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����I i�i� DEPt�RTI�r�E�`�3T C3F CC):�r1NIUNIT�&DEVELO►Pl�'IENT SER�ICES
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�"'',�`!�'� Bt�ILDINC�PER�'1r1IT�PPLI�t�TIC}i�
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'' ���' � APPLl�ATIC3N DATE: ; ��°� ��� P/C#
� JOB S1TE ADDRE �-� .�� �.�� ��'�,r� ���.. ...� _
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z AP�1 L4T TRACT ISSUE DA�E: .��'� PERMIT# - " J A� �
,� OWNER T1fPE�ONST (?CC GROUP:
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� AD�RESS
,a CITY _._�__Z1P„�__� TEL.___. _._. _ ZONING FRONT�KS RW
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� �PPLICANT TEL. REAR []�_
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� �(�NTRACTC�R �'+�-.�...�_��4� �.��,��►�,�t . �.r�. SIDE� ❑
o� A D D R E SS ��S'� �� ��'. •` ..__.���� ---._.._. _._._.
• PROP�JJSED USE
� ciTv �►�� Z!P �-��- TEL.�y� ��� �'�/z-- _
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o ARCHIENG/QESiGNER �'--�"'
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o ADDRESS — #Q1NEL.UN1TS #ST4RlES #BEDROOMS
z CITY Z1P TEL.
`� DE�CRIPTION SQ.�T. FAGT4R PSF ADJ.AREANALUATIQN
m OUVNER-BUILQER DE�LARATl4N
� SFR/ADO/REM
'� 1 hereby a#firm under pena�ty of perjury that I am exempt from the Con#ractor's 5tate License Law for the reason{s)
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o indicat�d bei�aw by the checkmark(s),I have placed next to the appiicab{e item{s)[S�etian 7031.5,8usiness and Garage/Carpnrt
W Professions Code:Any city or caunty that requires a p�rmit to construct,atter,improve,demolish,or repair,any
zstructure,prior#o its issaance,also requires tt�e applicant for the permit ta fi{e a signed statement that he or she � PatiolDeck
� is licensed pursuanE to the provisions t�f the Contractor`s State License law(Ghapter 9j Commencing wit�Section W
� 700U of aivisian 3 of the Business and Pr€�fessions Code]ar that he or she is exempt from licensure and the basis for � PoallSpa
� the aAeged exemption.Any vit�lati4n of Section 7Q31.5 by any applicant for a permit subjects ttte�pplicant to a civil penatty z Re-Roof
� of nat mare than five hundred dollars($500). �
o (�t,as ov#rner of the property,or my employees with wages as their sale compensation,will do{�all af or(�portions -� Commercial
� of the work,ar�d the structure is not intended or offered i+or sale(Section 7044.Business antl Professions Code:The m
� Contractars'State License Law does nat apply to an owner of prop�erty who,thraugh employees'or persona!e�fort,builds
� or improves the property,provided that the improvements are not intentled or offeretl far sale.!#however,the builtling or
� improvement is sold within one year of campietion,the Ovtrner-Builder will have the burden of proving that it w�s r�at buiit
p or improved for the purpase of safe.j.
�"� I,as owner of tl�e ro e am exclusivel c�ntractin witt�licensetl Contractors to ca��struct the ro ect Section
0 �-� � ��' y � � j � Vaivation: Adj.Area:
7044,Business and Professions Code:The Contractors'St�te License Laav does not apply to an owner of property who
z bui(ds or impraves#hereoi3,a��tl who contracts far the prajects with a licensed Contractor pursuan#to ifte Contractars'State QUAI�ITITY DESC Rf PTIQN FEE
cr�
� Li�ense Law.).
o (�)1 am exempt from licensure under ihe Contractor's State License!aw for the foll�wing reason(s}: �
� �
� By my signature beiow 1 acknowledge that,exce�t#or my perso�al resitlence in which f musi have resided fior at least one �
o year prior to completion o#the improvements covered by this permit,l cannot le�alfy sell a struciure that I have buii#as an �
Q owner-builder if it has not been cons#rtEcted in its entirety by licensed contractors.I understand that a copy of the applicabie ,�
� 1ati•o,Section 7044 af ihe Business and Professions Cade is available upan request�r�hen this application is submitted or at f' �� �" ,/'
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X the fallowing Web site:http/www.leginfo.ca.gov/caia���.html. z -
o D�TE: SIGN: � ''�� '
�' LIGENSED CONTRACTOR'S DEClARATION � A �'�' � �. ';:��i� +�,P��.
� �
� I hereby affirm under penafty of perjury that I am licensetl under provisians of Chapter 9(commencing wi#h Section 7000)
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m of Division 3 of the Business d Profess�ons Code,and my license is in ful!farce and effect. J
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� LfCENSE S: � ' IC.NO.: Y� ! � � � z
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c� DATE: CONTRACTOR: V J--�� `► * �f t'. �
d WORKER'S COMPENSA7IQN DECLARAT30N �
� I NEREBY AFFIRM UNDER PEIVALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
� I have and will maintain a Cert�ficate af Cansent to Self-lnsure for Worker's Compensai'son,as prflvided�y CORlSTRUCTION:�
� Sectior�3700 of the Labor Cotle,far the performance of the w�rk for whicl�#iiis permit is issuetl. PLAN REVIEIIV:
� -���1 haue and wil!maintain Wor�er`s Compensation Insurance,as required by Section 3700 of the Labor Code,far �
z the perfarmance of the wor��pt,�hich this permit is issued.My 1Norker`s Compensat'son Insurance Carrier and ELECTRIC: �__ _ ��_ ___._._...._..—_ _ � .__
�[ Po(icy Number are: ;�,,. PLUMBING: ��'�.,�...
� GARRIER '' �r� '��' `J . � MECHANICAL:__.____________.______ __.._..__.._.._._.._�..__. � .�.—
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� POLiCY NUMSER �� �'� � � INSPECTION FEE:
� (THIS SECTIdN NEED N�T BE C4MPLETED IF THE PERMIT IS FOR ONE NUNDRED DOLLARS��1�)OR LESS�.
lSSU�NCE;__ __ _.._.__ _.� _����._._.
� 1 certiiy t1�at in the performance�f the work for whicl�this permit is issued,I sl�a[I not empla any person in any manner so as to
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bec�me subject to`t�e Worker's C�mpe��sation Lav�rs Californi.And agree that if sh Id becom subjec�to th�Worker's SM 1 P: _�..._._
w Cc�mpertsali ro i�ns of Section 3700 ofi ihe Labor I st�11 f h itli mply it tto�"'ovi ru. ENERGY P/C:
--� ��'"` i" r S t�°�'q� '�/r�`r.�' .
� DATE: APPLICAPdT: �� ENERGY PERMIT.
� VI►ARNiNG:F�aift�re to secure Worker's Compensation coverage is unlawful,� shall sub}ect an employer tn criminaf RETENTIQN FEE: mm �.
� panalties antl c'rvi!fines up to ane hundred thnusand dolfars($100,OQ0),in atldition to ttte cast�f the campensation,
� tlamages as provided for in section 37U8 0#tl�e labor code,interest,and attnrney's fees. PRE-ALT FEE:___________.. ..__.._._�. ___. _� ______.___.._..
� GO�ISTRUCTI�N LENDI�IG AGENCY BSAF:
� !hereby affirm under penalty of perjury tt�at ti�ere is a Construction Le,�tling Agency#or the performance of the work for
._. __---.-----------------._.____.__.__._.._._._.�__.__..__ ___---�.____..__...__ _____. _..._
= which this permit is issued�Sec.3097,Civ.C.}.
? .._._....�.�.__ .�.. ._
� LENDER'S I�IAME:
� ._.._..___�...W..__.__�....___.__._._.....�_...._.__.._________.�..._W..__._ __....�__ __..._._.�W.. _...Z._',� .__._
� LEND�R'S ADORESS:
� I certify that 1 have re�d this applicaiio�and state ft�at the abave informatian is correct.l�gree to compiy with all city a�d TQTAL FEES
county ordinances and state laws relating ta builtling construction,and hereby authorize representatives of this county t�
� , ,� COMMENTS: --.__...---.------------.-------..._.---__.__._..�..._--------._____.__..�.__.._.�____.__...__.___.__.___.._.W....__...._..____._.._..__-------..._.
� enter upan the abo�e- nta€�ned property f mspection purp�ses.
-� � , _....��.._�..._..___....._.__._._._......_�.�......_...._�....__�..... �.__________ ___..._ .._
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_.._.__�___...__.._�.._._.._..__..._....._....___..._.__._...__..........__.__.._...._._.__...__._._._.__..__..._...._.____._...__...._�..._..______.�.____..._______..__...._.........__._
'� PER 1 E NAtUIE{ T� ¢, `
� , L..�.. A C �" ........... .�...__...._.____ _ ,.-�... ��..................
� � , PAID BY: ✓ � VALIQAT!{3N: �
= S1G�tATURE Of PERMfTt'EE ATE REGEIPT#
�
WH1TE—Department Copy,I�ELLOW—Finance Copy,PlNK—Assessor Copy,GaLDENRt�D—File Capy,GREEN—Appticant's Copy
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