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� ISSUE 7YPE OCC
APN LOT TRAC7 DATE CONST. GROi.►P _
g owNE� �he Trenton Group
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LENDER'S NAME�.,
F-� IENDER5ADORESS _ ,,,,
Wt CERTIFY TtiAT f HAVE R'cAD TNIE APPtiCATiON AN6 5TATE THA7 TNE ABOYE 9iFORMATlON VS CORRECT TUTA�FE ES ��� S�'`�,
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CITY OF DIAMOND BAIL f -+��� ��- � � +� -��� ' � ���
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
z i aso s. capTey or;.,e Svita 190
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICA'T'ION
/^'
PRESS
FIRMLY
JOBSITE
ADDRESS 1440 Bridclegate Qr.
APN LOT TRACT
OWNER�e Trenton Group
ADDRESS 5670 Wilshire Blvd
CITY Los nee es_zIP 6TEL. 3
APPLICANT��d Greene TEL.
CONTRACTOR KPRS
ADDRESS 4�am er u
CITY Brea ZIP 92821 TEL. 714 72080
ARCH/ENG/
DESIGNER PBWS/cordon Spice
ADDRESS�N-�e ve
cITY Pasadena ziP rEL. 6264325000
OWNER-BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM E%EMP7 FROM THE CONTRACTORS LI-
CENSELAW FOR THE FOLLOWING REASON(SEC. 7031.5 BUSINESS AND PROFESSKNS CODE:ANY CITY OR
COUNTY WHK*I REOUIRESAPERMR70 CONSTRUCT ALTER,IMPROVE,DEMOLISH,OR REPAIRANY STRUC-
TURE,PRIOR TO ITS ISSUANCE,ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI-
CENSELAW(CHAPTER B(COMMENCING WITH SECTION 7000)OF DIVISK)N 3 OF THE BUSINESS AND PRO-
FESSKNISCODE)ORTHAT HE OR SHE IS E%EMP7 THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TION.ANY VIOLATION OF SECTION 7031.5 BV ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
ACML PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS(5500).):
^I,AS OWNER OF THE PROPERTY,OR MV EMPLOYEES W ITH WAGES AS THEIR SOLE COMPENSATION,
PALL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC. 7044, BUSI-
NESS AND PROFESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BUILDS OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED WR SALE IF, HOWEVER THE BUILDING OR IMPROVEMENT IS SOLO WITHIN ONE YEAR OF COMPLE-
TION,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVWG THAT HE OFI SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
^I.AS OWNEp OF•HE PROPERTY,AM EXCLUSIVELY CONTRACTING W!TH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC. 7041, BUSINESS pND PROFESSK)NS CODE:THE CONTRAGTORS LI-
CENSE LAW DOES NOT APPLY TO AN OWNER OFA PROPERTY WHO BUILDS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS WITH ACONTRACTOR(S)LICENSED PURSUANT TO TFIE CONTRAG
TORS LICENSE UW.).
^I AM EXEMPT UNDER SEC._,_.. . B.f P C. FOR THIS REASON
DATE OWNER -�-
1
I
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDEq PROVISKNS OF CHAPTER
0(COMMENCING WITH SECTKNJ 7000)OF DIVISION 3 OF THE BUSIN SAND PROFES ON$COD�,�pND
MV LICENSE IS IN FULL FORCE AND EFFF�CT,/• �/-
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LICENSE CLASS
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DATE -- r' u � CONTRACTOR
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WOR ERS'COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PEAJURY ONE OF THE FOLLOWING DECLARATIONS:
I HAVE AND WIL L MAINTAIN A CERTIFICATE OF CONSENT TOSELF-INSURE FOR WORKERS'
COMPENSATION,AS PROVIDED BY SECTION 3700 OF:THE LABOR CODE, FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
I HAVE ANO WIII MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION
3700 OF THE LABOR CODE. FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY W!)RKEAS'COMPENSATION INSIRANCE GARRIER AND POLICY NUMBER ARE:
CARRIER
POLICY NUMBER-
(TH5 SECTION NEED NOT BE�MPLETED OF T/IE PERMR IS FOR ONE HU�DREDDOLIARS(f100)OR LESS}
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERIAIT IS ISSUED, 1
SHALL NOT EMPLOY ANV PERSON IN ANY MANNER 50 AS TO BECOME SUBJECT TO THE
WORKERS'COMPENSATKN! LAWS OF CALIFORNIA.AND AGREE THAT IF I SHOULD BECOME
SUB.IECT TO THE WORKERS'COMPENSATION PROVISKNS OF SECTION 37000E THE TABOR
CODE.I SHALL. FORTHWITH COMPLY WITH THOSE PROVISIONS.
i DATE: ,_-APPLICANT:_
�I WARNING FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL.AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS(f 100,000), !N ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
I SECTON 3708 OF THE'. LABOR CODE,INTEREST,AND ATTORNEY'S FEES.
I CONSTRUCTION LENDING AGENCY
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS ACONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC. 3097,CIV.C.).
I
LENDER'S NAME
LENDER'S ADDRESS
I I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE MFORMATION IS CORRECT.
I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE UWS RELATING TO BUILDING
j CONSTRIUUIffCTION,ANCI HEREBY AUTHOpIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
TKNJED PROPERTY F R I ISPECTION P RPOSES.
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