001195 (BLCK)County
of fliVerSide.
Department of
Building and Safety
1. A: :'
4080 Lemon St. 2nd Floor 135 N. Alessandro Rd. Rm. 203 880 N. Siate Street
227 North 'D" Street' 46.209 Oasis St. Rm. 310 160 N. Broadway
Riverside, CA 92501. Banning. CA 92220 Hemet, W92343
Perris, CA 92370 Indio. CA 92201 Blythe, CA 92225
Ph: 787-6146 Ph: 849-7312. Ph: 658-4464 ..•
Ph: 657.3898 Ph: 342.8271 Ph: 922.2670
This permit becomes void it work notcommencedwithin 180 days from date of issuance. OR. if work
has been suspended or abandoned (or a period of 180 days. '
LICENSED CONTRACTORS DECLARATION: 1' hereby.affirm that I am licensed under provisions of Chapterl) (commenting
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 inlfull force and effect.
permit is for one hundred (8100) 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 DECLAMATION: I hereby affirm that I am exempt from the Contractor's License Law for the following
Compensation provisions of the Labor Code, youmust 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, 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
❑ I hereby certify that no excavation five 15) 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 (s5D0)J:
C.A.C.)
0 I, 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 would require a permit from the Division of Industrial
Safety, as noted above, unless such person has a permit to do such work from that division.
structure -is not intended or offered for sale (Sec. 7044. Business and Professions Code:, The. Contractor's License Law
41
does not apply to an owner of property who builds or improves thereon, and who does such work himself or through
E] Division of Industrial Safety Permit No.
his own employees: provided.that such improvements are not intended or offered for sale. If, however, the building or
Date Applicant •-<r
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 theperformance of .'
^`xr" 't'
the work for which this permit is issued (Sec. 3097, Civ. C.).
I, as.owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044,
-
Lender's Name
tntl Professions _Code: The Contractor's License Law does not apply to an owner of property who builds or
usiness•a
improves-1hereon, and who contracts for such,projects with 'a contractor(s) licensed pursuant to the Contractors
Lender's Address '
License Ldw.).
exempt - .�-
Certificate),
I certify -that I have read this application and state that the above information is correct. I agree to comply with.all
city and county ordinances and slate laws relating to building construction, and hereby authorize representat ves of
I am under Sec. - 8 P.'C (Attach
. _:,u•• ;� r+er %^tom
Date =;� .. f <� .n.• Owner
- +_+,�,.4
this count to enleWupon the•abovvlyme 'To property for inspection purposes., -"3
"": .,w�•/ Cdr
v ;.� ,ZSr
WORKERS' COMPENSATION DECLARATION: I hereby afflrm'`I al I a ee�cerufi[ate of consent to sell -insure, or a„�'
paturejr-AOplicant or Agent Date
- i
certificate of Workers' Compensation Insura� efdr a certified copytn`e'reof (Sec. 38110, Lab. C.).�
.,,'CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify 1 have read this application and state that the i
6”
Policy No. f -company - '•"'"'•�
.•"" information given,fs,correct. I agree to comply with all state, laws and county ordinances relating to building con -
strucilon and authorize a representative -of;the County of, Miversi8e. Department of Budding and Safety to enter upon
Certified copy is hereby furnished.
therproperty for,whi K I have -a" plied r Phis permd�for;Ihe purpose of making inspections.
v„«. '..+-A+ ,�,;. ,�, ,- ,#...r�^'d, -,/ d'b7
Certified copy is filed with'the County Building Inspection Department or County Department.
Signature of'Applicair or'Agent - '” Date ,
-
,,Date- Applicant
-,f" Print Applicant/Agent Name
`r'APPLICANT NAME (L F MI)
.,-aK-.y-�vwy�� w.Yw ��,w•ri�,�`•�'BY1. <�r1(JM`r.';i�l••'L�i„'..7a� M0'M"
..:
�APPL/PRMT a'. - PS' DATE 1
!f<�!F"�`y�` a--_. .:•.ar�. - .
.0�O�f1 19 5
_ {r
�sU:•a,...'�.-�' F1 �..�
*�
,ARC/ENG FIRM NAME a
'
ADDRESS
'
C^ ry411411
>i
i
S'
QST./i'bNITY/STATE/ZIP
- •; -•<.. y wFk
I
{•
-
t' 130,3
: e
C C TW / RN S
`c
NJ
fRIX15f MOD SD
TRAC .N E
-
-
^`xr" 't'
OW E AME
C 09TOCM IRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP -
.L
PHONE a
LICNC a,
,
,ARC/ENG FIRM NAME a
'
ADDRESS
' CITY/COMMUNITY/STATE/ZIP
PHONE a .'
LICNC a
'USE OF PERMIT - •"'"a'�°""-
1
>
2 .FSB .SSB' '•SSB4 RSyB, OFC
. ZONE b R
LUT11 r -, .END
I
,.
i,R
.�.��..�INSPECTOR_S-COPY
' • 0. ,r <,■p�) eye yg(q {y�'r ■Y pwy.
•P 1 Tf. - S1 -l.. FOV000D .l FIVTd�4'�
r
r•
f �
i'
FORM.284: 208 12/81)
1
I
TOTAL .
FEE
001
>i
i
{•
1
I
TOTAL .
FEE
001
NO.
OPERATION
DATE
INSPECTOR
NO.
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
1
Set Back
:2�
33
Ventilation System
2
Figs & 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
)
C.'
40
Fire Damper
8
Vents •
41
Smoke Detection De,,ice
9
Garage Fire Wall
42
Commercial Hood
10
Fireplace P. L.
43
Final
10A
Fireplace T. 0.
NOADDITIONAL INFORMATION
... ...._-r-a..... _.._..._ _ ..-...�......_....�.-. .._.........�..4_..�...
----------' ---------- --- - ----- ,. -- --
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath 5
12 Internal Lath '
12A Drywall
"93 'Finisfi'Gedcle _...... _ . _-...,__ __... _ . _ _ . «. _�.._w
INSULATION Thick R
Value
7A Walls (Batts)
128 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
APPLICANT, NAME (L F MI)'
t
�1 :, [ 3i T tai .. �., �. y��..• 1. C:�. 1•r iN,: 1 ..ly. .-...
Mn.'
:AD
T'AftWlt NITY/STA -
-
JOB-SITE'ADDRESS/SPACE
'
GI O NITY/STATE/ZIP--
-
C C
- T
E:` S
,.RAC LO
MOD SB -
-
,L'�; .
TRACT NAME
M- AME-•(L,•F,'MI)
_
Tye ,
R -F RM NAME
q.C(3NTRACT
:ADDRESS
'
;C I TYYCOM M UN ITY/STATE/ZI P
PHONE p _
LICNC II
'ARC/ENG FIRM NAME
1XDDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE H '
LICNC #
USE OF PERMIT
'
rIn„
L
SB RSB
' ZONE'ORB.p.
C 3 :''ENDE',
'001194
l Y!�� .. ��• y Al P.LI AT Ria O.'M/WlrWool)-, S'r ENU.,�'.
w ,
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 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.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 (Botts)
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 Semite
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