalty of perjury that I am exempt from the Contractor's License Law for the following reason: Z_ ( ) 1, 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 L N Date Signature of Owner ON d Q WORKER'S COMPENSATION DECLARATION C:) 2 Z I hereby affirm under penalty of perjury one of the following declarations: Lo F2 O () 1 have and will maintain a certificate of consent to self -insure for workers' X w compensation, as provided for by Section 3700 of the Labor Code, for the O J Q performance of the work for which this permit is issued. m• Q U ( ) 1 have and will maintain workers' compensation insurance, as required by O U Q Section 3700 of the Labor Code, •for the performance of the work for which this LO H permit is issued. My workers' compensation insurance. carrier & policy no. are: ,It Z Carrierb ; Policy No. cD D c. .,.+..Gtr W9603)Mq O J (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 provisions .of Section 3700 of the Labor 3 Code, I shall forthwith comply with those provisions., f• j Date: �s f i i Applicant 4;1, /�.. i 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 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 • a correct. I agree to comply with all City, and State laws relating to the building / copstruction, and hereby authorize representatives of this City to enter upon the above-mentioned property for inspection purposes. ;j Signature (Owner/Agent)�'+s,y§11tGt �'Da4e y�. BUILDING PERMIT PERMIT '.` °°NTR°`# , 3721 DATE VALUATION ' $11)4000.00LOT TRACT JOB SITE APN ADDRESS .91--200 AV -IN! 0A VIS'." 'A00..N.n'A OWNER CONTRACTOR / DESIGNER / ENGINEER ICS11, 7T,S.E11TAES.M'�% MC INl;UL1:ONCONSI3fiON 54-140 PG -A LYM . W3/JP18j11VRD. LA.O f1NTA.. f A %2253 C:K174FUR AL CTIN' CA 922°11 1%4_1:+l3ii .. {619)328.1747 C:El1: 19. USE OF PERMIT F'111.IM1ON(i RD40VE AND 12F.s1'1_ &CC, "t ?(1 GAL GREASE Hf173,1w 1, Y,17Ok WITH 250 (JAM, GRE&S13 tW'f'!'::1tCEPTOR .IN `JAN'ty' LO CATION. VALLIA310N Ls i;,SiTs.s�$AT In COST OF WNS''UUa""i ONO 1ii.t}u0.Qa3 i'i RIVII.1T F10. SiIAIA:RY NAt1IMMO FEE t0.lwt ..14t4(lflf) T45,100 SWRY'.MI, CC3WSTP,:UC TIONI SND PLAN CRE?CK $45.00 LESS PR -PJVU) F'3,',S $0.001 TVI -AL VtAMiff >ti "E1" .DUE N0 $45.09 RECEIPT DATE - BY. D F L �. INSPECTOR s/., 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 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 SGL .2 '/L - 1040 Final Final Utility Notice (Gas) 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) COMMENTS: . 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. ' Licensev�7#4lcj / Lic. Class Exp. Daae -0/96 7 .n . 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). 4 ( ) I: as owner of the property, am exclusively Contracting with licensed contractors to construct the project (Sec. 7044, Business & Professionals Code). O 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: ( ) 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&iqueCUMy?workers' compensation insurance cagrieg f&.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, lishall 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. Date: - Applicant 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 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 the above-mentioned property for inspection purposes. ,� Signature (Owner/Agent) Date BUILDING PERMIT PERMITJaj i)q CONTROL# 711,8194 .���!'-'Q M.�Yer 3847 DATE VALUATION ' LOT. TRACT �.R,tAl'!. " ids?.i.K-,1GyADi'f.Y JOB SITE ��1p"�biYVY lwY A2.1. APN ADDRESS OWNER CONTRACTOR/DESIGNER/ENGINEER N IL Wlsfs.pllrl I'.ES011,1711S nmc I; LNM UC''KSON CaOC Sf`:'UC:":f10IN BLVD � � 68379 10 E(�L�`r.Y R{��.j�. y511-I/�dU�t'''��{:�Y►i` fey ' lr.f1 Lµ 1.�➢I,1.K' G.,A l✓M�J:7'. .' / /' to /��y !�,� {.iP�.{ Tl %/3.d3�.1'R 1:i �fi a 4' :�rt4 o�L-s+F gti�l-lf)�'R ti1281.747 C.BL# 194 USE OF PERMIT ti3: f.CyV:ls ANla:ttktl°f,il4.-t^': 1<5O (JAI, r.JR,L:;ll,`�hi1FV"t'Li6t,E?1't'Cald W11W. '25VOIUAL. QREANT; 11V't"FACIA "FOR l7rf sAtifta_ ,� )Ca1:1YC3?1f. , , `t1iEi i;0o-� � �� %+�IV�1T`i�ti1�".1..iON 1�I,0t0.00 Pi.fMv )ff O fh [til-! 00-4i43,d)()tl $45,00 z '(;ttiiST UC`!'ONAND't'i:.ANCH.L'CK V5.00 LE'SgS PRE-Pr'1:M P 1,5 .$0.00 RECEIPT DATE BY I DFIgA p 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 Gas Piping PLUMBING APPROVALS Gas Test Electric Final Waste Lines Neater 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 Utility Notice (Perm) COMMENTS: WMSAN 17Z tHeV elW) IASUlpuupn: ♦rnI I C—V111ou run, 7 c�v�.—.+yyn�u ren a r �+�•�+ L �r�w�n us j� ...etb. fJ -! MO a/TAi%V rc v/3NTiN f �� Signature of Applicant Date r CHECK BOX IF REQUIRED ❑ Holding Tank Agreements Completed ❑ Detailed Contour Plot_ Pians Required (1 to 5 foot inteiv4 '❑ Certification of Existing S.D. System Required ❑ Grading Handout Provided to ❑ WOCB Clearance Required ❑ Staff Specialist Lot Inspection Required Z 0 (Attach For DOH-SAN-007, Santa Ana Region Only ❑ Lot Inspection U❑ Soils Percolation Report Required 13 Date Lot Inspection Completed: Initials W N ❑ Special Feasibility Boring Repoli Required Remarks: ❑ Maintenance Booklet Provided Initials Date ❑ Final Inspection by Department of Environmental Health is required. C/42 I Soils Percolation Boring Report by Ugproject # ." Date Soils Map Page Soll'Type "I Approved By Date No of Systems T of Systems) O H ank O Replacement O New O Additlon No. GwoWmg Units (./Fk�Jr nits Sfa 17 d4 ; l� /+v! r (ttI, lc Tank '�` II Rate Qww jam# L�. Grease Intcp/Nrtiioap. O Existing tial. v? SO • urR.4.eP6-,' -Ybf bA41 Sq. Ft Total Linear Sidewall Allowance 9ch Bed sq. ft. of Bottom Area Ft So Area \\ rock/ sq. It. running It. Inlet Tested Depth Q NA Install Line(s)---JL kxtg -----JL wide with min. es rods below drelnlines or U Proposed Bottom Tested Dep . Z Lead Iinesrbed special. design for slope: (3) Pit Diameter No. Pits Pit Below Inlet (BI) Seepage Pit Maximum Other. k; Total Depth Allowable O Applicable r \ Depth W W WA Overburden Factor 0 5' 6' �•. TD Well Review Approved- Date: Well Wiing Permit # SIGNATURE , Grading Plan Approved- Date: SIGNATURE ! -7 / `11 -9 �oZ Sewer Verification Approved:W • Date: / ` / �• REMARKS: �. This application ROV FOR OFFICE USE ONLY above, regarding the design of a subsurface disposal system as Indicated on the acompanled plot plan, using ifte requirements set forth In SECTION C above. A build- p pC G 7� �Q �• Ing permit is necessary for the installation of the abovedesigned system. No construe- Revenue code Fee $ O tion is permitted In the required reserved 100% expansion areA 0Ca GQAI f %A (1) must be 100' minimum from any wells. - TA (2) Leach Ones must be 100' minimum from any wells, Including e n area tIf D r it al /Y (3) Sewer Iines,must be Sty minimum from any wells. BU MENT0 LINN PAFI I Z O (4) Seepage pits must be 150' minimum from any wells, Including okpanslon area C®NDMONALLY H W ACCEPTED FOR MNSTRUCTION rn SUBJECT TO INSTALLATION AS PER i �j Signature of Health Official _ i A lC? ALL APPLICABLE COD Date - DATA t. _..�.. �� } WMSAN 17Z tHeV elW) IASUlpuupn: ♦rnI I C—V111ou run, 7 c�v�.—.+yyn�u ren a r �+�•�+ L �r�w�n us j� t s ASSESSOR'S PARCEL NUMBER 60UNTY OF RIVERSIDE HEALTH SERVICES AGENCY rf 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 N rsicte, L.v of this appiic tion shall remain valid for a period not to exceed one year from date of payment. - `` '' a� 1.� LOG # i rY Of � 9 OL" ,;,w rHK il$.. 0 Agent, Contractor, Contact Person Address City. State Zip Telephone ,, 4'J A,voi's� /i�fJ1/ticc - /8�lock �9- 9 F tEn/ �Nif ivivV 14 G!uiNi7i (Q. ,�J -7 SbY-7690 Owner Address City State Zip Telephone I f) a KSL Drfc,,l7 /1rfmT rtic. 56 -/yo P6f1 QC ✓D. (A Ci'a,Air r 72r3 51:Y 76 �70 - Z Job Property Address City . - ZIP . �o o i4VEn/i m-, �//,S-rq /-?a,V/ r4 U Lot Size Water Agen Use of Pe�niL PSP SUP UP etc Legal Description W Y r rn/c fQJ�l 'L Exp , , . «aP. x -ti to - ('ud�iff'tc^ VA(cf y 6 c - .�c Q4 . tnssurH� �D.B�4.1.Z4 Arra /'.F!®a: 61Ocf %4,� _ tt!i%i Irl lac rc r —eta ff -( MO .t/rAi%1% C 1 v/jH&N f f . Signature of Applican Date v Well Review Approved: Date: Well Drilling Permit # SIGNATURE :* Grading Plan Approved: Date: •_' SIGNATURE �' Sewer Verification Approved: ✓( (N. r� C Date:'"11-!2 i F l r OA 614 F(IA REMARKS: ^'v i�,LLLi 4/1 r " ! /Jt h This application i ROV FOR OFFICE USE ONLY above, regarding the design of a subsurface disposal system as Indicated on ,the aoompanled pbt Plan, using the requirements set forth In SECTION C above. A build Ind permit is neoessary for the installation of the p oY abovedesigned system. No eonstruo Revenue code 7� �Q Fee : O /• '! Uan le permitted In the required reserved 100% expansion area ' - ��Q�/1%C �/L1!!AfLJ�/d'- r �. ... �ice. .. ....-�~F �J'. �§I: •''�.��L.// •S'• ¢.�.ta- .. ... � ... .�': L�S CHECK BOX IF REQUIRED _. ❑ Holding Tank Agreements Completed ❑ Detailed Contour Plot Plans Required (1 to 5 foot Intervaq ❑ Certification of Existing S.D. System Required ❑ Grading Handout Provided m ❑ WQCB Clearance Required ❑ Staff Specialist Lot Inspection Required Z 0 (Attach For.DOH-SAN-007, Santa Ana Region Only ❑ Lot Inspection U❑ Soils Percolation Report Required . WL3Date N ElSpecial Feasibility Boring Report Required Lot Inspection Completed: Initials h -Remarks: k ❑ Maintenance Booklet Provided 3. Initials Date ❑ Final Inspection by Department of Environmental Health Is required. - C/42 / Soils Percolation Boring Report by UcgPro)ect # Date Soils Map Page Soil Type Approved By Date .No of Systems T of Systems) O H ank. ' O Replacement . Niw O Addition No. G wWfpg Units (: / F* 1" nits ._ de l� ( Uc Tank ti Rate - aeeeejBe+d iAl .' Grease Intcp/Hah�iep t 5 A 1T � /hn y ) O Existing _ .. fi• _ Gad. el. Ir Sq. FL Total Linear Sldewall Allowance `; .• ,• 6/ ; . 7 Bed sq. it. Bottom Area. Ft t go Area rodr/ aq. ft nuri►Ing f< I (s)—ftLinkmg ft wide wftii \ Inlet Tested Depth NA mins rods below drainlines or " U Proposed Bottom Tested Dep Z Lealines/bed special design for slope: (3) Pit Diameter No. Pits Pit Below Inlet (BI) Seepage Pit Maximum Other. O Applicable § \ \ Toted Depth \ ITDL-- Allowable Depth \ n • U W WA Overtwrden Factor 0 5' V `-_ ' •. v Well Review Approved: Date: Well Drilling Permit # SIGNATURE :* Grading Plan Approved: Date: •_' SIGNATURE �' Sewer Verification Approved: ✓( (N. r� C Date:'"11-!2 i F l r OA 614 F(IA REMARKS: ^'v i�,LLLi 4/1 r " ! /Jt h This application i ROV FOR OFFICE USE ONLY above, regarding the design of a subsurface disposal system as Indicated on ,the aoompanled pbt Plan, using the requirements set forth In SECTION C above. A build Ind permit is neoessary for the installation of the p oY abovedesigned system. No eonstruo Revenue code 7� �Q Fee : O /• '! Uan le permitted In the required reserved 100% expansion area ' - ��Q�/1%C �/L1!!AfLJ�/d'- r �. ... �ice. .. ....-�~F �J'. �§I: •''�.��L.// •S'• ¢.�.ta- .. ... � ... .�': L�S Ck.-YUNTY OF RIVERSIDE HEALTH SERVICES AGENCY DEPHNTMENT;OF ENVIRONMENTAL HEALTH EXrsr.IsW,,x:1l. 4144 6 `Food µ0u21; 8� ) .. x Sewage DispesaX _Trailer ark Gal. Septic'rank Mlotel, Apt., Hotel_ 5q: Ft. of Leach Lino _Dwelling, No.' '_Dia BI _TD MD Seepage Pit Commercial Building EYrJt_Conr�ectic,nlnSew��r CaAr/�Eccsr (/ge(EyGe�r»it .�i1.7tecr(cvwoJl Swimming Pool Y_Conns�ct to Existing S. D.S. No on-site regenerating water sh approved without ckiaranco from the oftdning davices may bo discharged into tho i � 15.2�,.eV system he;sivi;wstgr 9f+ +ity C t ,l -Board. C l%(.,V. Water sull,ly servrn t is Ito from an aPprovod :source EX i1'T. (CUu Oj All sauago du;posa must (;;"nturm with requirement:) of current Uniform Plumbing Codo. Any cutti:ut, 9radinr odiliing in oxcits;. of hvo(2) 1e1,11 eOi nullify a0waga dr.:rc,sr,i approval. �Eyr;oval has boon obtained from the f 1Fpglafial Water Quality Conirvl Board for installatibn of the sewage This is ti? cortify that tho Riverside County approve; tho subsidace sewage disaosnl plot plan /to obbttaaiin building permit for i tails tk�n, con/strixiionn. DAT. F =_L5r`_. ElY ���!`�'L_'i L✓, C �K �� � °" ,� NEW brftdaUWd, l0(#1/f, 01-fl/l,il' IAC 1iu,%m" r NQIL �. ��" .. 't It 6L1 Q .iC 9'L'►C/l tK X�� 'Appm l of these plans by the loom DEPARTMENT OF PUBLIC HEALT or Aralil 6.atth of Wrerrtde Oounty does n tct m een�� IS VALID FOR ONE (1) YCAR Wr �rahttet� toot Of a `+puo,Jttadltty for the �rmw FROM DATE OF APPROVAL. 1 1 _G •y, LA QUI NTA RESORT GOLF CLUB us G.O. O ' DUNES & MOUNTAIN CLUBHOUSE ' 5�...N. . 50 200 AVENIDA VISTA BONITA 1 ` — \ 4 t, LA QUINTA, CA -92.253 a fa =, ref•:":•,• 'J ` '�S�' • � < 3� �jUMES-TIC.. 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Coachella Valley Water District requires' that all ,plans and specifications for Lite installation of interceptors/separators shall be submitted to the district in advance, of construction and no construction shall start uut:i.l plans aqd spacif icntio-as have been approved by the district. The proposed . di.scluirlSur shall complete an "interceptor application" and submit it with approved plumbing plans and specifications (whuru- applicable) ,ut itn headquarters in, Coachella. There i 11 s currently no charge for the filing of this application. No interceptor/separator shall be installed without prior approval'. of the Y'district. Applicants 'shall notify the district 48 •liours prior., to the start of installation and all installation* shall be inspected` by district personnel. i 3 y , There is currently no charge for this inspection. t If you have any questions or desire 'additional .information, please call Joe Barham , Demand Evaluation Specialist, x;619) 398-266:1_ Extension 536. t BKC : gh (September/92) .