00002155 (BLCK)County of: Riverside
Department of Building and Safety
4080 Lemon St. 2nd Floor 135 N. Alessandro Rd. Rm. 203 880 N. State Street t;r
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 w
Ph: 787-6146 Ph: 849.1312 Ph: 658-4464
Ph: 657-3898 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 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
Data Contractor
NOTICE TO APPLICANT: IL 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 file 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 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
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 thirty-six (36) feet high. (Chap 3.2. Grp 2. Art 2. Sec 341, Title 8.
penalty of not more than live hundred dollars (8500).):
C.A.C.)
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 work which would require a permit from the Division of Industrial
from
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saure 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 permit to do such work 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. It, 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 sate.).
CONSTRUCTION LENDING AGENCY: 1 hereby affirm that there is a construction lending agency for the performance of ,
the work for which this permit is issued (Sec. 3097, Civ. C.).
1, a5 owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044,
Lender's Name
usiness 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 contractor(s) licensed pursuant to the Contractor's
Lender's Address
License Law.).
I certify that I have read this application and state that the above information is correct. I agree to comply with all
O 1 am exempt under Sec. 8.8 P.C. (Attach Certificate),
city and county ordinances and state laws relating to building construction, and hereby authorize representatives of
Owner �Y
this county to enter upon the above-mentioded property for inspection purposes.
Dat
WDIf RS' COMPENSATION DECLARATION: 1 herb affirm that I have a c�bc a of consent to sell -insure, ora
Signature of Applicant or Agent Date
certificate of Workers' Compensation Insurance, or a certified copy thereof ISec. 3800. Lab. C.).
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-
Polis No. Com an
y D Y
struction, and authorize a representative of the County of Riverside, Department of Building and Safety to enter upon
Certified copy is hereby furnished.
.the property for which) have applied. to this permfl for the purpose of making inspections. .10
F-1Certifiedcopy is filed with'lhe County Building Inspection Department or County Department.
Signature of,Appficant or Agent ,f* Date
Date Applicant
-' Print Applicant/Agent Name
APPLICANT NAME (L. F, MI)
APPL/PRMT 4 PS DATE
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ADDRESS
115 0 CALLE ORT
CITY/COMMUNITY/STATE/ZIP
JOB SITE ADDRESS/SPACE
5 AVE DIAZ
CITY/COMMUNITY/STATE/ZIP pp pp��
LA UINTA CA l!' OO
BOK PAGPRC C TWN RNG SE S
e
loon an
TRACT LOT MOD A SB
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TRACT NAME
OWNER NAME (L, F. MI)
RUSISELL
'CONTRACTOR -FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE p
LICNC 4
Id
ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE a LICNC a e
USE OF PERMIT
BL ZON FSB SSB SS8 RSB OFC
i n 04 000ND
ZONE ORD 4 LOT SZ END "SIDE
f
P. E R H I T FOR Wong FENCE
TOTAL PERM'TT COST IS $10.00
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P
FORM 284-208 (2/81)
TOTAL
FEE '
00114 '1
Z ..
NO.
OPERATION
DATE
INSPECTOR
NO.
OPERATION -
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
1
Set Back
33
Ventilation System
2
Ftgs & Frms
34
Plenums & Ducts _
2A
Slob 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 s
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
11
Exterior Lath
12
Internal Lath
12A
Drywall
._.13
Finish"Giade -.. .�.
, _.. .. o .._ �_ _..,�_
_ ..... _..._ ... _ ....
..� .._ .. _ ... ..... _ . .
INSULATION
Thick R
Value
7A
Walls (Batts)
12B
Ceiling (Batts)
12C
Ceiling (Blown)
14
Final
------------
-----PLUMBING-:kPPROVALS
---------------------------------------------------------------
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
SEWAGE SYSTEM SIZE & LOCATION
25
Final
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
29B
Bonding
30
Fixtures
31
Service
'
32
Final
z
STREET NAME
f
5"