9601-068 (PLBG)LICENSED CONTRACTOR DECLARATION
I rereby'e&rm 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. 39tS� 12d;5i/L3S
License # Lic. Clas A f�xpaDate3 _
Date Signatureof Contractor rs� 1
OWNER -BUILDER DECLARATION
I hereby affirm 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:
( ) 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 issued. My workers' compensation insurance carrier & policy no. are:
Carrier ,-MA Policy No. 11141VIS r,a
(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
Code, I haIJ rthwith comply with, se r, is
Aate: 40 ( Applicant J.,,
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 application agrees to, & shall, indemnify
& hold harmless the City of Indian Wells, 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 inspp ton p4rposes. / / �y"/,
Signature (Owner/Agerrt) && r !1AJ24t Date ! ` f f `
A"'
BUILDING PERMIT
PERMITS 06x
DATE i/17/96
VALUATION $,;�
l0T TRACT
JOB SITE ADDRESS 48-761 SAN VICENTE /
APN
OWNER
CONTRACTOR
DAITLAND C'DNMiJCTi ON
JAuK'f lAOMPSi,7N
so -1051:11
SlumE
COACHELLAA CA 922,215
LA QUINTA `''A 9x2+3
(S.19)39k-S5I C.BLf# 31
DESIGNER/ENGINEER
USE OF PERWT;LUN!,-- 3iNG
)NS':1.'A.LL EX-PANSION SFITA..08 Ptl.'-
FEE DESCRIPTION
FEES
O,ONTRACT AIMOLI2vM 3,40}.00 LS
.ESTIL UMCOSTO, CONNSa RUC 11 ON
3,0.00
ipUMITF.EC, SUMMARY
PLUIVOONG FEE 101-0000 #19-{)00 $30.00
SUD-'t`i3rAL CDNS'i'RucTioN A14D .PLAN CHECK
$30,00
LESS Pi &PAID FEES
$0,00
O'OT AI,, PERAW FERN D1J1±: N0_VV
$30.110
J41VI 7
1
sy 996
RECEIPT
BY
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
S: 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 Pibg. 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
Final
Final / / 9G
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:
fIt
f, La Quinta GolfEstates
Community Association
P.O. Box 162
s� La Quinta, Ca 92153
619/564-2177
January 16, 1996
John R. Thompson
48-761 San Vicente
La Quinta CA 92253
RE: Relocation of Seepage Pit
Dear Jack:
Pursuant to your request to relocate and install a new forty foot seepage pit
in the Association right-of-way immediately in front of your property at the
above address, the Board of Directors has approved your plan (represented by
the attached sketch), subject to your obtaining all the normal permits and
authorizations required by the appropriate City and County agencies. Any cost.
of installation or future maintenance for this pit will be borne soley by you
or the future owner of the property, and not by the Association.
Please use this letter as your authorization to proceed with the installation.
Very truly yours,
ROBERT C. MONROE
President
RCM/at
EXisreCo
HOUSE
Xlsri�c
PATIO
ATTACHED
GARAGE
EXrsT��l6 WATER—FALL
EXISTING POOL AREA
IEX15nA lolveMI_
SEPTIC 20 FT DEE
TANK (TO P&WI 1PIT (To 8E Ali
I /lie
DRIVEWAY
M'' GARDEN WALL
�NEW 00 X
(HOMEOWNERS. ASSOC.
40 FT DEEP(&4o,jz4L'-'/ RIGHT—OF—WAY) .
ROLLED—CURB
STREET (SAN VICENTE)
10
DEPAW P ISM OF PUBLIC HEALTO
DIVIINON OF ENVIRONMENTAL HEALTH
Food Estabiishmw t /\ Sewage Disposal
Trailer Park is -Gal. Septic Tank( Id00 E4L)bv
Motel, Apt., katal Sq. Ft. ¢f Leach Line n
Dwelling EXIST, t!�9AA,m. M4X) �— x3E S page pit (&&j-eA�l
Commercial Building Conneztion to Suer
Swimming Pool
No on-site regenerating water softening devices, may be discharged into tie. individual sewage disposal
system
d herewith approy, without clearance, from the Water Quality Control Board..
�_ Water supply semi E e mu,t conform with .c�uire�
ellatiol must be from an approved source. LEXIS -r (CUIti'/
All sewage disp AZ nts of current Onifornt Plumbing Code. .
Any cutting grading or filling in excass of four (4.) fest will nullity s aga disposal approval.
:L Approval has been obtained from the Regional Water Quails;. Control Board for installation of the sewage
disposal system.
This 19 -to certify that the Riverside County Damrtna®nt of Public, Health approves for construction x
nstalletion the itwvXs) checked above.
dao
L/7
MIN. IV FROM ANY WME
/ TREE- OR WATM
D- 41R4,-6, ka,--a /14-�
✓t( � l e. /l �'i/�/l'Y.� i�2�t.f/Zce �C/�ld �/ i� �.
TRIS PROVE URINTM-TM
DEPARTMENT OF PUBLIC HEALTH WR.sae Of *Us plaea bY the Dwnnieutt or ruol,
IS VALID. FOR ONE (1) YEAR RmIth ol Biverafde county doeo not relieve the Eng;:
sw Or Architect of the responmibility for the amine a:
ROM DATE OF APPROVAL %ff or Architectural denim".
ASSESSOR'S PARCEL NUMBER
Ali
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. 01-17-96 09:36CU03 110,
LOG # (7/1"r of LA DSI/i✓Ti9 12�1$162.0cHK S162. arc
Aget Contractor, Contact Person
Address City State Zip
Telephone
1 ELA 1 JD ('O AvS7
Owner ,
Jo �, (�, i'r�oM Pso
Address City State Zip
9�-76 flwulca o?c, AAatmm C'� A-123
Telephone
Q
N u
-%
Z
Job Property Address
�� 76 / S�It/ irg5wrE
City
LA Qu„✓r�
Zip
9�62s'3
U
Lot Size
ater Agenc7/We)F
X i ✓''6,,-
Use of Permit, P/P, SUP, PUP, etc.
�EP�t[f EXis> . SE�A4GE iii
Legal DescriptionLU ��11 //��
LOT LA QW,, F Efrx`Xf II1V�T 5
Ili/Wil YIw orr
}� VO[
9
rH /7`
it �1 Cr)
elling, Site Prep., etc.
Signature of Appli t' / Ly 9
Date
CHECK BOX IF REOI ED'
❑ Holding Tank A r ements 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
O
(Attach For DOH -SAN -007, Santa Ana Region Only
❑ Lot Inspection
U❑
Soils Percolation Report Required
W
❑ Date Lot Inspection Completed: Initials
U
❑ Special Feasibility Boring Report Required
Remarks:
❑ Maintenance Booklet Provided
Initials Date
❑ Final Inspection by Department of Environmental Health is required.
C/42 / Soils Percolation Boring Report by Uc4Project # Date
Soils Map Page / Soil Type 0)l Approved By Date
No of Systems
Ty of System(s)
O Holding Tank Replacement
No. Dwelling Units �Il1Ill
Bedrooms, fixttMftf1�ffpits
(1) Septic Tank
Soil Rate
G ase Sand
Greas tcp/Unt Trap
x�f r
O New . O Addition
`
�()
O Existing
>� 11S7- �qi.
IX0 Gal
�•v a. o
Orae. Gal.
t`Z6
le-
�q. Ft.
Total Linear
Sidewall Allowance
Leach Bed sq. ft. of
Ba om Area
Ft.
� ock/ sq, ft. running ff.
A
Inlet Tested Depth�Depth
Install Une(s) ft. long -----jt. wide with
min. ekesrode below drainlines or
ottom Area
UProposed
Bottom Tested
Z
Leach lines/bed special design for slope:
(3) Pit Diameter
No. Pits
Pit Below Inlet (BI)
Seepage Pit
Maximum
Other:
il
Applicable
”'
11 -Ai
T(/
Total Depth
1; y
Allowable
Depth
/
N/A Overburden Factor �^
X75' lY6'
?
TD
�*3W
U
Well Review Approved: Date: " Well Drilling Permit #
SIGNATURE F
Grading Plan Approved: Date:
SIGNATURE
Sewer Verification Approved: Date:Y
•
���
REMARKS: u •
41A,
H
001
1E
Hca-QGc!$� �G�2 a Jzu �v��CJ 7Gi, .r.�'r a,I � t2 c�C. 414 D. � KX' .l- 7-
This application is A PROV.EDENIED for tKo category-checked�ln SEC IT ON B
FOR OFFICE USE ONLY
above, regarding th�(gn 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 constru
Revenue code
tion is permitted in the required reserved 100% expansion area.
(1) Septic Tank must be 100' minimum from any wells.
0' heck # /77�
(2) Leach lines must be 100' minimum from any wells, including expansion area.
/ is Initial �%
Dat�el ' /7- MI
0
(3) Sewer lines must be 50' minimum from any wells.
t.� y RT-
Z
O
U
(4) Seepage pits must be 150' minimum from any wells, Including expansion area.
d o P. -,{-,. aterta
a,
W
U
v
Signature of Health Official
/-0_ 96
Date
DOWSAN 122 (Rev 9/93) Distribution: WHITE—Office File; YELLOW—Appucant•, PINK—Bldg. Dept.; GOLDENROL—Pianslnecoras