19928 (SPIN)PERMIT APPLICATION
County of Riverside
Department of Building
and Safety
4080 Lemon St. 2nd Floor 135 N. Alessandro Rd. Rm. 203 880 N. slate Street
227 North "0" Street _ 46.209 Oasis SI. Rm. 310 160 N. Broadway
Riverside. CA 92501 Banning, CA 92220 Hemet. CA 92343
Perris. CA 92370 Indio. CA 92201 Blythe. CA 92225
Ph: 787.6146 Ph: 849.7312 Ph: 658.4464
Ph: 6573898 Ph: 3428271 Ph: 9222670
This permit becomes void fl work not commenced within 180 days from date of issuance: OR, it work has beer suspended
or abandoned for a period of 180 days.
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be Com -
LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions OI Chapter 9 (comment-
pleted it the permit is for one hundred ($100) or less. I certify That in the performance of the work for which this
Ing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in lull force and effect.
permit is issued. I shall not employ any person in any manner so as to become subject to the Workers' Compensa-
tion Laws of California. ,
❑
Dale Applicant
r OWNER -BUILDER DECLARATION: I hereby affirm that I am exempt from the Contractor's License Law for the
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject 10 the Workers'
Compensation provisions of the Labor Code. you must lorthwith comply with such provisions or this permit shall be
following reason (Sec. 7031.5. Business and Professions Code: Any city or county which requires a permit to con-
deemed revoked.
strucl, 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
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
(Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is ex-
QI hereby certify That no excavation live (5) or more leet in depth into which a person is required to descend, will
empt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a per-
FR mil,subjects the applicant to a civil penalty of not more than five hunderd dollars ($500).):
-
be made in connection with work authorized by this permit, and That no building structure, scalfoltling, lalsework,
Q - I, the
Or demolition or dismantling thereol. will be more than thirty-six (36) feet high. (Chap. 3.2. Grp 2, Art 2. Sec 341,
Title 8. C.A.C.
y as owner of property, or my employees with wages as their sole compensation, will do the work, and the
I,c "structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License
).
❑ As owner -builder, 1 will not employ anyone to do work which would require from the Division In
:,4 -Law does not apply to an owner of property who builds or improves thereon, and who does such work himself or
a permit of -
dustrial Safety. as noted above, unless such person has a permit to do such work from the division.
through his own employees, provided that such improvements are not intended or offered for sale. If, however.
- the building or improvement is sold within the have
[]Division of Industrial Safety Permit No. '
one year of completion, owner -builder will the burden of prov-
-'. ing'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 construct the project (Sec.
CONSTRUCTION LENDING AGENCY: I hereby affirm that There is a construction lending agency for the perfor- .
< 7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who
mance of The work for which this permit is issued (Sec. 3097. Civ. C.). -
builds or improves thereon, and who contracts lot such projects with a contractor(s) licensed pursuant to the Con-
Lender's Name
r tractor's License Law.)
Lender's Address
• Ql,am exempt under Sec. , B.8 P.C. (Attach Certificate).
DateOwner
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify I have read this application and slate
WORKERS'. COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to sell -insure, or a
that the information en is correct., I agree l0 comply with all state laws and county ordinances relating t0
building conslruplia p a�'nd authorizea'representative of th.eCounty. of Riverside. Department of Building and Safety
to enter upon Ihe.pfoperty for wh' II hhaavv6ppplied for this for the inspections.
. certificate of Workers' Compensation Insurance, or a certified copy thereof (Sec. 3800. Lab. C.).
permit purpose ofmaking
[]Certified copy is hereby furnished.
O
OCertified copy is filed with the County Building Inspection Department or County Department.
Signature of Applifanl or Agent a/ Date
/ ,
i j PrinifppJl' ant/Agent Name
APPLICANT NAME If, F. MI)
APPLIPlnRMT pr%
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PHONE#
LICNC #
- PHONE# .BLD SPECT R FINA ATE
ARCIENO FIRM NAME?
LICNC #
.PLAN # PLANS EXAMINER APPROVE DATE
USE OF PERMIT -
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ZONE ORD# LOP SZ END SIDE
f
FORM 284. 208(11.81)
S
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qPFUTAL t S ' ' E F $30.00
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CA CK NC I COUNTE B.I f A " COUNTER L.U.T.
S P
G I A L,
.1 N
S P E C •T I a N
TOTAL
PERMIT COST
$30.00
W611�,�
NO.
OPERATION DATE
INSPECTOR
NO.
OPERATION
%� DATE INSPECTOR-'
BUILDING APPROVALS
MECHANICAL APOTROVALS
1
Set Back
33
Ventilation System
2
Ftgs & Frms
34
Plenums & Ducts
2A
Slab Grade
35
Furnace Comport.
3
Steel
36
Inlets & Outlets
4
Grout Blocks
37
Combustion Air -
5
Bond Beams
38
Compressor
6
Roof Deck
39
Appl. Clearance
7
Framing
40
Fire Damper
8
Vents
41
Smoke Detection Device
9
Garage Fire Wall
42
Commercial Hood
10
Fireplace P. L.
43
Final 1,6 _/_
10A
Fireplace T. 0.
NO
ADDITIONAL INFORMATION
'
SEWAGE SYSTEM SIZE & LOCATION '
11 Exterior Lath
12 Internal Lath
12A Drywall
13 Finish Grade
INSULATION Thick R
Value
7A Walls (Batts)
12B Ceiling (Botts)
12C Ceiling (Blown)
14 1 Final
PLUMBING APPROVALS
15 Ground Plumb
16 Water Piping
17 Rough Plumb
18 Vents
19 Sewage Disposal
20 Sewer
21 Water Heater
22 Water Softener
23 Water Service
24 Gas Test
25
Final
Tank Pit L.Line
REAR OF PROPERTY LINE
PSL P)
ELECTRICAL APPROVALS
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Groundjng_W.ire
29B Bonding
30 Fixtures
31 Service
32 Final
STREET NAME
I
DEPARTMENT OF BUILDING AND SAFETY 9 COUNTY OF RIVERSIDE
OFFICE
DATE
PERMIT NUMBER
ITIME
3
7 z1,3 INSPECTION
RFQtJFSTFD
ADDRESS j$PACE NO. FOR:-
A.M.
OWNER COMMUNITY
BUILDING PLUMBING ELECTRICAL MECHANICAt
Ml DN,
TUE S
WED
REMARKS:
THUR
FRI
OWNER/CONTRAC�OR TEL.NO.