40126 (ELEC)PERMIT APPLICATION „t
County of
Riverside
Department of Building
and Safety
' 4080 Lemon St. 2nd Floor 135 N. Alessandro Rd. Rm. 203 880 N. Slate Street
j..
227 North -D- Street 46.209 Oasis SL Am. 310 160 N. Bro•
N Riverside. CA 92501 Banning. CA 92220 Hemet. CA 92343
Perris. CA 92370 Indio. CA 92201 Blythe. C625
Ph: 787-6146 Ph: 849.7312 Ph: 658.4464
Ph: 657.3898 Ph: 342.8271 Ph: 9222670 T
i This permit becomes void if work not commenced within 180 daysulrom date of issuance. OR, if work has beer suspended
or abandoned for a perioo of 180 days.
I,❑
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-
pleted it the permit is for one hundred ($100) or less. I certify that in the performance of the work for whit(• this
Ying 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' Com,11msa-,
lion Laws of California.
❑ �,••-
Date Applicant
OWNER -BUILDER DECLARATION: I hereby affirm that I am exempt from the Contractor's license law for the
NOTICE TO APPLICANT: ll, alter making this Certificate of Exemption, you should become subject to the Workers'
Compensation provisions of the labor Code. you must forthwith comply with such provisions or this permit shall be
followingreason Sec. 7031.5. Business and Professions Code: An cit or count g
y which requires a permit to con-
deemed revoked.
struct. alter, improve, demolish• or repair any structure. prior to its issuance, also requires the appliant 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:
p: (Chapter 9 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is ex-
empt therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a per-
"
❑I hereby certify that no excavation live (5) or more lee[ in depth into which a person is required to descend. will
•� mit subjects the applicant to a civil penalty of not more than live hunderd dollars ($500).):
be made in connection with work authorized by this permit. and that no building structure, scaffolding, falsework.'
❑ 1, as owner of the properly, or my employees with wages as their sole compensation, will do the work. and the
'f�11
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. ): _
structure is not intended or offered for safe (Sec. 7044. Business and Professions Code: The Contractor's License❑As
owner -builder. I will not employ anyone to do work which wouttl require a from the Division In-,
" Law does not apply to an owner of property who builds or improves thereon; and who does such work himself or
through his own employees, that improvements intended for
permit of
dusirial Safety. as noted above, unless such person has a permit to do such work from the division,
provided such are not or offered sale. If. however.
A.. 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.
,icing that he did not build or improve for The purpose of sale.)
ADDRESS
owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.
-� 7044.
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
'f builds or improves thereon, and who contracts for such projects with a contractor(s) licensed to The Con-
mance of The work for which this permit is issued (Sec. 3091• Civ. C.).
Name
pursuant
t` raclor'.s License Law.)
Lender's
'
7E]i am exempt under Sec. . B.8 P.C. (Attach Certificate).
Lender's Address
'
14 -Date Owner
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify I have read this appficalion and state
1�- -
that the information given is correct. I agree to comply with all state laws and county ordinances relating to
WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to self -insure, or a
building construction, and authorize a representative of the County of Riverside. Department of Building and Safety
certificate of Workers' Compensation Insurance, or a cerlified copy thereof (Sec. 3800. Lab. C.).
to enter upon the property for which I have applied for this permit for the purpose of making inspections.
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❑Certified copy is hereby furnished. •
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❑Certified copy is filed with the County Building Inspection Department or County Department.
Signature of Applicant or Agent _.w - Date
•SS8
Print Applicant/Agent Name
APPLICANT NAME (L„ F, MI)
GATE
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ACIDMESS •�_ �^ / �^,,r/
CITY/COMMUNITY/STATE/ZIP
JOB SITE ADD ES`SISPACE
CITY/COM U TTY/STAT IP
/y
BOK
PAG
PRC
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/ TWN
RNG
SE
S
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TRACT - LOT
MOD
SB
TRACT NAME
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OWNER NA E (L, F,MI)
PHONE /1
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CONTRACTOR -FIRM NAME
LICNC d
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE p
BLD P
FINAL DATE
Q�
�LICNC
ARC/ENG FIRM NAME
If
ADDRESS ,
CITYICOMMUNITYISTATE/ZIP ..
PLAN If '
PLANS EXAMINER
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APPROVE DATE
USE OF ,
BL
ZON
FSB
•SS8
SsEr
RSB
OFC
e ZONE ORD #
LOT SZ
END
'SIDE
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FORM 284.208(11-81) INSPECTOR
APPLIPRMT p PS
GATE
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40126
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TOTAL .
/- FEE
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CA
CK
NC
QOUNTER B.I.
�..,�
COUNTER L.U.T.
NO.
OPERATION DATE
INSPECTOR
NO.
OPERATION
DATE INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
1
Set Back
33
Ventilation System
2
Figs 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 (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
P/L
P/
26 Power Pole OCL
27 Conduit
28 Service Entrance
29 Wiring D' Z S D—(,
29A Grounding Wire Q
29B Bonding
30 Fixtures
31 Service
32 Final
STREET NAME
NOTICE: THIS IS NOT A BUILDING PERMIT
APPLICATION TO CONSTRUCT
DEPARTMENT OF BUILDING AND SAFETY
COUNTY OF RIVERSIDE
DISTRICT
Permit No
284 199A 9/74 CANARY—FILE, PINK—APPLICANT
Owner s L A'I Architect---.—.----.teContractor__-_-.
AddressLc/ 3 _G'� rc�3 Address__.___----__
4,01 1JALC 51OL-
City z?A ity__
City---
Phone :5 b T Phone _ Phone— ---_—.._
Phone
oC
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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
Z
Paving, and/or Dedication of right of way is required by the County of Riverside, the Riverside County Department of Building and Safety
3
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
O
without an encroachment permit.
NOW, therefore, it is agreed that I (we) will not occupy said property and will not cause said property to be occupied until I (we) have
complied with all laws of the County of Riverside - and the State of California governing said property.
DATE --'---- SIGNATURE OF OWNER AND/OR AGENT __ a �'
Approval by Signature from the Following Departments Listed Below
Must Be Obtained Prior to the Issuing of a Construction Permit.
J I SPACE NO.
I USE OF STRUCTURE
�-� I
>_LEGAL
JOB ADDRESS v SINGLE FAMILY � DUPLEX El
6�l Q 0/0
Z W
ESCRIPTION OF PRO ERTY - APARTMENTS AGRIC.
O wr
a
SeG-r�V�= COMMERCIAL INDUSTRIAL r -
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COMMUNITY ALTERATIONS ❑
:sDC
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NO. OF SUBMITTED PLANS _ USE OF PERMIT
p a /
CASE N0. ����/t-.�U-%a h
p Z
NO. OF/PAARRAINCG SPACES REQUIRED .— O. OF BUILDINGS NOW EXISTING
a
ZONE `-�-4.5 SETBACKS: FRONT SIDE REAR
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m
GRADING PERMIT REQUIRED? YES ❑ NO ❑ LOT SIZE
SETBA 0 INA CE OF FEET REQUIRED ON ST EET
DATE �� SIGNATURE OF LAND USE OFFICIAL -
DEDICATION REQUIRED: YES ❑ NO ❑ NO. OF FEET -- —
z
CURB AND GUTTER REQUIRED: YES ❑ NO ❑ _STREET
t -
a
CAN CURB AND GUTTER FEASIBLY BE INSTALLED? YES ❑ NO ❑
W
HAS AN ACCEPTABLE APPLICATION BEEN MADE FOR ENCROACHMENT PERMIT FOR DRIVEWAY AND STREET
Q
IMPROVEMENT? YES ❑ NO ❑
O
°C
DATE _ SIGNATURE OF ROAD DEPT. OFFICIAL_
=
SWIMMING POOLS PUBLIC
QW
DISPOSAL
SEWAGE
_
FOOD ESTABLISHMENT
WATER POLLUTION REMARKS
FLOOD CONTROL—
H
z AIR POLLUTION
� W
_ DIV OF HWY
H
c ce YOUR PROPERTY MAY BE SUBJECT TO
—
o.
c FLOOD. RIVERSIDE COUNTY ASSUMES
NO RESPONSIBILITY IN EVENT OF FLOOD.
284 199A 9/74 CANARY—FILE, PINK—APPLICANT
DEPARTMENT OF BUILDING AND SAFETY . COUNTY OF RIVERSIDE
OFFICE DATE \ TIME PERMIT NUMBER
INSPECTION
ADDRESSSPACE NO REUUESTED
OWNER
BUILDING
REMARKS:
I
7 8- 3 taw lC(
T I
I COMMUNITY
PLUMBING ELECTRICAL MECHANICAL
3C-),
( s- tq-lk.. ID S,P-II` .
OWNER/CONTRACTOR TEL.NO
FOR:
A.M.
P.m.
MON
E.TUE S
F] WED
El Ty?UR
F;Rf
284-1 11/75