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lit RIVefS de
i Department 01 Building and Safety
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1160
.'; -'•,* x . 4080 Lemon St. 2nd Floor 135 N. Alessandro Rd. Rm. 203 .880 N. State Stri'f;t ,.�
Riverside, CA 92501 • Banning, CA 92220 Hemet, CA 92343, a.,y�;'
-
••. 227 North "D" Street 46209 Oasis St. Rm. 310 ' N. Broadway
•Perris. CA 92310 Indio, CA 12201 Blythe, CA 92225. f
'r..� Ph: 787-6146 - Ph: 849.1312 Ph: 6564464
Ph: 657-3898 Ph: 342-&71 - Ph: 922-2670 -
This -permit becomes void if.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: I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed if the
5with Section 7000) of Division 3 o the Business and, Professions Cade, and my license is in lull force and effect.'_., .
•'
permit is lot one hundred ($100) or less. I certify that in :he 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
T _
`
Date 'Applicants "
Date - Contractor
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NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers'
Code, this be,
OWNER -BUILDER DECLARATION: I hereby affirm that I am exempt from the Contractor's License Law for the following '
Compensation provisions of the Labor you must 7rthwith comply with such provisions or permit shall
deemed revoked. - t
reason (Sec. 9031.5. Business. and Professions Code: Any city or county which requires a permit to construct, alter,
a'improie, 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 Contractor's License Law (Chapter 9 (commencing
for
I hereby certify that no excavation five (5) or more fret in depth into which 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
the alleged exemption., Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil
'
made in connection with work authorized by this pernit. and that no building structure, scaffolding, fafsework, 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.) '
9 penalty of,not more than five hundred:dollars (5500).): -'
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A; > I, as owner of the property, or my, employees with wages as their sole compensation, will do the work, and the
sructure. isnot intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License Law
As owner -builder, I will not employ anyone to do wck which would require a permit from the Division of Industrial
Pa ety as noted above. unless such person has a perrtit to do such work from that division.
'does not apply to an owner of property who builds or improves thereon, and who does such work himself or through
• 0 Division of Industrial Salety PermitNo. ,
own employees, provided that such improvements are not intended or offered for sale. If, however, the building or
did
Date Appliwn•
,.improvement is sold within one year of completion. the owner -builder will have the burden of proving that he 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 o1
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the work for which this permit is issued (Sec. 3097, Cib. C.).
❑ I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044,
'Lender's Name
Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or
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improves thereon, and who contracts for such projects with a contractor(s) licensed pursuant to the Contractors
Lender's Address
tLicense Law.). 1
I certify that I have read this application and state that the above information is correct.. I agree to comply with all
I ,am exempt under Sec. ? . B. 8 P.C. (Attach Certificate),
city and county ordinances and state laws relating to building construction, and hereby authorize representatives of
- - - -
lhate" ' f Owner --
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this county to enter upon the above-mentioned property for inspection purposes.
tWORKERS'�COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to self -insure, ora
nature of Applicant
9 PP cant ar Agent 'gate .
„certificate of Workers' Compensation Insurance, or a certified copy thereof (Sec. 3800, Lab. C.).
y
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify I have read this application and state that the }
a Company
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rJPoficy- No.
information given is correct. I agree to comply with all slate laws and county ordinances relating to building con- y
Y.
-
0 Certllfed coi5 hereby furnished
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struction, and authorize aeepresentative of the County of Riverside, Department of Building and Safety to enter upon r
the property for which rAave applied for this permit for the purpose of making inspections. ;
' Certified copy Is filed with•the County Building Inspection Department or County Department.
Si ature of Applicant or Agent Pate,
ate Applicant,
- �• Print Applicant)Ageenntt Name
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INSPECTORS COPY: ��_
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FORM 284.208 (2/81) ,f •
, 3
NO.
OPERATION
DATE
INSPECTOR
NO.
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
1
Set Back
33 Ventilation System
2
Figs & Frms
34 Plenums 8 Ducts
2A
Slab Grade
35
Furnace Compart.
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. 0.
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ADDITIONAL INFORMATION
SEWAGE SYSTEM SIZE 8t LOCATION
ll Exterior Lath
12 Internal Loth ,
12A Drywall
-13 - ' Finish Grade
INSULATION Thick R
Value
7A Walls (Batts)
12B Ceiling (Batts)
12C Ceiling (Blown)
14 1 Final
_I ----------.- --PLUMBING APPROVALS ----------------------------------------------------------------
15 Ground Plumb
16 Water Piping
17 Rough Plumb
18 Vents
ge
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
D -
Plato
RESS/SPACE, ,
lg/ZIP, o:o
TWN
S
ti 0 om
SB
rinal-i CLU a -.1,16"t 05
MI) WARP
CONTRACTOR -FIRM NAME
ADDRESS
CITN'!COMMU NITY/STATE/ZIP
PHONE #
YCNC #
ARC?ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE # -
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OWN6601, - 141-11611"Vaihi. d 001836'
ARP . LICATiON FbkliEj:W8PeCYj0N
. TOTAL,
FEE F
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. 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.
°o.
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 1 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