HomeMy WebLinkAbout14-3994 . _ ' w s.rTe mo►��ay� �e�1'
' _'.,:'.�""���. C1TY OF DIAMOND 13AR
i I .Ls I 1 i ' I DEPARTMENT OF COMMUNITY&DEVELOPMGNT SERVICES
� , ,��Ill��i �: 21810 Copley Drive,Diamond Bar,cA 9i��s PRESS ,
,,,��� ' (909)839-7020 I+ax: (909)861-3117 Building Inspection Hotline(909)839-7027
� .�'":U�':'-� suiLniNc PExv�iTArPLicATioN FIRWILY
� � � , �
APPLICATION DATE: P/C#
¢ JOB SITE ADDRESS ) �f n
a ISSUE DATE: �—��� �� PERMIT# �'�— J �7�
I z APN LOT TRACT
0
o OWNER TYPE CONST.�—'Q� OCC GROUP:
N ADDRESS`�2� � ZONING SEfBACKS
� CITY Ir ZIP TEL. � FRONT RW ❑
a APPLICANT S L. S� REAR ❑
�
0
� SIDE/SIDE STREET RW ❑
a CONTRACTOR � � �K� Q ' 1 SIDE ❑
oro ADDRESS � A�
PROPOSED USE 2 v1
� CITY • ZI�TEL. D� � S � �-
o ARCH/ENG/DESIGNER • PJ1t.°�.r`q < � � S�OII Ii y'� �-�J J
z ADDRESS ��e- 't��' / ` �6 4'1L�
o �i L.UNI N STORIES_l_ #BEDROOMS
z CITY ZIP TEL.
� DESCRIPTION SQ.Ff. FACTOR PSF ADJ.AREANALUATION
OWNER-BUILDER DECLAflATION
� I hereby atlirm under penalty of perjury that I am exempt from the Coniractor's State License Law for the reason(s) SFA/ADD/REM
� indicated below by the checkmark�s�,I have placed ne#to the apDlicable item�s)[Section 7031.5,Business and
o Garage/Carport
o Professions Code:Any city or county that requires a permit to construct,alter,improve,demoiish,or repair,any
z structure,Drior to its issuance,also requires the applicant for the pe�mit to file a signed statement Thal he or she � Patio/Deck
a Is licensed pursuant to the provisions ol the ConVactor's Sfate License Ww(Chapter 9)Cammencing with Sedion W
� 7000 of Division 3 of the Business and Praiessions Cade]or lhat he or she is exempt from iicensure and the basis for LL Pool/Spa
� the alleged exemption.Any violation of Section 7031.5 by any applicant for a permR subjects the applicant to a civil penafty �
� ot not more than five hundred dollars(5500). Q Re-Roof
o �1 I,as owner of the property,or my employees with wages as their sole compensation,will do(�all 01 or(1 partions � Commercial
� of ihe work,and the struclure is not intended or oflered for sale(Section 7044,Business and Pmfessions Code:The m
Z ConVactors'State License Law does not apply ro an owner of property who,through employees'or personai effort,builds
� or improves ihe properry,provided that the improvemenis are not intended or offered tor sale.If however,ihe building or
� improvement is sold within one year of completion,the Owner-Builder will have the burden of proving that it was nat 6uilt
p or improved for the purpose of sale.).
� (�I,as owner af the property,am exclusively conVacGng with licensed ConVactors[o construct the project(Section
z7044,Business and Professions Code:Tlie Contractors'State License Law does not apply to an uwner ol property who ValuatiOn: Adj.Area: '
� buildsorimprovesthereon,andwhoconuaclslortheprojectswithalicensedContractorpursuanttotheContracrors'Stale QUANTIIY DESCRIPTION FEE
Y License Law.).
o U I am exempt trom licensure under the ConUactor's State License law for the following reason(5): �
� s
ZBy my signature below I acknowledge that,except tor my personal residence in which I must have resided for at least one w
� ycar prior to compleUon of ihe improvements covered by this permit,l cannot legally sell a shucture that I have built as an W
a owner-builder if it has not been constructed in its entirery by licensed contrac[ors.I understand Nat a copy of the applicable
� law,Section 7044 ot the Business and Professions Code is availabie upon request when this appliration is submitletl or at
X the lollowing Web site:http/wvnv.leginfo.ca.govlcalaw.html. Z
0 DATE: SIGN: �
� LICENSED CONTRACTOH'S DECLARATION �
� I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9(commencing with Section 7000) �
w
m of Division 3 ot the Business/a+nd Professions Code,and my license is in full force and effect. J J
� LICENSE C SS: �+ J � LIC.NO.: S����C a
o DATEi CONTRACTOR� . � � _
Z �
¢ WOHNEH'S COMP4! ATION DECIAflATION �
w I HEREBY AFfIRM UNDER PENALTV OF PERJURY ONE Of THE FOLLOWING DECLARATIONS: Q
oI have and will maintain a Certificate of Consent to Self-Insure for Worker's Compensation,as provided by CONSTRUCTION: '��7� ��
� Seclion 3700 of ihe labw Code,for the performance of the work for which lliis permit is issued. p�,qN REVIEW:
> �I have and will maintain Worker's Compensation Insu2nce,as repuired by Section 3700 of the Labor Cade,(or ELECTRIC:
o the peAormance at the work tor which this permit is iuued.My Worker's Compensa6on Insurance Carrier antl
¢ PolicyNumberare: �� � � -1 PLUMBING:
� CARRIER 0. ���l�DI MECHANICAL:
w
� POLICYNUMBER�pS��T? INSPECTION FEE:
(THIS SEC(ION NFED NOT BE CAMPLEfEO IF THE PFAMIT IS FOR ONE Hl1NDRED DOLLAHS($100)OR LESSJ. � ^�
o� ISSUANCE: �„pr•f�1
I cedify that in lhe pedormance of Uie work for which Nis permit is issued,I shall nol employ any person in any manner so a5 to SM IP: /r 3-/
o become subject to Ihe WakerS Compensation Lavrs of Calitomia.Md agree Ih ' I should 6ecome su6ject ro the Worker's
� Compensa'on pr 'ns o(Seclion 3700 o1 Ihe Labor ,I shall torUnvith mp ith those provisions. ENERGY P/C:
LL DATE: nPPUCar�r: ENERGY PERMIT:
� wARNI :Failure to secure Workers Cam salion coverage is unlawtul,and shali subject an employer to criminal RETENTION FEE: �• a
w penatties and civil fines up to one hundre thousand dollars($100,000),in addition to the cost ot the compensation, ,
a damages as provided for in section 3708 of the la6or code,interes[,and attomey's fees. � PRE-ALT FEE:
0 Jf p
a CONSTRUCTION LENDING AGENCY BSAF:f •v Y
w I hereby affirm under penalry ot perjury that there is a Constmction Lending Agen�y tor ihe pedomiance of the work for
= which this permit is issued(Sec.3097,Civ.C.�. -
� •
� LENDER'S NAME D
� LENDER'SAD�RESS: '� � �
a I certify that I have read this aDPlication and state tha[the above intormaUon is correct.I agree to comply with all city and TOTAL FEES
Z county ordinances and sfate laws relating to building construction,and hereby authorize representatives of this county to COMMENTS:
p enter upon the above-mentloned property far in�n purposes.
J
m
� 1
a PERMITTEE NAME(PRINn
� � � � �
�
= SIGNATURE C9iMITf E DATE . RECEIPT# PAID BY: VALIDATION:
H
WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—ApplicanYs Copy
1
.___. _ . -___ _ �. - ,_ _ .
CITY OF DIAMOND BAR � �
INSPECTION RECORD ,
• • P � � a - � • � , . � .
SETBACK/,LETTER `= ` ' TRACT AND LEDGER
"FOOTINGS FORMS `':;, .. . '�. -" , -- -j :' . , "�'' ., :':, ': SWITCH GEAR
SLAB::` �;; � su. '° �� ' ��u ���,��� COMMERCIAL HOOD
UG.`P'LUMBfNG.' - '' T-BAR
UG:ELECTRICAL;, - � INTERCEPTER
UFER GROUNQ'�`. . - - _ ' - HOT MOP/SHOWERPAN
SEWER LATERAL SEPTIC/CESSPQOL
MAIN WATER LINE HERS REPORT RECEIVED
SEWER CLEANOUT DEMOLITION
ROOF SHEATHING 4. L,/ � ROOF DRAINS
FLOOR SHEATHING ROUGH CONDUIT
SHEAR'WALLS E'XTERIOR ' � ' >' h POOL/SPA'':� ,� ; �:� ->� -
SHEAR WALLS INTERIOR �` ;. ,```' ;' , ,_ ..' : ,'` RO,UGH PLUMBING . ; ��;: "
FRAMINGNENTING ROUGH ELEGTRICAL;::` r' ' `
_ � . :..,
ROUGH MECHANICAL �-. ' • ` s ' " ' '� ROUGH MEGHANICAL_ � �
: ,
�, �. �. ,, , ; �, � �� �,
ROUGH ELECTRICAL W(.)�( ) �` . �, .. ;�, , -. .. . .'- ' GAS,TEST ;: . s. . .; _ ..�, ., .. �.� �:: P�` , :`, -
`ROUGH PLUMBWG ' ''; �� ' ;: " ` ` .` ' .,`>;' '- PRE GUNITE,; !�. -
INSULATION WALL FOOL PRE DECK BQNDING " � ` ' '} "
INSULATION CEILING P-TRAP < - -
DRYWALL FENCE/,GATEI ALARM , �.' -
LATH(PRE) FIPVAL POOL� ,_;;. : ,���`
LATH EXTERIOR WALLS:
LATH INTERIOR WALL FOOTING/STEEL
GAS TEST WALL STEEL 1�T( )2ND( )LIFT
SCRATCH COAT WALL BOND BEAM
ELECTRIC METER RELEASE WALL DRAIN/SEAL
GAS METER RELEASE WALL FiNAL
SPECIAL WSPECTION R0.FRAMING PLANNINGAPPRQUAL - -
.;; , ' '.
,.,_ , .
FINAL`BUILDINB ,, ; .- -'_ ,. ,` ; ROUGHFIREAPPROVAL ''` '
� ,:
FINAL'�MECHANICAL'-' '- ;�'' `' z, ;:` ,:i ;` '-_ `, '; FINAL FIRE'DEEARTMENT `; �. .. .
FINALfLECTRIGAL .- ' - , �� � ; , = '' . ,; _ `
- � � .�_2 � �� - � � � ._ " : :PINAL PLANNING� r ��;
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FINAL,PLUMBING .- - FINAL ENGINEERtNG/PW �' � � `
TC.of;OCCUPANCY; � .� �_` ;` . ' �� ;:: -, FINALCOMMUNITYSERVICES ' � _
CERL of OGCUPANCY;;> . ,;;., ," � ,�•`. ... ;'',.. `.: ; . ;.. : .. '. FINAL`HEALTH'DEPT., . y >;�. � ..��<. _..�
, �.� _ x +�
FINA6'INDUSTRIAL;WASTE. : ...� ' `
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COMMENTS: A-���2� ,. .l.�b�
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r�'���+� C1TY OF DIAMOND BAR � �
i I I I { DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
. . _. .,
' '�j� '. � ' 21810 Copley Drive,Diamond Bar,ca 9i�6s . PRESS
��
(909)839-7020 Fax:(909)861-3117 Building Inspection Ho�line(909)839-7027 FIRMLY
. ���'�s'� . , BUILDING PERMIT APPLICATION.
~ L '"" �. APPLICATION DATE ` � I� �I �
w JOB SITE ADDRESS� , �` t r ��'�t! �'` ��t P/Cq
j- ��r-� ;�f td..;_ � r ;
a .J ISSUE DATE: PERMIT# �r i •
z APN LOT TRACT •� � �r ,
0
o OWNER � ' TYPE CONST. f�� "-'��Q 1"' OCC GROUP:
� ADDRESS� ` � T. 'r t ._ i .� ': , � !�
� "r, ; . I I 1 r .�-� I � w !�J"�. CY.'` ZONING S�BACKS .
�
CITY , r +.ti • �„�,F ZIP'•�, ,��•.. TEL. FRONT RW ❑
'� APPLICANT `�.'� ,rE�fi�.l••i" �,Jds+f,Dt�EL.{��(,�7���' --�6��':�' REAR ❑
' � .✓ SIDFJSIDE STREET RW ❑
� } r.. �r r.•...
CONTR,4CTOR :�i.��i f't^.�'�,t'!k' t�C t.i�}4 a 1,�-A; SIDE
o �.r . . . 1 i': • �� i J !.➢' 7 � •
o ADDRESS'.� ? { �t r•:l�,,.ti,. �,:a,,,r Fs s �'-, v� e;• r o...,,�. ' ! ' �
°�p, PROPOSEDUSEfJ�► �v.�< '�;� �cr�-a l..�i �+.+.t i'n. re t 1'rl� :` �.�,..,,,....
!r i Yl i r . � P. -f✓} ...-�y+. �'� v!k�i7��� � .
¢ CITY,,..i�a�.,,�,t-•.c��o� r>1 i ZIF;ir 7e.:�.s TEL.�'r t 'i � > r r, ✓S x sr ,.�,..� �. t,,, �r �r � �
'�'1•L� ' S '� � � �.: -:., 7 \ 1:�. . . �.`.' �� i`k': r',�� �
� ARCH/ENG/DESIGNER ,y: T; ' �^ �"�; { '`° �I�� ,,f.lEil S �:: ��? �
p ��' 'r t4 t.... .,il't ft.I�1 f �!i 'r r(t,.+
G�,.. ld .ti�'S.«rt�ti,?. . � ." .�.}'.l:.' . �
z ADDRESS �-- ��- � - • , F. ('
o q DWEL.UNfFB� #STORIES_� #BEDROOMS
z CIIY ZIP TEL. '
� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION
OWNFA-BUILDER DECLAflATiON �
� I hereby aKrm under penalty of Oerjury U�at I am exempt hom tlie Cantractor's SUte lJcc�nse Law lor the rcason(s) SFR/ADD/REM
o indicated below by�the checkmark(s),I have�placed neM to�the aDDlicable�em(s)[Sectlon 70315,Busluss ertd Garege/Carport -
"� Professions Code:Any city or couMy that requlres a perml[tn coretruct,aller,lmprore,�demolish,m repal,�any
z struclum,�prior to Its tssuance,also requlres ihe apD��caM for the parmR to file a aigrred atatemrnt that he or she y �PatldDeck . � .. � .
a Is licensed�pursuant to ihe provislons of the CoMractor's State Llarrse�Law(Chapter�Commerwinp with Sestion . w �
� 7000 of Uivision 3 of the Business and Professlom Code]or that he a slie is ezemDt hom�ke�ure and 1he basis for LL ?°°�1Spa
� the alleged.exemption.Any violation of Section 7031.5 by any app6p�rt lor a pertnd subjects Ihe aDD�iprtt to a civll percatly Z Re-Roaf '.% .���;.-� .
¢ ol.not more than live hundred dollars(5500). . � � . � . �� � � � _�
o (J I,as owner o1 ihe property,or my employees wtth wages as thelr sole compensatlai,w�l do O all of or(�portlais � Commerclal �'�
0 01 the work,and the 56ucture is not Intended a a(fered 1or sale(Sec6on 7044,Business aiid Professlons Code:The m . �
� Contracturs'State License Lew dces not apply fi an owner af property vfio,through employees'or personal effa[,huilds
w or impmves the property,pmvided tt��at the ImprovemenLS are nat irRended or oTfered fm sale.tt however,the buitding or � �� . . ' - .
� improvement is sold wimin one year of comple6m,the Owner-Buitder witl have tlie burden oi proNng ihat it wav not Wift
0 or imprmed hx the purpa5e ot sale.). �- . . ' � � .
v (,]I,as owner af the properry,am ezdusMety conVactlng withlicensed Contractors tn construcl the proJect(SecUon
- Z 7044,Business and Rotessions Code:The Contractms'State Llcense law does nat appty In an owner o1 propely who Valuation: '�1�� �Y�' �' ' Adj.Area: �
N buildsaimprovesthereon;andwhocontracfsiwfhepro�ectswithellcer�sedContracmrpursuaMtoUreQmtractors'State QUANTITY � DESCRIPTION �FEE �
Y License Law.).
o U I am exempt hom Iicensure under the ConVacNr's State ucense law im Ne tdlowinp reason(s): �
3 - . �
LL By my signature below I acknowledge that,except for rtry personal r�sidence in which I must have reslded fa at leasl one � . - �_ - � �
o year prlor to completlon of Ne Improvements covered by ttiis permit,l carirmt lepaly sell a sWcMe that I have buifl as an w ,
�a owner-builder II ft has rrot been constructed In ifs entlrery by�icensed contractors.I imderstaM thffi a cap�of the applicab�e
� law,Section 7044 oi the Busines5 and Professlons Code Is available upon request when thls appfiratlon Is suMnitled a at . . .
X the following Web site:MtpJwww.leglnfi.ca.gov/calaw.html. , . . � , , ' Z .
� DATE:� SIGN: � - �
~ � ' . LICENSED CONTAACTOH'S DECLAHATION � � �
H n.
� I hereby attirm untler pe�lty of perjury.that 1 am licensed under provisians ol Chapter 9(commer�cing with Seclion 7000)
w
� oi Divlsion 3 01 the Business and Prolessians Code;and my Iicense is In 1u11 force and etfect. J i
N� . .`��'.i.t . .-.-+s.-' t_���I,.'1 _ �
y LICENSE CLASS . � ..-' � LIC N0� %. "G�' zQ
oZ DATE t`i YF'. i r s`� CON7AACTORr:..•:�� �^. � ..e.��t�. � � v � , . . . �
�¢ - �� � � WORKEFI'S COMP ATION DECLARATION � g , �
� 1 HEREBY AFFlRM UNDER PENALTY OF PERJURY ONE OF iHE FOLL�WING DEpl�AA710NS: � ,� !
oI have and wlll maintain a Certi�cate ol Consent to Sell-Insure tor Worker`s Compensation,as provided 6y ' CONSTRUCTION: �``
� _ �Sectlon 3700 ollhe Laba Code,for Ihe pertmmance a1 Ne wak ta whfch this pertnft Is issued. � p�qN REVIEW: - ��� �
> �'" I hare and will maintain Worker's Compensatlon Insurance,as repuired by Seciion 3700 of the Labor Code,for ELECTRIC:
o ihe perfortnance of the work tor which this pertnd is Issued:My Waker's Compensatiori I�urance Cartier and
a PoliqNumberare: . -- � � PLUMBING:
j�
� CARRIER .:a�� e;l�� ' ' c..:t ►re.c.. MECHANICAL:
. � � . POLICY NUMBER � ' �!.: �-;� r3���'� . � . . .
� �f .. t_.—� INSPECTiON FEE:
� (iMS SECf10N NEED NOT BE CAM%.EfED IF THE PEf1MR 6 FOR ONE HUNDRFD DOLLAfS�$100)OR LESS7. , � '7 �� �� �"s �
� ISSUANCE: 1 j ,
� I cerIAY that in ihe Dertomiance of ttie wak fa which this Dermft ts,BsueA,I stdl no[emPbY&N 0���aiy marmer so as ro . .
� bemme sibject ro the wdker's Compensation Laws of Calilomia.Md egree tfial.B I shaild hecome subject m ticeWake,r� SMIP: � � � � �, �� j�
� CompensaVon prwisions ot Sedion 3700 ol Ihe latior,Cod,I shall lorthwi�h u�mpy w�lh 1Mse provisla�s. ENERGY P/C: � �
LL DATE:7 r�k.�l��'Jr APPLIGwi:^'.�-,.'J..�G�!^c.r�' � ENERGY PERMff:
� WARNING:�Fallu're b secure Workers Com satlon�cwerage h unlawhil,and shall�sub�ect an employer to cAminal � . �:
w penatties and clvll fines�up to one hundred thousand dallars(a100,000�,In addition to U�e cost of the compe�atlon, RETENTION FEE: .,r�•�':�
a damages as provided ta in sectlon 3708 0l me labor code;interest,and attomey's fees. PRE-ALT FEE:
o .
a - . �� � CONSTRUCTIONLENDIN6AGENCY � , � � � BSAF: ��• ��/f
w ��ereby affirm unde(penalty of perJury tnat there is a CorrsWction Lending Agency 1w the pertmmance oi the work fm
� which this permit is Issued(Sec.3097,Gv.C.).
�. LENDER'S NAME �,..!
� ���� ! 4F��.
� LENDER'SAD�RESS: � � ' . . �
a I certify ihat I have read this�applicalion and sfate that the above infirmation is cortect I agree tri compty wlll�all dty and TOTAL FEES � � � . .
counry ordinances and siate laws relating fi buBding construcdon,and hereby authorize represerdalivves M thls couMy to
Z eS CpMMENTS:
p :enter upon the above-mentloned pmperty to�ins�ecti purposes. �
m r 4�'��-!:� f r��
¢ PERMfT'fEENAME(PRINn � � � � - � - .
. tn _�, � +�/�:l/
�, .�. ;��`' �...,�.,, �. ,.�'�t:�
� SIGNATURE QFF�ERMfTTEE,,.�✓ � .DATE � � �� � � RECEIPT q PAID BY: • VALIDATION: �
� � . �! .. . . • - . . . . . - . . � -
WHITE=Department Copy,YELLOW—Fnence Copy,PINK=llssessor Copy.GOLDENROD—Fle Copy,GREEN—Applicarrt's Copy '
. . . . . . . �.. _,�.,e' ffi„ ^..i�r «�• !' `r,.
. . . . � . . .. . '-.',i i
_ ��_, CITY OF DIAMOND BAR � _ �
i;
i I I I I , DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
�l PRESS
�` ''21810 Copley Drive,Diamond Bar,CA 91765
,4,�,W�,� (909)839-7020 Fax:(909)861-3117 Building InspecUon Ho�line(909)839-7027 �
- �"�""� BUILDING PERMITAPPLICATION FIRMLY
� /' �
� JOB SITE ADDRESS �" L ? 4 •i ',i 4 �'� ` � ��,,) � APPLICATION DATE �� I_C� �� � P/Cq
w ".J ,;..: ;t� 6J.;_ :t,� ,;;�f
a -� iSSUE DATE: � � l PERMIT# � �.� < <
zo APN LOT TRACT � ; ,
w OWNER , � k NPE CONST. ��e: �'�.�l�1�' OCC GROUP:
,
N ADDRESS��� � '+ t t"v�^ �, , W.� i" ZONING SEfBACKS -
—' CI'TY� '.�:- ti�.s �j ���+' ZIP�'S� •�t'" TEL. / ' r � /?f'" � I`
v� --��e�«, 6� �--�--� �.. ` FRONT RW ❑
� APPLICANT 7P'� �.. ,vt';�.I�y),��.F' r�ttiu:,►L�EL.t`�f.���t'�:' .ti'(�',S.,i y REAR ❑
� t -� i SIDE/SIDE STREET RW CL
a CONTRACTOR -�1 � i't'a,l�,�'t k' �.0 t.%fi,'t : 4•°�4 , SIDE ❑
� + i t � ' �` t C,fi 7
o ADDRESS i I(, i ��!t:��•,.^� L..: ki.�, � -,`vu t �� +.,..s
� �) u� r"' Ti r� .s�. si'r i:�.. PROPOSED USE{ l'.� :. � r • 'r . r � t-_ �n ':>r � �ci i, '' ��a�:,..:
[C �.IN� 't"q t�a.».1"nc'«ri� 1:;t.:� ! ZI��I f�'..r TEL.{ r�-'� � . Y' ,�� �i t i.^�' o.�� ,. - wi r a
� .� . . . . t si.4�j'ti", ". ,�y k ..T-r--�y+--� �,�:.�.� 1;;. � ; t. t. �f '�� .
`y ARCH/ENG/DESIGNER � } ; { j r ,��,,.-
o `M. . " r...� i�n�.3,<\.a. , _..+a} T.;1l1 r�� �'f �lr����{�i � . �;;'
o ADDRESS i�•t.�ta { 'Fa,�1 'i�,'• ' ,��, t'.. f.`�
#DWEL.UNIT6� #STORIES I . #BEDROOMS. �
z CITY ZIP TEL.
� DESCRIPTION S0.FT. FACTOR PSF ADJ.AREANALUATION
owrr�-euuo�oEcuwanox
� 1 hereby amrm under penatty oi perjury ihat I am exempl from the Caitrector's S[ate License Law tor ttie reason(s) SFR/ADD/REM . - . . .
0
`p indiwted below by the checkmark(s),I have�placed next to the aDN��e Aem(sJ[Section 70315,Buyness and Garega/Carport
'o' Professlons Code:My Gty or county that reqWres a permit to construcl,atler,Mprore,domoflah,a repaV,any ,
'�z strucWre,prior W its issuance,also requlres the applicant(or Ihe pertntt to file a algned stetement that he or she � �PatiNDeck - - � . � � .
a is lice�ed pursuant ta ihe provisions of Ihe CoMractor's Sfate llcease Law(Chapter 9)Cwnmencing with Sectim w
N7000 of Ohrislon 3 of the Business and Pralesslons Cade]or that he a stie is exempt hom Ilcerisure and the bazis tor LL P�USpa
N the alleged e�cemption.My violatinn of Sec6on 7031.5 by any applicant 1or apermit subjects the aDD��tfi aciuil penafty Z Ro-Roof "'?
� oi not more than(ive hundred dollars(5500). 0 'r.{' `�-.f-
o� (,J 1,as ownerof Ne propeM1y,or my employees with weges as their sole compensatlon,will do(_,)all 01 or(�portions � Commercial � . . ..
w ot tlie woAe,and me struchue is not intended a offered for sale.(SecOon 7044,Businrss and Professia�a Code:The m . . . � �.
� Contracturs'State License Law dces not appty Uo an owner of property vfio,thmugh employees'or peismal eitort,buildv � '
� or improves the property,provided lliat ihe improvements are not intended or offered for sale.tl howevrr,ihe building or
� improvement is sold within one year af completion,the Owner-Builder wili have 1�e burden ot pmvinp that It wag not buitt
p or impmved for fhe purpose of saie.).
� I,as owner al the m e am exclusNe conVazdn wilh ticensed Contractnrs fn construct the ro ec[
� lJ P v�x N 9 p 1 �'on Valuation: �a, :s'" i^' Adj.Area:
0 7044,Business and Protesslons Cotle:The Contractnrs'State License Law does not appty to an avmer of property who
z bulldsorimprovesthereon,andwhocontractsiartheprojectswithalicensedContractorpursvantlotheConVactars'Shate QUANTITY DESCRIPTION FEE
�
Y ycense Law.).
o U I am exempt from Iicensure under the ConVaclnr's State Liceose law for the tollowing reason(s): � . . . .
� By my signature below I acknowledpe tl�a[,except tor my peisaial residence In which I must have resided for at least rne � . .- - � . - �
Z. J
� year pdor to completion at Ne improvements covered by ihis permit,l cannot legalty sell a shucNre ihat I have buill as an W . . . ,
� owner-buitder If It has nol been constructed in its entlrety by licensed contracturs.I understand that a copy ol the applicaGle
� �law,Sectbn 7044 0l the Business and Professlons Code Is available upon iequest when this appliratlon Is su6Mtted or at . �
X ihe tollowinp Web site:hripAvww.leginfo.ca.goY/calaw.hhnl. . Z . .. . .
o UATE: SIGN: �
� � � � � � � LICENSED CONfiIACTDN'S UECLNSATION � �
w I hereby aflirm under penalty o1 Rerlury ihat 1 arn licensed untler provisians ot Chapter 9(commencing with Section 7000) � � �
m o1 Divlslon 3 of the Business and Pratessions Code,and my license is in full force and eTfect. J
N � .-;� �f .....,.,,:~" r; 1�:.�. �
� LICENSECIASS: . ..=� L1C NO ' Q
�Z DATE• `�i Yf'+r�� ��S 'CONTMCTOR:...�-+'•"� . � ..•.'._: .n�_t_. .::'t ' .. v � . . � .
� �a. �. � WORNEfl'5 COMP AiION UECLARADON g. � - - . . " � . �
' � I HFAEBY AFFIRM IINDER PENALTY Of PERJURY ONE OF THE FOLLDN7NG OECLAfiAT10NS:
oI have and will maintain a Cenificate ot Consent tn Setl-Insure tor workets Compehsation,as provided by CONSTRUCTION: ' �� '��
� Seclion 3700 o11he Labor Coda,tar Ihe pertormance o(the wak tor which Nis permit is issued. p�,qN REVIEW:
� �I have and will mtintain Worker's Compensation Insurance,as required hy Section 3700 0l the Labor Code,for � . � . �
� me peAortnance of the work tor which this permd is issued.My Waker's Compensation Insurance Camer and ELECTRIC:
¢ PolicyNumbuare: s -• � PLUMBING:
w CARRIER :":�e;�"'�� ��_t ,� rn..s_, MECHANICAL:
. � � . POLICY NUMBER i c: �i;� .�y""3 c• w . . . . .
� �=� �� � INSPECTION FEE:
(fHIS SECTION NffD NOT BE COA�PLEfEOIFT}iE PERMff IS FOR ONE FRINDHED DOLLARS(�10�OH L�. ��> t"'
� ISSUANCE � �
� I cerUfy ihat in ihe Perfomiarice of Ne work la which this pertnit is,issueA,I shall rot emDaY�Y D��any maruier so as to � . . . n ..
o nemme sub�ed tn me wmerfs eompen,sauon taws m calilomia nnd agree u,�sna,�a becane subject m me waxers SM IP: 1\ ;. � ,�'
� canpensaum a��ons of Secum 3�0o m me ianq.GQd,i snau�ormwim Piy vviu�mose arovisi«s. ENERGY P/C:
LL DATE:�����`aPPUCtwT:"`"""�= u';tG'+�•�-t> �" ENERGY PERMIT:
� WARNIN6:Faiiure tn.secure worker's Co�pEfaadon couerage is unlawful,and shall s�ject an empbyer to aiminal. RETENTION FEE: ��"�
w penattles and civil tines up to me hundred thousand tlollars,�$700,000),in atldi�on N ihe cost of the compensadon, � � �
o Oamages az provided for in sectian 3708 ut ihe labor code;interast,and attomey's hes. PRE-ALT FEE: f
a � � � CONSTHUCTION LENDING AGENCY �� � � BSAF: �' f��
,Z I hereby affirm wder�penalry of perjury that there is a Construction Lending Ageniy for tha Dertamance ot the work ta�r � � � � �
� which ihis Dermit is issued(Sec.3097,Civ.C.).
r LENDEA'S W1ME ti'r`f s"•F`
� LENDER'SADORESS: � i.:�'t�
a I certily ihat I have read ihls applicatirn and state that the above iniormatlon is correct I agree to campty willi all dty and TOTAL FEES
Z counry ordinances and siate laws relatlng fn huilding consWcdm,and hueby author(ze.representatives of this county to CpMMENTS: � � � � � �
9 �enter upon the abave-mentloned property fa in�ec �purposes. �. � . - . ,� .,. � � � � - � ^ � � �
m ,i.t� � �� v �"'"��`� Y� `�� . � � � - . . . �
.r^
¢� PERMfTTEEWIME(PRINn � �� � { t�,�,{ � � � � � � � �
. t!) � _^a. �� - ��l / ..
.1•-� r ,Y ('`,..e> ` .;` '/�. /L:' ,;
� � �� ,�—_
= SIGNATUREdFPFAMIITFE DATE RECEIPTfI PAIDBY: VALIDATION:
�
WHITE-Department Copy,YELLOW—Finance Copy,PINK—Assessa Copy,GOLDENROD—Fila Copy,GREEN—ApplicanYs Copy . ' "