25743 (GRD)PERMIT APPLICATION
County of Riverside
Department of Building and Safety
4060 Lemon SI 2nd Floor 135 N Alessandro Rd Ron 203 890 N stale Street
227 Norm 'D ' Street 46.209 Oasis Sl Ron 310 160 N Broadway
Riverside, CA 92501 Banning, CA 927F0 Hemet CA 92343
Perris CA 92370 Indio, CA 92201 Blythe, CA 92225
Ph: 787.6146 Ph: 849-7312 Ph. 65e-4464
Ph. 657.3898 Ph: 342.8271 Ph: 922.2670
This permit becomes void It work not commenced within 180 days from dale of issuance OR if work has beer suspended or abandoned for a pertoo at 180 days
CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE: This section need not be com-
pleted if the permit is for one hundred ($100) or less I certify that in the perlormance of the work for which this
LICENSED CONTRACTORS DECLARATION: hereby affirm that I am licensed under provisions of Chapter 9 (commenc•
permit is issued, I shall not employ any person in any manner so as to become subject to the Workers' Compensa-
Ing with Section 7000) of Division 3 of the Business and Professions Code, and my license is in lull force and effect
tion Laws of California.
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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-
struct, alter. Improve, demolish, or repair any structure, prior to its Issuance, also requires the applicant for such
permit to file a sli)ned statement that he is licensed pursuant to the provisions of the Contractor's License Law
(Chapter 9 (cummencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is ex-
empt therefrom and the basis for the alleged exemption. Any violation of Section 7031,5 by any applicant for a per-
mit subjects the applicant to a civil penalty of not more than five hundrrd dollars ($500) ):
❑ I, as owner of the properly, or my employees with wages as their sole compensation, will do the work, and the
structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Contractor's License
Law does not appty 0 an owner 0 property who builds or Improv5s thereon, and who dues such work himsell or
through his own empllryess. praalded that such ImpTwomVis. are hol mWficad or ollefod for sale. If, however,
the building or ImprovembW is sold within one year of comnlellon, the owner.bpilder. will have the burden of prov-
ing that he did not build or Improve for the purpose of sale,)
01, as owner of the properly, am excluslvelyy contracting with licensed contractors to construct the project (Sec.
7044, Business and Professions Code: The Contractor's License Law does not apply to an owner of properly who
builds or improves thereon, and who contracts for such projects with a contractor(s) licensed pursuant to the Con -
(factor's License Law )
❑I am exempt under Sec. — 8 & P.C. (Attach Certificate).
Date Owner _
WORKERS' COMPENSATION DECLARATION: I hereby affirm that 1 have a certificate of consent to self -insure, or a
certificate of Workers' Compensation Insurance, or a certified copy Ihereol (Sec 3800. Lab C.).
❑Certified copy is hereby furnished.
❑Certilied copy is tiled with the County Building Inspection Department or County Department
APPLICANT NAME (L, F, MI)
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CONTRACTOR -FIRM NAME LICNC #
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FINAL DATE
ARCIENG FIRM NAME
L1CtJE e
ADDRESS
CITYICO M M U N ITYISTATEIZI P
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EX AM NE RPpJWVlE DATE`
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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:
01 hereby certify that no excavation five (5) or more feel 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 Ihersoi, will be more than thirty-six (36) feet high. (Chap. 3 2, Grp 2, Art 2, Sec 341,
Title 8, C.A.C.),
❑As owner -builder, I will not employ anyone Io do work which would require a permit from the Division of In-
dustrial Safely, as noted above. unless such person has a permit to do such work from the division
[]Division of Industrial Safely Permit No
CONSTRUCTION LENDING AGENCY: I hereby allirm that there is a construction lending agency for the perfor-
mance of the work for which this permit is issued fSec. 3097, Civ. C.).
Lender's Name
Lender's Address
CERTIFICATE OF COMPLIANCE AND AUTHORIZATION OF ENTRY: I certify I have read Ihis application and stale
that the information given is correct. I agree to comply with all state laws and county ordinances relating to
building construction, and authorize a representative of the County of Riverside, Department of Building and Safety
10 enter upon fire properly for whic
h I have applied for Ihls permit for the purposa of making inspecllons.
Slgnaluye of Applicant or Agent D3;C
Print Applicant/Agent Name
APPLIPRMT H PS
DATE 5743
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TOTAL .
FEE
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COUNTER L.U.T.
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Gradinq P1arr Reuiow [ two (b4ased ort ctit) i.c VdCu't and P=i.I1i? Ii ;
FORM 284-208(11-e1) INSPECTOR
NO.
OPERATION DATE INSPECTOR
NO.
OPERATION DATE
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
Garage Fire Wall
42 Commercial Hood
10
Fireplace P.L.
43 Final
T.O.
No
ADDITIONAL INFORMATION
10A
Fireplace
11
Exterior Loth
12
Internal Lath
12A
13
!Finish
Thick RValue
a
7A
12B
Ceiling (Batts)
12C
Ceiling (Blown)
14
Final
PLUMBING APPROVALS
15
_
Ground Plumb
16
Water Piping
17
Rough Plumb
18
Vents
19
Sewage Disposal
r
r Heater
T23Water
r Softener
Service
24
Gas Test
SEWAGE SYSTEM SIZE & LOCATION
25
Final
Ton.k 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
PIL
STREET NAME
INSPECTOR
P/L