BLCK (00002189)53605 Avenida Martinez
00002189
APPLICANT NAME (L, F. MI)
TE/ZIP
MOD I SB
NAME
S
I I APPL/PRMT p
ADDRESS
CI n'!COMMUNITY/STATE/ZIP
PHONE N LICNC It
ARC/ENG FIRM NAME ' +
ADDRESS
CITY/COMMUNITY/STATE/ZIP -
PHONE 4 LICNC n
USE OF PERMIT
q
FORM 284.208 (2/81)
FSB I SSB I SSB I RSB
OFC,
END E
PS
TOTAL PERMIT COST IS
Y*,A I 001162 1
TOTAL
FEE
WA V
001162
County
of Riverside
Department of
Building and Safety
4080 Lemon St. 2nd Floor 135 N. Alessandro Rd. Rm. 203 880 N. Slate Street
n 244 North "D" Street 46-209 Oasis St. Rm. 310 160 N. Broadway
Riverside. CA 92501 Banning, CA 92220 Hemet, CA 92343
Perlis. CA 92370 Indio, CA 92201 Blythe. CA 92225
Ph: 787.6146 Ph: 8447312 Ph: 658.4464
Ph: 657-3898 Ph: 342-8271 Ph: 922-2670
This permit becomes void if work not commenced within 180 days from date of issuance. OR, if work has been suspended or abandoned for a period of 180 days.
LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
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 ($100) 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.
License Class Lit. Number
Date Applicant
Date Contractor
NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you should become subject to the Workers'
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.
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
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
signed statement that he is licensed pursuant to the provisions o1 the Contractoes License Law (Chapter 9 (commencing
E] I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be
with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and the basis for
made in connection with work authorized by this permit, and that no building structure. scaffolding, falsework, or
the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil
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 not more than five hundred dollars (S500).):
C.A.C.)
I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the
As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial
a ety, as noted above, unless such person has a permit to do such work from that division.
structure is not intended or offered for sale (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 does such work himself or through
Division of Industrial Safety Permit No.
his own employees, provided that such improvements are not intended or offered for sale. It, however, the building or
Date Applicant
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.).
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. Civ. C.).
I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044.
Lender's Name
usiness 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 contractor(s) licensed pursuant to the Contractor's
Lender's Address
License Law.). r"- .
= ''
I certify that 1 have read this application ^and state That the above information is correct. I agree to comply with all
city and county ordinances andstate.faws relating to building construction, and hereby authorize representatives of
C] I am exempt under Sec. •- . B..6`P.C. (Attach Certificate).
for inspection "
C - r'
Date "% o Owner uax G....d`" •'
this county to enter upon Ihe.pbove-mentioned property purposes. " 0 ,r'
.w--
WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to self -insure, or a
_._. +"'•
Signature of Applicant or Agent Date
certificate of Workers' Compensation Insurance, ore certified copy thereof (Sec. 3800. Lab. C.).
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION'OF ENTRY: I certify I have read this application and slate that the
'•information given is correct.. l -agree to comply"with all state laws and county ordinances relating to building con -
Poli No. -Company
Policy P Y
struction, and.authorize aKiepresentative'of the County of Riverside. Department of Buifding.and,Safety,lo enter upon
❑ Certified co Is herebyfurnished.
the property for whlc l-have,applfed for this permit for the purpose of making inspections. " Ti
Certified copy is filed with'the County Building Inspection Department or County Department
wSignatute of Applicant,or,Agent ." r' ,e' t.,,,, Date . I
Date Applicant
Print Applicant/Agent Name
APPLICANT NAME (L, F. MI)
TE/ZIP
MOD I SB
NAME
S
I I APPL/PRMT p
ADDRESS
CI n'!COMMUNITY/STATE/ZIP
PHONE N LICNC It
ARC/ENG FIRM NAME ' +
ADDRESS
CITY/COMMUNITY/STATE/ZIP -
PHONE 4 LICNC n
USE OF PERMIT
q
FORM 284.208 (2/81)
FSB I SSB I SSB I RSB
OFC,
END E
PS
TOTAL PERMIT COST IS
Y*,A I 001162 1
TOTAL
FEE
WA V
001162
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 C3mpart.
3
Steel
36
Inlets 8 Oitlets
4
Grout Blocks
37
Combustion Air
5
Bond Beams
38
Compressor
6
Roof Deck
39
Appl. Clecrance
7
Framing
40
Fire Damper
8
Vents
41
Smoke Detection Device -
9
Garage Fire Wall
42
Commercial Hood
10
Fireplace P. L.
43
Final
10A
Fireplace T.O.
NO
------
ADDITIONAL INFORMATION
_._-...___-_.
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
12 Internal Lath
12A Drywall
1.3 'Finisli Grode
INSULATION Thick R
Value
7A Walls (Batts)
12B Ceiling (Botts)
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
P/
26 Power Pole
27 Conduit '
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
. 31 Service
32 Final
STREET NAME
APPLICATION FOR -WOOD P CIN C C,
T.H 5 AM AP DL.ICAT 1-0M 0HL,Y
' t
•
,FORM 284208 (2/81)
NO.
OPERATION
DATE
INSPECTOR
NO.
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
1
Set Back
33
Ventilation System
2
Ftgs 8 Frms
34
Plenums & Ducts
2A
Slob 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
10A
Fireplace T. 0.
°o
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 (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
PSL
P/
.
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final
STREET NAME