25648 (GRD)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 "D" Street 46.209 oasis St. Rm. 310 160 N. Broadway
Riverside. CA 92501 Banr'&O. CA 92220 Hemet. CA 92343
Perris. CA 92370 Indio. CA 92201 Blythe. CA 92225
Ph: 787.6146 Ph: 849.7312 Ph. 658.4464
Ph: 657.3898 Ph. 3428271 Ph: 9222670
This permit becomes void if work nor commenced within 180 days from date of issuance. OR. if work has beer suspended
or abandoned lot a permm 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 of Chapter 9 (comment.
pleled if the permit is lar one hundred ($100) or less. I certify that in the performance of the work for which [his
ing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect.
permit is issued. I shall not employ any person in any manner so as to become subject 10 the Workers' Compensa-
i/Bt1�T��
WO 000 3122
lion Laws of California.
❑
Dale __ Applicant
S13
NOTICE TO APPLICANT: If, after makingthis Certificate of Exemption. you should become subject to the Workers'
OWNER -BUILDER DECLARATION: I hereby affirm that I am exempt Tom the Contractor's License Law ter the
Compensation provisions of the Labor Code. you must forthwith 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 permil to con-
deemed revoked.
struct, alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such
HURs 1638
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-
❑I hereby certify that no excavation five (5) or more feel depth into which person is required to descend, will
empt therefrom and the basis lar the alleged exemption. Any violation at Section 7031.5 by any applicant for a per-
t. inI
made in connection with work authorized by This permit, and that building scaffolding.
mit subjects the applicant to a civil penalty of not more than live hunderd dollars ($500).):
or fel hno ghstructure.
or demolition or dismantling thereof. will be more than thirty - six (36) feet high. (Chap. 3.2. Grp 2, Art 2. Sec 341,
2, . Sec 41.
❑ I, as owner of the property, or my employees with wages as their sole compensation. will do the work, and the
Title 8, C.A.C.).
structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License
❑ As owner -builder, I will not employ anyone to do work which would require a permit from the Division of In -
Law does not apply to an owner of properly who builds or improves thereon, and who does such work himsell or
dustrial Safely, as noted above. unless such person has a permit to do such work Irom the division.
his own employees. provided that such improvements are not intended or offered for sale. If, however,
:he
0U�
the building Or improvement is sold within one year of completion, the owner -builder will have the burden of prov-
❑Division of Industrial Safety Permit No.
Ing that he did not build or improve for the purpose of sale.)
�F D
❑I, as owner of the properly, am exclusively contracting with licensed contractors to construct the project (Sec.
CONSTRUCTION LENDING AGENCY: I hereby affirm [hal 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 properly who
mance of the work for which this permit is issued (Sec. 3097. Civ. C.).
builds or improves thereon, and who Contracts tar such projects with a contraclOr(s) licensed pursuant to the Con-
Lender's Name
tractor's License Law.)
Lender's Address
01 am exempt under Sec. BA P.C. (Attach Certificate).
Date Owner
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify I have read this application and stale
h h '1 I 'h
WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to self -insure, or a
certificate of Workers' Compensation Insurance. or a certified copy thereof (Sec. 3800. Lab. C.).
❑Certified copy is hereby furnished.
❑Certified copy is liled with the County Building Inspection Department or County Department.
001 yAMFr�LAFtfI)
IYURs 1633jj8
F)TA _ff `Y-8TENCT CA 922600000
FJ fJ6EI40BRESSISPACE ARRANZA
AVEi�Vl. lr
�:�DDi�'if4IF16rST'AT67ZIP
22530000
CRA!"1�1922530000
11�� 1
' U 31�p
1F
TWN
Ino
+n0
S
i/Bt1�T��
WO 000 3122
e�.�r
app
JWTA
S13
Bt1C '285 , 3CV LAQ #26
Q rp4�A��E `L{
PHONE N
NM1AN ♦
1 i"1�1AVL17Y N,L'-i�Il�Rr
p� A ry� E-
LIs:.W aa5436
HURs 1638
PTA12 �Df�3� 91!Tr1' CA 922600000
7'V41-568-1 0.48
ii V
BLDG. INSPECTOR
FINAL DATE
ARC/ENG FIRM NAME
UCNC N
ADDRESS
CITYICOMMUN ITY/STATE/ZIP
PLAN M
PLANS E� ER"
APPFVEQAT�
S O(y
i WNIPx14G-2436 CY FILL
100
RZPN
021€!
0U�
01f1D
Silo
�F D
ZONE ORD N
LOT SZ
u tEM,r„f0 h Join
f 3_Pp�
t at t e m ormat on gwen Is correct. I agree [o comp y wu all state laws and county ordinances relating to
building construction, and authorize a representative of the County of Riverside, Department of Building and Safely
to enter upon the properly for which I have applied for this permit for the purpose of making inspections.
1Siggature ol'Applicanl or Agent Date
Print Applicant/Agent Name
UPUU Ta71 l04l26, 2
GRADING PLAN REVIEW FEE
25648
++ tr..-
f
TOTAL
FEE
$15.00
CACWV
A
NC
COUNTER rP.I.
COUNTER L.U.T.
PERMIT FOR GRADING PLAN REVIEW !/
TOTAL PERMIT COST I8 $15.00
of Lots t 0 CU YDS --Cuts 0 Fills 236 Total Moved i 236
Gr•adinq Flan Review Fees (based on cubic yds Cut and Filled) is % $15.00
FORM 284.208 (11.81) INSPECTOR
r
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 8 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.O.
OP'N
NO.
ADDITIONAL INFORMATION
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
12 Internal Lath
12A Drywall
13 Finish Grade
INSULATION Thick R
Value
7A Walls (Botts)
12B Ceiling,(Batts)
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 Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final
STREET NAME
• •Q