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DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21660 E.Capley Drive Suite 190 S C P 1 O ZOOZ PRESS
� (909)86a3195 F�(909)861-3117
������',� BUILDING PF.�tMIT APPLICATION __ � , FIF�MLY
} JOBSITE ���fl �, V f� �I�S APPLICATION ��.,���� NUMB R� S� #/C
, o ADDRESS v DATE
c� ISSUE nQ TYPE OCC
APN LOT� TRt/ACT DATE � � _lCp CONST. GROUP
p OWNER ��DE� �l�►L7`/ .S��C �
ADDRESS ��jDI b(�/(,tN��� L�Y� � yT�! Lf�. ZONWG SETBACKS
W CITY �14 ZIP�TEL.3/O- FRONT RW ❑
� APPLICANT � TEL:7/� Q97- REAR ❑
SIDEJSIDE STREET RW ❑
� CONTRACTOR ' SIDE ❑
� ADDRESS PROPOSED USE '� . � . . /'1
o CITY ZIP TEL. � �
wo ARCH/ENG/
iz DESIGNER NO.DWEL. NO. NO.
a ADDRESS UNITS STORIES BEDROOMS
� CITY ZIP TEL.
y DESCRIPTION S�.FT. FACTOR PSF ADJ.AREANALUATION
� OWNER-BUILDER DECLARATION SFR/ADD/REM
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p I HEREBY AFFlRM UNDER PENALTY OF PERNRY THAi I AM EXEMPT FROM THE CONTRACTORS LI� G8f996/CflfPOR
W CEHSEUWFORTHEFOLLOWINGREASOH(SEC.703t.5BUSINESSANDPROFESSIONSCODE:ANYCI7VOR (n .
U COUMYWHICHREOUIRESAPERMRTOWNSTRUCT,ALTERIMPROVE,DEMOLJSH,ORREPAIRANYSTRUC- � W Patio/Deck
Z TURE,PRIOR TO ITS ISSUANCE,ALSO REOUIRES THE APPLICAN7 FOH SUCH PERMIT TO FILE A SIGNED
w STATEAIEM THAT HE OR SHE IS LICENSEU PURSUANT TO 7HE VROVISIONS OF THE CONTRACTORS LI- w
.� CENSE UW(CHAPTER Y(COMMENCINO WITH SECTqN 7000)OF DIVISION 7 OF THE BUSINESS AND PRO- � Pool/Spa
FESSqN500DE)ORTHATHEORSHEISEXEMPT7HEREFROMAN07HEBASISFORTHEALLEGEDEXEMP- (�
TION.ANYVqLATIONOFSECT10N70.11.6BYANVAPPLICANTFORAPERMITSU&lECTSTHEAPPLICANTTO Z Re-Roof
� A CML PENALTY OF NOT MORE hIAN FNE NUNDRED OOLURS(f5oo).):
� �I,tiSONMEROFiHEPROPEiiTV,ORMVEMPLOVEESWIiHWAGESASTHEIRSOLECAMPENSATION, � Commercial �
WILL DO THE WORK AND THE STRUC7URE IS NOT IMENDED OR OFFERED FOR SALE(SEC.7oW,BU51� J
N NESS AND PROFESSIONS CODE:THE COHTMCTORS LICENSE UW DOES NOT APPLV TO Ml OWNER OF � ,
VROPEHfYWIpBUILDSORIMPROVESTHEREON,ANDWHODOESSUCHWOqKHIMSELFORHERSELFOR m
� THROUGHHISORHEROWNEMPLOYEES,PROVIDEOTHATSUCHIMPROVEMENTSARENOTINTENDEDOR
QOFFERmFORSALEIFMOWEVERTMEBUILDINGORIMPROVEMENTIS50LDWlTHINONEYEAROFCOMPLE•
Z �'TqN,THE OMMERSUILDER WILL HAVE THE BURDEN OF PROVINO THAT NE OR SHE DID NOT BUILD OR
� WPROVEFORTHEPURPOSEOFSALEJ.
❑1,AS ONTIER OF THE PROPEHTV,AM EXCIUSIVELY CONTRACTINO WfTH LICENSED CONTRACfORS p,
Q TO CONSTRUCT THE PRO.IECT(SEC.70H,BUSINESS AND PROFESSIONS CODE:7HE CONTRACTORS LI- V01U8fI0n U�/ ADJ.AREA
W CENSEUWDOESNOTAPPLYTOANOWNEROFAPROPERiYWHOBUILDSORIMPROVESTHEREON,AND
� N'FpCOHTMCTSiORSUCHPRQIECTSWITHACONTRACTOR(S�LICENSEDPURSUANTTOTHECONTMG pUANTITY DESCRIPTION FEE �.
� 70RS UCENSE UW.).
Q ❑I AM IXEMPT UNDER SEC. B.6 P.C.FOH THIS REASON Q
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DATE OWNER U
Z W
� LICENSED CONTRACTORS DECLARATION W
� I HEREBY AFFIFUI UNDER PENALTY OF PERIUtiY TMAT 1 AM LICENSED UNDER PROVISIONS OF CHAPTER �
� Y(COMMENCINO WITH SECTION 7000)OF DIVISION 30F THE BUSINESS AND PROFESSIONS CODE,AND Z
�� MY LICENSE IS IN FULL FORCE AND EFFECT.
� LICENSE CUSS �_ LIC.NO. �� J
DATE CONTRACTOR a
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� WORKERS'COMPENSATION DECLARATION Q
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� I HEREBY AfFiRM UNDEN PENALTV OF PERIURV ONE OFTHE FOLLOWING DECLARATIONS: �
C� Q
O _IHAVEANDWILLMAINTAINACERfIFICATEOFCONSEMTOSEIF-INSUREFORWORKERS' 2
Z COM�ENSATION,AS PROVIDED BY SECTION 3700 OF 7HE LABOR CODE,FOH THE PERFORMANCE U
Q OF THE WORN FOR NMICH THIS PERMIT IS ISSUED. �
�
W _I HME ANU WILL MNNTAIN WORKERS'COMPENSATION INSURANCE,AS REOUIRED BY SECTION
Q 970o OF THE LABOR CODE,FOR THE PERFORMANCE OF 7HE WORK FOR WHICH 7HIS PERMIT IS �h 9`2�
ISSUED.MY M/ORKERS'COMPENSATION INSURANCE CARRIER AND POLICV NUMBER ARE: CONSTRUCTION �
jCARRIER t"'V�✓ PLAN REVIEW
� PIX.ICY NUMBER�1Q��+ '�Q ELECTRIC
� (fHBSECf10NNE�NDiBE001rPLETmOFh�PERMfISFi�RONEHIN�DFimD011ARS�t100)ORIESS� PLUMBING
Z 1 CERTIFY THAT IN THE PERf-0RMANCE OF THE VlORK FOR WHICH THIS PERMIT IS ISSUED.I MECHANICAL
(,7 SHALL NOT EMPLOY ANY PERSON IN ANV MANNER SO AS TO BECAME SU&IECT TO THE
N WORKEHS'CAMPENSATION UWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME INSPECTION FEE
SU&IECT TO THE WORKERS'COMPENSATION PROVISION F SECTION 3700 F TNE LABOR O O
S CADE,ISHALLFORTHWI7HCOMPLVWITHTHO PRO I S. ISSUANCE T �
� SMIP P�./
p DATE: ��Q�-�APPLICANT: . .
� ENERGY P/C
WARNINO:FAILUHE TO SECURE WORNERS'CO PENSATION COVERAGE IS UNUWFUL,AND SHALL BE
� SU&IECT AN EMPLOVER TO CRIMINAL PENPLTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND ENEFGY PERMIT
DOLURS(i100.o00),IN ADDITION TO THE COST OF COMPENSATION,DAlAAGES AS PROVIDED FOH IN �
� SEC710N 370E OF THE UBOR CODE,INTEREST,ANDATfORNE1"S FEES. RETENTION FEE:
d CONSTRUCTION LENDING AGENCY PRE-ALT FEE:
O
� I HEfiEBY AFFIRM UNDER PENALTY OF PERIURY THAT THERE IS A CONSTRUCTION LENDING AGENCV
FOR iHE PERFOHMANCE OF 7HE WORK FOR WHICFi 7HIS PERMIT IS ISSUED(SEC.3007,CIV.C.). .
Z
W
� LENDER'S NAME
H LENDER'S ADDRE55 �
� ICEfiTIFYTHATIHAVEREADTHISAPPLICATIONANDSTA7ETHAThiEABOVEINFORMATIONISCARRECT. TOTAL FEES � / �/ /, D
W I AGRE•':TO COMPLY WfTH ALL CITV M1D COUNTY ORDINANCES AND STATE UWS REUTING TO BUILDING S _/
� CONSTRUCTION,AND HEREBV AUTHORRE REPRESENTA7IVES OF THIS COUNTY TO ENfER UPON THE �
ZABOVE-MEHTIONED PROPERTI FOR INSPECTION PURPOSES. COMMENTS � - ✓ `
j LL/r�'y �A'.1..�.�iZT
m VERMI NAME � �
� �/ �
� � RE OF PERM EE DATE
� RECPT.NO. PAID BY VALIDATION . i
WHITE—Depertment Copy,YELLOW�inance Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—Applicant's Copy
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FTGS/FORMS/STEEL � FHA REQMTS �
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GROUND PLUMBING UNDER�LOO'ft�CO�IDUIT•t..�.. �-- � '_: ,;� ' .�� ;.,
SLAB GRADE FIREeLAC���;UNDATION`�'� `��� `"�-`•
TEMP POWER FIREPLACE BOND'B�AM
WATER SERVICE MID HT. BOND BEAM
ROOF SHEATHING � - ; '; 8 FT. BOND BEAM i
FRAMINGNENTILIATIDN ' ' _i FINAL BOND BEAM ;
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ROOF COVER ' PRE-GRADING j
ROUGH HEATING BENCHING
ROUGH ELECTRIC ROUGH GRADING
ROUGH RLUNIBING FINISH GRADING j
SHOWER/TUB TEST POOL ELECTRIC �
EXT. LATH/SIDING P�OL FENCING �
WALL INSULATION POOL FINAL . " f
CEILING INSULATION ' '; � ' OFF SITE IMPS.
DRYWALL NAILING '" � �DEDICATIONS �
SEWER FINAL ENG.
SEPTIC TANK _ � LANDSCAPE/IRRIG.
SEEP PIT/L.L. ' � ' ON SITE IMPS.
GAS AIR TEST FINAL ZONING
FINAL CONST. FIRE DEPT. FINAL
FINA�HEATING HEALTH DEPT. FINAL
FINAC ELECTRIC DEV. FEES PAID
FINA�PLUMBING ENERGY
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