418339 (BLCK)PERMIT NO DEPARTMENT OF BUILDING & SAFETY FIELD F/MT
1418339 COUNTY OF RIVERSIDE
CONSTRUCTION
ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
IST FL.
2ND. FL.
FOR.
GAR.
CAR P.
WALL �"
ESTIMATED CONSTRUCTION
SQ. FT. @
UNITS
Community %
SQ. FT. @
YARD SPKLR SYSTEM
MOBILEHOME SVC.
SQ. FT. @
BAR SINK
.
POWER OUTLET
SQ. FT. @
ROOF DRAINS
SQ. FT. @
DRAINAGE PIPING
SQ. FT. @
DRINKING FOUNTAIN
SQ. FT. @
URINAL
VALUATION $ Ur
WATER PIPING t
NOTE: Not to be used as property tax valuation
Mech. Fee Dbl E
SWIM POOL, PVT
FLOOR DRAIN
MECHANICAL FEES
SWIM POOL, COMM
WATER SOFTENER
VENT SYSTEM FAN EVAP. COOL HOOD
F
SIGN
WASHER (AUTO)(DISH)
APPLIANCE DRYER
Zone Resctions
lSMI
Group
GARBAGE DISPOSAL
FURNACE UNIT WALL FLOOR SUSPENDED
Fee E
Plumbing Fee
LAUNDRY TRAY
AIR HANDLING UNIT CFM
Plan No.
IDLE METER
KITCHEN SINK
ABSORPTION SYSTEM B.T.U.
y
Final .t'C-"(Q, s r Unit
`
TEMP USE PERMIT SVC
WATER CLOSET
COMPRESSOR HP
E
POLE, TEMP/PERM
LAVATORY
HEATING SYSTEM FORCED GRAVITY
Supplimentol Permit Numbers
...///111
,/1 L1 9
AMPERES SERV ENT
SHOWER
BOILER B.T.U.
Address City Zip
SQ. FT. @ c
BATH TUB
Owner/Agent
SQ. FT. @ c
WATER HEATER
Tel.
Zip
S0. FT. RESID @I th c
SEWAGE DISPOSAL
E
Address
S0. FT. GAR @ 3/4 c
HOUSE SEWER
City
Zip
M.O.jj N.C.Ej Cash Check
Received by
GAS PIPING
PERMIT FEE
(!�
'
t,
PERMIT FEE
PERMIT FEE
-T-
DBL.
TOTAL FE E$1
MOB. HM. FEE
MICRO FEE
MECH. FEE
PL. CK. FEE
I CONST. AE ELECT. FEE
SMI FEE
FEE PLUMB. FEE
T LL P
Sewer District
Form 284-208 (Rev.8/78) @s -
THIS PERMIT SHALL BECOME VOID IF WORK IS NOT COMMENCED WITHIN 120 DAYS. CESSATION OF WORK
FOR 120 DAYS SHALL ALSO CAUSE PERMIT TO BECOME VOID.
I HEREBY AGREE THAT ALL WORK IN CONNECTION WITH THIS PERMIT WILL BE DONE IN ACCORDANCE WITH
THE LAWS OF RIVERSIDE COUNTY AND THE STATE OF CALIFORNIA.
I HEREBY CERTIFY THAT THE INDIVIDUAL WHO PREPARED THE PLANS AND SPECIFICATIONS HAS DONE SO IN
ACCORDANCE WITH SECTION 5541 OF THE BUSINESS AND PROFESSIONS CODE OF THE STATE OF CALIFORNIA.
verified by:
Job Address
Spaceip
Z
Owner
PERMIT NO.
-
Community %
Valuation
Date
Dist.
Off.
F.C.C.
MH.Permit Fee E
Micro Film Fee
Cop E
Use of permit
m� � /`C3 < YV .%
/`
`Parcel
No. t ��y
/7 "�(�J�p "V ��j
Use/Cose No.
I)e
CkBy
Mech. Fee Dbl E
PI. Ck. Fee §
Set Backs
Lot Size
Construction Fee Dbl E
Legal Description
�/"};
F
S
/
S R
Electrical Fee Dbl E
Zone Resctions
lSMI
Group
Type
Fee E
Plumbing Fee
Dbl E
Bond Amt.
E
Plan No.
Plan Checker
y
Final .t'C-"(Q, s r Unit
`
Sp. Insp. Fee E
Demol. Fee
E
Const. Lender Branch
Supplimentol Permit Numbers
...///111
,/1 L1 9
Regisir. Fee §
Mileage Fee §
Address City Zip
Witness Fee E
Reinsp. Fee
Owner/Agent
Tel.
Zip
(
Total Fees
E
Address
City
Zip
M.O.jj N.C.Ej Cash Check
Received by
Contra/cto ,/t 44�
!+Y C•/ �lfllll }t/
(!�
'
t,
TeL
License#
Trees required
Sewage System
Address
City ��yy � Zip
T LL P
Sewer District
Form 284-208 (Rev.8/78) @s -
THIS PERMIT SHALL BECOME VOID IF WORK IS NOT COMMENCED WITHIN 120 DAYS. CESSATION OF WORK
FOR 120 DAYS SHALL ALSO CAUSE PERMIT TO BECOME VOID.
I HEREBY AGREE THAT ALL WORK IN CONNECTION WITH THIS PERMIT WILL BE DONE IN ACCORDANCE WITH
THE LAWS OF RIVERSIDE COUNTY AND THE STATE OF CALIFORNIA.
I HEREBY CERTIFY THAT THE INDIVIDUAL WHO PREPARED THE PLANS AND SPECIFICATIONS HAS DONE SO IN
ACCORDANCE WITH SECTION 5541 OF THE BUSINESS AND PROFESSIONS CODE OF THE STATE OF CALIFORNIA.
verified by:
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 v
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. E]
43
Final
10A
Fireplace T.O.
FI
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
PSL
REAR OF PROPERTY LINE
ELECTRICAL APPROVALS
PSI
'
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final
STREET NAME
DEPARTMENT OF BUILDING AND SAFETY APPLICATION CERTIFICATE
COUNTY OF RIVERSIDE PERMIT N
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.
® 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.Class . F)License No.
Date '�(l -Q I Contractor �(%//
OWNER -BUILDER DECLARATION 1
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.BP.C.).
Q I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, B.BP.C.).
[� I am exempt under Section B.8P.C. for this reason:
Date Owner
® 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. Code).
Policy No. �Q -02 -2,2"/ L,? Insurance A %X_ FAW
Q Certified copy is hereby furnished.
Certified
copy is filed with the County /of�JRiverside, DDeep/(arrt�ment of Bui%�l,ding and-fSafe.ty.
Date �_% -_ 6 `� � 1 Applicant /,,�Z/ ,7"'4i4-1-.�/1�7r�1.f%f`ti�f
Q CERTIFICATE OF EXEMPTION -FROM WORKERS' COMPENSATIONIINSURANCE U i a
(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 Applicant
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. '30097;•Civ. Code).
Lender's Name iT
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
comply with all state laws and county ordinances relating to building construction, and authorize a
representative of the County of Riverside, Department of Building and Safety to enter upon the pro-
perty for which I have applied fdr this,'permit forthe pu.pose of making inspections.
Signature -of pp scant gent / ) % Date
284-2000 7/80