13950 (PLBG)• 9bA
P.O. BOX 1504
Building 53-230 Eisenhower 78-105 CALLE ESTADO
Address LA QUINTA, CALIFORNIA 92253
Owner .Tari Valdez
Mailing
Address Same
OLa Quanta, Ch zlp 92253
and Construction Co. Inc.
Address
50-305 Hay 111
%bachella CA Z'992236 1 Tel 398-5 544
State Lic. City
& Classif. C-42 336698 Lic. # 31
Arch.; Engr.,
Designer
Address Tel.
CityI Zip I State
Lic. #
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm thgt I am licensed under provisions of Chapter 9 (commencing with Section
7,p00)toflDiViisio'n` oof)they Bussiinte_ss aand P - f€ssions Code, and my license is in full force and
SIGNATURE DATE
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following
reason: (Sec. 7031.5,Business and Professions Code: Any city or county which requires a
permit to construct, alter, improve, demolish, or repair any structure, prior to its Issuance also
requires the applicant for such permit to file a signed statement that he is licensed pursuant to
the provisions of the Contractor's License Law, Chapter 9 (commencing with Section 7000) of
Division 3 of the Business and Professions Code, or that. he is exempt therefrom, and the basis
for the alleged exemption. Any violation of Section 7031.5 by 'any applicant for a permit
subjects the applicant to a civil penalty of not more than five hundred dollars ($500).
❑ 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, Buisness and
Professions Code: The Contractor's License Law does not apply to an owner of property who
builds or improves thereon and who does such work himself or through his own employees,
provided that such improvements are not intended or offered for sale. If, however, the building
or improvement is sold within one year of completion, the owner -builder will have the burden
of proving that he did not build or improve for the purpose of sale.)
❑ I, as owner of the property, am exclusively contracting with licensed contractors to con-
struct the project. (Sec. 7044, Business and Professions Code: The Contractor's License Law
does not apply to an owner of property who builds or improves thereon, and who contracts for
such projects with a contractors) licensed pursuant to the Contractor's License Law.)
❑ 1 am exempt under Sec. B. & P.C. for this reason
Date Owner
WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -insure, or a certificate of
Worker's Compensation Insurance, or a certified copy thereof. (Sec. 3800, Labor Code.)
Policy No. Company
El'Goris filed with the city. ❑ Certified copy is hereby furnished.
CERTIFICATE OF EXEMPTION FROM
WORKERS' COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100) valuation
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.
Date Owner
NOTICE TO APPLICANT: If, after making this Certificate of Exemption you should become
subject to the Workers' Compensation provisions of the Labor Code, you must forthwith
comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of the
work for which this permit is issued. (Sec. 3097, Civil Code.)
Lender's Name
Lender's Address
This is a building permit when properly filled out, signed and validated, and is subject to
expiration if work thereunder is suspended for 180 days.
I certify that I have read this application and state that the above information is correct.
I agree to comply with all city and county ordinances and state laws relating to building
construction, and hereby authorize representatives -of this city to enter the above-
mentioned property for inspection purposes.
Signature of applicant -Date-
Mailing Address
City, State, Zip
LDING: TYPE CONST
P. Number
Description
Project Description
No.
OCC. GRP.
13950
Seger Connect/Greese Intercepto
i
hwwn ,• n
I
� V
ZONE: BY: --
Minimum Setback Distances: –�—
Front Setback from Center Line k�
Rear Setback from Rear Prop. Liney1
a
Side Street Setback from Center Line
Side Setback from Property Line
FINAL DATE
INSPECTOR
Issued by: Date Permit
Validated by:
Validation:
Sq. Ft.
Size
No.
Stories
No. Dw.
Units
New ❑ Add ❑
Alter ❑
Repair ❑ Demolition ❑
Estimated Valuation
$81500.00
PERMIT
AMOUNT
Plan Chk. Dep.
Plan Chk. Bal.
Const.
Mech.
Electrical
Plumbing
.S.M.I.
Grading
Driveway Enc.
Infrastructure
TOTAL
REMARKS
I �i
i
hwwn ,• n
I
� V
ZONE: BY: --
Minimum Setback Distances: –�—
Front Setback from Center Line k�
Rear Setback from Rear Prop. Liney1
a
Side Street Setback from Center Line
Side Setback from Property Line
FINAL DATE
INSPECTOR
Issued by: Date Permit
Validated by:
Validation:
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBINGnFEES . y.
1ST FL. SQ. FT. ® $
UNITS
+
ROUGH PLUMB.
BONDING
YARD SPKLR SYSTEM
2ND FL. SQ. FT.
FORMS
SEWER
ROUGH WIRING
MOBILEHOME SVC.
BAR SINK
POR. SO. FT. ®
GAS (ROUGH)
METER LOOP
GAR. SQ. FT. ®
POWER OUTLET
ROOF DRAINS
GAS (FINAL)
TEMP. POLE
DRAINAGE PIPING
CAR P. I SO. FT. ®
GROUT
WATER HEATER
WALL SQ. FT. Q
11
FINAL INSP.
DRINKING FOUNTAIN
SQ FT ®
WATER SYSTEM
URINAL
ESTIMATED CONSTRUCTION VALUATION $
_$
WATER PIPING
NOTE: Not to be used as property tax valuation
FINAL INSP.
FLOOR DRAIN
MECHANICAL FEES
WATER SOFTENER
VENT SYSTEM FAN EVAP.COOL HOOD
SIGN
WASHER(AUTO)(DISH)
APPLIANCE DRYER
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
LAUNDRY TRAY
AIR HANDLING UNIT CFM
FIRE ZONE ROOFING
KITCHEN SINK
ABSORPTION SYSTEM B.T.U.
TEMP USE PERMIT SVC
WATER CLOSET
COMPRESSOR HP
POLE, TEM/PERM
LAVATORY
HEATING SYSTEM FORCED GRAVITY
AMPERES SERV ENT
SHOWER
BOILER B.T.U.
SQ. FT. a c
BATH TUB
SO. FT. ® c
WATER HEATER
MAX. HEATER OUTPUT, B.T.U.
SO. FT. RESID ® 1Ya c
SEWAGE DISPOSAL
INSULATION/SOUND
SQ.FT.GAR ® 3/4c
HOUSE SEWER
FINISH GRADING
GAS PIPING
PERMIT FEE
PERMIT FEE
PERMIT FEE
DBL
TOTAL FEES
MICRO FEE
MECH.FEE PL.CK.FEE
CONST. FEE ELECT. FEE
SMI FEE PLUMB. FEE
STRUCTURE PLUMBING ELECTRICAL HEATING & AIR COND. SOLAR
SETBACK
GROUND PLUMBING
UNDERGROUND
A.C. UNIT
COLL. AREA
SLAB GRADE
ROUGH PLUMB.
BONDING
HEATING (ROUGH)
STORAGE TANK
FORMS
SEWER
ROUGH WIRING
DUCT WORK
ROCK STORAGE
FOUND. REINF.
GAS (ROUGH)
METER LOOP
HEATING (FINAL)
OTHER APPJEQUIP.
REINF. STEEL
GAS (FINAL)
TEMP. POLE
GROUT
WATER HEATER
SERVICE
FINAL INSP.
BOND BEAM
WATER SYSTEM
GRADING
cu. yd.
$ plus x$
_$
LUMBER GR.
FINAL INSP.
FRAMING
FINAL INSP.
ROOFING
6:—"onQ Te +, �
—9 C��C'//`�'p/moi/
'
REMARKS:
VENTILATION
FIRE ZONE ROOFING
FIREPLACE
SPARK ARRESTOR
GAR. FIREWALL
LATHING
MESH
INSULATION/SOUND
FINISH GRADING
FINAL INSPECTION
CERT. OCC.
FENCE FINAL
INSPECTOR'S SIGNATURESIINITIALS
GARDEN WALL FINAL
COACHELLA VALLEY WATER DISTRICT
Regulations Regarding Interceptors/Separators
(excerpt)
The Coachella Valley Water District requires that all plans .and
specifications for the installation of interceptors/separators shall
r
be submitted to the district in advance of construction and no
construction shall start until plans and specifications have been
approved by the district. -'The proposed discharger shall complete an
"interceptor application" and submit it with approved plumbing plans '
and specifications (where. applicable) at its headquarters in
Coachella.
There is currently no charge for the filing of this application.
No interceptor/separator shall be installed without prior .approval
of the. 'district. Applicants shall notify the district 48 -hours prior
to the start of installation and all installation shall be inspected
by district personnel.
There is currently no charge for this inspection.
If- you have any. .questions or desire additional information, please
call Charles H. Holt, Demand Evaluation Specialist, (619) 398-2651
Extension 235.
BKC:gh
(September/92)
ItLlSnAt sL a '✓ — —
2
E.A. -
--
_
�f �tb ra
GAL1.DiJ TOTA
. .. ....... .:
(To r3 a a,J}�1
O:1cC � • +' rERVOti'.G.TED
i
COO R E ti%!sI'D PITS)
'iAkiv TO Pli S1 ul.
(177 PIT 12 1 N .
'PITS
MAID EL EG. SEK\GE V cu* �+ 9
' .. CA�.lCJ1T r; C.D►JpOG.TORS \ /; �'�
..S£E 'S10Cn E L�u.IE t� %. i W:
_ RE M/ 1 RA -
A -q RECEIVED
%PA a %1*3
NEuJ 1000 6a�i� '671FA19 Aned
--=MAlt�: Tv: 5�¢�..'S.� ., q � i n77,E71z�PTb��• Ott-7/'6�s � /�
.A". � n :..:.... LSD r24FirC hll. 60tT LN✓ !1'4�/IVo
MATO TEL 6K5Q
"TT6'
� � / GREASE 1�JTF�.GEPSER' ..WIJOTTi►.SC�NP.M�, I
MEET U KEQ 9F-Me#JTS of
KtNEK ICE CLXJ►JT• RY"AAEA-rik i
�Zy1Q-3•,a+—
MWEMIDE COUNTY DEPARTMENT OF PUBLIC RMTH
---DIVISION OF ENVIROMMENTAL-MBALTH-
/ SE 4 -ri?J
—�L 4�isitabfishrnentf X Sewage Disposal-
mailer Perk Gal. Septic Tank
Motel, Apt., Hotel Sq. Ft. of Leach Line'
— Dwelling :=-Sa agoPI
— Commercial Ulding Connection to S&wer/61,4"6"-' V4((e, J/ r)
— Swimmning rmf
No on-s--te muter softmira d-o%rjm3 may be elisch-mrrgsd into Me individual sewage disposal
sw4am herewith _app ri.-vad tim-im c --j lua&S- atrol akzrd.
A
-,,miaLm fim,-n Lm rp.-
deikvcd sc.urm. —W/S7
Y- All wmja dizm, cm-;I-rl
rrus: cm�om ef rent Unjorrn Plumbling Code.
Approval has been obtained. from Gm RU, ionvi Watcr Quality Cciitrcil board for installation of the seviage
disposal syztem.
-WWW16 —cerlify-that the Riverside County Department of Public Health approves for asewpancy, copstruction x
nstalLation the hem*) clwcl• d alzm.
79
MAP
mr
NAM,
VlTeme
Interceptor shotdd-d-//
-777-7��=Afrp J)jr,Jq11.-6-
77Z4,-,cic &t/rl &C7- 9-1, 4114"LE C-0(195�t-r- ACA14
fax 7V OA40ff
F
al of these plans by the Impartm
`Approval ent of rubtu
V -HEA- ---Hcalth-of-Mverside-Cmmty-dop, not r lieyeAhe-&j1P—
*ex or Architect of the responsibility for the Enginak
Y Euh R
Ing or Architectural desim.".
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 # QTY OF Lsf iVy, -✓rte
Agent, Contractor, Contact P ,aonMot /2,-r
Address City State Zip Tel hone
-3o f14J I I 97- �3(o 6iJ 3r f��s�
a
Owner /�
ACK /ylc&,Z1r
Address City State Zip Telephone
o. aUx /�01' ZAA,,,olw CQ. &7Iy
Z
Job_Property Address _ r _ - _ City. Zip
WLot
Size
Agency
of Permit, P/P, SUP, PUP, etc. Legal Description
rn
X /I T,A/G
76A,
DUse
ICEPM ue« o� E irnJ e Ft7�►eu ,c,F✓r
/J%L(A (�ACCEY Dl Td,ct CVf✓a
DB Q. �ei CeKF CAFE"�
Signature of Applicant
Ii
Date
CHECK BOX IF REQUIRED
❑ Holding Tank Agreements Completed
❑ Detailedlntour Plot Plans Required (1 to 5 foot Interval)
❑ Certification of Existing S.D. System Required
❑ Grading Handout Provided
ca
❑ WOCB Clearance Required
❑ Staff Specialist Inspection Required
Z
(Attach For DOH -SAN -007, Santa Ana Region Only
O
❑ Lot Inspection
f
❑ Soils Percolation Report Required
LU
N
❑ Special Feasibility Boring Report Required
❑ Date Lot Inspection Completed: Initials
Remarks:
❑ Maintenance Booklet Provided
Initials Date
❑ Final Inspection by Department of Environmental Health is required.
C/42 / Solis Percolation Boring Report by—LIC/Project A Date
Soils Map Page Soil Type Approved By �._ Date —'
No of Systems
T of System(s)
No. BwelllroUntts
(1 ptlo Tank
Soil Rate
Or"E"I18errd
V
O Tank O Replacement
O New O Addroon
Fixture Units
SEatl, 4 : IZA A,ryr
Grease Intcp/W "flap
O Exlmng
hh04f. /S.r"C
Gal.
000 Gal.
,J
Sq. Ft.
Total Linear
Sldewall Allowance'
ach sq. It. of
Bs,om Area
Ft.
\.
c/ sq. ft. running ft.
Install ft king, fL wide with
Bottom Area
\
Inlet•Tested Oepth 171 NA
min. Inches rode low dralnlines or
U
roposed Bottom Tested Depth
Z
Leach line d special design for aloe:
(3) Pit Diameter
No. Pits
Pit Below Inlet (BI)
Seepage Pit
Maximum
Other:
Q
Total Depth
Allowable
Appficable
\
Depth
W
N/A Overburden Factor '
❑ 5' E3&
\
TD `
�.
Well Review Approved: Date: Well Drilling Permit If
SIGNATURE
Grading Plan Approved: Date:
SIONeAT:UR
Sewer Verification Approvdw Uya_Z� 1&/1// Date: GV '�2s-
REMARKS:
C.
This application IsPRPgnof
FOR OFFICE USE ONLY
RMYN regarding the dea aubsurtace dlspoaal ayatem as Indicated on the
aoompanted plot plan, using the requirements set forth In SECTION C above. A build-
M
73 �� 0
Ing permit Is necessary for the installation of the above -designed system. No construe-
Revenue code Fee 7
tion Is Permitted In the repuired reserved 100% expansion are
u eAf A
(1) Septic Tank must be 100' minimum from any weds.
0 Check ft
(2) Leach lines must be 100' inlnlmum from any wells, Including expansion area.
Date =5614 Initial
3) Sewer lines must be 50' minimum from any weds.
R
' ` W o
Z
O
(4) Seepage pits must be 150' minimum from any wells, Includirip •dxpanslon area.r
r•..)
1.D ^t 1-"cJ .• 9W.
U
.0
00 $
W
p
Cn
L
0
Signature of Health Official
0
8 a s- 9y�
co .
Date
�
DOH -SAN 122 (Rev 9/93) Distribution: vvr11I t—Unice rue; TELLOW—Appimani; rinn—olog: uepc; wwcnnvL—rmnarr