2202 (BLCK),�rcmm�nrr�wn nue '
County. -of Riverside
Department of -Building and Safety
4080 Lemon St. 2nd Floor 135 N. Alessandro Rd. Rm. 203 880 N. Slate Street ` `Q
227 North "D" Street 46-209 Oasis St. Rm. 310 160 N. Broadway
Riverside. CA* 92501 Banning, CA 92220 Hemet. CA 92343 ' �»
'e: Perris, CA 92370 Indio. CA 92201 Blythe, CA 92225
Ph: 787-6146 Ph: 849.7312 Ph: 658.4464 41`'
Ph: 657-3898 Ph: 342-0271 Ph: 922.2670
This permit becomes void if work not commenced within 180 days Irom 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 if the.
with Section 7000) of Division 3 of the Business and Professions Code, and my license is in full force and effect.
permit is for one hundred ($100) 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: II, after making this Cerlificat= 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 fhrthwith 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 fife 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 live (5) or more fat 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, fafsework, 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 thirM-six (36) feet high. (Chap 3.2, Grp 2. Art 2. Sec 341, Title 8,
penalty of_'not more than five hundred dollars ($500).):
C.A.C.) -
�,, 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 worx which would require a permit from the Division of Industrial
s rlicture is not intended or.offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License Law
Safety, as noted above, unless such person has a perm to do such work from that division.
does not apply to an owner of properly who builds or improves thereon, and who does such work himself or through
El 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 tpere is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.).
PI, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec7044,
Lender's Name
siness and Professions Cade: 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 contractor(s) licensed pursuant to the Contractor's
Lender's Address
License Law.).
I certify that I have read this application and stale that the above information is correct. I agree to comply with all
I am exempt under Sec. - 8_11 P C. (Attach Certificate),
city and county ordinances and state laws relating to bu::ding construction, and hereby authorize representatives of
,,..,/ • ,,,,,..r �, •`
`- r'« „+^'•',�'
this counlyto enter upon the above-mentioned propeity mr inspection purposes.
Date . :�,• Owner :.,-"''"'.,o
„ee'x96^ra'", .w.s,:'Y'v.+•�Y• 6w%n: :L..�
WORKERS' COMPENSATION DECLARATION: I hereby affirm thilYthave-icerfiffcale of consent to sell -insure. ora
,a'.�+'
*, Slgnat0alof,Applicant of Agent Date .'
certificate of Workers' Compensation Insuran,q,pr.a certified copy I&riof (Sec. 3800. Lab. C.).
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF EN;.RY: I certify I have read this application and state that the
-Policy"No. Company
#,.information given is correct. I agree to comply with all =_tate laws and county ordinances relating to building con•
0 Certified copy is hereby furnished.
struclion, and authorize a representative of the County of Riverside. Department of Building and Safety to enter upon
the property.for,WhichGhave applied forrthis permit for tfle purpose of making inspections.
Certified copy is filed with* the County Building Inspection Department or County Department. - 40' ,„q»!'Signatwe�,of-Applicant or Agent Date .
- G,
Date Applicant
.? �_.r '• Print Applicant/Agent Name
4.
APPLICANT NAME (L, F. MI)
APPL/PRMT pPS
DATE
/tw7
001177,
A t' )
DR
V 1
C / ONIIISTM9 -.
MOD I SB
FZ1Q •
M NAME.
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE N `LICNC q
ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE n LICNC e
USE OF PERMIT,
�Z 10 s FSB SSB SSB RSB, OFC
ZONE R6 a L V END
y.
FORM 284-208 (2/81)
TOTALMM, T CG, ST 19 $10.00
JV
TOTAL
>,-FEE '
0011177 R
r•
•7
, 4
f '
•..
TOTALMM, T CG, ST 19 $10.00
JV
TOTAL
>,-FEE '
0011177 R
r•
•7
, 4
NO.
OPERATION-
DATE
INSPECTOR
NO.
OPERATION
DATE
INSPECTOR
BUILDING 'APPROVALS
MECHANICAL APPROVALS
yI
Set Back -
-
33
Ventilation, System
2
Ftgs 8 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
'RoofDeck
39
Appl. Clearance
• 7
Framing
40
Fire Damper
8
Vents
41
Smoke'Detection Deice
9
Gciroge Fire Wall
42
Commercial Hood
10
Fireplace P. L.
43
Final
40A
Fireplace T.0.
OP'
........�.
-----------------------------------------_-F----
ADDITIONAL INFORMATION
-
"
,.__ �+ _�....._.._.�..r. _..�.�...._. _.,,_ �..,____-y ._.... _._...,
SEWAGE SYSTEM SIZE & LOCATION•
11 Exterior Lath.
12 _ Internal Loth
12A Drywall
1.3.•,.., w'Fini'sh Grade ... .�..........,.._......._ _... .... .. .. ..... _ �_.. _.,_.,�....__._
INSULATION Thick R
Value
7A Walls (Batts)
12B 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
4
REAR OF PROPERTY LINE
ELECTRICAL APPROVALS
P/L
r
P/
-
26 Power Pole
27 Conduit
28 Service�Entrance
29 Wiring
29A Grounding Wire
298 Bonding '
30 Fixtures
31 Service
32 Final
APPLICANT NAME. (l F. MI)APPUPRMT
N
PS
DATE
,
��
.�- :�
.0 0'11..7.6
mim 2-2 Em n _
l4rul
C ' NITY/ST f -•
- -
010
SIT .A S S CE:
VILLA
NITY/STATE/ZIP
-
-
r -
C
C
- T
•S
fRA& L
MOD
S8.
C
,
`
• O T A ft,NAME .. ...
-
.
..
ADDRESS
-CITYYCOMMUNITY/STATE/ZIP
PHONE N
LICNC N
:ARC/ENG FIRM NAME'
ADDRESS
CITY/COMMUNITV/STATE/ZI P
-
/PHONE
N
LICNC N
-
USE OF PERMIT'
L- -
FSB,
-SSB
SSB .RSB
.,
OFC
'
•- ZON r6 N f i
L
- END
E
TOTAL •
f '.
FEE. ' •.
-
'
INSPECTOR'S COPY �► ,o-
,.,
,
. ; ✓.'00
17 6
�'y
FORM _280 -208 (2/81)__... _._ ... ,....
._,.
_.. .. .. .. ,.._.. .... �.I,._
..�.. ._ .. .. _. _ ._.. ,. _.
_t: �.....
,
NO.
OPERATION
DATE
INSPECTOR
NO.
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
1
Set Back
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.
E
43
Final
10A
Fireplace T.0.
[]
°o
----------------
ADDITIONAL INFORMATION'
-
_- _-
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
12 Internal Lath
12A Drywall
13 Finish Grade
INSULATION Thick R
Value
7A Walls (Batts)
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 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
32Final
STREET NAME