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� `----��� -- DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21825 E.Copley Drive �� ,
(909)860.3195 Fax(909)861-3117 .. , ' ' ' PRE$$
�'��" BUILDING PERMIT APPLICATION ^ �� FIRMLY
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p OWNER CJ1,.�L1 ('�p DATE CONST. GROUP
p ADDRESS S� I�A� I_ Q' ZONING SETBACKS
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� DESCRIPTION SQ.Ff. FACTOR PSF ADJ.AREANALUATION
p� OWNER-BUILDER DECLARATION SFR/ADD/REM
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p I HEREBV AFFIRAI UNDER PENALTV OF PE0.0.1RV THAT I AM EXEMPT FAOM THE CONTRACTORS LI- G8f89B/CBfPOR
W CENSE LAW FOR THE FOLLOW WO REASON(SEC.7031.5 BUSINESS AND PROFESSIONS CODE:ANV CITYOR (n
C-� COUNTVWHIC}iRE�UIRESAPERMRTOCONSTRUCT,ALTER,IMPROVE,DEMOLISH,OHREPAIRANVSTRUG w
w TURE,PRqR TO ITS ISSUANCE,ALSO REW IRES THE APPLICANT FOR SUCH PERMIT TO FlLE A SIONED w Patio/Deck
� STATEMENT THAT HE OR SHE IS LICENSED WRSUANT TO THE PROVISIONS OF THE CONTRACTORS LI-
� CENSE LAW(CHAPTER Y(COMMENCINO WITH SECTION 7000)OF DIVISION 7 OF THE BUSINESS AND PRO� � POOI/SP0
0 FESSqNS CODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEOED E%EMP- C7
U TION.ANV VIOLATION OF SECTION 7031.5 BV ANV APP�ICMlT FOR A PERMIT SU&IECTS THE APPLICANT TO Z Re-Roof
� A CIVIL PENALTV OF NOT MORE THAN FNE HUNDRED DOLURS(f500)J:
� ❑I,ASOWNEROFTHEPROPERTV.ORMVEMPLOVEESWITHWAGESASTHEIRSOLECOMPENSATION, � COffIrt18fC18I
Z WILL DO TME WORK,AND THE STRUCNRE IS NOT INTENDED OR OFFERED FOR SALE(SEC.70a�,BU51� J l
� NESS AND PROFESSIONS CODE:TNE CONTRACTORS LICENSE UW DOES NOT A7PLV TO AN OWNER OF �
PqOPERTV WHO BUILDS OR IMPROVES THEREON,M1D WH0 DOES SUCH WORK HIMSELF OR HERSELF OR
wTHROUOM HIS OR HEfl OWN EMPLOYEES,PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR m
Q OFFEREDFORSPLEIF,HOWEVERTMEBUILDINGORIMPROVEMENTISSOLDWITHINONEVEAROFCOMPLE-
Z TION.THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVINO THAT HE OR SHE DID NOT BUILD OR
� IAIPROVE FOR THE PURPOSE OF SALE).
W ❑I,AS OWNER OF THE PROPER7V,AM EXCLUSIVELV COMRACTINO WITH UCENSED CONTRACTOHS
� TO CONSTRUCT THE PROJECT(SEC,7o�a,BUSINE55 AND PROFESSIONS CODE:THE CANTMCTORS LI- V8I118(10I1 ADJ.AREA
W CENSE UW DOES NOTAPPLY TOM!OWNER OF A PROPERTY WFiO BUILDS OR IMPROVES THEREON,AND
� WHOCONTRACTSFORSUCHPRQIECTSWITHACONTRACTOR(S)LICENSEDPURSUANTTOTHECONTRAG QUANTITY DESCRIPTION FEE
Y TOqS LICENSE LAWJ.
� O I AM IXEMPT UNDER SEC. B.6 P.C.FOR THIS REASON Q
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� DA7E OWNER V—
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� LICENSED CONTRACTORS DECLARATION W
� I MEREBV AFFIRM UNDER PENALTV OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER �
� e(COMMENCINO WfTH SECTION 7000)OF DIVISKKJ 3 OF THE BUSINESS AND PROFESSIONS CODE,AN� Z
��� MY LICENSE IS IN FULL FORCE AND EFFECT. m
� LICENSE CLASS LIC.NO. � �
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� � WORKERS'COMPENSATION DECLARATION Q
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, � I HEREBV AFFIRM UNDER PENAL7Y OF 7ERIURV ONE OF THE FOLLOWING DECLARATKKJS: Z
�Z _IHAVEANDWILLMAWTAINACERTIFICATEOFCONSENTTOSELF�INSUREFORWORKERS' ¢
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COMPENSATION,AS PROVIDED BV SECTION 37ao OF 7HE LABOR CODE,FOR THE PERFORMANCE U
OF THE WORK FOR WHlpi THIS PERMIT IS ISSUED. W
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w _I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE.AS REOUIRED BY SECTION
Q 3700 OF THE LABOR CODE,FOR 7HE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ' ��
ISSUED.MV WORKERS'COMPENSATqN INSURANCE CAARIER AND POLICV NUMBER ARE: CONSTRUCTION ��'l
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j CAfiRIER PLAN REVIEW _� � V
Z aa.ICV NUMBER ELECTRIC �
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� (IWSSECIqNN�NOTBE�.GLEfmOFhEPEHMrISFOqONEV4I�DREDDp1/3LS(tlao)ORLESS} PLUMBING '
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Z �CERiIFY TH�T IN THE PERFORMANCE OF THE WORK FOR WHICH iHiS PERMIT IS ISSUED,I � MECHANICAL
U' SHALL NOT EMPLOV ANY PERSON IN ANV MANNER SO AS TO BECAME SU&IECT TO THE
(/� WORKEHS'CAMPENSATIONUWSOFCALIFORN10.�DACtREETHATIFISHWLDBECOME INSPECTIONFEE
� SUBJECTTOTHEWORKERS'COMPENSATIONPROVISIONSOFSECTbN37000FTHELABOR �
CODE,I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS. ISSUANCE
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p DA7E: APPLICANT: SMIP
w ENERGY P/C �SO
J WARNINO:FAILURETO SECUF7E WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL BE
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� SU&IECTAN EMPLOVER TO CRIMINAL PENALTIES AND CNIL FINES UP TOONE HUNORED THOUSMID ENERGY PERMIT
DOLLAAS(f 1 a0,000),IN/�DDRION TO THE COST OF COMPENSATION,DAMAOES AS PROVIDED FOR IN
J SECTION 3708 OF THE LABOfl CODE,INTEREST,AND ATTORNEV'S FEES.
OC RETENTION FEE:
OCONSTAUCTION LENDING AGENCY PRE-ALT FEE:
� � I HEREBV AFFIRM UNDER PENALTV OF PERJURV THAT THERE IS A CONSTRUCTION LENDM�AGENCV
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.3oe7,CIV.C.�. �
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� LENDER'S NAME
1-- LENDER'SADDRESS
w I CERTIFY TMAT I HAVE READ THIS APPLICATION AND STATE 7HAT THE ABOVE INFORMATION IS CARRECT. TOTA L FE ES �v��
� I AGREE TO COMPLV WI7H ALL CITY AND COUNTV ORDINMlCES AND STATE UWS REUTING TO BUILDING (((''''''���(((���n �
� CONSTRUCTVON,AND HEFEBV AUTHORIZE REPRESENTATNES OF THIS COUNTY TO ENTER UPON THE �/J/'� Q���
Z ABOVE�MENTIONE�PE�TVFOR��CTKKyPURPOSES�� COMMENTS `��
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m PERMITTEE NAIAE �
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� SIONANREOF ERMITfEE DATE �
� RECPT.NO. ' PAID BY VALIDATION
WHITE-0epartment Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENRO File Copy.GREEN—ApplicanYs opy �
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SE7 BACK FLOOR JOIST
FTGSIFORMSISTEEL � � FHA REQMTS
ELECTRIC GROUND � � � UNDER FLOOR DUCT
GROUND PLIfMBING I UNDER F6_OOR CUMDUIT
SLAB GRADE i FIREPLACE FOUNDATION
TEMP POWER FIREPLACE SOND BEAM
WATER SEI�VICE MID HT. BOND BEAM � ��
ROOF SHEATHING 8 FT. BOND BEAM
FRAMIIVGNENTILIATION FtNAL BQfVD BEAM � ~
ROOF COVER PRE-GRRDING ��
ROtJGH HE,4TING BENCHING
ROUGH ELECTRIC ROUGi-i GRADING
ROUGH PLUfV1BING FINiSH GRADWG
SHOWEF�/TUB TEST POOL ELECTRIC
EXT. LATHJSIDING POOL FENCiNG
WALL INSULATIOI� POOL FIPJAI.
CEILING INSULATiON OFF 51TE IMPS.
DRYWALL NAILING � DEDICATIONS
SEWER FINAL ENG.
SEPTIC TANK LANDSCAPE/(FtRiG.
SEEP P(T/L.L ON SITE tMPS.
GAS AIR 7EST FINAL ZONlNG
F1NAL CONST. � GlRE DEPT. F1NA� �
FlNAL HEATING HEALTH DEPT. FINAL �
FINAL ELECTRIC DEV. �EES PAID �
FINAL PLUMBING ENERGY
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SEPTIC TAiVK SIZE
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