00002985 (ELEC)County of Riverside
Department of Building and Safety
4080 Lemon St. 2nd Floor 135 N. Alessandro Rd. Rm. 203 880 N. State Street 227 North `D" 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: 657.3898 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 7100) of Division 3 of the Business and Professions Code, and my license is in full force and effect.
I License Class
I Date
Contractor
Lic. Number
OWNER -BUILDER DECLARATION: I hereby affirm that 1 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,
improve, 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
penalty of not more than live hundred dollars (5500).):
❑ 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. 71044. 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. If, 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.).
VI, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec 7044
ness and Professions Code: The Contractor's License Law does not apply to an owner of property who bulids or
improves thereon, and who contracts for such projects with a contractor(s) licensed pursuant to the Contractors
License Law.).
❑ I am exempt under Sec. . B. & P.C. (Attach Certificate)
Date Owner
WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to self -insure, or a
certificate of Workers' Compensation Insurance, or a certified copy thereof (Sec. 3800. Lab. C.).
Policy No. Company
❑ Certified copy is hereby lurnished.
❑ Certified copy is filed with'the County Building Inspection Department or County
Date Applicant
Department.
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CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be completed if the
permit is for one hundred (S1D0) or less. I certify that in the performance of the work for which this permit is issuEU. I
shall not employ any person in any manner so as to become subject to the Workers' Compensation Laws of Califofnia.
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:
E] 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, falsework, or
demolition or dismantling thereof, will be more than thirty-six (36) feet high. (Chap 3.2. Grp 2, Art 2, Sec 341, Title B,
C.A.C.)
RRS' As 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.
M 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. C.).
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 Applicant/Agent Name
APPL/PRMT 4 PS DATE 001438_ 0 1 ^ 3^
0000298 AE 09/21/81 14 �{J yV{
APPLASUAW 1MVOR ELECTS AAL-. 'ERMIT
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F00143
APPLICATION FOR ELECTRICAL PERMIT
T H I S I S A N A P P L I C A 'T x 0 N 8 N L Y