00002223 (BLCK)County of Riverside
Department of Building and Safety
Riivveerside. CA 8250 Floor Banning. N. Alessandro9222 Rd. Rm. 203 880 N. et. CtAate Street:' ' µ � rt Perris227 �CA 92370treet Indio.
OasisTRm. 31F! Bllyyl e, CAN. a92225 ,.
Ph: 787-6146 Ph: 849.7312 Ph: 658-4464 ' ;� � Ph: 857-3898 Ph: 342-8271 -Ph: 922.2670
' This permit becomes void i1 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: 1 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 performar;e 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 com rly with such provisions or this permit shall be
reason (Sec. 7031.5, Business and Professions Code: Any city or county which requires a permit to construct, atter• deemed revoked. .. 1 ,
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 of the Contractors License Law (Chapter 9 (commencing C] Thereby 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 (8500).): - - C.A.C.)
[[�A1, 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 woLld require a permit from the Division of Industrial
ss ructure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License Law Safety, as noted above, unless sato person has a permit to do sucl work Irom that division.
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.).
PI, as owner of the property. 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 property who builds or Lender's Name
improves thereon, and who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's Lender's Address
License Law.). t I certify that I have read this application and state that the above ir_formation is correct.`I agree -to comply with all
1 cit and count ordinances and. state laws relating to
.1•am exempt under Sec. •••^"' ��"••% Q 8 P.C. (Attach Certificate). Y Y 9 building pectbncpurp and hereby authorize representatives of
this county to. enter, upon the'above-rrlentioneO,p,Soperty^for inspectbn purposes. � ,A
Date '••"""t:o-r .:J'1.�wr, s Owner f' �_ W,,.,.r•'• :r'.. •,r"
WORKERS' COMPENSATION DECLARATION: I hereby um"t at l^pa A. ate of consent to self -insure, ora 4 - S�gnaNre I'AApppeant o Agent Date . -
certificate of Workers' Compensation Insurance or a,certil�wpysihereof'(Sec. 3800. Lab. C.). . e4' CERTIFICATE OF COMPUANCE-AND AUTHORIZATION OF ENTRY: I ceriry I have read this application and state that they
Policy No. Com an inlormation given is correct. I agree to comply with all state laws and county ordinances relating to building con,
Y r Company r-"struchon and autho7ae a representative of the County cotJRNerside_Department of Budding and Safety to enter upon
the property„larwihlch.l haye4apPtied for9his permlYfor the purpov;e of makirrg,ippections. �,. ,,,”
Certified copy is hereby furnished -!,,,.. _ ,•a,..,••� fir,;;;,. ,,,, ,y . t�'
Q Certified copy is filed with'te County Building Inspection Department or County Department. �,,, •T";'= gSlgture ak'A pPhcapt. Agent �„'•N f _ - Date
bate Applicant ~ •.�%.:� r- rs'�r 2"'sf / •.a,v= -
!„ - Print Appticant/Agent Name
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APPLICANT NAME (L F MI) •" . APPL/PRMT 4 ` PS DATE546
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WIDWIFIMSY
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PHONE 4 LICNC 4
ARC/ENG FIRM NAME . \
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CITY/COMMUNITY/STATE/ZIP -
PHONE q . LICNC 4
USE OF PERMITlet— 7 Ale 11
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INSPECTOR'S COPY,
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FORM 284-208 (2/81). ••
-
NO.
OPERATION I.
DATE
INSPECTOR
NO.
OPERATION
DATE
INSPECTOR
BUILDING. APPROVALS
MECHANICAL APPROVALS
1
Set Back
33
Ventilation System
2
Ftgs & Frms
34
Plenums & Ducts
2A
Slob 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
_g`2
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 Loth
12A Drywall
` 13 Finish Grade
INSULATION Thick
R
Value
7A Walls (Batts)
12B Ceiling (Batts)
12C Ceiling (Blown)
14 Finalre
-- _- 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
APPLICANT NAME (L, F. MI)
AD•R• S .
I NITY/ST
'JOB SIT ADDRESS/SPACE
_ 4
•CI MIR NITY/STATE/ZIP
AV C C
oft n
R C - LO
TRAC NAME 1
"OWNER NAME (L. F, MI) -
CONTRACTOR-FIRM NAME `
ADDRESS
CITY!COMMUNITY/STATE/ZIP ,
PHONE N
.ARC/ENG FIRM NAME
",ADDRESS .
CITY/COMMUNITY/STATE/ZIP
: PHONE #
y
OSE,OF PERMIT
z
_ .X .
L FSB '
ZONE p, L
NO.
OPERATION
DATE
INSPECTOR
NO.
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
1
Set Back
33
Ventilation System
2
figs & Frms
34
Plenums & Ducts
2A
Slab Grade
35
Furnace Comport.
3
Steel
36
Inlets 8 Outlets
i 4
Grout Blocks
37
Combustion Air
5
Bond Beams
38
Compressor
6
Roof Deck
39
Appl. Clearance
7
Framing
40
Fire Domper
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 I,R
Value
7A Walls (Botts)
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
29B Bonding
30 Fixtures
31 Service
32 Final
STREET NAME