00010901 (RER)_.... .. ... * _... ... _. .,� ., ,... c. .. .. -,rcnml r- nrrelcn nun ..;+,f,. ... .r ..
Countyy' of Riverside
Department Of'Building and Safety
CITY/COMMUNITY/STATE/ZIP
ix�A'014 4 6#` "� daS X14:130
.f 4080 Lemon St. 2nd Floor.,_ 135 N. Alessan iro�Rd. Rm. 203 880 N. State Street
s '+ 2220 iverside. CA 92501' Banning, CA 9Hemet, CA 92343 '�
.41` 227 North ••D" Street 46.209 Oasis St. Rm. 310 160 N. Broadway
tti', Perris. CA 92370 Indio. CA 92201 Blythe, CA 92225
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5 , -4 Ph, 787-6146 Ph: 849-7312 Ph: 658-4464 ,
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Ph: 651.3898 Ph: 342.8271 Ph: 922-2670
� - This permit becomes void if work not commenced within 180 days from date of-issuanie,rOR; it wiitk
has been suspendedor abandoned for a period of 180 days.
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•. LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing'?
';t CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed if the
with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect: . '
permit is'for one hundred (5100) or less. I certify that in the performance of the work for which this permit is issued, 13.
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shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of California.
icense Class • Lic. Number
Date I Applicant
M1Date Contractor
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should became subject to the Workers' '
Y OWNER -BUILDER DECLARATION: I hereby affirm that I am exempt from the Contractor's License Law for the following
•
Compensation provisions of the Labor Code,.you must forthwith comply with such provisions or this permit shall be.
deemed revoked. r
reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, alter,
-ADDRESS
improve, demolish, or repair;any,struclure, prior to its issuance, also requires the applicant lot such permit to lite a
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
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signed statement that he i2.Oi ensed pursuant to the provisions of the Contractors License Law (Chapter 9 (commencing
- I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be
iSwith Secti7000) of QivNion3 of the Business and Professions Code) or that he is exempt therefrom and the basis for
;the allegeRzempt�dn. Any violation of Section.1031.5 by any applicant for a permit subjects the applicant to a civil
made in connection with work authorized by this permit, and that no building structure, scaffolding, falsework, or t
demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap 3.2, Grp 2. Art 2, Sec 341. Title 8, -`
.'penalty of ribr of re thanfive hundred dollars (5500).):
C.A.C.)
1, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the
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As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial ;
a ery. as noted above, unless such person has a permit to do such work from that division.
ruclure is not intended or offered for sale (Sec. 7044: Business and Professions Code: The Contractor's License Law
F does not apply to an owner of property. who builds or improves thereon, and who does such work himself or Through
intended 'for If. however, Ing
❑ Division of Industrial Safety Permit No.
his own employees, provided that such improvements are not or offered sale. the but or
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Date Applicant
. Improvement is sold within one year of -completion, the owner -builder will have the burden of Droving That he did not
build or improve for the purpose of sale.).
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CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the performance of
'❑❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044.
Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or
the work for which this permit is issued (Sec. 3097, Civ. C.). r
Lenders Name
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�•'improves thereon, and who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's
Lender's Address �• +.
'License Law.).
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I certify That I have read this application and state that the above information is correct. I agree to comply with all
laws
I am *exempt under Sec. .B. 8 P.C. (Attach Certificate),
city and county ordinances and state relating to building construction, and hereby authorize representatives of
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�Da'te F' : '. 6` P � Owners �.: `, �; t;.., r ..• ,-
this county to enter upon the above-mentioned property for inspection purposes.
S WORKERS' COMPENSATION DECLARATION: I hereby affirm that Phave a certificate of consent to self -insure. or a
Signature of Applicant or Agent Date .
t%ertificate of Workers' Compensation Insurance, or a certified copy thereof (Sec. 3800, Lab. Q.
� CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify I have read this application and state that the
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k Policy'No. Company
information given is correct. I agree to comply with all state laws and county ordinances relating to building can.
struction, and authorize a representative of the County of Riverside, Department of Building and Safety to enter upon '..
1 .0 Certified copy is hereby furnished.
the properly for which I have applied for this permit for the purpose of making inspections.
Q Certified copy is filed with' the County Building Inspection Department or County Department.
'gyp
! Applicant or Agent'.
./�, Signature of ey fp;�
Dal Applicant
vDat
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Print Applfcant/Agent Name
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APPLICANT NAME,(L MI)
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CITY/COMMUNITY/STATE/ZIP
ix�A'014 4 6#` "� daS X14:130
JOB.SITE ADDRESS/SPACE. t
5,2740 , , ,' . . AV l� R4 C9R1 r . • .
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4- ENDERSOWNE R NAME (L. 64
-CONTRACTOR-FIRM NAME i
-ADDRESS
CITI!COMMUNITY/STATE/ZIP -
PHONE p. -
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ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE 4
LICNC 4
USE OF PERMIT
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TOTAL 41ERK. 1, COST M.
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FORM_284-208(2/81 ). ..,. ,.....
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NO.
OPERATION
DATE
INSPECTOR
NO. OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
1
Set Back
33 Ventilation System
2
Figs 8 Frms
34 Plenums & Ducts
2A
Slab Grade
35 Furnace Comport.
3
Steel
36 Inlets & Outlets
4
Grout Blocks
37 Combustion Air
5
Bond Beams
38 Compressor
6
Roof Deck
39 Appl. Clearance
7
Framing
40 Fire Damper
8
Vents
41 Smoke Detection Device
9
G•u.a3e Fire Wall
42 Commercial Hood
10
Fireplace P. L.
43 Final
10A
Fireplace T. 0.
°o ADDITIONAL INFORMATION
D'.
--- ---------------------
SEWAGE SYSTEM SIZE & LOCATION
11 ' Exterior Loth
12 Internr•.1 Lath
12A Drywall
•13 Finish Grade
INSULATION Thick
Value
7A Walls (Batts)
12B Ceiling (Batts)
12C Ceiling (Blown)
14 Final
_ PLUMBING APPROVALS--------
----
15 Ground Plumb
16 Water Piping
17 Rough Plumb
18 Vents
19 Sewage Disposal
20 Sewer
21 Water Heater
22 Water Softener
23 Water Service
24 Gas Test
25
Final
Tank Pit L. Line
REAR OF PROPERTY LINE
ELECTRICAL APPROVALS
P/L
er
.
n
P/
26 Power Pole
27 , Conduit'
28 Service Entrance 1
29 Wiring
29A. Grounding Wire' s
29B Bonding
r,
' 30 Fixtures
31. Service
32 Final
.. STREET NAME
'APPLICANT NAME'(L,'P. MI( '
INSPECTOWS COPY
ADDRESS /-•y
e AUK
:tITYCOMMITYSTXTTE/ZIP
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JOB. SITEADDRESS/SPACE
CITY/COMMUNITY/STATE/ZIP
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CONTRACTOR -FIRM NAME
ADDRESS
CIT\!COMM UN I TY/STATE/ZIP '
PHONE a
LICNC a
l ARC/ENG FIRM NAME
ADDRESS-
CITY/COMMUNITY/STATE/ZIP
PHONE #
LICNC N
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• TOTAL
FEE
INSPECTOWS COPY
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FORM, 28x208. 12/811
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NO.
OPERATION
DATE
INSPECTOR
NO.
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
1
Set Back
33
Ventilation System
2
Ftgs 8 Frms
34
Plenums 8 Ducts
2A
Slab Grade
35
Furnace Comport.
3
Steel
36
Inlets & Outlets
4
Grout Blocks
37
Combustion Air
5
Bond Beams
38
Compressor
6
Roof Deck
39
Appl. Clearance
7
Framing
40
Fire Damper
8
Vents
41
Smoke Detection Device
9
G-u;.ge Fre Wall
42
Commercial Hood
10
Fireplace
P. L.
43
Final
I0A
Fireplace
T. 0.
°o
ADDITIONAL INFORMATION
'
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Loth
12 Intemcrl Lath
12A Drywall '_-
13 Finish Grade
INSULATION Thick R
Value
7A Walls (Batts)
12B Ceiling (Batts)
QC Ceiling (Blown)
14 Final
- PLUMBING APPROVALS-
PPROVALS
15
15 Ground Plumb
16 Water Piping
17 Rough Plumb
,18 Vents
19 Sewage Disposal
20 Sewer
21 Water Heater
22 Water Softener
23 Water Service
24 Gas Test
25 Final
Tank
Pit L. line
REAR OF PROPERTY LINE
ELECTRICAL APPROVALS
P/L
P/
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding -
30 Fixtures
31 Service
32 Final
STREET NAME