34944 (GRD)❑ - CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE, This seclinn nead not he rnm.
LICENSED CONTRACTORS DECLARATION: I hereby affirm that 1 am licensed under provisions of Chapter9 (comment-
r I
pleted if the permit is for one hundred ($100) or less. I certify that in the performance of the work for which this
rtiNnm GRrrL16R nun
permit is issued. I shall not employ any person in any manner so as to become subject to the Workers' Compensa-
t.
-❑ -
tion Laws of California.
DaleApplicant
CounlYY161` Riverside
Department otjBuitding and Safety
NOTICE TO APPLICANT: If. after making this Certificate of Exemplion, you should become subject to the Workers'
Compensation provisions of, the Labor Code. you must forthwith comply with such provisions or this permit shall be.
4080 Lemon St. 2nd Floor
135 N. Alessandro Rd. Rm. 203
880 N. Slate Street ; ;$�f{ 227 North "D" Street
_l
46209 Oasis 51. Rm. 310 160 N. Broadway
Riversitle. CA 92501
Banning, CA 92220
Hemet. CA 92343 Perris. CA 92370
Indio. CA 92201 Blythe. CA 92225
Ph: 787.6146
Ph: 849.7312
Ph: 658.4464 Ph: 657.3898
Ph: 342.8271 Ph: 922.2670
This permit becomes void if
work not commenced within 180 days from dale of issuance. OR, it work has beer suspended or abandoned Ior a period of 180 days.
the building or improvement is sold within one year of completion, the owner -builder will have the burden of prov-
in that he did n t b dt f
i
❑ - CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE, This seclinn nead not he rnm.
LICENSED CONTRACTORS DECLARATION: I hereby affirm that 1 am licensed under provisions of Chapter9 (comment-
r I
pleted if the permit is for one hundred ($100) or less. I certify that in the performance of the work for which this
Ing with Section 7000) of Division 3 0l the Business and Professions Code. and my license is in lull force and effect.
permit is issued. I shall not employ any person in any manner so as to become subject to the Workers' Compensa-
t.
-❑ -
tion Laws of California.
DaleApplicant
- OWNER -BUILDER DECLARATION: I hereby affirm that I 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 con-
NOTICE TO APPLICANT: If. after making this Certificate of Exemplion, 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.
struct. alter, improve, demolish, or repair any structure, prior to its issuance, also requires the applicant for such
deemed revoked.
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 ex-
DIVISION OF INDUSTRIAL SAFETY PERMIT CERTIFICATION: -
empl therefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any applicant for a per-
❑I hereby certify that excavation five (5) or more feet in depth into which person is required to descend, will
mit subjects the applicant to a civil penally of not more than -five hunderd dollars ($500).)_ . '
with
made to connection with work authorized by This permit. and that n
building structure. scaffolding. 2l. Art
❑ I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the
or
' or demolition or dismantling thereof. will be more than thirty-six (36) feet high. (Chap. 3.2. Grp 2. Art 2. Sec 341,
feet .Sec 41,
' Title 8. C.A.C. ).
structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License
❑As owner -builder. I will not employ anyone to do work which would require a permit from the Division of In -
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,
dustrial Safety. as noted above. unless such person has a permit to do such work from the division.'
'
the building or improvement is sold within one year of completion, the owner -builder will have the burden of prov-
in that he did n t b dt f
i
❑Division of Industrial Safety Permit No.
-
g o uomprove or the purpose of sale.)
❑I, as owner of the property, am exclusively contracting with licensed conlractors'to construct the project (Sec.
7044, Business 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 Con-
tractor's License Law.)
❑I am exempt under Sec. . 8.8 P.C. (Attach Certificate).
Date Owner
WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certificate of consent to sell -insure, or a
certificate of Workers' Compensation Insurance, or a certified copy thereof (Sec. 3800. Lab. C.).
❑Certified copy is hereby furnished.
❑Certified copy is filed with the County Building Inspection Department or County Deparimenl.
APPLICANT NAME (L, F, MI)
H ,HUGH WYNNE
ADDRESS'
p y,� +' GUM
1 34 N BLUE GUM STREET
CITYICOMMUN ITYISTATEIZI P
ANAHEIM CA 926800000
JOB SITE ADDRESSISPACE
'''79435 HWY 111
CITYII�COM�MgUtN�ITYISTAT/EI�ZIP p I,� g t' �y n
LA: QUINTA CA ?22530000
BOKPAG
`a1 3
412
PRC
025
C
6
TWN
1.0058007E119
PING
SE
S
0
TRACT LOT
000000
MICROFILM FEE
$5s75
MOD
011
SB
TRACT NAME
S 1/2
OWNER NAME (L,F,
DWWNLy� SAVINGS
HONE
CONTRACTOR-FIRM NAME
LICNC #
ADDRESS
CITYICOMMUNITYISTATEIZIP
PHONE#
BLDG. INSPECTOR
FINAL DATE
ARCIENG FIRM NAME
LICNC #
ADDRESS
CITYICOM M UNITYISTATEIZIP
PLAN NPLA
NJ E)KAMINER
AP; VE DATE
USE OF PERMIT
PLAN CHANGE
BL
o u
ON
�:P7[7
CKX
0
SSB
a 10
RSB
010
'
OFC
I Nl?
` 3EWEk�� kii 119. rl 1 Industrial Waste Poe -treat xnterrcpt {
,` y� ZONE ORAD If -
`�F''o'5248.
!4:'i. r0
GAS PIPING YETEM- 1 to 5 Outle,�ts{2 6 or More Outletf1'ss 0
FEE
$5.00
END
-
n SIDE
611 it6J
CONSTRUCTION LENDING AGENCY: I hereby affirm that there is a construction lending agency for the perfor-
mance of the work for which this permit is issued (Sec. 3097. Civ. C.).
Lender's Name
Lender's Address
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify I have read this application and stale
that the information given is correct. I agree to comply with all stale laws and county ordinances relating to
building construction, and authorize a representative of the County of Riversitle. Department of Building and Safety
to enter upon the property for which I have /appl,,e.for this permit for the purpose of making inspections.
'Sibnaturerd('A 1117
,Agent- " '+% � f Date
Print Applicant.IAAent Name. /•✓
APPLIPRMgT p PS� DATE
t;�
34944 4 /'� /1
-EWJl L(d1�,
PLUMBXNC FEE
$27,00
PRIMARY 976288 $62.88
FEE
MECHANICAL. EE
$31 4 00
PLAN CHANGE -4 MRS.
$60.00
$35762.88
MECHANICAL. F'F-E COMPUTATIONS * Permit Fee (if applicable)
F EEE
$3-00
MICROFILM FEE
$5s75
$4.01)
CCD�'il�F?E Citi '�=0-3 lS� r X93 >3�1 { AO >1� 3Q s U0 ?30-5000 >50 { 4()
FEE;
$12.00
A, 't EATING SYSTEM -v-1-100 001 BTU193 100 001 or hi r e .BTU:00
F.;.L�: I'RICAL.
FEE:
$12.00
��, FFA' COMPUTATIONS % Permit Fee (if applicable)
FEE 1.
$3.00
s: No o+ Unil s{ 2 Service Volts: 0
FEEL
$5.100
Service Amps -1i tOO Service Amps -2s 100 Service Amps -3{ ..0
` OLUMBING
FEE,,
$10.00
P'C-X COMPUTAT113NS Permit Fee (if applicabl)
FEE,..
TOTAL
ES
"K F'IXTUFiCS-Dar Sinks 0 Dri:nkinc F , F*ntn s 0 Ir trains 0
'}s 1 1 • . aj
CA
CKX
NC
COUNTER B.I
COUNTER L.U.T.
'
349
3-T rR U C 1' U Ft A L ( BUILDING ) P E R M i T
•TOTAL, PERMIT C09T 13 $141.75
CONSTRUCTION ESTIMATE (NOTE t Not to be used as propelf- s v YaJ.Qi9;{'l ion )
Des gripti,on FCC Group Type Sq Ft Rate
Valuation
PRIMARY 976288 $62.88
$38976288
Clonsiruc,tion Fee .based on Total Actual. Valuation of $33976288
3.ss
$35762.88
MECHANICAL. F'F-E COMPUTATIONS * Permit Fee (if applicable)
F EEE
$3-00
VENTS Fans i 02 Evaap Cooler i 0o Moods 0U Misc: s 00
6-�:E i
$4.01)
CCD�'il�F?E Citi '�=0-3 lS� r X93 >3�1 { AO >1� 3Q s U0 ?30-5000 >50 { 4()
FEE;
$12.00
A, 't EATING SYSTEM -v-1-100 001 BTU193 100 001 or hi r e .BTU:00
F.;.L�: I'RICAL.
FEE:
$12.00
��, FFA' COMPUTATIONS % Permit Fee (if applicable)
FEE 1.
$3.00
s: No o+ Unil s{ 2 Service Volts: 0
FEEL
$5.100
Service Amps -1i tOO Service Amps -2s 100 Service Amps -3{ ..0
` OLUMBING
FEE,,
$10.00
P'C-X COMPUTAT113NS Permit Fee (if applicabl)
FEE,..
$4,00
"K F'IXTUFiCS-Dar Sinks 0 Dri:nkinc F , F*ntn s 0 Ir trains 0
: tt�hen Sinks 0 Launfir Tray i •0 Irina:l s 0 Wtr• Closets 2
Lavptory 2 Shsowe-?r�: Tubs
F U 0 Dide i s 0 Others 0
FF -Et
$10,00
` 3EWEk�� kii 119. rl 1 Industrial Waste Poe -treat xnterrcpt {
FEE.-
!4:'i. r0
GAS PIPING YETEM- 1 to 5 Outle,�ts{2 6 or More Outletf1'ss 0
FEE
$5.00
REPAIR/ALTERATION- DrainageVent. Water Pipinel/T'reat#ient { 1
F'EEi
$2,50
.' SMI FEE
$89762-88
"141CROF 1M FEE.
'PLAN CHkNGG(.,-A MRS,
$$ , Off
M.
FORM 284.208 (11.81) INSPECTOR
NO.
OPERATION DATE
INSPECTOR
NO.
OPERATION =
DATE
INSPECTOR
BUILDING APPROVALS
MECt4ANICAL APPROVALS
1
Set Back
33
Ventilation System
2
Figs 8 Frms
34
Plenums i3 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. 0.
OP'N
NO.
ADDITIONAL INFORMATION
`
_
SEWAGE SYSTEM SIZE & LOCATION
11 Exterior Loth
12 Internal Lath
12A Drywall
13 Finish Grade
INSULATION
Thick R
Value
7A Walls (Batts)
128 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
REAR OF PROPERTY LINE
ELECTRICAL APPROVALS
26 Power Pole
27 Conduit
28 Service -Entrance
29 Wiring
29A Grounding Wire
29B Bonding
30 Fixtures
31 Service
32 Final
STREET NAME