00002219 (BLCK).1. County of Riverside
Dnty epa�iment of Building and Safety
4080 Lemon St. 2nd Floor 135 N. Alessandro Rd. Am. 203 880 N. StaleS?treel%
227 North "D" Street 46-209 Oasis St. Am. 310 160 N. Broadway
Riverside. CA 92501 Banning, CA 92220. Hemet, CA 92343 `
.' Perris. CA 92370 Indio, CA 92201 Blythe, CA 92225
Ph: 787-6146 Ph: 849.1312 Ph: 658-4464. -
Ph: 657-3898 Ph: 342-8271 Ph: 922-2670
This permit becomes void it work not commenced within 180 days from date of issuance. it work has 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 lot one hundred (6100) 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: If, 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
reason (Sec. 7031.5. Business and Professions Code: Any city 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 provisions o1 the Contractors 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 Cade) 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 B.
penalty o6 not more than five hundred dollars (5500).):
C.A.C.)
Rlas Owner of the property, or my employees with wages as their sole compensation, will do the work, and the
[] As owner -builder, 1 will not employ anyone to do work which would require a permit from the Division of Industrial
re is not intended or offered for sale.(Sec. 7064, Business and Professions Cade: The Contractor's License Law
SatelyVas noted above• unless such person has a permit 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
❑ Division of Industrial Safety Permit No. -
his own employees. provided that such improvements are not•intended or offered for sale. ll, however, the building or
Date Applicant
improvement is sold within one year of completion, the owner -builder will have the burden ol, 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 at the properly, am exclusively contracting with licensed contractors to construct the project (Sec. 7044,
Lender's Name
siness and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or
improves thereon, and who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's
Lender's Address
License Law.).
'1.
I certify that I have read this application and state that. the above information is correct. I agree to comply with all
ldin truclion, hereby
I am exempt under Sea ! -�:§. B B-P.C.,(Altach Certificate).
city and county ordmances and state laws relat Og.Io.b and authorize representatives of
,!
aabove-men i
r$' /
Date ix • , F pe Owner
this county to enter uponOlhie probe nsDeclion purposes. .f i
*^`
WORKERS' COMPENSATION DECLARATION: I hereby affirm that I fiave,arcertiflcatef consent to self -insure• or a
s,, y.. is • ( .
01 �,•�'Y•Slgnatur o AppliIG>n gent gate.
AND
certificate of Workers' Compensation •Insurance. or a cerfllied copy thereof (Sec. 3800. Lab. Q. „+CERTIFICATE OF COMPLIANCE AUTHORIZATION OF ENTRY: I certify I have read this application and stale that the
information given is correct. I agree to comply with all slate. laws and county ordinances relating to building con -
Policy No. Company
struction, and authorize a representative of,the County,of Riveelside", Department of Building and Safety to enter upon
a
the properly{for_whlch l have applied for this perV1,!09the`.purpose of making inspecth ��' jA�; � ;�✓
Certified copy is hereby furnished.' _,,,., ,;; ;,>,«,�•_ y..j',4cr ,,.,.
Certified coPY,is filed with'the County Building Inspection Department or County Depart nt.
ture46YApphcantBPrAgent , Date".
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ARC/ENG FIRM NAME -�
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CITY/COMMUNITY%STATE/ZIP
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FORM 284.208 (2/81) - . • •, •+ st •..{• -n» ,.. • ;, x,w j A. b; t
•y
}
NO.'
OPERATION
DATE.
INSPECTOR
NO.
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
1
Set Back
33
Ventilation System
2
Ftqs & 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
�Z G
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 St LOCATION
11 Exterior Lath
12 Internal Lath
12A Drywall
_...1`3._ -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
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
`APPLICANT NAME.)L, F: MI)
bNITY/STCA"t
_'d*ld
SI S CE
/ 6 NITV/STATE/ZIP - ..
C C
R
L L.
x_
tls
iM"AefdftYM4 NAME-
'ADDRESS l�Y
iC1T1;tCOMMUNITY/STATE/ZIP '
,PHONE N
ARC/ENG FIRM NAME ,
.ADDRESS
C CITY/COMMUNITY/STATE/ZIP
. rl
'• 'PHONE 41
USE ;OF-PERMIT,
a.,
.. Lr
-t ZONETFfb It
NO.
OPERATIONDATE
INSPECTOR
NO.
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
1
Set Back
33
Ventilation System '
2
Ftgs 8 Frms
34
Plenums 8 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. 0.
NO
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
REAR OF PROPERTY LINE
ELECTRICAL. APPROVALS
PSI.
.
P/
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final
STREET NAME