00002193 (BLCK)i
1 Count`Yy of
Rlversitle•
Department of Building.
and Safety
4080 Lemon St. 2nd Floor 135 N. Alessandro Rd.•Rm. 203 880 N. State Street
•�?' 227 North "D" Street 46-209 Oasis St. Rm. 310 160 N. Broadway
' Riverside. CA 92501 Banning. CA 92220 'Hemet, CA 92343 -
Perris, CA 92310 Indio. CA 922111 Blythe. CA 92225
Ph: 7873146 Ph: 849.7312 - Ph: 658-4464
Ph: 657-3898 Ph: 342.8271 Ph: 922-2670
This permit becomes void if work not commenced within 180 `tfays'Irom data of issuance. ORi.il: workhas 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 it the
with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect.
permit is tot 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 Lic.-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, alsorequires the applicant for such permit to file a
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: .
signed statement thal'he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing
❑ I hereby certify that no excavation live (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, lalsework, 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 (5500).):
C.A.C.)
I, as owner,ol.ihe property, or.myemployees 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 Industrialri
satety, as noted above, unless such person has a permit to do such'wark from that division.
sTruclure is not. intended or offered for sale (Sec. 7044. Business and Professions Code: The Contractor's License Law
does nota I to'an,owner of. ro ert who builds or im roves thereon, and who does such work himself or through
apply P D Y. D 9
Division of Industrial Safe Permit No.
❑ Safety
his own employees. provided that such iinprovements are not intended or olfered.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 herebyy affirm. that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097. Civ. C.).
PI, as owner of the properly, am exclusively contracting with licensed contractors to construct the project (Sec7044,
siness and Professions Code: The Contractor's License Law does not apply to an owner of who builds or
Lender's Name -
properly
improves thereon, and who' contracts for such projects with ii—contractor(s)licensed pursuant to the Contractors
Lender's Address
License Law.). - -
-
I certify that I have read. this application and state roar the above information is correct:�fagree;to;comptywdn all
❑ I am exempt under Sec. a•` B. P C. (Attach Certificate),
city and county ordinances and state laws, relating to building construction, and hereby authonierrepiesenlatives of
. .•1�, ,n.—
Date i,r .'.r"' Jf Owner ._. ,..ta' e:.,t-:.
this county to enter upon the -above -men oned;pr'operty for inspection purposes.' r ` - -
v �.
WORKERS' COMPENSATION DECLARATION: I hereby affirm that 1 have a cerad�cate',otconsent to self -insure. or a
,+,"r+..
Mc .'Sr —Slgnature;of•Applicant or Agent ""� •Date .
certificate of Workers' Compensation Insurance, or/a certified.copY thereof (Sec. 3800, Lab. Q. -,
{rCERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify I havereadthis application and slate that the
Policy No. Comp .Jdf
, Y D Y
•P'"'"~�theyp
information,given is correct. I agree to comply with all stale laws and county ordinances relating to building con.
structmn and authorize a representatwefof'the:Counl of Riverside, Department of Building and Safety to enter upon
❑ Certified ca a hereby furnished.
DY Y
opertyfor•whI5 . havi'.;i pired forsthis'permit for the' purpose of making inspections. . � b ,✓
._.s.A.s•....,,+..::.s-• :..r �..!+!,r .¢ .
❑ Certified copy is filed with'the County Building Inspection Department or County Department.
f".a�l"'h,Signature.of-AppanNt=or Agent Date .
mow, �.
Date Applicant 't r' -' Print Applicant/Agent Name -
APPLICANT NAME (L F MLI ' t' • • .r-L�
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APPL/PRMT N
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DATE
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IA NAME
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ADDRESS �.
.CITY/COMMUNITY/STATE/ZIP
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PHONE N
LICNC N
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ARC/ENG FIRM NAME cls
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ADDRESS
CITY/COMMUNITY/STATE/ZIP. - -'
PHONE N `
LICNC N ..
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USE OF PERMIT
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SSB
,SSB
RSB
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ZONE ti :p
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.END
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- .. -. TOTAL., .YV
FEE
INSPECTOR'S COPY_
. _ .. .
0 011.71
r
NO.
OPERATION
DATE
INSPECTOR
NO.
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
1
Set Back
33
Ventilation System
2
Ftgs & 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
loA
Fireplace T. 0.
E
°o
--------------
ADDITIONAL INFORMATION
-
-----------+-------------
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
12 Internal Loth Y
12A Drywall
13Finish 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
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
298 Bonding
30 Fixtures
31 Service
32 Final
STREET NAME
APPLICANT NAME (L F MIF
..
-
APPL/PRMT # '
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-CO A - NAME
•ADDRESS
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OMMUNITY/STATE/ZIP
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cPAONE # .. ,.
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LICNCsp:r ".. .
ARC/ENG FIRM NAME:
ADDRESS
CITY/COMMUNITY/STATE/ZIP.
PHONE 4 ,...
. LICNC p
USEOFPERMIT.'
L• , •-
,_ y- :
• -FSB
SSB .
SSB
RSB
OFCCIA
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ZONE
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END
TOTAL •
'
FEE
INSPECTOR'S .COPY
001-170
v.
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j
,
rh',FORM 284-208.(2/81) ? e- F -
�`_
'1 Ns 1 ,..._
_. ..... .. .... ....... ..... . _.._. .. ._,._,.
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
loA
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 (Botts)
12B Ceiling (Batts)
12C Ceiling (Blown)
14 Final
--------- " - PLUMBING- APPROVALS- - - - - - - ----
--15
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