0012-0178 (AR)LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury that I am licensed under provisions of
Chapter 9 (commencing with Section 7000) of Division 3 ofrttie Business and
Professionals Code, and my License is in full force and effect.
License #' Lic. Class/1 i ✓ Exp. Date
Date Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) 1, 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 STATE MND Policy No. 22949 UNIT 0020047
�y
(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 shall forthwith comply with those provisions:
Date: ! �'' ` Applicant
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 who behalf this application is made & each personpt
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
& 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 day`s Will subject permit to cancellation.
I certify that I have read this application and;siate that the above information is.i
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 inspection purposes.
Signature (Owner/Agent)- Date
. j
BUILDING PERMIT PERMIT!!
DATE 1Z Gl J VALUATION. LOT �+� TRACT !
2 ` fi,2 i7�4ai1 X4275 kM4
JOB SITE
ADDRESS 49-818
OWNER CONTRACTOR/DESIGNER/ENGINEER
SOY MCAIbI-601
49.811 A."WZrOI)RIVE
l..{3Q'tTJN :.A. CA 93253
USE OF PERMIT
74.315: �A3MR3'WOODDMVE
RA;t t111.0"FAR11' CA 92260
laS�J'� x4CM 7,9 CBI.41 5243
I��IIII VIII III VIII IIII 59
IE
31s S.F. RODM ,At>3i':iITION 044Ik> ODFL 1rt'PCfiEN A DY) IgDO C ,a
DATIIROOM:V , C.H NOF: WINDOWS) AS PFR APE'ROVM PIANS ONIX
ADDITION
313.00 31
FKF41K J.1yA) col f: OF CON-1-MMAMC3N
17,267.40
FERM, `I' Fa1E 9UTAMA,t1t,'
Pia! I CHECK FFF.
-101-000-439-318
31�7ott�
C.ONSTIZU4:4104FM
2C1i��+0t��7£3 0
�lE?r,Gt]
MrXHAA ICAL VEEP
ti �Q;1t3-� 2Y +3C3U
�3�.OD
2,14CTRI:CAL ME.,
w 101 -00 20-400
&3(►, Ofz
8T3z+ f3 A+l )'f lC�k€ F fi 11i�
103-030;241.000
� 19 -To rA4MME�mYnT.ION,
N AyY)PtAi0110 $341. 18 31-.18
1 L F'itFi�: 'l3ilfJ i�� MOO
G C 2 C 22_3
-^ E
' • (f,�''� �"`` EXHIBIT.• �-
7 GATE: a�
RECEIPT DATjE wf BY DATE FINAL
! G^ 1 - • �f! t .. LAURA S.CKELF O�Z
SNq
I / ORD
CSR 3S68
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
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
-'p
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wall Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - Int. LathZ,/
s �—
Final
Final
BLOCKWALL APPROVALS
POOLS - SPAS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
-Equipment Location
Underground Electric
Underground Plbg. 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
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:
N t)
W
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1-— Q LO
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0 CD
I. -(D
J
W LUQ
F- a
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XWW
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J
LICENSED CONTRACTOR DECLARATION
I hereby affirm under penalty of perjury 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.
License # Lic. Class Exp. Date
645369. B 05/31/2(
Date Signature of Contractor
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury 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
compensatron, 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 jnsurance, 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 Policy No.
STATE FUND . 229-99 UNIT 0020047
(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 shall forthwith comply with those provisions.
Date: Applicant
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
& 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 property for inspection purposes.
Signature (Owner/Agent) Date
BUILDING PERMIT PERMIT#
DATE VALUATION LOT 0012•478 TRACT
$17,267.40 1 TR4275 ELK4
JOB SITE APN
ADDRESS
49-811 ADELTTO DRIVE 646-250-001
OWNER CONTRACTOR/DESIGNER/ENGINEER
LEROY MCANINCH J.A. DOLAN CONSTRUCTION
49-811 ADEL1-TO DRIVE 74-315 BUTTONWOOD DRIVE
LAINITA CA 92253 PALD'A DESERT CA 92200
(760)340-9529 C'BL4 5248
USE OF PERMIT
318 S.F. ROOM ADDITION (REMODEL KITCHEN ADD NOOK &
BATHROOMS, CHANGE WINDOWS) AS PER APPROVED PLANS ONLY
ADDITION
318.00 SF
ES HATED COSI' OF CONSTRUCTION
PERAM FEE SUMMARY
PLAN CHECK FEE
101-000-439-318
1122,85
CONSTRUCTION FEE
101-000-415-000
$1999.00
MECHANICAL FEE
101-000-421.000
$30.00
ELECTRICAL FEE
101-000-420-000
$30.00
STRONG MOT ION FEE - RESID
101-000-241-000
$1.73
SUB -TOTAL CONSTRUCTION AND PLAN CHECK
LESS PRE -PAID FEES
TOT -L PER_MMTT FEES DUE NOW
RECEIPT I DATE I BY I DATE FINALED
IIIIIIIIVIIIIIIVIIIIIII 64
IE
17,267.40
$373.55
$0.00
$373.58
EXHIBIT: `f
DATE: /02
LAURA S. SHACKELFORD CSR 3568
BUILDING PERMIT
DEPARTMENT OF BUILDING & SAFETY
COUNTY OF RIVERSIDE
FIELD OFFICE
CONSTRUCTION ESTIMATE>.--- _•. ELECTRICAL FEES",
PLUMBING FEES DST
1ST FL 'G/r
2ND FL.
POR.
GAR.
CAR P.
WALL
ESTIMATED CONSTRUCTION VALUATION
SQ. FT.
NO,
NO.
SQ. FT.
OUTLETS
MOTOR I OR LESS H.P.
SQ. FT. Cia
SQ.FT. Cia MOTOR 5 OR LESS H.P.
FIXTURE OR SOCKET
SQ. FT, @MOTOR 20 OR LESS H.P.
DRAINAGE PIPING
SQ.FT. �D
DRINKING FOUNTAIN
SQ. FT. @
URINAL
$ OK K.W. UNITS
WATER PIPING .F.b .
NOTE: Not to be used as property tax valuation
yl
FLOOR DRAIN
MFCHANICAL FEES
f SHOWER
WATER SOFTENER
MOBILE HOME HOOKUP FEE Is 40, 1 FtKMII rtt FtKMII I-tt �
VENT SYSTE FAN ❑EVAP. COOL HOOD l
SIGN
WASHER (AUTO DISH) P
DBL. CK. FEES.'
APPLIANCE p
TRANS-. K.W.
FORMER
GARBAGE DISPOSAL
S1MI FEE
FURNACE ❑ UNIT ❑ WALL ❑FLOOR SUSPENDED
OUTLETS
LAUNDRY TRAY
AIR HANDLING UNIT I CFM
FIXTURE OR SOCKET
KITCHEN SINK %)
GAS PIPE ❑ NATURAL ❑ L.P.G. ❑ OIL
CONST. SERV. ENTRANCE
_2 WATER CLOSET
COMPRESSOR ++ HP
POLE
�' LAVATORY
yl
APPLIANCE VENT
AMPERES SERV. ENT,
f SHOWER
/
ABSORPTION SYSTEM B.T.U.
SO. FT. @ ¢
BATH TUB
JOB ADDRESS
fys
INCINERATOR ❑ DOMESTIC ❑ INDUS. OR COMM.
SO. FT. @ Q
WATER HEATER
USE OF BUILDING
HEATING SYSTEM FORCED ❑ GRAVITY 41 ab
SO. FT. RESID. @) ¢
SEWAGE DISPOSAL
M.H. HOOKUP FEE
BOILER 0 B.T.U.
SQ. FT. GARAGE @° I/2¢
HOUSE SEWER
COMMUNITY /
f
PERMIT FEE
BALANCE OF MIN. FEE
GAS PIPING
MOBILE HOME HOOKUP FEE Is 40, 1 FtKMII rtt FtKMII I-tt �
P/J
TOTAL FEE'`Sf
MOB. HK. FEE MICRO FEE MECH. FEE
DBL. CK. FEES.'
CONST. FFEEE_
DBL. ELECT. FEE
DBL.
S1MI FEE
FEE
PLUMB.DBL.
"//J� (�y�N7
pPL.
` 40
IFINALDATE;�-1
vl
yl
XT
$
/
BRANCH OFFICE
.NO LENDER INVOLVED
J F M A M J J A $ O N D
JOB ADDRESS
fys
OWNER
73
ELECTRICAL.FEE
USE OF BUILDING
�.
E� � � � P Mj�NQ,, 282c
ERP•/ly `(Tj{'OFFICE
75
M.H. HOOKUP FEE
$
ADDRESS
COMMUNITY /
f
D T
UNITS]
/
ROOMS
VALUATION
SUPP. TO PERMIT
THIS PERMIT SHALL BECOME V D IF WORK IS NOT COMMENCED WITHIN 60.DAYS. CESSA-
TION OF WORK FOR 120 DAYS SHALL ALSO CAUSE PERMIT TO BECOME VOID. `
FEE
$
MICROFILM FEE
COPIES
$
DBL
LEGAL D PTION
% �'
MECHANICAL FEE
DBL
$
SETBACK
LOT SIZE
ZONE USE NO.
GRP TYPE
CK BY
F-2
121VV
+per
COD'F Ol' THE STATE OF CALIFORNIA. 40
OWNER, CONTRACTOR
p
'
CASH ❑ CHECK �" M.O. ❑ N.C. ❑
RECEIVED BYl
fit
F S R
PLAN CHECK FEE
$vzp-7
BOND AMT.
PLAN NO.
PLAN CHECKER
INSPECTOR
` 40
IFINALDATE;�-1
vl
CONSTRUCTION FEE
DBL
$
NAME OF CONST. LENDER
BRANCH OFFICE
.NO LENDER INVOLVED
ELECTRICAL.FEE
DBL
$
17
ADDRESS
CITY
STATE
SMI FEE
$
THIS PERMIT SHALL BECOME V D IF WORK IS NOT COMMENCED WITHIN 60.DAYS. CESSA-
TION OF WORK FOR 120 DAYS SHALL ALSO CAUSE PERMIT TO BECOME VOID. `
FEE
$
I HEREBY AGREE THAT ALL WORK IN CONNECTION WITH THIS PERMIT WILL BE DONE IN AC-
CORDANCE WITH THE LAWS OF RIVERSIDE COUNTY AND THE STATE OF CALIFORNIA, I ALSO
PLUMBING FEE
DBL
$
AGREE TO CARRY COMPENSATION INSURANCE UPON MY EMPLOYEES. COMPLIANCE WITH
00
THE LAWS OF THE STATE OF CALIFORNIA COVERING CONTRACTORS IS ALSO GUARANTEED.
I HEREBY CERTIFY THAT THE INDIVIDUAL WHOPNFS AN SPECIFICATIONS
TOTAL FEES�l
F-2
HAS DONE SO IN ACCORDANCE WITH SECTION 4 S D. PROF SSIONS
>BU
COD'F Ol' THE STATE OF CALIFORNIA. 40
OWNER, CONTRACTOR
p
'
CASH ❑ CHECK �" M.O. ❑ N.C. ❑
RECEIVED BYl
ADDRESS
ADDRESS
SEWAGE SYSTEM
T
LL
P
..
CITY
CITY
TREES kEQUIRED
YES
NO
•fit
IN
AT N
S
TEL. NO.IIIIIIII VIII III VIII ILII 65
TEEN LICENSE
FORM 284-208 (Rev. 1I/721
IE
BUILDING PERMIT DEPARTMENT OF BUILDING & SAFETY FIELD OFFICE
dh COUNTY OF RIVERSIDE A
CONSTRUCTION ESTIMATE-.
1 ST FL.
SQ. FT.
2ND FL.
SQ. FT. @
POR.
SQ. FT. Q_
GAR. �5g-4 4Z
SQ.FT. Cia 2
CAR P.
SQ. FT. @
WALL
SQ.FT. @
FURNACE ❑ UNIT ❑ WALL ❑FLO R ❑SUSPENDED
SQ. FT. @
ESTIMATED CONSTRUCTION VALUATION
$
NOTE: Not to be used as property fox valuation
MECHANICAL FEES
ELECTRICAL FEES=--
i eno NO.
MOTOR I OR LESS H.P.
MOTOR 5 OR LESS H.P.
MOTOR 20 OR LESS H.P.
K.W. UNI
NO.
PLUMBING FEES
DRAINAGE PIPING
DRINKING FOUNTAIN
URINAL
WATER PIPING
FLOOR DRAIN
WATER SOFTENER
MOBILE NOME HOOKUP FEE 1$ 1 1 1 F I rtKMI I rtt I _1a I/J.e 1 / I rtHMl I rtt I -;? I 'u'^
N
VENT SYSTEM °FAN ❑EVAP. COOL HOOD
SIGN
PL. CK. FEE
WASHER (AUTO DISH)
DBL. ELECT. FEE
DBL.
APPLIANCE
FORMER W'
w
FEE PL . FEEDBL.
GARBAGE DISPOSAL
4EEBL.
FURNACE ❑ UNIT ❑ WALL ❑FLO R ❑SUSPENDED
OUTLETS
f✓
LAUNDRY TRAY
MI
`5�-U
AIR HANDLING UNIT I = CFM
FIXTURE OR SOCKET
KITCHEN SINK
�`
GAS PIPE ❑ NATURAL ❑ L.P.G. ❑ OIL
CONST. SERV, ENTRANCE
WATER CLOSET
,.
J F M A M J J A S. 1 O L N
COMPRESSOR HP
POLE
OWNER
5
LAVATORY
_-7
74
APPLIANCE VENT
AMPERES SERV. ENT.
F.C.
�J�2
SHOWER
PERM2NO
8ia 1°�
75
ABSORPTION SYSTEM B.T.U.
SQ. FT. (ria
BATH TUB
INCINERATOR ❑ DOMESTIC ❑ INDUS. OR COMM.
SO. FT. @ Q
f
WATER HEATER
SUPP. TO PERMIT
OFFICE
HEATING SYSTEM WORCED ❑ GRAVITY
SO. FT. RESID. @ I4 t
f
SEWAGE DISPOSAL
}
BOILER 0 B.T.U.
SQ, FT. GARAGE@1/2¢
40
HOUSE SEWER
MICROFILM FEE
PERMIT FEE
BALANCE OF MIN. FEE
GAS PIPING
MOBILE NOME HOOKUP FEE 1$ 1 1 1 F I rtKMI I rtt I _1a I/J.e 1 / I rtHMl I rtt I -;? I 'u'^
N
TOTAL FEE
MOB. HK. FEE MICRO FEE MECH.
PL. CK. FEE
CONST. FEE
DBL. ELECT. FEE
DBL.
FEE
w
FEE PL . FEEDBL.
�PE$)[r11T
1]1,7§7
4EEBL.
' S
��
f✓
MI
`5�-U
L�
�`
J F M A M J J A S. 1 O L N
D
JOB ADDRESS
OWNER
5
73
74
U OF BUILDING
,s % .�
F.C.
�J�2
PERM2NO
8ia 1°�
75
M.H. HOOKUP FEE
$COMMUNITYU
DST
ITS
ROOMS
VALUATION^
SUPP. TO PERMIT
OFFICE
40
MICROFILM FEE
COPIES
$
LEGAL DESCRIPTION
q
+
MECHANICAL FEE
DBL
$
SET BACK
LOT SIZE
ZONE
US NO.
GRP
TYPE
CK BY
R
PLAN CHECK FEE
$
NO.
PLAN CHECKER
FINAL DATE INSPECTOR
`1 -O
J-�.,�
CONSTRUCTION. FEE
DBL
$
ECCONST.
DER BRANCH
OFFICE .NO
LENDER INVOLVED
ELECTRICAL FEEDBL
$
CITY
STATE
lf. '
SMI FEE
$
THIS PERMIT SHALL BECOME VO I IF WORK IS NOT COMMENCED WITHIN 60 DAYS. CESSA-
$
FEE
TION OF WORK FOR 120 DAYS SH ALSO CAUSE PERMIT TO BECOME VOID.
I HEREBY AGREE THAT ALL WORK IN CONNECTION WITH THIS PERMIT WILL BE DONE IN AC -
CORDANCE WITH THE LAWS OF RIVERS]DECOUNTY AND THE STATE OF CALIFORNIA, I ALSO
PLUMBING FEE
DBL
$
AGREE TO CARRY COMPENSATION INSURANCE UPON MY EMPLOYEES. COMPLIANCE WITH
THE.LAWS. OF THE STATE OF CALIFORNIA COVERING CONTRACTORS IS ALSO GUARANTEED.
I HEREBY CERTIFY THAT THE INDIVIDUAL WHO THE-PIN'
HE NSA SPECIFICATIONS
$
TOTAL FEES
HAS DONE SO IN ACCORDANCE WITH SECTION 41 B NESS P OFES IONS
ronr OF THE STATE OF CALIFORNIA.
CASH ❑ CHECK [.�,. M.O. Cl' N.C. ClOWNER.
CONTRACTOR
RECEIVED BY �
ADDRESS�
ADDRESS
SEWAGE SYSTEM TLL
P
CITY.
CITY
TREES REQUIRED YES
NO
INFORMAT N
SjE=�✓
TEL. NO. IIII I�I VIIIIIVIII IIII 66
Elf. NO. LICENSE
FORM 284.208 (Re, 17172)
1E[
BUILDING PERMIT DEPARTMENT OF BUILDING & SAFETY
• COUNTY OF RIVERSIDE •
CONSTRUCTION ESTIMATE -,. , ELECTRICAL FEES
I ST FL 13 A— SQ FT @ + NO. It
FIELD
FURNACE ❑ UNIT ❑ WALL ❑FC OR SUSPENDED OUTLETS LAUNDRY TRAY
2ND FL.
SQ. FT. @
GAS PIPE ❑ NATURAL ❑ L.P.G. ❑ OIL CONST. SERV. ENTRANCE WATER CLOSET►
POR.
SQ. FT. @ L/
GAR.
SQ.FT. @
tp
ABSORPTION SYSTEM 0 B.T.U.
50. FT. @ Q J BATH TUB
_
CAR P.
SO. FT. @
WALLEEI
SQ.FT. @
BOILER 0 B.T.U.
SQ. FT. @
PERMIT FEE .2jj
MOBILE HOME HOOKUP FEE $ _
ESTIMATED CONSTRUCTION VALUATION $ t72
PE IT NO.
2 2 8
NOTE: Not to be used as property tax valuation
DBL
PL. CK. FEE CONST. FEE
MECHANICAL FEES
SMI FEE
VENT SYSTE
FAN ❑EVAP. COOL HOOD
J I F I M A, I M I J I J I A I S 0 1 N D
APPLIANCE
1-1-1) — —
A-
MOTOR I OR LESS H.P.
MOTOR 5 OR LESS H.P.
MOTOR 20 OR LESS H.P.
K.W. UN
SIGN
FTRANS-R K.W.
(1RM F
OFFICE
PLUMBING FEES DST„0
�t
DRINKING FOUNTAIN
URINAL
WATER PIPING 7
FLOOR DRAIN
WATER SOFTENER
WASHER (AUTO ISH)
/ GARBAGE DISPOSAL z 4-A
FURNACE ❑ UNIT ❑ WALL ❑FC OR SUSPENDED OUTLETS LAUNDRY TRAY
AIR HANDLING UNIT CFM FIXTURE OR SOCKET KITCHEN SINK
GAS PIPE ❑ NATURAL ❑ L.P.G. ❑ OIL CONST. SERV. ENTRANCE WATER CLOSET►
_
COMPRESSOR HP POLE OV LAVATORY ¢:
APPLIANCE VENT
AMPERES SERV, ENT. SHOWER
_
ABSORPTION SYSTEM 0 B.T.U.
50. FT. @ Q J BATH TUB
_
INCINERATOR ❑ DOMESTIC ❑ INDUS. OR COMM.
SQ. FT. @ Q WATER HEATER
HEATING SYSTEM FORCED ❑ GRAVITY
SQ. FT. RESID. @ 14 SEWAGE DISPOSAL
BOILER 0 B.T.U.
SQ. FT. GARAGE @124 HOUSE SEWER
PERMIT FEE .2jj
MOBILE HOME HOOKUP FEE $ _
BALANCE OF MIN. FEE } GAS PIPING /
PERMIT FEE PERMIT FEE
PE IT NO.
2 2 8
TOTAL FEES MOB. HK. FEE MICRO FEE MECH. FEE
��.
DBL
PL. CK. FEE CONST. FEE
DBL. ELECT. FEE DBL.
SMI FEE
FEE
PLUMB. FEEJDBL.
,.�
J I F I M A, I M I J I J I A I S 0 1 N D
JOB ADDRESS -
O: MER --
73
74
USE'OF BUILDING
F.C.
o
EA I ° • ERM2N
-- 283E
75
M.H. HOOKUP FEE
$
O MUNITY
DS U ITS
OOMS
VALUATION SUPP. TO PERMIT 7FFICE
MICROFILM FEE
COPIES
$
LEGALIfESCR PTION e/
` y
MECHANICAL FEE
DBL
$
rn
SET BACK
LOT SIZE
-
ZONE
`FINAL
USE NO.
GRP TYPE
JCK BY
F 5 R
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PLAN CHECK FEE -
$"
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B ND AMT.
IPLANN(j-.—.
PLAN CHECKER
DATE
8 �O
INSPECTOR
CONSTRUCTION FEE
DBL
$
NAME OF CONST. LENDER BRANCH
OFFICE .NO
J
LENDER INVOLVED
ELECTRICAL FEE
DBL
F'
A RESS CITY
STATE T
3'.
SMI FEE
$
THIS PERMIT SHALL BECOMEOID IF WORK IS NOT COMMENCED WITHIN 60 DAYS. CESSX.
TION OF WORK FOR 120 DAYS JALL ALSO CAUSE PERMIT TO BECOME VOID.
I HEREBY AGREE THAT ALL WORK IN CONNECTION WITH THIS PERMIT WILL BE DONE IN AC -
CORDANCE WITH THE LAWS OF RIVERSIDE COUNTY AND THE STATE OF CALIFORNIA, I ALSO
AGREE TO CARRY COMPENSATION INSURANCE UPON MY EMPLOYEES. COMPLIANCE WITH
THE LAWS OF THE STATE OF CALIFORNIA COVERING CONTRACTORS IS ALSO GUARANTEED.
I HEREBY CERTIFY THAT THE INDIVIDUAL WHO' PREPARED THE P S AND SPECIFICATIONS
HAS DONE SO IN ACCORDANCE WITH SECTION 5 F USI ESS ROFESSIONS
T O CALIFORNIA. i
FEE
$
PLUMBING FEE
DBL
$
fJ
T
��
TOTAL FEES
$
A
CASH ❑ CHECK gii< M.O. ❑ , N.C. Cl
OWNER.
CORA OR
RECEIVED BY
ADDRESS
ADORE
'
f
SEWAGE SYSTEM
T
LL
P
'
TREES REQUIRED
YES
NO
clrr _.
TEL. NO. I IIIIIIII VIII III VIII IIII 67
I IE
c TY .
. NO. LICENSE
{�el
INFORn4PTI0N_
FORM 284.208 (Rev. 1) /721 .£ �A�) A - ,meq