354106 (SPIN)` NOTICE TO APPLICANT
In conformity with the provisions of State of California Labor Code Section'3800, the applicant shall have on file.or file with the Riverside County
Department of Building and Safety a certificate as designated in Items I or.11 below, or shall indicate Item III, IV, or V, whichever is applicable.
CERTIFICATE OF APPLICANT.
Please mark the appropriate block:
❑ I• Certificate of Consent to self -insure issued by the Director of Industrial Relations.
❑ Copy on file 1❑ Copy submitted
❑ ll. Certificate of Workers' Compensation Insurance issued by an admitted insurer.
I ❑ Copy on file Acicapy submitted
❑ III. The cost of the work to be performed is $100 or less.
' ❑ IV. 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. I further certify that, in the event I become subject to the Workers' Compensa-
tion provisions of the Labor Code that I will comply forthwith with the provisions of Labor Code Section 3700, et seq., and understand '
that, if I do not comply, the permit shall be deemed revoked.
❑ V. I certify as the owner (or they agent of the owner) that in the performance of the work for which this permit is issued
I have engaged
contractor. (Contractor must, have on file, or submit certificate required.by I or II above) "
/r Applicant's Signature
Date 'Permit
Address and location where work is to be performed
J
284-141 Rev 6/77
N
0010ING PERMIT
PERMIT No. DEPARTMENT OF BUILDING & SAFETY
354106 COUNTY OF RIVERSIDE
FIELD DST,
CONSTRUCTION ESTIMATE
NO. ELECTRICAL FEES
NO. PLUMBING FEES
IST FL.
2ND. FL.
6t POR.
f f
GAR.
,r CAR P.
/( f WALL
ESTIMATED CONSTRUCTION
SQ. FT. (R $
UNITS
!
SQ. FT.
YARD SPKLR SYSTEM
"@ . < . _ .,
SQ. FT. �-, ' ' ' MOBILEHOME SVC.` ' '
• -
' BAR SINK
SQ. FT. @ POWER OUTLET
ROOF DRAINS
SQ. FT. @
DRAINAGE PIPING
SQ. FT. @
DRINKING FOUNTAIN
SQ. FT. @
URINAL
VALUATION $
WATER PIPING
NOTE: Not to be used as property tax valuation
SWIM POOL, PVT
FLOOR DRAIN
MECHANICAL FEES
SWIM POOL, COMM
WATER SOFTENER
VENT SYSTEM FAN EVAP. COOL HOOD
SIGN
WASHER (AUTO)(DISH)
APPLIANCE �.+ • iDRYER.,,•. , .. K s w- -
- C.
GARBAGE DISPOSAL . !
FURNACE UNIT WALL FLOOR SUSPENDED L'
Unit
LAUNDRY TRAY
AIR HANDLING UNIT CFM `
IDLE METER
KITCHEN SINK
ABSORPTION SYSTEM B.T.U.
TEMP USE PERMIT SVC
t WATER CLOSET
COMPRESSOR HP
POLE,TEMP/PERM
: 'LAVATORY
HEATING SYSTEM FORCED GRAVIYY
AMPERES SERV ENT
SHOWER
BOILER B.T.U. r
SQ. FT. @ t
BATH TUB
`
SQ. FT. •@ • •U
+. WATER•HEATER
License#
SQ. FT. RESID @1 t/.
SEWAGE DISPOSAL
Address
SQ. FT. GAR @ 'G c
HOUSE SEWER
GAS PIPING
PERMIT FEEPERMIT
FEE
PERMIT FE
DBS"
TOTAL FEES
MOB. M..FEE
MICRO FEE MECH. FEE
PL. CK. FEE
CONST. FEE ' -ELECT FEE
SMI FEE
ff kVi FEE PLUMB. FEES
a
PERMIT NO.
�3 5 410 6
-
Job Address - Space Zip
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Owner
Community -'
�I� (:I'N'ir v'�%+f
Valuation
E •
Date
�
Dist.
Off.
F.C.C.
tAH.Permit Fee E
'Micro Film Fee Cop E
Use of Permit -
4.- /1t✓,,,�1I''J �il.� / <f �%� %~/
-
Parcel No. . -
"�„ "��
Use/Case No.
Ck. �Byyr/;'
Mech, Fee Dbl Er
PI. CkFee E
Set Socks -
Lot Size -
-
-
Construction Fee Dbl E
tio
Legal Descripn -
F S S - R
-
EleUricol Fee Dbl E
Zone Restrictions
Group
Type
SMI Fed E
Plumkiing Fee Dbl E
Bond Amt.
E -
Plan No.Plan
f,
Checker
Final Date�xA
Inspector
Unit
Sp Insp. Fee E
Demol. Fee E
Const. Lender Branch
..
Sup I Permit Numbers ,
. " • .• r. +t .tt
-
1
Registr. Fee E
Mileage Fee
g E
Address City. Zip
/ ✓" %
Witness Fee E
Reinsp. Fee
Owner/Agent r rr•
la
Tal. Zip
Total Fees t j /Q� '(,�
Addreis - '-� - -
% � ✓ _✓ %
City' - _--/
M.O. f C. Cash Chec
Received by
Contractor
+
Tel.
License#
Trees required 14,
Sewage System
Address
City Zip
T' f LL P THIS J'ERMIT SHALL BECOME VOID IF WORK IS NO`F COMMENCED WITHIN 120 DAYS. CESSATION OF WORK verified by:
Sewer,Diitricti FFOR 00 DAYS SHALME
E P;=jyyIT]0 BECOME VOID.
I HEREBY AGREE A W K IN (C�dI[VN�ECTION WITH THIS PERMIT WILL BE DONE IN ACCORDANCE WITH
THE L/1 S OF RIVERSIDE COU AND THE STATE OF CALIFORNIA.
N �. �.... 1♦ NYA a. sl.i.r•- ..y. ,... {r•.•"•. t. '>•
1'Ht EE1Y CERTIFY i'HArTF 0NbIVIDUAL WHO PREPAOED THE PLANS 'AFS HAS `tJ 50 I
ACCORDANCE WITH SECTION 5541 OF THE BUSINESS AND PROFESSIONS CODE OF THE STATE OF CALIFORNIA.
Form 284-208 (Rev.8/78) .`,
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 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
10A
Fireplace T.O.
P'
ADDITIONAL INFORMATION
'
i
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
12 Internal Lath
12A Drywall 2,
13 Finish Grade
INSULATION- Thick . Value
7A Walls (Botts)
12B Ceiling (Batts)
12C Ceiling (Blown)
14 Final 2 (
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
PSL P/
ELECTRICAL APPROVALS
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final
STREET NAME