010902 (CSCS) Review ApplicationAPPLICANT NAME (I., F. Ml)
H MICH blyNNg
ADDRESS �
1234 * W ULUlt, CUM 01
CITY/COMMUNITY/STATE/ZIP
ANAME 114 CA 9.?600.0000
JOB SITE ADDRESS/SPACE
70435 HWY III
CIATYXOMMUNITY/STATEIZIPQUINTA CA 922.530000
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6VINER NAME (L. F. MI)
OWNEY SAVINCS
CONTRACTOR -FIRM NAME
CITN'!COMMUNITY/STATE/ZIP
HONE #
LICNC #
"ARC/ENG FIRM NAME
'ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE , �j
I LICNC #
USE OF PERMIT
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APPL/PRMT # DATE
010902
R OtROCTURAL PLA R REVIEW
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APP1.10ATION F01 STRUCTURAL PL REVIEto
Y60 moot srym the f o I I owillf) Vopartoleota (if
iiited) for. co'licurr-opto BE
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Count of Riversid
Department oY Building
and Safety
4080 Lemon St. 2nd Floor 135 N. Alessandro Rd. Am. 203 880 N. State Street
227 North "D" Street 46-209 Oasis St. Rm. 310 160 N. Broad a
Riverside. CA 92501 Banning, CA 9= Hemet. CA 9M
Ilit Perris, CA 92370 Indio. CA 92201 Blythe. CA
Ph: 787-6146 _�fh: 840,7312 Ph: 658-4464
Ph: 657-31198 Ph: 342-8271 Ph: 922-2670
This permit becomes void if work not commenced within 180 days from date of issuance, OR, it 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 70DO) of Division 3 of the Business and Professions Code, and my license is in full force and effect.
permit is for one hundred (SIDO) or less. I certify that in the performance of the work for which this permit is Issued. I
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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: If, 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 lot 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 buildin8 structure, scaffolding. falsework, 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. ( hap 3.2. Grp 2. Art 2, Sec 341, Title 8,
penalty of not more than five hundred dollars (S500).):
C.A.C.)
Ye r of thedproperly. or my employees with wages as their sale 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
He
S uc�,uas,own
re s not intende or offered for sale (Sec. 7044. Business and Professions Code: The Contractor's License Law
ety. as noted above. unless such person has a permit to do such work from that division.
does not apply to an owner of property who builds or improves thereon. and who does such work himself or �hrough
E) Division of industrial Safety Permit No.
his own employees, provided that such improvements are not intended or offered for sale. It. however, the bui ding or
Date Applicant
improvement is sold within one year of completion, the owner -builder will have the burden of proving that he did not
ARC/ENG FIRM NAME
build or improve for the purpose of sale.).
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. 3D97. Civ. Q.
P1. 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
CITY/COMMUNITY/STATE/ZIP
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
0 1 am exempt under Sec. B. & P.C. (Attach Certificate),
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.
Date Owner
WORKERS' COMPENSATION DECLARATION: I hereby affirm that I have a certilicale of consent to self -insure. or a
Signature of Applicant or Agent Date
certificate of Workers' Compensation Insurance, or a certified copy thereof (Sec. 31101), Lab. Q.
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify I have read this application and state that the
Policy No.
information given is correct. I agree to comply with all state laws and county ordinances relatin? to building con-
-Company
struction, and authorize a representative of the County of Riverside. Department of Building and Sa ety to enter upon
E] Certified copy is hereby furnished.
the property for which I have applied for this permit for the purpose of making inspections.
n Certified copy is filed with' the County Building Inspection Department or County - Department.
Signature of Applicant or Agent Date
Date Applicant
Print Applicant/Agent Name
APPLICANT NAME (L, F, MI)
4.DNWr_14
1234 N BLUE
CUM ST
CITY/COMMUNITY/STATEJZIP
ANAHEIM
CA
926800000
JOB SITE ADORESS/SPACE
78435
HWY lit
CITY/COMMUNITY/STATE/ZIP
LA QUINTA
CA
922530000
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OWNER NAME (L. F, MI)
DOWNEY
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ADDRESS
CITY,ICOMMUNITY/STATE/ZIP
PHONE#
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ARC/ENG FIRM NAME
ADDRESS
CITY/COMMUNITY/STATE/ZIP
PHONE #
LICNC #
USE OF PERMIT
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APPL/PRMT It XPS DATE
010902
APPLICATION FOR STRU P AN REVIEW
ASSESSOR COPY TOTAL
FEE I
APPLICATION FOR STRUCTORAL PLAN REVIEW
A
T H I S I S A N A P P L I C A T 1 0 N 0 N L Y
You most see the
a Permit can be
Description
HOLD-
HOLD -
�ORM'�k_,208 (2/81)
101090
following Departments (if listod) for concurrence BEFORE
issuedi
----------------------------------------- Dept 'to See
HEALT
ROAD
A fea -
62,
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cc 11"14).
NO.
OPERATION
DATE
INSPECTOR
NO.
OPERATION
DATE
INSPECTOR
BUILDING APPROVALS
MECHANICAL APPROVALS
1
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
Roof Deck
39
Appl. Clearance
7
Framing
40
Fire Damper
8
Vents
41
Smoke Detection Device
9
Goioge Fire Wall
42
Commercial Hood
10
Fireplace P. L.
43
Final
IOA
Fireplace T. 0.
°o ADDITIONAL INFORMATION
3.
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 APPROVALS- - - - - - - -
15 Ground Plumb
16 Water Piping
17 Rough Plumb"J
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
P/L
REAR OF PROPERTY LINE
ELECTRICAL APPROVALS
P/
26 Power Pole
27 Conduit
28 Service Entrance
29 Wiring
29A Grounding Wire
298 Bonding
30 Fixtures
31 Service
32 Final
STREET NAME