9901-073 (PLBG)LICENSED CONTRACTOR DECLARATION
hereby affirm under penalty of perjury that I am licensed under provisions of
-Chapter 9 (commencing with Section 7000) of Division 3 of the Business and
Professionals Code, and my License is in full force and effect.
License # Lic. Class Exp. Date
74il j .=.4i
C; 14
N,29!00
Date f Signature of Contractor _
OWNER -BUILDER DECLARATION
I hereby affirm under penalty of perjury that I am exempt from the Contractor's
License Law for the following reason:
( ) I, as owner of the property, or my employees with wages as their sole
compensation, will do the work, and the structure is not intended or offered for
sale (Sec. 7044, Business & Professionals Code).
( ) 1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044; Business & Professionals
Code).
( ) I am exempt under Section , B&P.C. for this reason
Date Signature of Owner
WORKER'S COMPENSATION DECLARATION
hereby affirm under penalty of perjury one of the following declarations:
( ) I hav&and will maintain a certificate of consent.to self -insure for workers'
compensation; as provided for by Section 3700 of the Labor Code, for the
performance of the work for which.this permit is issued.
( ) I have and will maintain workers' compensation insurance, as required by
S4on 3700 of the Labor Code, for the performance of the work for which this
permit is issued. My workers' compensation insurance carver & policy no. are:
Carver Policy No.
WOI.;: E."N EAGLE IPP&
(This section need not be completed if the permit valuation is for $100.00 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, and agree that 'if I should become
subject to the workers' compensation provisions of Section 3700 of the Labor
Code, I shall forthwith.comply with those provisions.
Qate: : ' r% jApplicant
Warning: Failure to secure Workers"Compensation coverage is unlawful and
shall subject an employer to criminal penalties and civil fines up to $100,000, in
addition to the cost of compensation, damages as provided for in Section 3706
of the Labor Code, interest and attorney's fees.
IMPORTANT Application is hereby made to the Director of Building and Safety
for a permit subject to the conditions and restrictions set forth on his
application.
1. Each person upon whose behalf this application is made & each person at
whose request.and for whose benefit work is performed under or pursuant to
any permit issued as a result of this applicaton agrees to, & shall, indemnify
& hold harmless the City of La Quinta, its officers, agents and employees.
2. Any permit issued as a result of this application becomes null and void if
work is not commenced within 180 days from date of issuance of such.
permit, or cessation of work for 180 days will subject permit to cancellation.
I certify that I have read this application and state that the above. information is
correct. I agree to comply with all City, and State laws relating to the building
construction, and hereby authorize representatives of'this City to enter upon
the above-mentioned property for inspection purposes.
, Vnature (Owner/Agent) N�µ Date
BUILDING PERMIT PERMT#
DATE VALUATION, ortIEE4 E� LOT TRACT
JOYSITE ADDRESS 1.{ tD � :� i �,!�I t� C 4D �C 1:
APN 77440.2A 16
OWNER
CONTRACTOR / DESIGNER / ENGINEER
S'G/�T•�'� t t:1'yrtR c' e`I IO
c �,�.. r,• ,..,
.i3620AV-E1141DA :Ok1lz.Z
9403 .W.70NiW,iVlifU,CA,9�La7i
C'
LAQU(NTA CA 922.5
PAIA1E3'ESERI' (:'A %201.
f'7F!)'tl�fti—?7tiri C`Iif,#f �tl?
USE OF PERMIT
I'Li.iA1�1lN� i
SEPTIC AF3t\iVLtiOK NEWMI (LAO -14100 F'&OJ C_'1` 498-W)
u���1T� i;K��c ��r.��ti�ulaT i, •irr0.j�� i.$
,,��
if 4'' MA: A' 1"R� �'� A'R` F !'+ TFA R'7 i d' IN
/i:.,.��ai•id-sa nie �•�.+�i. �at t,�,��_y.R ae�1s.. �.ax�a�
1" F. ifdma ll7Elfi, s.1j t `Ji1kR
PLU PAIN+ FEE- -_ SF'1k' K1t 1UE-OW-4j?,—W)0 S3001
IR-'t'l: TAY.e;ONS` RIJ�"',TI;O N A�NtI P1 N t'14P(:ti
SU
LESS PRE.-PAj'D FET".
S0,00
TOTAL, PERMIT FV EN 04) F A't OW
tii,iF4.ti>D
RECEIPT
DATE
BY f
DATE FINALED
INSPECTOR
INSPECTION RECORD
OPERATION
DATE
INSPECTOR
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
Set Backs
Underground Ducts
Forms & Footings
Ducts
Slab Grade
Return Air
Steel
Combustion Air
Roof Deck
Exhaust Fans
O. K. to Wrap
F.A.U.
Framing
Compressor
Insulation
Vents
Fireplace P.L.
Grills
Fireplace T.O.
Fans & Controls
Party Wail Insulation
Condensate Lines
Party Wall Firewall
Exterior Lath
Drywall - int. Lath
Final
Final
POOLS -SPAS
BLOCKWALL APPROVALS
Steel
Set Backs
Electric Bond
Footings
Main Drain
Bond Beam
Approval to Cover
Equipment Location
Underground Electric
Underground PIbg. Test
Final
Gas.Piping,
PLUMBING APPROVALS
Gas Test ..
Electric Final
Waste Lines
Heater Final
Water Piping
Plumbing Final
Plumbing Top Out
Equipment Enclosure, '
Shower Pans
O.K. for Finish Plaster
Sewer Lateral
Pool Cover
Sewer Connection
Encapsulation
Gas Piping
Gas Test
Appliances
Final
COMMENTS:.
z
:.
Final:
Utility Notice (Gas)
ELECTRICAL APPROVALS
Temp. Power Pole
Underground Conduit
Rough Wiring
Low Voltage Wiring
Fixtures
Main Service
Sub Panels
Exterior Receptacles
G.F.I.
Smoke Detectors
Temp. Use of Power
Fina!
Utility Notice (Perm)
4SCONO SEWER SERVICES
P.O. BOX 192
PALM DESERT, CA 92261
/7Cnl 4AC_7704 17Cn\ '2qO '77Cn
J00 WORK ORDER
0910.6
FAX (760) 347.4978
DATF�FORDER
LEASE PAY FROM THIS INVOICE.
JL
CUSTOMER'S'ORDERNO.
PHONE
ME'20
C
HELPER
STARTING DATE
BILL TO
ORDER TAKEN' BY
ADDRESS
❑ DAY WORK
i
❑ CONTRACT
CITY
❑ EXTRA
JOB NAME AND LOCATION
JOB PHONE.
DESCRIPTION OF,WORK PAYMENT TERM5 NET lU UAT5 MUM UAIE Ur SEMUL
l�h% PER MONTH CHARGE AFTER 30 DAYS.
TOTAL MATERIALS
TOTAL.LABOR
LEASE PAY FROM THIS INVOICE.
NO MENT L BE MAILED. TAX
DA OMPL ED 'WORK ED BY
F TOTAL AMOUNT
$
e home dotal amount due [ITo& billing to
Signature,. for above work: or be mailed after
completion
I hereby acknowledgethe satisfactory completion of work
of the above described work.
RIVERStOE' COUNTY DEPARTMENT OF BUILDING AND SAFETY
CORIRECTION NOTICE
To: Permit No.
Address; 3 ��c ALLe L- Date: B
FRAME INSPECTION - U.B.C., 1976 EDITION
1. Approved plans,shall be on job for inspection. 1302(b)) .
2• Changes from approved plans.mustbe made on all plans:and approved in Plan,Check. [302(a)]'.
3. Add shots where indicated per Research Recommendation Card.
4. Maximum spacing of.studs 24" o.c. [2518(f)31 .
5. Horizontal stabilizing blocks to be placed in all stud walls over•6' in height to conform to
Ordinance 457.
6, Double top plate joints at least 4' apart.. [25181
7. Ceiling joist overspanned. [2518'(h)21,•.
8• 3-8d nails joist to plate. Nail top plates together- 1,6d 1.6" o.c. [25181 Table 25-P.
9. 3-8d nails rafters to plate. [2518] . Table -25-P.
10. Nail corner studs 1.6d. - 24" o.c. [25181 . Table 25-P.
11. Rafters overspanned at [2518 (h)21.
12. Purlin overspanned at [25,18 (h)51 .
13. Slope of struts not to, be less than a 45' angle from the horizontal. [2518(h,$1.
14.; Add backing at [4706(c)] .
15, Rafters do not fit.ridge - fix. [2518(h)3] .
16., Nail ceiling joist to rafters: Add cross ties, Max. 4' o.c. [2518 (h4)] .
17. Add brace at [2518 &.'Ord. 4571.
18. Shim and nail trimmers. [2501(b)I I.
19. Metal strap on studs and plate where pipes -are located. [2518(g)81.
20. Install windows as per approved plan. [14041.
21. Fasten post to concrete. Use "T" strap post to beam. [ 2310(e).] .
22. Attic access minimum 22" x 30 [3205(a)] .
23• All plywood exposed to weather to be exterior grade [3202] .
24. Replace short trimmers in (2518(g)71.
25• Foundation ventilation. [2517(c)61 .
26• Install sway braces in garage. [2312(aF]..
27. Provide flashing and counter=flashing at junction of roof and vertical surface. [3208) .
28• Secure -chimney straps at ceiling line to frame [3704(c)] .
29• Install solid sheathing and 15 Ib. felt between masonry and wood studs at planter. [2517(c)71.
30. Plumb all walls [2309(4)'] .
31. Install screened attic ventilation ratio 1 to 150. [3205(c)] .
32• Bath requires vent to outside air. [1405(a)]
33. _{ovide'adequate space for comfort heater.
'A"
CORRECT THE ABOVE CIRCLED ITEMS.AND CALL FOR. RE -INSPECTION.
284-231. REV. 3/77
RIVERSIDE COUNTY DEPARTMENT OF BUILDING AND SAFETY
CORRECTION NOTICE
To: Permit No.
Address,. �J 3 _ ��D 0 7 Date: /b r%%- �
�
LATH INSPECTION. — U.B.C., 1.976 EDITION
1. Backing wire shall be stretched taut. Maximum spacing 6 inches vertically attached every 32
inches horizontally.
2. Add furring nails, maximum spacing 6 inches apart vertically, 16 inches apart horizontally.
[4706).
3. Wire shall lap one full mesh at all joints [4705(c),],.
4. Building paper shall cover all wood. [1707(a)] [4706(d)] .
5. Wire on exterior corners.shall be pulled out minimum Y4 inch. (4706(9)1.
6. Recheck gyp. lath nailing. [Tables 47-b, 47cl .
7.. -Lap cornerite minimum one mesh. (4705(c)].
Self -furring stucco. wire to be attached at indicated places only. Use furring nails around all
T47RL
9. ve wall to be perforated type lath or an approved equal. [4302] .
10. Area around shower and tub with shower -to be approved inateri al s,C711 (aJ.
'11. Use metal lath over joints where, two or more are together. Use on voids 3/8' or more.
[4705(b)!.
DRY WALL INSPECTION
1. Maximum spacing single nails: Ceiling seven inches; walls eight inches: (Table ,47g] , [47o5(b)] .
2. 5/8" type X gyp. board used for 1 hr. firewall; nails to be 7" o,c. Joints taped and finished.
[Table43=b, Sec. 4711.1.
Inspector
CORRECT THE ABOVE CIRCLED ITEMS AND CALL FOR RE -INSPECTION
284-235 REV 3/77
WEIGH MASTERISCERTIFICATE OF WEIGHT AND) MEASURE
This is .to certify that the following described merchandise was w.elghed; measured or counted by a Private Weighmaster, and his signature.is a recognized authority of accuracy as
prescribed by Chapter 7,3 (commencing' with Section. 12740) of Divislom d.of'the CaliforniaBusiness and PrefessionwCod% Administered by the' Division of Measurement Standards of the
Department of Food and Agricultureot'the State of Californim
MASSEY SAND & ROCK CO.
CONTRACTOR'S LICENSE #271769 PHONE 347.8535
WINDIO PLANT ❑ PALM SPRINGS, PLANT ❑ EL CENTRO PLANT
38115 MONROE 21500IN:DIAN AVE N. 51 E. HWY.80
PHONE 347.3232 PHONE 325-5222 PHONE 352-3152
❑ 43850 MONROE ❑ OCOTILLO PIT
MSR Cust. No.
SOLD
MSR Job
.No. � GIL Item
Sub
- Date _ _ ,.
Weighmaster, No.
Iltfr,tII 12-06130
r ,
ORDERED BY PHONE li CUST. JOB #
JOB ADDRESS. l
1. C
Pte' ZnClass• Quantity Price • Unit Amount
Gude ce -
READYMIX"
Cement
Tare
114 C
sand
l I I
[ YD
Rock
CONCRETE
Rock
MASSEY SAND & ROCK CO.
•
o
• I
I I 1 •
(WEIGHT IN LBSJ
Gross
Cement
Tare
114 C
sand
l I I
N
i 0
Rock
Wale? at Plant [Job
Rock
MASSEY SAND & ROCK CO.
Private: Weighmaster
•
•
SPHALTIC
TN
•
•
TN
MINIMUM LOAD
•
ROCK �'[. TN
MINIMUM LOAD TN
[SAND
TN
MIMIMUM LOAD
TN
OL
Driver mpl #1 I I I
Truck # I 1 1 k Trailer q Load # II
r t
Lett. Plant Arrive Job StarLPour MIXER.DRUM REVOLUTIONS
Flnish.Pour Leave Job Arrive Plant Plant Job Discharge
UNLOADING TIME: A maximum of 5 minutes per yard of readymix or a'maximum of 15 minutes per loan of dry" material will be free:.
Additional unloading,time will be charged at current prevailing rates.
WARNING NOTICE: Use of readymlx concrete without protective clothing could cause bodily injury. Every .effort should be taken, to avoid
contact'.with the skin. Also, waieror,other Ingredients added to this concrete.mayreduceats:strength'and quality and shall be added ,only at
customer's request. Customer hereby agrees to. indemnify•MASSEY from°any claim arising from such additions.
RELEASE: I hereby agree riot to hold MASSEY or any of its employees' liable for damages inside cyrb or property :fine caused by any of their
equipment, as I have requested delivery on the property for the'material listed and hereby acknowledge receipt of same.
e
CUSTOMER RELEASE SIGNATURE CUSTQMER MATERIAL RECEIPT SIGNATURE
RIVERSWE COUNTY DE,QARTNWhkT.OF BUILDING AND SAFETY
CbRRECTION NOTICE
To: Permit No.
Address: 3' L7 �` o t2 Z Date: -
FRAME INSPECTION - U.B.C:, 1976 EDITION
1. Approved plans shall be on job for inspection. (302(b)) .
2. Changes from approved plans musrbe made on all plans and approved in Plan Check. [302(a)] .
°d. Add shots where indicated per ResearchRecommendation Card..
4. Maximum spacing of studs 24" o.c. [2518(f)31.
5. Horizontal'stabilizing blocks to be placed in all stud wails over 6' in height to conform to
Ordinance 457.
6. Double top plate joints,at least 4' apart. (2518) .
7. Ceiling joist overspanned. [2518,(h)21..
8. 3-8d nails j'oist`to plate. Nail top plates together- 16d 16"o.c. (25181 Table 25-P.
9. 3,8d nails rafters to! plate. 12518). Table 25-P.
10. Nail corner studs 16d - 24" o.c. [25181. Table 25-P.
11. Rafters overspanned at [2518 (h)21:.
12. Purlin overspanned.at 12518 (h)51.
13. Slope of struts: not -to be less than a 45• angle from the horizontal. 12518(h)51.
14. Add backing at [4706(c)].
15. Raftersdo not.fit ridge - fix. [2518(h)31.
16. Nail ceiling joist to rafters: Add cross ties; Max. 4'.o.c. [25113(h4)1.
17. Add brace at [2518 & Ord. 4571.
18. Shim and nail trimmers. [25011b)1 .
M., -Metel-strap-omstuds-end p6te.whera,pipesare..located_ .I2b18(a)81.. - -
20. Install windows as per approved plan. (14041.
21. Fasten post to concrete. Use "T" strap post to beam. ( 2310(e)1 .
22. Attic;access.minimum 22",x 30" [3205(a)] .
23. All plywood -exposed to weather to be exterior grade [3202) .
24. Replace short trimmers in [2518(9)71
25. Foundation ventilation. 12517(c)61.
26. Install sway braces in garage. ( 2312 W .
27. Provide flashing and counter -flashing at junction of roof and vertical surface. [32081.
28• Secure chimney straps, at ceiling line to frame [3704(c)) .
29. Install solid sheathing and 15 ib. felt between masonryand wood studs at planter. 12517(c)71.
30. Plumb all walls [7309(a)1 ,
31. Install screened attic ventilation ratio_1 to 150. [3205(c)1
32• Bath requires vent to outside air.1'1405(a)) .
284-231 REV. 3/77
RIVERSIDE COUNTY DEPARTMENT OF BUILDING AND SAFETY
C&RlE&IO'N'WOOiICE
To:CC Permit No.
Address: _LZ._ — CQuer-C 2 Date:,
GROUND PLUMBING — U.P.C., 1976 EDITION
1 • Approved plans shall be on job for inspection. [U B.C.3021.
el"TToilet facilities shall be on iobsite. (Calif. Health & Safety Code).
Postjob.card. [U.B.C. 3041 .
4. Replace defective fitting at [3091.
5• Support.soil pipe each joint ( 1, continuous ( ) [3161.
6• Closet bend to extend minimum floor level. (8051.
7. Off set.plumbing out of bearing footing: [3151..
8. Fill soil pipe with water for testing. (3181.
9. Stop'leakson line. (3181.
10• Unapproved fittings on line. [405 and 3101..
11. Minimum Y." per foot grade required on line. 14071:
12• Gas line not,permitted under slab. (121.3-b1.
13. Pipe shall not be installed in a strained position. [503] [1206).
14. All horizontal vents required to drain to fixture it serves. [5051.
1.5. Total, vent area to be equal to largest required building sewer. [5041 .
16. Cleanouts to grade. [4061.. .
FOOTING AND FORM INSPECTION—1.12.C., 1976 EDITION
DMArovedplans shall: be on ob for inspection.(3021 .
2. Provide.legal lot stakes. [301 and 3041.
3: Foundation footing to be 12 inches — 18 inches into undisturbed soil and 12 inches — 15
inches *dAJTable 29=A]W. Regrade and compaccfill, minimum thickness of concrete floor, 3% inches. [2623) .
5• Fireplace footing to be 12 inches larger'each dimension than fireplace. [37071b11.
6• Interior. bearing footings to be 12 inches into undisturbed soil; width, minimum 12 inches..
[2907 (b)]
7• Pier footings minimum 1.6 Inches square. [Chapt. 29).
8• Forms shall.conform to plan; tied and braced. [2606(a)).
9, Minimum foundation height'S inches above finish grade. 12907(a)).
10. Rebar shall be tied in place. 12607(d),].
11 -Provide footing for veneer. Brick ( 1, Rock ( ) [2006(b)] .
12 -Water piping on branch to too small. [.1009 U:P.C.1..
13.Gas piping not permitted underslab. (1213- U.P.C.1.
14•Mastic required on all metallic pipes where they come through slab or footings. (315 U.P.C.] .
1�`kForm shall be in, place for tub trap recess. It shall be poured monolithic. [803 U.P. Z.1.
Post job card [U.B.C: 304(b)1:
1-7- Job not readv for —insm-ection.
Inspector
CORRECTTHE. ABOVE CIRCLED ITEMS AND CALL FOR RE -INSPECTION
284-233 REV 3/77
x.. NOTICE: THIS IS NOT A BUILDING PERMIT
APPLICATION TO CONSTRUCT
DEPARTMENT OF, BUILDING -AND SAFETY
COUNTY OF RIVERSIDE
DISTRICT
Permit No
284' 199 9%74 t C%U1RRY—FILE, PINK -O LICANT
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� C T/.'AJC �
Ownir►iaTisri` Archite iV,
Contracto
�,' £ '% ? •f v
AddrePddr.e�s- -
Addr�4-
�4,
- -
�s ff�/�'JiY` t!fki
iRsir/
City City City- -
'g6� t'// .7 � r r -
Phone Phone��
Phon e
W
1 (we) iFie undersigned, hereby certify and acknowledge that I' (we) have read the application and agree that if Curb and Gutter, and
Z
Paving„and/or Dedication of right of way is required by the County of Riverside, the Riverside County Department of Building and Safety '
3
shall not make a Final- Inspectlon:lTntil said requirements have been met. I ,am, also aware that no work- is to be: done within the County R/W -
., O
, without an encroachment permit. _ • • -- --
NOW, therefore, it is agreed that I (we) will not occupy said property and will not cause said prorty to be pl until I (we) ve
complied with ail laws of the County of Riverside and the State of California, governing said pr rty, f
/
DATE SIGNATURE OF OWNER AND/OR AGENT
Approval by Signature from the ,Following Departments Listed Below
Must Be Obtained. Prior to .the Issuing of a Construction Permit.
I SPACE 140.
� , , �_ , L7 � "• ..T:. USE OF,.STRUCTURE
y r
JOB ADDRESS
SINGLE. FAMILY [ DUPLEX
LEGAL DESCRIPTION OF PROPERTY
APARTMENTS AGRIC.
116
N
_ COMMERCIAL INDUSTRIAL []
'^
,;. �.p
Z
COMMUNITY --
��: � .. _ __ •� �– •, ALTERATIONS n
NO., OF ;SUBMITTED`PLANS USE. OF PERMIT
CASE NO.
s
p _Z
NO. OF PARKING SPACE_ S_REQUI.RED NO. OF BUILDIM•GS (STING
Z -o.
,yOWt
t /' _i e1 _
ZONE” �ETBACKSi FRONT J SIDE •�� REAR
J m
GRADING PERMIT REQUIRED? - YES ❑ NO ❑ LOT SIZE'
SETBACK ORDINANCE # -- OF FEET REQUIRED ON ;STq, EMTs f I
DATE SIGNATURE OF LAND USE OFFICIAL`S
DEDICATION 'REQUIRED: YES ❑ NO ❑ NO. OF'T
H
Z.a-
I, ..�' , ,:: l: t::' cTREET
CURB 'AND GUTTER REQUIRED: YES El NO' El
d:
CAN_ CURB AND GUTTER FEASIBLY BE INSTALLED? YES ❑ NO ❑
HAS AN .ACCEPTABLE APPLICATION JEEN DE F R ENCROACHMENT PERMIT FOR DRIYEVi AY AND STREET
C
G: f
IMPR1EMENT?` YES [3NO ❑ -
' ' /
00
"
DATE_ SIGNATURE OF ROAD DEPT. OFFICIAL—
SWIMMING POO 5IC
SEWAGE DISPAL'
Will
FOOD ESTABLISHMENT ,
WATER,POLLUTION - REMARKS
�n FLOOD CONTROL -
m W AIR POLLUTION
W DIV OF HWY
p — YOUR PROPERTY MAY BE SUBJECT TO
d
o I FLOOD. RIVERSIDE COUNTY ASSUMES
NO RESPONSIBILITY IN'EVENT OF FLOOD.
284' 199 9%74 t C%U1RRY—FILE, PINK -O LICANT
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1z
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3
O
• , APPLICATION FOR TREE PLANTING
I (we); the undersigned, hereby certify and acknowledge that I (we) have read the application and agree that if trees are required under River-
side County Ordinance No. 457, the applicant agrees to install said trees prior to final inspection. It is understood that no final insppection
will be given until said requirements have been met or exception has been granted by the County. Now, therefore, it is agreed that the prop-
erty owner shall cause the property lines to be surveyed in the event no survey stakes can be found. Further, it is agreed that the County of
Riverside shall assume no responsibility shout ees have to be removed due to lot line errors.
0 . N 37
ILI-
wner s ams
Mailing Add res 4'/!!40 Ci,y `s
Job Address
Legal Description
Assessor's Map, Book & Page _ -% l7< 621
Type of Soil Is water.ovailable Road Dept. Plot Plan No.
Type of existing trees in road right—o—way
Trees preferred by applicant (1) ^ (2)
Date J� Owner's Signature
Planning Commission Case No.
Type Structure
Zip
r
ROAD DEPARTMENT APPROVAL.
Approved species Ceratonia siliqua (Carob) Number of trees 1
4a. Spacing of trees Distance from lot lines: Front 2' in R/W Side
N c Additional requirements Per plot plan on reverse. No street trees will be planted
within 10' of driveways.
Date Building and Safety notified 10/79 Signature
REQUEST FOR EXCEPTION
Reason
O >-
X I—
UJ
0 LL
(attachadditional page if; necessary)
m.agRequest for hearing: YES ❑
Owner's Signature
(Forward application to Planning Dept. if exception requested)
NO REQUEST FOR HEARING
Cd F-
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Planning Dept.
Concur ❑
Date
Non -concur ❑ Explanation
Signature
Road Dept.
Concur ❑ Non -Concur ❑
Date Signature
REQUEST FOR HEARING AND COMMITTEE DECISION
Date hearing established Date hearing notice mailed to owner
Approved ❑ Disapproved ❑ Date Owner notified of decision
Date Building & Safety notified Signature
APPROVAL BY BUILDING INSPECTOR
Final Date Inspector Building Permit No
Job Address Community
Requirements for tree planting complied with
Remarks
(Detach and forward above information to Road Department Riverside)
284-230, REV. 1/74 �1
M
DIT 1 1979
I
I