0007-236 (PLBG)LICENSED CONTRACTOR DECLARATION
CO I h7.-reby affirm under penalty of perjury that I am licensed under provisions of
CI'(a:Pter 9 (commencing with Section 7000) of Division 3 of the Business and
WProfessionals Code, and my License is in full force and effect.
O =, ) M • License,# Lic. Class Exp. Date
LO
w 6541.67 A ,.--"'%'"`09f3t)12C
i
Z r- Date � � Signature of Contractor
ca O
J I— C) OWNER -BUILDER DECLARATION
w w r- I hereby affirm under penalty of perjury that I am exempt from the Contractor's
~ ID_ License Law for the following reason:
(n '
Z ( ) 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).
co () I am exempt under Section B&P.C. for this reason
N Date Signature of Owner
O0)
a Z WORKER'S COMPENSATION DECLARATION
o 2 Z I hereby affirm under penalty of perjury one of the following declarations:
r � 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 � Q performance of the work for which this permit is issued.
m Q C) ( ) I have and will maintain workers' compensation insurance, as required by
O � Q Section 3700 of the Labor Code, for the performance of the work for which this
v Z permit is issued. My workers' compensation insurance carrier & policy no. are:
Carrier STATE FUND
Policy No. 04d 00-ODO�b2�
00 Z)
CT
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
3 subject to the workers' compensation provisions -of, Section 3700 of the Labor
Code, I shall forthwith comply with -those provisions. .
Date: 7X2/er t 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/Agen_ 5e_ "^ '" �^"' ' Date 7/A14 -_
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 7--236 TRACT
0 f 2 1. 0C $ 00
JOB SITE
APN
ADDRESS 4"" jas�OW� Dmsw
OWNER
CONTRACTOR/DESIGNER/EN INEER
X91- DINVLOP MENT CORPORATION
IIEMIZZCIC O N CON=tTC°t ON
55-920 PO :11UD
68.379 MLEY ROAD
LA QUIN LA CA 922a3
CATEWRAL CT1Y CA 92234
(760)328-1747 (-YBI* 194
USE OF PERMIT
PI.U1.1+IBM
(1) ORF", JINTNRMTOR INSTALLATION P;r'R APPRCrVMJi PLANS ONLY
VALUk f 1 ON 106000.00 Is
XVIN"TED COST OF COMTIt1:1MON
10,W0,00
P1iV1:6T I'is�: 5t?A�ili>�fAaE23�
PLUM13l O FLY, 101 -000-419.OW $27.00
r ,
e•
5
SUB TOTAL f:CyMSFiU=ON AW i?7C.!` R CAW
$27.00
1,= PRE PA1'.I> PIM
$0.00
I'O`dWAL PM.-MIf 111—M DUE NOW
MAP
�B�Y
RECEIPT
DATE �
F ALED
INSPECTOR
INSPECTION RECORD
s.
OPERATION DATE INSPECTOR
BUILDING APPROVALS
Set Backs
Forms & Footings
Slab Grade
Steel
Roof Deck
OX to Wrap
Framing
Insulation
Fireplace P.L.
Fireplace T.O.
Party Wall Insulation
Party Wall Firewall
Exterior Lath
Drywall - Int. Lath
OPERATION DATE INSPECTOR
MECHANICAL APPROVALS
Underground Ducts
Ducts
Return Air
Combustion Air
Exhaust Fans
F.A.U.
Compressor
Vents
Grills
Fans & Controls
Condensate Lines
Final
Final
POOLS - SPAS
BLOCKWALL APPROVALS
steel
Set Backs
Electric Bond
Footings .
I Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underaround Electric
PLUMBING APPROVALS
Sewer Connection
Gas Piping
Gas Test
Final I 7,,Z A CO I /L.,K.
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Final
Utility Notice (Perm)
Gas Piping
Gas Test
Electric Final
Heater Final
Plumbing Final
Equipment Enclosure
O.K. for Finish Plaster
Pool Cover
Final
COMMENTS:
COUNTY AF RIVERSIDE HEALTH SERVICES AGENCY--7
CEPARTMENT OF ENVIRONMENTAL HEALTH AssessoR's PARCEL NUINBER
PERMIT APPLICATION FOR A SUBSURFACE SEWAGE DISPOSAL g
AI�PLICANT. Submit this form with four copies of a SCALED plot plan (1.20 SC SYSTEM
A non-*•efundable filing fee is required when the drawn to County specifications as indicated on the attached check list.
tion shall remain valid for a application is submitted. Check must be made payable to the County of Riverside.
period not to exceed one year from d to of
LMS # ! ' Y // Approval of this applica-
L"l (A 7,
Contact Person Address
Q yy< k , — nuura53
OJob Property Address
P y � -e
L) / C
Lot Size ater A e
�I; a of Perm , P/P SUP PL
71
Signature of Aooliram amew
fT�r T
C
State ZP Telephon
Ga �. -71<
AA AN 7 S
❑ Detailed Contour Plot Plans Requir d (1 to 5 foot interval)
❑ Staff Specialist Lot Inspection Required
Thomas Bros. Page_ Grid
❑ Date Lot Inspection Completed:
Initials
Remarks:
❑ Maintenance Booklet Provided
❑ Final Inspection by Department of Environmental Health is required.
Please call 24 hours PRIOR to inspection.
C/42 / Soils Percolation Boring Report by
Soils Map Page Soil Type Lic/Project # Date
0 of Systems T APProved By
e of System(s) Date
Holding Tank Replacement No. �s 1/M^T (1) tic Tank
New Addition ��'wn �r'x rr So' ate
Existing : , l rev s'! c: 4-
Sq. �ti& / - 3 t ji14A 'g =7 i
Ft. Total Unear
ttom Area F
Leach lines/bed special design for slope:
I
Applicable
N/A Overburden or
Ledoan
K BOX IF REQUIRED
box is checked, this application shall be considered rejected until
ormation is provided and the fee paid. Resubmittals later than 90
fter date noted below may require repayment of fees.
lding Tank Agreements Completed
rtfication of Existing S.D. System Required
CB Clearance Required(Attach for DOH-SAN-007, Santa Ana Region Only)s Percolation Report Required
cial Feasibility Boring Report Requiredview Required Initials Date
Sidewall Allowance , 01, r vim``
6rewF6rod ,�� i? �; fs
Grease
//Intepm�i�'��. :
0.(ll 7,5 QO Gal
i
' k/ sq. It. running ft. ' Install / f J" '' Leach
R of
Inlet Tested Depth e(c) ft. long
C3 NA min ft. wide with
dc m
Proposed Bottom TesteDepth— —amino rock below drainlines or_
(3) Pit Diameter No. Pits Pit Below Inlet (BI) Seepage Pit
otaf Depth
❑5' ❑U �.
TD
Well Review Approved:
SIGNATURE Date:
Grading Plan Approved:
sl /
Sewer Verification Appiaved:
Plan Check -On
REMARKS: 1
Maximum Other:
Allowable l
Well Drilling Permit #
_Date:41
This application ��pROVED
ibcwe, regarding the eslgn of a T '� ' ��
system as indicated on the f ji�oles ) _ OFF
3companied plot plan, using the requirements set forth in SECTION C above. A build- , �,�a�
ng permit is necessary for the installation is the forthaboindesi ned s "`t '1f3sGf �,;T•rts !_;,. AE c-:.•+.F.
9 ystem.'Rev
enue code-`n�/
s l 7V- G 0
c r-,fr
I 861960.Tenk must be M minimum from any wells; ( ✓E
WC f rid /► �, / r v "heck # t�
') Leach lines must be 100' minimum from any wells, Ineludin e '
8 expansion area: Date_C J ('7
Sewer lines must be 50' minimum from any wells:p ; q ,,•. ;-ter y �G �Initlal �:
6vC,`r�..
I Seepage pits must be 150' minimum from any wells, including expansion area.
inatu • "ca=ei umgal
-122 (Rev 9/9s)
t i
COUNTY OF RIVERSIDE HEALTH SERVICE:?
; 17PAt'i:TPAAFnN4T �F` Eh' ,R.NIE TAL HEAL
TH
JiW6:.f6 p(r&4A4ruM pBn
od Sa Disposal
Ailnr Park Gat. Septic Tank
Apt., Hotel Sq. Ft. of Leach Line
` Gv:011ing No. _Dia BI TD MD Seepage Pit
C-mmarcial Building Connection to Sewer
Swimming Pool Connect to Existing 111W._CRWe.t•• (000el e//a /414 44*k-,D/OLMO(MU
wo on -site regent+rating water softening devices may be discharged into the.—,.SerriPr
Systam herewith approved whhnut clearance from the C f.
Water supply servixhis installation must be from an approv 8�u�ce,6X jjTj V/ cc ✓cL/p
All sewage disposa�rA a rra'triln must conform with requirements of current Uniform Plumbing Cod)
ny cutting, grading or filling in excess of two(2) feet will nullify sewage disposal approval.
Approval has been obtained from the Regional Water Quality Control Board for installation of the sewage
disposal system. reaee iA farce 75�
This is to certify that the Riverside County Environmental Health Services approves the
plot plan to obtain building permit for stallation,.const ion. D s
DATE 6 `M-DD BY
AlE`a
A 7-600 gcillor> greaseAnWoMW
e interc®ptor
ba izutctlled, /o c a7r?or, �r,r{Q 1ze b�ri /Ce%:,4q fo rQP Ia c P 7� e
2X1s7`rnl 9�eGrQ ih.7r,Pr��p/Ofor•, //i�cJ 9T�a� �hfFrc.eP7�oh /�,Yc�',�.Q.
r frcn-any tN2/!r /O N��n•'FHon,%free.f dGJa'iZ►. h.air,S•�
Sc ,► �M1 n
pl S'rv,rn . f�o,ti W4L*F /(ad S'eo✓cr /1K0,r n.ur/ b-e Soinrh"
frc.. an7 ('IVe//s� d / rrtri`ti. -�ro n wa'{e"A- h"n e,f
00,
�c oa I F
Q
HEAL �"� of thw >o� by fibs Dvarb.t w raft
DEPARTMENT OF PUBLIC H
IS VALID ..ith of Riverside County doss not rellers the � .
FOR ONE (j) YEAR ear or Architect of the reeponsibi1ity for t+e &XIMew
FROM DATE OF APPROVAL. '-- or Architectural a.eiQa"
J.
7500 6��/
SEE NOTE NO. 3-,,
A,JM=^
SEE NOTE NO. 2�
O{lfT y
IPA
L
I
�CONCRETE MANHOLE LID, BOLT DOWN WATER RESISTANT
!1'X2Yl2O'X2$' CLEAR OPENING CAST IRON FRAME AND COVER
PLAN VIEW
HANDLE NO 3 RESAR VARIARLE TO GRADE
VFl/T-1 IN
6' INCR ENM TS
LIQUID OEPTH
i G ,
4w.gr
\-OATTERY OPENING .
SEE SPEC SHEET NO & 161
SEC710N A -A
NOTES:
1. FOR MATERIAL SYECIFiCA71ONS AND MR GENERAL
NOTES SEE SPECIFICATION SHEET N0. 6.214
2. RE FEN 70 SPECWICA7IOH SHEET NO. S-252
3. REFER TO S►ECTFICATION SHEET 11O. S1S1
yWT�A
CAY LACK
FITTING SEAL SEE
SIEC. SHEET NG. 5250 7 E
END .SIDE
{•
WALIS
C
[JFTING
RECESS
3!4' TYPICALEND
k SIDE
VMLLS
2'XVR SLEEPERS
OUTLET
END VIEW
ALL DIMENSIONS IN INCHES
EXCAVATION SPECIFICATIONS
DWG. NO. 1070
GREASE INIETICEPTOR WITH SAMPLE LION
THREE MANHOLES EXTEM DED TO GRADE
OESMGNED F(OORR TIME�EpFOOT [OF E.AR1N COVER
am
ISWOPT'HRU 7300" DA ��
MODEL
A
R
C
D
E
F
G
H
NODEI.
C.SO{O
GAIW -
PC G-TSOO
SCALE: 1/4' - r7
C G-5{O0
SO
td
62
74
7S
3/4
{)/Z
29
LENGTH
47'-W
47'4'
t7'A'
SWEET 1 .1 1
C 6{1SO
57
57
71
74
71,
241314
t 1/t
30
WIDTH
10'-0'
1O14'
1LI-W
DATE T ! 15 / S7
..
A -0il%
lIOX 6�t HIGHLAND, CA 91346
CG-7 SOO
2 t/t
4 1/7
14 Lit
85
66
303/4
i
41 L!t
rto INLET
C-2'
Y-1)'
V-21i2'
DRAWN BY
TANKT.O.
HEIGHT
S'-2.^
S'-1 /'
t'•2 fi11'
CHXD !Y
71./,E25A481 714•79S-74Ot
Z3
m
C7
Z
00
12:40 7603287417 HENDRICKSON CONST. PAGE 05
RED'D J U N 8 2000
SPECIFICATION SHEET NUMBER S-101
PRECAST UNITS SHALL BE PLACED WITH ONE -QUARTER INCH
MINIMUM TO ONE-HALF INCH MAXIMUM SPACE BETWEEN UNITS.
THIS WILL PROVIDE A PROPERLY DESIGNED JOINT MATERIAL
VOLUME TO COMPENSATE FOR MAXIMUM EXPECTED MOVEMENT.
JOINT SEALANT MATERIAL SHALL CONSIST Of A TWO PART, GUN
GRADE, POLYURETHANE SEALANT WHICH WILL CURE TO A 30
SHORE Ai-5, ELONGATION ABILITY OF 750%, TENSILE STRENGTH.
350 P.S.I. AND TEAR -RESISTANCE OF 85 P.S.I. MATERIAL SHALL BE
APPLIED PER MANUFACTURER'S RECOMMENDATIONS.
END VIEW
PENLDFR 11gSHERS,1 �A2L
r-
I
SEI
MATERIAL SHALL BE APPLI
EDGE TO EDGE AND A CASTINGS. MATERIAL SHAL
C
A MINIMUM OF 1/4^ OVERG
1 1 /2" DIAMETER SOLT
HOLES
TYPICAL FOR TWO.
Imo-
D BOLT SIX CADIMUM PLATED
D FOR SPACING, NUT 1/2"-13
-i-0-p-a-D- ®-
PRO -CAST PRODUCTS INC.
Y
. o
s c
IJ „- L' .�L �,•F/�T� J- �c vrr�/�ffT VC-7
—
i
,CIO, i��irE. %� �jY':JyEP /jci.G� ��7(/r'Q �Ni�`�+ '`�'•i•c
C
z EX, Jr� G ' COW'1V T Art cc T
(To�cgsc r��o o EulS/ SEcvE:L [Arr�a AFT it
S
C.:.4�!/'fin`✓Ep Z Con'NECi—
/IT
m
m
LO �6ri/bM i�
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LO
oo;
COAC1111-*LLA VALLEY WATER DISTRIC'1
II:; Regulations 1Zcgarding Interceptors/Separators
(excerpt)
Thc.CoachcIla Valley Water District requires that all plans- and
spccl.fications for the installation of interceptor;./separator;; uhalJ.
. r
be submitted to the district in advance of construction and no
construction shall start- until pllus and specification;, have been
approval by the district. The proposed discharger shall complete all
"interc:eptor application" an& -.submit -it with approved plumbing plans
and ::pcciLicatlons (where. applicable) at its headquarters in
Coachc.11.a.
There is currently no charge for the filing of this application.
No interceptor/separator shall be installed without prior approval
of the 6istriet. Applicants shall notify the district 48' `tiours prior
to the start of installation and all installation shall be inspected
by distiict personnel.
There 1.:; currently no charge for this inspection.
If you have any questions or desire additional information, please
call Joe Barham
Extcri:;:Lon 536.
BKC:gh
, Demand Evaluation Specialist, (619) 398-2661
C
(September/92)