HomeMy WebLinkAbout16231 <--''"��'-
_!„� CITY OF DIAMOND BAR �
— DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
� 21660 E.Copley 13rive Suite 190
� (949)86(}-3145 Fax{909)861-3117 PRESS
.,�A�^.f� BUII.DING PERMIT A.PPLICATION j � FIRMLY
�' JOBSITE -�7 � t-"' / �. APPLIGATION �-�„ J` NUMBEFl 1, 3 �!C
a ADDRESS �" J DATE
c� ISSUE 7YPE OCC
APN LOT v TRACT. ����,� DATE CONST. �RQUP
p CIWNER
``� ADDRES � 't- S' u2 ZONING SETBAGKS
W C4TY 'Z ZIP�J Z-� Z-TEL,fL��,���7 REORT RW Q
� APPIiCANT TEL. g�DElSiQE STREEI" RW T ❑ �
� CONTRACTOR^. . SIDE
� ADDRESS r` r
CIIY ZIP TEE. PROPOSED USE ��_..�`��l_. E� srl'C. —
� ARCWENG/ �
dESIGNER � _-� . NO.DWEL NQ. NO.
ADDRESS__ UNiTS STOFtf ES BEDROOMS
� CITY S IP TEI. l'
� pESCRiPTION SQ.FT. FAGTOR PSF ADJ.AREIWALUATIQN
� OWNER-BUILL?ER QECLAFiA710N ���� SfR/ADDIREM
(� 1 HEAEBY AFFIRIA UNDER PENAL7V OF pE%JURV THAT I N.1 EXEMPT FRqM THE CONTRACT4R5 t�- �a�a98/GafpOfk
W CENSELAWFOR7HEFOL40WINGPEASONi5fiC.7o3r.50U^uMESSANOPi�FESSqMSGOOEANYCittaft (j'} -
C� CpJNTYVfMiCNREOUiRES+1PEpMRTOIX}N57HtlCt.RL7Efl,1MPROYE.OEMOL15H2ORREPA1flANY9TRUG W PatialDeck
w TURE,Pf3pR 50'tTS 1SSUMICE,ALSO REC1UlRES THE APPUCANT FOR SUCH PERMIT TO FILE A SIGNED
.� STATEMENT iHAT!IE OR SHE IS LICENSED PURSUANT TU THE PRpYISiONS OF THE CONTRACTORS Li•
� CENSE lAW(GHAPTER a(COMMENCINO WITH SECTiON)a00)OF DIVfSKxN 3 OF TNE BUSiNESS AND PR4• i'�' PooVSpa
FESSpNSCWE}MiTNATHEOR5HEISEXEMATiHfREfROAAANDTHEeA515FORTNEALLEGEDEXEMV� (�J
7lQN.ANYYIOI.ATKKfpF$EGT16N7431.56YANYAPpUCANTFORAPERMIT5U9JECT5TMEAPPLICANTTO Z pe•Roof
r ♦CIVII PENALTV OF NCI7 MONE THP.N FIVE HUN�RED 6QLLARS iZ500j.):
� pI,ASOWMEROFiNEPtiOPERTY,ORMYEMPIOVEESWtTHWAGESA$THEIRSOLEfAMFENSATION, (a �p�pmgtG�el
Yt9LL 00 THE WORY.,AND THE STHtlGTUFIE 15 NQ7 IMEt�ED OR OFFERE[)FOR SALE(SEC.7Da{,BU51� .,,.,1
HESSANp PAOFE5SI6N5 CpDE:THE CONTNACTORS UCENSE LAW DQES NOT APP�V TO AN OWNEfl OF
� PfqPEATVWHp8U1LpSORIMPR04ESlNEHEON,ANOWFiODOESSUCHIWRNH�MSELFDRHERSEtFOR �
(,t 7TiA0U(iFIHiSpNNEROWNERiPLDYEE5,PA6V�cOTHATSUCHiMPROYEMfNtSARE�WTINTENl7E00fl m
� OFFEflEDF4R3KEli,H04V6VEP,TNEBUfLDlNGORIMPRbVEMENTI5 ' W17HINONEVEAFOFCOMpLE�
� TK7N,THE OWNER�BUIIDER WILL HAVE 7NE BURDEN OF PRpYING THAT NE OP SHE DID NOT BUILO OR
IMPROVE FOR TFIE PURPOSE OF SALE).
�y,� ;7 i,AS ONMER pF TNE PROFERTY,PM EXq.USiVEIY CONTRACTINfi W1TH LICENSED C(7NTMCTORS "-'
(,r TC}CONSTHIk.^T'THE PR0.IEGT(SEC.TGM.BUSINESS ANp PROFESSIONS CQDE:THE CONTRACTOflS ll� Va��'d(lOfi _ AOJ.AREA_
1.1.1 CENSE UW OOES N07APPLV IOMI OYMER OF A PROCEq7V WMO BUILDS Ofi IMPqOYES THEREqN,AND �l��
� NMOCONTMCTSKORSUCHPROJEC75WiTMACOqFRACTOR(5}L;CENSEDPUR5UANTTOTHEGONTMG pUANTtTY DESCRIPTIqN FEE
� TpRS LICENS£tAW.}. „__
J
Q p I AM E%EMPT UNOER SEC._,,,_ ___„_.._,_,H.8 p,C.�OR FNIS REASON Q
� - ..__��. ._..—_.-._.� U
�
LL' DATE oWNEa.�_._._._ �
Z � �
� UCENSED CONTRACTORS DECLAHATIQN W ! �
� 1 HEREBV AFFIRAi I1NbEfl PENALTY OF�PE WURY TNAt IAM IICENSED UNDCR GR6VISICSIS OF CNAPTEF � /
a, YtCtlidMENCiN(3WiiHSEC7iIXi70W}6fDiYiS10N34FTHEW1SiNESSAND�ROF£SSION9COOE,MID � ''�✓ .� ,
}C MY LICENSE G5 tN FULL faFlCE ANp EFFECT,
0 LICENS/E CLASS_,_,l��_�LIC.NO.�_J .L,__]__L ' �
� OATEy�.r=�,���/ CONTRP.CTOR a ��
ti.i �� `�f•--._._
� ��J ' WQf?KER5'CAMPEhJSAT10N dFGLARATIUN � �
� 1 MEFlEBY PFflqM UNGER 7611pLTY OF PER.IUAY ONE OF TNE FOLLOWIN4 DECI.APATPONS: � �
�j �y%L/ Z
�7 �:;)ir,IHAYEANDWilLMA1NTAitiACEHTiFIGATE6GIXIVSENTT08GLFdN5UHEfOftWORKEft3' z - -��
Z f' �pENSA1K7N,AS?RC:Vt�[08Y5ECF1QN3T004FTHElABC�RCODE,F4flTNEPERrURMANCE C)
�� Of"fNE WORN FOp WHICM TH15 PEflM17151S5UE0. �
C] �'
� I M�VE AND WIU.MAINfF�IN WORKERS'CQMPENSATION INSUWWGE.A5 RE4UtPE69V SECTf�N
Q 3700 Of TNE LABOF G{�DE,�OR THE PeFFO�iMANCE Clf iN£WQiiK FQH WN'H 7H45 PEFlMIT IS
iSSUED.FAY RS'CX�MPENSATtON IM;URANCE C0.kR�Eft 4ND POLICY NUMBE FE: CQNSTRUCTION A�„_. �_
j cnucuE�+_..��'C-/f��- t r^ 'f- �G�• PIAN qEVIEW ,---
� �---��
� ICYNUMBER 7 . .�r r+� ELECTRIC _. _,
�"��l��
Q
�� � � ,--�
Q (ncss[t'17CNNE w76Ect)i.AV'tEtEooF'it-EPEPMfiiSwacNEra.Yi�EaOWaRs(5"ae)ofl�Ess1 PWMBING _ .._ ._,_ �l�l
� i C£RTIFY THAT H+i TFtE�'£nfoftMANCE 4F TNE WnqN KON WHICN THIS VERMR I5 ISSUED,I MECHAN{CAL _„_„ , _ _„
(� SIiAI L NOT EAlPL(3Y A4Y PERSpN IN ANY MANNER SO A4 TO BECOME SUBJECT i0 iHE INSPECTION FEE
(� VJORKE%5'COMPENSATiON LPV75 tJF CAI.iFOaN�A,ANI?AGREE THAT iF i SHWLP BECC7ME .
� SU&IECT TO THF_WQRhEftS'COMPENSAtiON Fft�3VtSidNS 4F SECTION 370�OF THE lABOq
� ccoe,�siiau FoarHwirN coMvl�+wirH i osE vnows�arvs.• 13SS3ANCE _._ ,��,�
� sI�JF�'�/'3/ �JLj`�'L�.�r.�CL-.s-"'.-� SMIP
p �ATE. yvY APPIICANT: �, ----- — ..
� £NERGY PIC . _
J WAFlNINQ:FAt.URE TO SECURE Xk7RKERS'GY3MPEN5ATKKJ CAYERAGE 15 UNUWFUL.AND SHAIL 0E
� SUBJ£CTANEMPipYEftTOCRIM7NALPENAlTIESANPCNILFINESUPTOONEHUNDREpTHOUSAND ENERC�YPERMIT
DCM.LAR3�f1 oa,oWl.IN ACIDITION Tl7 THE CO3T pF CDMPENSATION.DAMACES AS 7HOV�DE6 FOR IN �
J SECTqN J]OB OF TNE LABOR COOE.INTEflEST,ANO ATi'ORNEV'S FEES. RETENTION FEE:
� .� � __
� CONSTRUCTION LENDING AGENCY PRE-ALT FEE _.,, ,_ _,� _
� 1 HEREBV AFFIRIA UNDER PENAl7Y OF PEPJURY TMAT THEFE IS A CONSTRUCTION tENOING AGENCY _
FOR TriE PERW RMANCE OF THE WORK FOA W»t Mi5 PERMi7 iS{SSU6 SEC.3067.GV.C.),
W /,y�f/�' y��r ♦ �r
� IENDER'S NN-0E_,__j_i+j�*'j<""` Y � _�. V. .
!�- LENDERSADDRESS �_, -
� ICERTIFYTHA7IHAVEREADTNISAPPLIGATIONPNPSTATETHATTHEABdV£INFiJRMA1pNiSCORREGL TOTAL FECS �� � ��
4 1 AGFlEE TO CA6iPLY W1TN ALL C1TV AN6 COUNT'Y OR4INANCES AhR&TATE L4w5 RELATING TO BLIIL�ING �� �
� GONuTRUGTFf7N,lND NFREBYAUTHORIZE REPRESENTATNES OF THIS COUNTY TO ENTER UPON THE
Z ABOYE-MENI'N?NEO FROPEFTV FOR INSPECTION PURPOSES. COMMENTS
�
� _�`.��-� ��_ .-
¢ PERM�TTEE N^A�AtE(PFU� ) ������ _ _,_ _
u"a ,fg���FP � ..c" _-.__
� SIGNATU ERMITTEE OATE
z RECP7.N0. � PAi6 BY VA�.IQAT�N
~ WHi7E-DspaetmeM Copy.YELl4W-Flnarwe PtNK-Assessor Co GOLDENROU�-File Co GAEEN-
C�f�X PY. GY, ApPlicanYs Copy
� 0.r�� E I �i� i.»A 1�.. ���«$ 6��t"'8
Ifi�����'�":C3� ��������
������
.. . 9 c.
� � � A ■ � � t. � # y • �`��fs�„"��4 1�
` ��2r�"s� i ! � ` ��.���;d.�t�tc-a�. a
�._� _ �+,r� � �
_ _____. _.�.___, __. m.___.�, .� _ ._ �._ . __ _ ._ __ _ T_� _
r �.t�.3..J;�--=1Cdj.�...),..`��z€ l _ .x--1 _�._d$< . �
; __�. . . ._..,._. ._,... ..__._. ._ ._...,._ � __. .... _.... ._ ... ..
_.... _ .._...__ _ ..,.._... _..
' �i � Yt� '�_�-?��E1 .ts� � ��flr`��_�� � �;=! r 3 ;. ,
� � __� __ �.� � _ _ __. __. __ _
_� _ _ __ _ . ._E� _._ e
,
� ,.,,�:r��€ !� , . Rx�� ,r° � ��e , � r � � :;, s, .j;-
� >.�d .x>, d.�, F . , . ; . . , ,. _ - ,
.._ .... .. ... ._ ._.._..a__� -_..,._.._. _.�.. , _ _._ �.. _.._ __ .. . _...�_ , ,_ .. .. . ..
..� �'
Q �J'_�� .d .W _ ?" �, f?k..�',.� - i �.t.✓�i�
�_. ,_........ ..._....�.� . ,. ....,, .._......�._ _..__�..�._..�..�_.__ �... _ . . .__.._ ,...._ �....._.. ... ..... . ..
r ' > r�,,l, € ¢ � 5'2s ;�" �s;�a �
{���.��5 3 d�...,"s 't 'z_-_' €
, .. �._ ...,__.,,..,_ ._ ..... .._.. __, _.. ... .._ _ _." ' _.. ._ _ _ . ... _..
a�`�f3�C�'4 `� ��€ -�.- i , �. &
, � -P"� f s iY . � .
�..__�. . _ ._.___. `.' .___.. ._ ___ .._..._ ..u.._,__ _ _._ _ . ... _.`._, ` _ _
a , , —�— — . _ . � _ ._ . ..
� �p i ��-sr �;;+����� � a �=s ��€.:� �" �. ;;,+�r
, y , .
�.___ _ __ _ __,�____ ___ _ ..� _._ __�__._ ..__..__ _.�� _ ._._ _ _.__ �
._ .._____ __ _ _
� t'({ix#��i�'��:z�, _�.'4#? �/`t���.,1�e;i. ! ; : c' R r�.; y�. Ca:'�'.z�':,t� ,. . .
.._ ` .. . ,.+, ..... . _..
......._,.._.. . .. _..._. . �_..___ . __.___ .._....... . _ . . _._._ _ . ._. . . . _._.. .._.._. . .
_. _ _....._ - . .
s
i� °�e �0 C° t � �C` ,: `� U�t3�f y ' r .
,
. �
�„_ � _ ..._ _r . .._. ,.. . . ..� . . .... ,._. �. . _ . .._. ;'_ ___. .,._._ . ._. . , �
� ,�~e� ,3�,tt'`9 '�S ��� t c�°�# ;���'rt * '
s
,__- _.� �.,�,_. _.__�_____,"w. _,___ _._____� �__�__,..� '-.. _ _ __�r., _ .___, __-�—__ �._______w
` =tf�3l.)t�`#�s_.�,C:l'�IC: � ' ; ; :~�. ,,;.� r �i';3fa,.j�, _ __ ._
_
� , ,
, . ...._ _ .
� _ __ __ ___�.._,. _ ..__ _. __ � ._ _ . __. r_ _._. _ __ _
��,�<�,�1 i, ':�,"�;lt�9r': � - ,��+ a :����ab: �
, � � -
� __ . —-�, ,__.__�_ -- m_,_�_ _._____ _._ __ �_ _ - -_ __�___ ._. ...;_. __ . ..___ _ ,_.._
:"Y .�„ y.. . 3.��1 n±}'4`�i,.,l. , �$ sl. . ',.�A ��,.`S�(.,r ..
�,`._.�,_ ._.�...»....,..._.e�_.. _ a.�._._ ( . _ _ . ... .
.._ . .i_...._ _ _..�_... , .. ...__ ...[�� ... ...__ L..._ ._,.—i- �e..._.___ ...... ...�_., ..._..
� 1�4?��} .M�tj°�G..' f�,.74. ��3..,.�dt.+'13.Y�i .{..v.,_
�.. � 5
_>
E_,._. .._ _..,�__ ,.._._. ,_........ __.._. _�_..,......_ ... _ ._.._ ....__.....___....y-.,ti........._� _.. __.�.�...,._...___ _..._. ...1_. . .,._�.._.._..__.., ..__. ____._�._ _. ._, .
r .. . �-...+n� a i
. `��`L'Su..'...'f:��' '�C1-!.:'l�7��: , �; ; ' �i..�.� `-'�i\�.3,. ' , .
..�_. .�__ ' _____ .. ._.. __ .�..—_______.._ . --_.._..._._...._._�._�........�. ' . .
,. . . „ ._._ , � _ _ ..__ __ .�._�...... __ . _.__.._._ _._.._ _ __.
. . . .e� . ?:h. . , � .., F ,��,�L.r. .
` . _. _., _... .._:__ ._ � � .__ ._.�._.._. ._.__. . .._ .....�.,_...,_ .__. __ .._.. .__. .. .
,5 ; F.r: m _ � �
` �
_. v,°`_ �_.._ _r=-:,�^��
. ._._ _ � ._. _�_.._ < .__._ ._._____ .._ . _ _ _� ,_______._ � ___ _. __
e_ . � "r',� �. T. �
,._ __ .. . . ______._ ,____ __. _._�__.w.. _._, ._„ ,.�_ _____. _m.,. _ __ _. _
�.�. :"� , _ `_, ..z �
__,.__._�__________._,.._ _ ___. _ _ A
____,._____._ .�_._._ _u____ __ _ _._.
_ _ .. _ .__,.
. _ ._ � _ �Exr �
_... __._ _.__�__-�.____�____.______.___._._ _ _... _ _ _�_.._..___. . . __. �__ _
_
� _. � , ��'� r� _ �
_.._, ._ . _ �..�._, _. . �__ _ -- _ _ _. ..,� � ��>xe � _ ��
� �
, -:r�- � rl�.,,,��'_�pf` I_ �"'-���` __. ..L�.�'.��?��1.�'��_/:����,�..,... „�'�A'1�G�'"1�',
,.,,..,�_ ,�,,, � �.,
..�� . �. ,. _ �� �.
___ __
_ ..,... � r'.�,a
�
�___
;_._�r'1��w��i '���''�,�t�''��_:_�,._,���'�. �'��'s'� "`� _.�_< �-_ _
E
�
�
.--._ _ __ . __ _. ���.__�_ ___ �__.__.� _ .
�
�
�= ___ _____ ___m_ ..____ ,__ ___ ___.� ___.. ____ __ __. _____ m_. .___. . _._ _ _
��_ __ ,__— -
E_._ . _.. , ___ __ ._ __
_ _v _ __.
�� � . � - � ���
� �: � . � , .
�,� ��. _�� _ _ - ____ _ __ _ . .,_ ____. _ _ _ _ __ _
., � . ,,�..
.
_
'��� '�o �Y�,.��u� ��i��`"�s�.�Jyh�°�vY(i� � . . . ...._. . .._.. .._.. .._... . . .. ..
, ___._ __ ._. . _._ , __ .__ ..._ . ._ .
��� �u ���� ��� �� � ��1 �
ii dY
q
� i
r I �
E � Q � ... .. . . ... _...... . .
ii i ....._.._....__ .._.__.,..._._._,_ �,.. , —.. .. . �_ ,,._._..0 ,..�__-� �
q __ '_ —. .— ._
f
i. � �.. 1 ... ....... .... .... .. . ..... . ..... ....
.. :i _.._._ . ._..___ •_ _.._. _.... . _.__ . ._. — .
V � `
� . .. ...,.e_.. ...,.... .._ ...._. ._.. , _.._ , . _._ ..._... —..._ ..... . .... . ... . ... . .�,
� � _.,,..�._..__ .. _.._.�_ _..........._... .. _.. .... . .. ... _.._. . . . . . _ . �
�
1
(lIA I11JD 11AR I
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21660 E.Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
��o
PRESS
FIRMLY
JOBSITE
ADDRESS C--
APN LOT TRACT 2Z J
OWNER
ADDRES ghwosofw S� ?
CITY 2/ZIP97Z6/2-TEL.y Zi
APPLICANT TEL.
CONTRACTOR
ADDRESS
CITY ZIP TEL.
ARCH/ENG/
DESIGNER
ADDRESS
CITY IP TEL.
OWNER-BUILDER DECLARATION
09/7
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE LAW FOR THE FOLLOWING REASON (SEC.7031.5 BUSINESS AND PROFESSIONS CODE:ANY CITY OR
COUNTY WHICH REQUIRES A PERMITTO CONSTRUCT,ALTER,IMPROVE, DEMOLISH,OR REPAIR ANY STRUC-
TURE,PRIOR TOOTS 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-
CENSE LAW(CHAPTER 9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSIONS CODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TION.ANY VIOLATION OF SECTION 7031.6 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS(SOCK).):
^ I,AS OWNER OF THE PROPERTY. OR MV EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION.
WILL 00 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 BURRS 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 FOR SALE IF,HOWEVER THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF COMPLE-
TION.THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
1-11.AS OWNER OF THE PROPERTY,AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC. 7044, BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI-
CENSE LAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS WITHA CONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAC-
TORS LICENSE LAW.).
^ I AM EXEMPT UNDER SEC. B. &P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
(HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
9(COMMENCING WITH SECTION 7500)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND
MY LICENSE IS IN FULL FOPCEAND EFFECT
/
�0. N0./
DCENSECLASS
7<
��
pA7E CONTRACTOR CONTRACTOR
��
wAe
WORKERS'COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-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.
'OJ/__-(HAVE AND WILL 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 WO RS'CCIMPENSAJION INSURANCE CARRIER AND POLICY NUMBS RE:
1 "
CARRIER
ICYNUMBER/j �_71-01i4�7i4_
P
0
E
I
A
R
7
LETED OF THE PERMIT IS FOR ONE F J
R
0
XXJA
S($700)0
LESS
(15110
ECTlOW NEED NOT BE OCM
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE
WORKERS'COMPENSATION LAWS OF CALIFORNIA.AND AGREE THAT IF I SHOULD BECOME
SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR
C
DE,I
SSHALLLFOORTHWITH COMPLY WITH T OSE PROVISIONS.
0
72-01
DATE: I L�APPLICANT:�
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($100,000),IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3709 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES.
CONSTRUCTlON LENDING AGENCY
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHIG 'THIS PERMIT IS ISSUE SEC. 3007,CIV.C).
LENDER'S NAME
LENDER'S ADDRESS
i 1 CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES.
PERMITTEE NAME(PRINT)9 .-7
3 SIGNATU F°PERMITTEE DATE
APPLICATION PERMIT P/C
DATE NUMBER#
ISSUE TYPE OCC
DATE CONST.GROUP
ZONING SETBACKS
FRONT RW^
REAR^
SIDE/SIDE STREET RW^
SIDE
PROPOSED USE i L(?
N0. DWEL. N0. N0.
UNITS STORIES BEDROOMS
DESCRIPTION S0. FT. FACTOR PSF ADJ.AREA/VALUATION
SFRIADD/REM
U) Garage/Carport
LLI Patio/Deck
LIJ
LL Pool/Spa
Z
Re-Roof
Commercial
M
Valuation ADJ.AREA
QUANTITY DESCRIPTION FEE
J
U
I-
U
W
J
w
Z
co
CL
Q
U
Z
Q
CONSTRUCTION
PLAN REVIEW
ELECTRIC
PLUMBING_L.
MECHANICAL
INSPECTION FEE
ISSUANCE
SMIP
ENERGY P/C
ENERGY PERMIT
RETENTION FEE:
PRE-ALT FEE:
TOTAL FEES
COMMENTS
RECPT N0. PAID BY VALIDATION
WHITE-Department Copy,YELLOW-Finance Copy, PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy
-,-7 wlr