2221 (BLCK)Count yy df' Riverside
Department W.Building and Safety
4080 Lemon SI. 2nd Floor 135 E. Alessandro Rd. Rm. 203 880 N. State Street
• .' 227 North "0" Street 46209 Oasis St. Rm. 310 160 N. Broadway '
Riverside. CA 92501 Bannmg, CA 92220 Hemet, CA 92343
Perris. CA 92370 Indio. CA 92201 Blythe, CA 92225
Ph: 787.6146 Ph: $49.7312 Ph: 6564464
Ph: 657.3898 Ph: 342.8271 Ph: 922-2670
This permit becomes void if work notcommencedwithin 180 days from date of issuance. OR, if work has been suspended or abandoned for a period of 180 days.
LICENSED CONTRACTORS DECLARATION: I hereby affirm that I am licenslid 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 performance of the work for which this permit is issued. I
License Class Lia Numbershall
not employ any person in any manner so as to become subject to the Workers' Compensation Laws of California.
Date ApplicantNOTICE
Date Contractor
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 ex=mpt 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
reason (Sec. 7031,5: Business and Professions Code: Any c[y or county which requires a permit to construct. alter,
deemed revoked.
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 provision: of the Contractors License Law (Chapter 9 (commencing
❑ I hereby 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 Prolessio=s 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 (5500).):
C.A.C.)
j� I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the
Q As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial
Wely
sTucture is not intended or offered for sate (Sec. 7044, Business and Professions Code: The Contractor's License Law
as noted above, unless such person has a permit to do such work from that division.
does not apply to an owner of properly who builds or impro•-es thereon, and who does such work himself or through
[:]Division of Industrial Safety Permit No. -
his own employees, provided that such improvements are noCintended or offered for sale. It, however, the building or
Date Applicant
improvement is sold within one year of completion, the owne,-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.1, as owner of the property, am exclusively contracting wim licensed contractors to construct the project (Sec. 7044,
Lender's Name
usfness and Professions Code: The Contractor's License Lav does not apply to an owner of property who builds or
improves thereon_ and who contracts for such projects wits a contractor(s) licensed pursuant to the Contractors
Lender's Address
Licepse Law.). -
' I am exempt under Sec, ✓'^.'✓ �,.,..+""B. 8 B C- Itat;li.Certificate),
❑ p '
1 certify that 1 have read this application and state that the above information is correct. I agree to comply with all
city and county ordinances 2nd, state-Iaws•relatin to bw(dln construction, and hereb authorize representatives of
y p
Date it-"^y,'yw e� "'_ l,!OwnerA'`
this county to'enter u dn+the-above=men 'oned+ rapeAylor Inspection purposes.
P
,.r"'+^..,.•<':s-.'�.,-;.�X+,...'ti�.'��,
WORKERS' COMPENSATION DECLARATION I her6y.4f m that I ha ea�c€ilfl� of consent to sell -insure, ora
Signature -of Applicant or Agent Date .
certificate of Workers' Compensation Insufanceeor" a certifies copy thereof'($ec. 3800. Lab. C.). �j°�
`„�•
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify I have read this application and stale that (he
Policy No. Company,".,. --information given is correct. I agree to comply-�with�all state laws and county ordinances relatingg to building con-
struction, and authorize�a representative/oflhe Cdpnty of Riverside. Department of Burping and Salety to enter u on
Certified co is hereby furnished.
the property„ for wfii6t0.ha've.-applied;for-th& A
crt for the purpose of making inspe tions. -
❑ Certified copy is filed with' the County Building Inspecti,an Department or County Department. "•.fit ' ;�„�[",Signature of ADPlicant or Agent date .
Date Applicant 1 -
„y- Print Applicant/Agent Name
APPLICANT NAME (L, F. MI)
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-
APPL/PRMT p PS GATE
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Ab 1m
MOD
NAME
S
ADDRESS
CITY/COMMUNITY/STATE/ZIP -
PHONE p LICNC p .
t
ARC/ENG FIRM NAME
ADDRESS -
CITY/COMMUNITY/STATE/ZIP
PHONE p LICNC p,
USE OF PERMIT
r
L -Z .. FSB I SSB I SSB RSB OFC -
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ZONE p L T - END 1 E TOTAL
-."`FEE ,
INSPECTOR'S COPY
001191
TOTAL PUNIT COST IS
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A
FORM 284-208 I2/811
NO.
OPERATION
DATE
INSPECTOR
NO.
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
1
Set Back
33
Ventilation System
2
Ftgs 8. Frms
34
Plenums & 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 Deice
9
Garage Fire Wall
42
Commercial Hood
10
Fireplace P.L.
43
Final
10A,
Fireplace T.O.
°o
j7
/-\
-------
ADDITIONAL INFORMATION
�._l. __.____.._._- _�___r. _� �..
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Loth
12 Internal Lath
12A Drywall
1'3—Finish'Gr6de' •. _ �. _ ._ �_ .._ ._
INSULATION Thick „RI,
Value
7A Wolls (Batts)
12B Ceiling (Batts)
12C Ceiling (Blown)
14 Final • Z6i
--- ----- 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, MI(
RUSSELL,. 404"TE
w
ti-RIWAIRIe%
NITY/ST f
'.r0 SIT A RE9SISAACE `
CALM Q0140
I M NITY/STATE/ZIP
PiA In
C - T
LO MOD SI
]KAUE ... ..
OWNER NAME -(L. F, -
C MM-PRM.NAME
ADDRESS - .-
CITY!COMMUNITY/STATE/ZIP'
PHONE #
LICNC N
ARC/ENG FIRM NAME '
-ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE a
LICNC'N
USE OF PERMIT - -
•
'BL - FSB SSB SSB RSI
zo.NellFllp I
NO.
OPERATION
DATE
INSPECTOR
NO.
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
1
Set Back
33
Ventilation System
2
Ftgs & Frms
34
Plenums & Ducts
2A
Slab Grade
35
Furnace Comport.
3
Steel
36
Inlets & Outlets
4
Grout Blocks
37
Combustion Air
5
Bond Beams
38
Compressor
6
Roof Deck
39
Appl. Cleo once
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.
°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 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