001155 (BLCK).. -. ir[nmll RrrLI6911Ur1. .... .: . .. ... .... , .. _.. - _.... ,
T
County of
Riverside
Department of Building
and Safety
4080 Lemon St. 2nd Floor 135 N. Alessandro Rd. Rm. 203 880 N. Slate Street V-
227 North "O'Street 46209 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: 6564464
Ph: 657-3698 Ph: 342-8271 Ph: 922-2670
This permit becomes void it 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
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed it the
with Section 7000) o1 Division 3 of the Business and Professions Code, and my license is in full force and ellect.
permit is for one hundred (8100) or less. I certify that in the performance of the work for which this permit is issued. I
License Class Lic. Number
shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of California.
-
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 lile 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
ED I hereby certify that no excavation five (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 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
made in connection with work authorized by this permit, and that no building structure, scaffolding, lalsework, 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.
penalty of not more than five hundred dollars (SW).):
C.A.C.)
I7 I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the
Q As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial
Ra
s ructure is not intended or offered for sale (Sec. 7044. Business and Professions Code: The Contractor's License Law
as 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. IL however, the building or
Date Applicant
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 the performance of
I, as owner of the properly, am exclusively contracting with licensed contractors to construct the project (Sec7044,
PSiness and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or
the work for which this permit is issued (Sec. 3097, Civ. C.). - ,
Lender's Name
improves thereon, and who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's
Lender's Address
License Law.). �,
I certily that I have read this application and state that the above information is correct. I agree to comply with all
I am exempt under Sec. .w�''�-'�B. B•P.`C. (Attach Certificate).
city and county ordinances and state laws relating to building construction, and hereby, authorize representatives of
�,F. _ f�
/.! t
this county to above-mentioned property for inspection purposes.
� � ���-'
Date Owner
WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to sell -insure, or a
Signature of Applicant or Agent Datea; e�s�t,:.�•
certificate of Workers' Compensation Insurance, of a certified copy thereof (Sec. 3800. Lab. Q.
I CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify I have read this appligittion and state that the
Policy No. Compir-formation
any
given is correct. I agree to comply with all state laws and county ordinances relatingg to building con-
struction. and authorize a representative of the.County of Riverside. Department of Building and•Safety to enter upon
❑ Certified copy is hereby furnished.
the properly for which,I have applied for, this permit for the purpose of making inspections., - ,,.+- '
❑ Certified copy is filed with' the County Building Inspection Department or County Department.
..,,,Signature of Applicant or Agent Date . -
� �~ �
Date Applicant � -
Print Applicant/Agent Name
APPLICANT NAME (L. F. MI)
APPL/PRMT fl
PS
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ai
-ATE
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S
MOD I Se
NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE If LICNC H
ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE k LICNC 4
USE OF PERMIT
Z FSB ,SSB I SSB RSB OFC
ro
it
ZONE16R15 k I N I L END
I
w
,
V
.
FOr
.r
A .. ,TOTAL
FEE
IAICDGr Tr1RrC r nov
ELECTRICAL APPROVALS
26
Power Pole
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
ELECTRICAL APPROVALS
26
Power Pole
27
Conduit
28
Service Entrance
29
Wiring
29A
Grounding Wire
y 29B
Bonding
30
Fixtures
31
Service
32
Final
SEWAGE SYSTEM SIZE & LOCATION
REAR OF PROPERTY LINE
P/L P/L
STREET NAME
t
4F
P
NCE 1, T FOR WOOD Fi
TOTAL P'E'RMIT CM I S '$10,00ti
10011551.
NO.
OPERATION
DATE
INSPECTOR NO.
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
1
Set Back
33
Ventilation System
2
Figs & 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
IDA
11
12
12A
13
Fireplace T. 0.
Exterior loth
Internal Loth
Drywall
Finish Grade
°o
ADDITIONAL INFORMATION
INSULATIONI Thick I Value
7A Walls (Botts)
12B Ceiling (Botts)
12C Ceiling (Blown)
14 Final
APPLICANT NAME (L. F. M�I)
FNMELE
I NITY/ST LA
;YAR 'TA
.
thSIMMAHS 3ACE
CA 922530000
4M
r .
t;A
I NITY/STATE/ZIP
-VE A
ttmC C T S
MOD SB
A E (L, ,
A NAME
ADDRESS
CIT\ ;!COMM U N ITY/STATE/ZIP
PHONE .#
LICNC N
ARC/ENG FIRM NAME
'.ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE #
LICNC N
USE OF PERMIT
Zb FSB SSB SSB RSB OFC
ZONE W
L END 41INE
V w v "
• APPUPRMT k I PS I DATE 1001154 OO1^r4
TOTAL
FEE
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
SEWAGE SYSTEM SIZE & LOCATION
Tank Pit L. Line
REAR OF PROPERTY LINE
ELECTRICAL APPROVALS
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire P/L P/L
29B Bonding .
30 Fixtures
31 Service
32 Final
STREET NAME
NO.
OPERATION
DATE
INSPECTOR NO.
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
1
Set Bock
33
Ventilation System
2
Ftgs 8 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.
OW
ADDITIONAL INFORMATION
O.
11
Exterior Lath
12
Internal Lath
12A
Drywoll
13
Finish Grade
INSULATION
Thick R
Value
7A
Walls (Botts)
12B
Ceiling (Botts)
12C
Ceiling (Blown)
14
Final