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NOTICE: THIS IS NOT A BUILDING PERMIT
APPLICATION TO CONSTRUCT
DEPARTMENT OF BUILDING AND SAFETY
COUNTY OF RIVERSIDE
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DISTRICT ( J _ _
Permit No 0,046041-- ODQ -/ --
284 199 9/74 CANARY—FILE, PINK—APPLICANT
OwnerAnden Corporation Berkus Group An en Corporatio
Architect Contractor
Address 49-991 Eisenhower 1531 Chapala Eisenhower
Address- Address -49-991
City La Quinta, CA 92253 City Santa Barbara, CA City_ La Quinta, CA 9225
71) 564-1315 ) 63-890 (714)564- 1315
Phone phone phone
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I (we) the undersigned', hereby certify and acknowledge that I (we) have read the application and agree that if Curb and Gutter, and
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Paving, and/or Dedication of right of way is required by the County of Riverside, the Riverside County Department of Building and Safety
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shall not make a Final Inspection until said requirements have been met. I am also aware that no work is to be done within the County R/W
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without an encroachment permit. I
NOW, therefore, it is agreed that I (we) will not occupy said property and will not cause said prop ty to be occupie until I (we) have
complied with all laws of the County of Riverside and the State of California governing said property. +
4/27/8' 0
DATE SIGNATURE OF OWNER AND/OR AGENT
Approval by Signature from the Following Departments Listed Below
Must Be Obtained Prior to the Issuing of a Construction Permit.
SPACE NO.
USE OF STRUCTURE
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JOB ADDRESS=SINGLE FAMILY DUPLEX
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COMMUNITY _ _ .
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NO. OF SUBM TTE PLANS USE OF PERMIT
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CASE NO.
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NO. OF PAOKI SP9rCES REQUIRED NO. OFA ILDINGS NOW='EXISTING
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ZON 54A62)FR0NT SIDE REAR
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GRADING PERMIT REQUIRED? YES ❑ NO ❑ LOT SIZE
SETBACK ORDINANCE # _— OF FEET REQUIRED ON 'STREET
DATE SIGNATURE OF LAND USE OFFICIAIX
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DEDICATION REQUIRED: YES ❑ NO ❑ NO. OF FEET___
CURB AND GUTTER REQUIRED: YES ❑/ NO ❑ - STREET
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CAN CURB AND GUTTER FEASIBLY BE INSTALLED? YES ❑ NO ❑
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HAS AN ACCEPTABLE APPLICATION BEEN MADE FOR ENCROACHMENT PERMIT FOR DRI EWAY AND STREET
IMPROVEMENT? YES ❑ NO ❑
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DATE SIGNATURE OF ROAD DEPT. OFFICIA
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SWIMMING POOLS PUBLIC
SEWAGE DISPOSAL \C+LMrr! ih/c_ SP✓r O L S- S/- .. . f` {
FOOD ESTABLISHMENT
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WATER POLLUTION REMARKS
n FLOOD CONTROL S
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= H DIV OF HWY ) QQ Dk`
o a — J YOUR PROPERT AY BE SUBJECT TO
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o FLOOD. RIVERSIDE COUNTY ASSUMES
NO RESPONSIBILITY IN EVENT OF FLOOD. -,
284 199 9/74 CANARY—FILE, PINK—APPLICANT
DEPARTMENT OF BUILDING AND SAFETY APPLICATION CERTIFICATE
COUNTY OF RIVERSIDE PERMIT k
Effective July 1, 1980, Chapter 1301 Section 19825 of the Health and Safety Code requires the execu-
tion of the following applicable declarations prior to the issuance of.a building permit. Please
print or type and sign below.
CJ LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of
Division 3 of the Business and Professions Code and my license is in full force and effect.
License Cla V ^ Li ense No.. 37/ 5_8(2
Date. Contractor_
0 OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the following reasons:
0 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. If I sell within one
year of completion, I understand I will have the burden of proving I did not build or
improve for the purpose of sale (Sec. 7031.5, B.&P.C.).
Q I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, B.&P.C.).
[: I am exempt under Section , B.&P.C. for this reason:
Date
Dwner
M WORKERS' COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self -insure, or a Certificate of Workers'
CompensatiW Insurance, or a certified copy thereof (kc. 3800, Lab. Code).
Policy No.r e .20-5%7_101 MI Insurancej0dAy-r!:2i r1 AyeG (:: :2,
Q Certified copy is hereby furnished.
Certified copy is filed with the Cotrty of Riverside. Depa t nt oy Buil inq a Safety.
atej9_w_ 0 Applicant ( ,(f _
Q CERTIFICATE OF EXEMPTION FROM WORKERS' CO ENSATION INSURANCE
(This section need not be completed if 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.
I further understand that if after making this Certificate of Exemption, I should become subject to
the Workers' Compensation provisions of the labor code, I must forthwith comply with such provisions
or this permit shall be deemed revoked.
Date Applican
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. 3091; Civ. Code).
Lender's Name
Lender's Address
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION
] I hereby certify that no excavation five (5) or more feet in depth into which a person is re-
quired to descend, will be made in connection with work authorized by this permit, and that no
building, structure, scaffolding, falsework, or demolition or dismantling thereof, will be
more than thirty-six (36) feet high. (Chap 3.2, Grp 2, Art 2, Sec 341, Title 8, C.A.C.)
[ As owner -builder, I will not employ anyone to do work which would require a permit from the
Division of Industrial Safety, as noted above, unless such person has a permit to do such work
from that division.
[] Division of Industrial Safety Permit No.
Date Applicant
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY
I certify I have read this application and state that the information given is correct. I agree to
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ith all state laws and county ordinances relating to building construction, and authorize a
tative of the County of Riverside, Department of Building and Safety to enter upon the pro -
b ich h -hpV sed for this perms for the purpose of making insp d o s.
ggaJiture of ApplicantLAgent Date
/V I CsA4Q_ O' WeKG Fbe- 1, r0Ded
Print-Applicant/Agent Name
284-2000 7/80