00002161 (BLCK)County of Riverside
Department of Building and Safety
4080 Lemon SI. 2nd Floor 135 N. Alessandro Rd. Rm. 203 88¢ N. Slate Street
227 North "D" Street 46-209 Oasis St. Rm. 310 160 N.Broadway
Riverside, CA 92501 Banning, CA 92220 Hemet. CA 92343
Perris. CA 92310 Indio. CA 92201 Blythe. CA 92225
Ph: 787-6146 Ph: 849.7312 Ph: 658.4464
Ph: 651-3898 Ph: 342-8271 Ph: 922-2670
This permit becomes void it work not commenced within 180 days from date o1 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 1000) 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
shalt 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: It. 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 E] I hereby certify that no excavation five (5) of 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, lalsework, 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.lhan live 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 Q As owner -builder, I will not employ anyone to do work which would require a permit from the Division of Industrial
from
sl"ructure is not intended or offered for sale (Sec. 7044. Business and Professions Code: The Contractor's License Law Rarely as noted above. unless such person has a permit to do such work that division.
doe`s 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. If, 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 fending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.).
1, as 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
city and county ordinances and state laws relating to building construction, and hereby authorize representatives of
❑r I am exempt under Sec. !"s�0'f8 P . (Attach Certificate),
-✓ l /,J
this county to enter upon the above4entio ed -property for inspection purposes.
Date - Owner .ut
,rr�;,�,,,,.•w„'war ,�,,/
WORKERS' COMPENSATION DECLARATION: I hereby affirmthat l:h"ate ve certillcate of consent to sell -insure. or a�_Signa(ure•ro�Applicant or Agent Date
F
certificate of Workers' Compensation Insurance, or a certified crip'(%'thereof (Sec. 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-
Polic No. Company
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struction. and authorize a representative of the„County of Riverside. Department of Building and Safety to enter upon
E] Certified copy is hereby furnished.
property for which„Lh.hve, applied mihis permit for the purpose of making inspections. L, t
r
�the
Certified copy is filed with'the County Building Inspection Department or County Department. J Siliptur - o Applicant. or Agent Oate '
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Bate Applicant
w. Print Applicant/Agent Name
APPLICANT NAME (L, F. MI)
—
APPUPRMT NPS DATE
1001147
000 gn r5i
ADDRESS
51130 CALLF ORISPIA
CITY/COMMUNITY/STATE/ZIP
�+y
! CN922010000
JOB SITE ADDRESS/SPACE
52350 AVE HERRERA
CITY/COMMUNITY/STATE/ZIP
N A CA 92 530000
BOK PAG PRC
C
TWN
RNG SE
S
I
771 02A no%
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TRACTLOT
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SB
nnnnnn nnI
11
TRACT NAME
SCVLAQ 10 MY 64
OWNER NAME (L, F. MI)
CONTRACTOR -FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE N LICNC N
ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE N CICNC N
USE OF PERMIT
BL ZON FSB SSB SSB RSB OFC yy
�!
ZONE ORD N LOT SZ END SIDE
P K R ” I Y FOR WOOD FENCE
TOTAL PERMIT COOT 14 $10.00
[FORM 284.208 (2/8/)
TOTAL
FEE1n,n
001147
NO.
OPERATION
DATE
INSPECTOR
NO.
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
''MECHANICAL APPROVALS
1
Set Back
33
Ventilation System
2
Ftgs 8 Frms
Y y s
34
Plenums & Ducts
2A
Slab Grade
= .;t� • ._
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
Fireplace - T. 0.
°O
ADDITIONAL INFORMATION
-----
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Lath
12 Internal Lath
12A Drywall
.-13._—Finish-Grdtfe
INSULATION
Thick Value
7A Walls (Batts)
12B Ceiling (Botts)
12C Ceiling (Blown)
14 Final
-------------------PLUMBING APPROV'ALS----------------------------------------------------------
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
298 Bonding
30 Fixtures
31 Service
32 Final t
APPLICANT NAME (l, F, MI)
ADD ESS
if{
CITY/COMMUNITY/STATE/ZIP
:JOB SITE ADDRESS/SPACE
i g
CITY/COMM U N ITY/STATE/ZI P
CA 092%3dftfl0
,BOK
PAG _PRC
C
TWN
RNG
SE
S
WO D FENCE
TOTAL
FEE
TRACT
LOTMOD
1
SB
TRACT NAME
Fillif 84
OWNER NAME (L, F. MI)
k _ '
CONTRACTOR -FIRM NAME
ADDRESS
1
C I T Y!CO M M U N I TY/STA TE/Z I P
'
PHONE #
LICNC N
ARC/ENG FIRM NAME
013RESS
"CITY/COMMUNITY/STATE/ZIP
PHONE #
LICNC a
USE OF PERMIT
t
20N
FSB
SSB
RSSB
{{�►SSB
U
0
Y
yO�FFCa1
d lt47
ZONE ORD p
LOT SZ
END
SIDE
nona
i
APPL/PRMT #PS DA E p p 114 6
ra
au.
a .0
WO D FENCE
TOTAL
FEE
y
T w 1 9 1 S A N A P P L I C A T 1 0 N ® N L Y
FORM 284.208 (2/81)
001146
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
Froming
40
Fire Damper
8
Vents
41
Smoke Detection Device
9
Garage Fire Wall
42
Commercial Hood
10
Fireplace P. L.
❑
43
Final -
10A
Fireplace Y.O.
El /
°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 (Batts)
12C Ceiling (Blown)
14 Final
-• - -- -- PLUMBING APPROVAL---------------------------------
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
P/L
P/
26 Power Pole
'27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final
STREET NAME