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9712-015 (RC)LICENSED CONTRACTOR DECLARATION I Ywreby affirm under penalty of perjury that I am licensed under provisions of H:Chapter 9 (commencing with Section 7000) of Division 3 of the Business and N w Professionals Code, and my License is in full force and effect. O =) ch License # Lic. Class Exp. Date r— CY dU.) oZ r— Date Signature of Contractor CID O 11� J U � OWNER -BUILDER DECLARATION W W I hereby affirm under penalty of perjury that I am exempt from the Contractor's ~ 11 License Law for the following reason: 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() I, ,as owner of the property, am exclusively contracting with licensed /contractors to construct the project (Sec. 7044, Business & Professionals Code). 01 ce) I am exempt underSectionB&PC.Jor this reason. "' ✓Date N ��A�� /Signature of Owner O rn Q WORKER'S COMPENSATION DECLARATION o Z I hereby affirm under penalty of perjury one of the following declarations: r H 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 Oro J Q performance of the work for which this permit is issued. 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 rn H permit is issued. My workers' compensation insurance carrier & policy no. are: .,t Z Carrier ZV t= tG H 1 tJra . C-o Policy No. Ljc, �t'�3w �� (lr�"a cb 5 C) 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 ode, I shall fort wit comply with those pjr�ovisions. Date: J: .%� �i /Applicant " 4 .f 'e . 1,/ _-_ ^. ~-_^�... , 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 �^Vlp & 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 propertytforipspectioh purposes. Signature' (Owner/Agent) -"�. •— �~"^D'ate PERMIT # CONTROL # BUILDING PERMIT DATE VALUATION LOT TRACT G401 1-�.clnv JOB SITE 4 ADDRESS 49-41Y)°a"C�`,!����VYa. 4i,������' APN OWNER CONTRACTOR/DESIGNER/ENGINEER l�Si, €�1:.M1l3��• 13�:',4??;'f°�: Sv'�° f ti�`��t°1`s � 131."Il,.?i° �� 44 t AQ1ill+y'1'A PAS D USE OF PERMIT tiL'Ax tiliaiL iW i t, iNt a W 3i P_I?� 16 (0 t-'O Y° r 614Atc CITY OF LA OLHWA 1 V ALI.IATIO v y PLAN, r�#irc'�: f1th i`f��5tii'13a ,CfOxxf � lrt: 1A1 ?fl�..a1#S +,' rl � �, ;I� A1.17g`I1AN, `V_.'A1, H ' , �41 i.1C;t,"ARV'ALi,hlll�. kill-S jJ Y ti i iiy.aa�� Y(UNIIHINOk1 G I �G)CC41 NIA1TO4Xil F .F' - 0 )XINI 10041,flfV4!.-0fm t Sidi yt&va:lil'AI,t'tl}S�7i?r?C"1`1ff� AP<".reI(1�V[Afvppf lj7itt/°j���r�:7fj3f(!yti.t . R.�:�'r�i t�l�.*�''d�d��iJ d•l�l<•i �•3.!d4➢ RECEIPT DATE BY DATE FINALED INSPECTOR .r F C�'ION RECORD,:..... ' OPERATION DATE �r ':�; �NSPE—CTOR ::< OPERATION DATE iNSP€CTC BUILDING APPROVAL—&`__ - + MECHANICAL APPROVALS' �o Set Backs ''- Underground Ducts - Forms & Footings. Ducts Slab Grade Return Air Steel +s Combustion Air Roof Deck __, - ` ' - —" -Ekhaust Fans O.K. to Wrap F.A.U.e Framing __ Compressor r �::' ;?{;3 �; • a :'s Insulation • vents Fireplace R.L. - -. • -- -- _Grills _ �. i Fireplace T.O. s : Fans &'Controls,; . ., Party illlnsulation -= ;�' o erfsatel_ines'• Party W $-Firewall Exterior Lath Drywall - Int. lath •,f. .I . ,. .. ?• :'wU :'nCOtMW�j�o4 3�:... .. uwa 'Y' ,.�r�'�aY*o'a''ra - � Final - Final . ;; p;cQ. POOLS - SQ�Sa' _ S l z wa BLOCMZiLL�,APP1OVALS - Steed et Backs Electric Bond tpotings T Main Drain Bond Beam Appr'oval to Cover Equipment location Underground Electric Underground Plbg. Test " ' Final -' Gas Piping PLUMBING APPROVALS Gas Test Electric Final Waste Lines -. AO Heater Final - Water Piping _ Plumbinig Fir—. plumbing.To Out P _ .+ E ui ment Enclosure q P ;ate: ;.a :�• i Shower Pans O.K: for Finish Plaster ewer Lateral Pool Cover 0 Sewer Connection Encapsulation Gas Piping Gas Test - Appliances �•• Final ,•. '.:, COMMENTS: :=7:�:;� •- ._.._ ..__,. ... ._._._.....w..:.;i:�'",'.....>. ...._ _ _�..�. �e o -_- . r - is final Utility Notice (Gas) ELECTRICAL APPROVALS Temp. Power Pole Underground Conduit Rough Wiring Low voltage Wiring Futures Main -Service Sub Panels .'^ "' ^ ` rr � ._r Exterior Receptaclesz., G.F.I. ez:' �a ai4i r'Aii3 Smoke Detectors4 ,T OY.. Temp, Use of Power 'ou -' „• Final " PRCJJ NAME DATE �V►ti1�� �2 I NHS ��i�'1C'�— �2 I PROJECT ADDRESS PRI MAL DESIG R - LIGHTING TraLEPKIONE DOCU NTATIONgTHOR LE N Ctiaoicad bye= INFORMATIONGENERAL DATE OF PPLA BUILDING CONDITIONED FLOOR AREA ,,, �� `J BUILDING TYPE NONRESIDENTIAL HIGH RISE RESIDENTIAL HOTEL/MOTEL QUEST ROOM PHASE OF CONSTRUCTION NEW CONSTRUCTION ADDITION 5t ALTERATION METHOD OF LIGHTING COMPLETE BUILDING AREA CATEGORY TAILORED PERFORMANCE COMPLIANCE This Certificate of Compliance lists the building features and performance specifications needed to comply with Title 24. Parts 1 and 6 of the Califomia Code of Regulations. This certificate applies only to building lighting requirements. The Principal Lighting Designer hereby certifies that the proposed building design repreresented in this set of construction documents is consistent with the other compliance forms and worksheets, with the specifications, and with any other calculations submitted with this.permit application. The proposed building has been designed to meet the lighting requirements contained in sections 110, 119, 130 through 132, and 146 or 149. Please check one: I hereby affirm that I am eligible under the provisions of Division 3 of the Business and Professions Code to sign this document as the person responsible for its preparation; and that I am a civil engineer, electrical engineer or architect. j I affirm that I am--eligble under the exemption to Division 3 of the Business and Professions Code by Section 5537.2 of the Business and Professions Code . -to sign this document as the person responsible for its preparation; and that I am a licensed contractor preparing documents for work that I have contracted to perform. I affirm that I am eligible under the exemption to Division 3 of the Business and Professions Code by Section of the Code to sign this document as the person responsible for Its preparation; and for the following reason: PRINCI�L LIGHTING DESIGNE NAME SIGNATURt: JC. NO. DATE I ooD R� , .(�l LIDS 357-co I2'�I �1 t" Indicate location on plans of Note Block for Mandatory Measures For detailed instructions on the use of this and all Energy Efficiency Standards compliance forms, please refer to the Nonresidential 1 Manual published by the California Energy Commission. J LTG-1: Required on plans for all submittals. Part 2 may be incorporated in schedules on plans. LTG-2: Required for all submittals. LTG-3: Optional. Use only if lighting control credits are taken. LTG-4: Optional. Use only if Tailored Method is used. Parts 2 and 3 used only if applicable. Nonrasidiur; / Comcfianoa Fwm DeownD.r 1991 PROJEMUIATU\ DATE � I �l r I tJ� S I INSTALMP,1-10NTING SCHEDULE BALLASTS 00© TYPE MANDATORY AUTOMATIC CONTROLS CONTROL LOCATION CONTROL CONTROL TYPE NOTE TO (Room �) IDENTIFICATION (Auto Tme Switch, Exterior, etc.) SPACE CONTROLLED FIELD • •• •- CREDIT CONTROL LOCATION CONTROL CONTROL TYPE LUMINAIRES CONTROLLED NOTETO (Room cc 1 or Dwg. •) IDENTIFICATION (Occupant, Daylight, Dimming. etc.) TYPE # OF LUMIN. FIELD I� 1 M NL t ►•� . NOTES TO FIELD'• For Building Department Use Only �l • •• •- CREDIT CONTROL LOCATION CONTROL CONTROL TYPE LUMINAIRES CONTROLLED NOTETO (Room cc 1 or Dwg. •) IDENTIFICATION (Occupant, Daylight, Dimming. etc.) TYPE # OF LUMIN. FIELD I� 1 M NL t ►•� . NOTES TO FIELD'• For Building Department Use Only �l NOTES TO FIELD'• For Building Department Use Only �l PROJECT NAME., DESCRIPTION Ru—:U� sc-D power La G�-i R.C-CAErrs C-0 NUMBER OF LUMINAIRES Clfn7otusing tta CEC Default value, please provide supporting documentation. DATE 1� A WATTS PER LUMINAIRE CEC DEFAULT _ (Inclucling Ballast) I W I . So 13 M SUBTOTAL FROM THIS PAGE OO PLUS SUBTOTAL FROM CONTINUATION PAGE LESS CONTROL CREDIT WATTS (FROM LTG-3) ADJUSTED ACTUAL WATTS -m - - ALLOWED LIGHTING ,POWER (Choose One Method) . I COMPLE-TE:BUILDING*METHOD""'-"-'--'-..-"-".,-.".-',"'-...".-'..-'-."�.-"-'.-'-.-'........ WATTS PER SF COMPLETE BLDQ AREA ALLOWED WATTS BUILDING CATEGORY (From Table 2-53M) AREA CATEGORY (From Table 2.S3N) WATTS AREA ALLOWED PER SF (SF) WATTS jz TOTALS L—AREA WATTS TAILORED OR PERFORMANCE METHOD-:: ❑ TAILORED ❑ PERFORMANCE TOTAL ALLOWED WATTS (From LTG-4 or from computer run.) :i'�'�t��..;,•*yt':-"i.�''�L��rry.�'-S�.,.r..�:�1�.yv..i.._�.�,./f``?'�•is, a,�� Wit`^ •,. ..t-..�,n.� Y ; � .t; M ' ASSESSOR'S PARCEL NUMBER COUNTY OF RIVERSIDE HEALTH SERVICES AGENCY 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, LOG # 6 Agent, Contractor, Contact Person Address City or State Zip Telephone D S' 4-- 76fr'l� Owner � � ���� �� 1 Address City State Zip Telephone < � Z Job Property Address "Cl 1-(S61bkA044-*pA" dr! City Zip U Lot Size Water Agen/cy//Wee�lll� Use of Permit, P/P, SUP, PUP, etc. Legal Description y Dwelling, MH Site Prep., etc. Signature of Applicant _11hi Date /q -7. CHECK BOX IF�kEQ IRED f y ❑ Holding Tank Agreements Completed ❑ Detailed Contour Plot Plans Required (1 to 5 foot interval) ❑ 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 W 0 ❑ Special Feasibility Boring Report Required ❑ Date Lot Inspection Completed: Initials t Remarks: ❑ Maintenance Booklet Provided Initials Date ❑ Final Inspection by Department of Environmental Health is required. C/42 / Soils Percolation Boring Report by Uc/Project # Date Soils Map Page Soil Type Approved By Date No of Systems Type of System(s) No. Dwelling Units (1) Septic Tank Soil Rate Grease/Sand ❑ Holding Tank O Replacement Bedrooms, Fixture Units Grease Intcp/Unt Trap ❑ New ❑ Addition ❑ Existing Gal. Gal. Sq. Ft. Total Linear Sidewall Allowance Leach Bed sq. ft. of Bottom Area Ft. Bottom Area ft. rock/ sq. ft. running ft. Install Line(s) ft. long tt. wide with Inlet Tested Depth ❑ NA min. inches rock below drainlines or U 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: O Total Depth Allowable Applicable Depth U W N/A Overburden Factor ❑ 5' ❑ 6' TD t'n Well Review Approved: Date: Well Drilling Permit If SIGNATURE Grading Plan Approved: Date: SIGNATURE Sewer Verification Approved: Date: REMARKS: !!A ,,// r �4/O milype C, Q. l" 6 4 4 1h 1% L- H zl,/ This application is APPROVED/DENIED for the category checked in SECTION B FOR OFFICE USE ONLY above, regarding the4design,of-a subsurface disposal system as Indicated on the aoompanied plot plan, using the requirements set forth in SECTION C above. A build- �) �) ing permit is necessary for the installation of the above -designed system. No construc- Revenue code o Fee s 99. v (� tion Is permitted in the required reserved 100% expansion area. '(1),S ptic Tank must be 100' minimum from any wells. a �+ ! Check # J 3 6i. a A I (2) Leach lines must be 100' minimum from any wells, including expansion area. Date f< 1 / / ') h / Initial DL (3) Sewer lines must be 5V minimum from any wells. Z _O (4) Seepage pits must be 150' minimum from any wells, Including expansion area. H U W W Signature of Health Official % Date T UUM-SAN 1ZZ (NOV ti/VJ) UlstrlDutlon: VVNI I t—UTTICe FIIe; TtLLUVV—Applicant; t-INK—brag. Uept.; UULUtNHUL—F'IanS/HecoraS COUNTY OF RIVERSIDE HEALTH' SERVICES AGENCY DEPARTMENT OF ENVIRONMENTAL HEALTH ENVIRONMENTAL HEALTH SERVICES SUPPLEMENTAL REPORT TO SAN. FORM # DATE ' .. On % / SUBJECT M r,-v+ e�-t I PERMIT NO. ADDRESS INSPECTOR REMARKS: COKS4(_(&C-1 i C) Y) A� 6-� Los if— a , � 4 0 %,1 a/n' z i K K /0 C-d("DA /IS A104 ah 4nC_l'X l 'C e eD 4,1 14 e LA 4*1 rc/ I 4AA *24 'lt (^0 r (4 ge 144 �1� t o/I W'D f(7 a- g)A r e_ E)"V�4;L a C c4A -41- 4'0 tA C(6 14 A 1A rekl? 15 1e3-olll'd'e q4e o)?A ell4o_ 11 /� I U OLP70 I DEH-SAN-118 *(Rev 2196) Distribution: WHITE —Office; CANARY —Owner; PINK —Office