00004727 (BLCK)rcmmi I nrruI A I IUM - -
County of Riverside
Department of Building and Safety
4080 Lemon St. 2nd Floor 135 N. Alessandro Rd. Rm. 203 880 N. State Street'6 227 North "D" Street 46.209 Oasis St. Rm. 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: 849-7312 Ph: 658.4464 Ph: 657-3898 Ph: 342-8271 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 I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect.
`License Class Lic. Number
Date
Contractor
.OWNER -BUILDER DECLARATION: I hereby affirm that I am exempt from the Contractor's License Law for the following
:reason (Sec. 7031.5. Business and Professions Code: Any city or county which requires a permit to construct, alter,
Jmprove, demolish, or repair any structure, prior to its issuance, also requires the applicant for such permit to file a
signed statement that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt therefrom and the basis for
the alleged exemption. Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil
penally of not more than five hundred dollars (5500).):
.0 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 and Professions Code: The Contractor's License Law
does not apply to an owner of property who builds or improves thereon, and who does such work himself or through
his own employees, provided that such improvements are not intended or offered for sale. ll, however, the building or
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.).
P1, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec7044,
PI1,
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 contractors) licensed pursuant to the Contractor's
License Law.).
ZI am exempt under Sec. . B. 8 P.C. (Attach Certificate)
Dale _- Owner
WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certilicate of consent to self -insure. or a
certificate of Workers' Compensation Insurance. or a certified copy thereof (Sec. 3800, Lab. Q.
Policy No. Company
Certified copy is hereby furnished.
Certified copy is filed with'the County Building Inspection. Departme�Lnt. ,or County Department.
Date Applicant
APPLICANT NAME (L, F. MI)
ADD
54450 AVE {
CITY/COM MUN ITV/STATE/Z I P
LA QUINTA CA $202350000
JOB SITE ADDRESS/SPACE
RQ AVE VELASCO
CITY/COMMUNITY/STATE/ZIP -
LA QUINTA Cil 922350000
BOK
77
PAG PRC
262 Oft,
C
TWN
RNG
000
SE
S
TRACT
LOT
0 , 6
WALL
1MOD
i
SB
TRACT NAME
26
OWNER NAME (L, F. MI)
WORN VAN
CONTRACTOR -FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE N
LICNC .
WALL
ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE N
LICNC .
USE OF PERMIT
BL
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yy8
BSSB
tV 006
SE10RSB
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OFC
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ZONE ORD .
LOT SZ
END
SIDE
21OX3.5 RET WALL
FORM 284-208 (2/81)
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed if the
permit is for one hundred (S100) 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.
Date Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers'
Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this permit shall be
deemed revoked.
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION:
❑ I hereby certify that no excavation five (5) or more feet in depth into which a person is required to descend, will be
made in connection with work authorized by this permit, 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.)
VAs owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial
a ety, as noted above, unless such person has a permit to do such work from that division.
❑ Division of Industrial Safety Permit No.
Date Applicant
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. Q.
Lender's Name
Lender's Address
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 state laws relating to building construction, and hereby authorize representatives of
this county to enter upon the above-mentioned property for inspection purposes.
Signature of Applicant or Agent Date
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify I have read this application and state that the
information given is correct. I agree to comply with all state laws and county ordinances relating to building con.
struction, and authorize a representative of the County of Riverside. Department of Building and Safety to enter upon
the property for which, I have applied for this permit for the purpose of making inspections.
Signature of Applicant or Agent Date
Print ApplicantlAgent Name
APPUPRMT. -�
.. PS DATE ieT_22
7 / 008283
2111X3.5 RET
WALL
J
2100.5 RCT
WALL
'
TOTAL
FEE
INSPECTOR'S COPY
008.283
P c R M x 'r FOR 21OX3.5 RET WALL
TOTAL PERMIT COS! 1$ 0,14 oSQ
NO.
OPERATION
DATE
INSPECTOR
NO.
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
1
Set Back
33
Ventilation System
2
Ftgs & Frms
O /3 ®�
34
Plenums & Ducts
2A
Slab Grade
35
Furnace Comport.
3
Steel
1,o115161
36 1
Inlets & Outlets
4
Grout Blocks
37
Combustion Air
5
Bond Beams
3E
Compressor
6
Roof Deck
39
Appl. Clearance
7
Framing
40
Fire Damper
8
Vents
41
Smoke Detection Device
9
Garage Fire Wall
42
Commerc of Hood
10
Fireplace P.L.
43
Final
loA
Fireplace T. 0.
°O.
-----------------•-----
ADDITIONAL INFORMATION
"
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
12 Internal Loth
12A Drywall
.--13.. _.. Finish.Grade—
INSULATION Thick R
Value
7A Walls (Botts)
12B Ceiling (Botts)
12C Ceiling (Blown)
14 Final
PLUMBING - PPR VAL-S-------------
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
�r
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service I
32 Final
STREET NAME
APPLICANT NAME (L. F, MI) -
ADDRESS -
CITY/COMMUNITY/STATE/ZIP
LA + QUINTA
JOB SITE ADDRESS/SPACE . V ,+ Q�K-_
E. - 1. faco
CITY/COMMUNITY/STATE/ZIP
LA QUIR I A CA 922350004
BOK
7 7T
PAG PRC
Oil
C
TWN
RNG��aa
Al 0
SE S
Wo
TRACT I LOT
2'920ah .
001
MOD
i f
SB
TRACT NAME
6
OW"HR NA (L, F. MI)ORN
CONTRACTOR -FIRM NAME
ADDRESS
CIT1'!COMMUNITY/STATE/ZIP '
k
I PHONE N
LICNC N
ARC/ENG FIRM NAME
- ADDRESS
CITY/COMM UN I TY/STATE/ZI P
PHONE N
LICNC #
USE OF PERMIT
BL ZON
{l R`1
FSB - SSB SSB RSB
.60 0o 00-0 0.0
OFC
IN -.
ZONE ORD #
LOT SZ
I
I END
SIDE
APPUPRM7 p r YD uNl[ ' U U 8` V 2
f
• I
r
r
. f
z
• 7
210XI1.S ftE'T 'WALk'e..
TOTAL .
FEE
5 E T RS rnpv
_
.--.>_..--r-, � - - ---�.-..+a......v:- -----'�'_.._. �-,-....- _.—«r _'-.. ���.-....ter.-,....T «•+'�•.•�.:—
p/ 00828ZI.
t -
1 v
NO.
OPERATION
DATE
INSPECTOR
NO.
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
1
Set Back
33
Ventilation System
2
Ftgs & 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. 0.
°o
,
ADDITIONAL INFORMATION
-
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
12 Internal Loth
12A Drywall
13 Finish Grade
INSULATION Thick R
Value
7A Walls (Batts) '
12B Ceiling (Batts)
12C Ceiling (Blown)
14 Final
PPROJALS---
FLt1i1 Gh%Gr 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
PjL
P/
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final
STREET NAME