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-�-�------` --.__.,_____�_ . . . . crrY aF�r�orm s� �_� � --�`' --� DEPARTMENT OF COMrrILJNITY&DEVELOPMENT SERVICES Tf�r«rn � � 11:1SSLL1 21825 E.Copley Drive `` (909)864-3195 Fa�(909)861-3117 PRESS �,"'-�»�,. B�JdL�bIlotG PE1tMIT APPLICATION FIRMLY � JOBSITE � "' � RPPLICATION C� o ADDRESS������ �"�'�"'�'9A��dC�11 �f�8 DATE � NUMBE � 9 ��/C � , ISSUE TYPE OCC �- APN LOT/ TRACT DATE CONST. GROUP °C OWNER 1 a"�'�� ,���� � � 'p ZONING SETBACKS ADDRESS oCITY I ZIP�7 L� L�'�� S„2 �- '„f FRONT RW ❑ o APPGC NT TEL�`� SIDE/SIDE STREET RW ❑ aCONTRACTOR � P ^Y�"2`' _ SIDE ❑ , � <ADDRES 1 p PROPOSED USE CITY ' �� I ZIP�pTEL`�.✓�E/• ��A•�f oARCH/ENG/ �Q � �a^d o-S a c:3 t�`e P'°' z DESIGNER �` Y NO.DWEL. NO. NO. I � ADDRESS S C��""-�'^'?, �LG" is UNITS STORIES BEDROOMS � 'CITY ZIP TEL. �' I DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� � O�NER-Bl11LDER DECLARATION SFR/ADD/REM � O 'p �, '1 HEHEBY AFFIRM UNDER PE ALTY OF PERJURV THA71 AM EXEMPT FROM THE CONTRACTORS U- GflfflJE/CHYp011 W�. �CENSELAWFORTHEFOLLOWING EA50N(SEC.703t.b0U51NE55AN�PROFE5510N5CADE:ANYCIiYOfl (n U' �.COUNTVWHICHREdUIRESAPERM�Y70�CqV$TRUCT,ALTER,IMPAOVE,DEMOLISH,ORREPAIf1ANY5TFiUG W PdtiO/DBCk Z 'il1FE,PRIOR Tp li$ISSI7ANC6,A SO REQUIFiES iHE�APPLICANT FOR SUCH PERMIT TO FILE A SIGNED W, 'STATEMENT THAT HE OP'SHE IS IC,ENSED PURSUAN7 TO THE PROVISIONS OF THE CONTRACiORS ll- w ' Z.'��, �;�.CENSE LP:W(CIiAPTER 9(COMMEt�CING IMTH SECTION 7000)OF DIVISIOM 3 OF THE BUSINESS AND PFO- � POOVSpB �FE8310NSCOD�.ORTHATHcOfiSH,EISEXEMPTTHEREFFlOMANDTHEBASISFORTHEALLEGWEXEMP- (� �',. �'�TION:ANYVIOLqTIONOFSEGTION p3i;5BYANYAPPUCANTFOFiAPEflMITSU6JEG7SiHEAPPLICANTTO z Re-Foof ' A CIYIL PENALTV OFNOT MORE T N FIVE HUNOFiEO bOLU1R5(5500).J� ���, . .❑I,ASOWNEROfTHEPFiOP RT1$oRMYEMPLOYEESWtTHWAGESASTHEIF50LECOMPENSATION, � Commercial - Z�.�. '„WILL�O THE WORK,ANti THE ST,UCTURE IS NOT INTENqED OR OFFEHE�FOR SALE(SEC.7044.BUSI- J NESS'AND PROFESSIONS,COO� E CONTRACTORS LICENSE LAW DOES NOT APPLV TO AN OMMER OF � .PROPERLVWHOBUILDSORIMPR VESTHEqEONAN�.WHO'DOESSUCHWORKHIMSELFORHERSELFOR m ' ��, I THROU6HHISOIiHEROWNEMPL YEES,PROVI�EDTHATSUCHIMPROVEMENTSARENOTIMENDEDOR � w' �"�.OFFEREDFORSALE.IF,HOWEVER,i� EBUILDINGORIMPFOy�MEMTISSOIDWITMINONEYEAROFCOMPLE- .Z��'. j�.TiON.THE OWNER-6UILf1ER WILL�..AVE THE'BUR�EN OF PROVING THAT HE OR SHE DID NOT BUILD OR �, '�.;IMPROVEFORTHE'PURPOSEOF .EE), � � �OI,ASOWNEFiOFTHEPROP, RTY,AMEXCLUSIV�LYCONTf1RCTINGWihiLCENSEDCONiAACTOFS '�� .TO'�CANSTRl1CT'?HE PROJEC-'�S;C,70a4,�1J51NE55�AND'�,PROFESSIONS CO�E:THE CONiRACTORS LI- VAIIIHtIOfI ADJ.AREA 'W�'. ',�'CENSELAWDOESNOTAPPLVTO N';OWNER�.OFdPROPERT�YWHOBUILD50RIMPROVESTh'EREON,AND � '�;.�WHOCONTRACTSFORSUCHPFiO'ECTSWITHACONTFtACibR(&)'LICENSEDPURSUANTTOTHECONTFAG QUANTITY DESCRIPTION FEE Y ''TOq3lICENSELAW.�, ; � ) ��� �', �❑I AM ExEMPT UNDER SEC,�. � 9.a P.4 POR7Hl5 REASON U ,I LL'. � ' � .. � '� DATE �� oWNER U - '- Z,.. , . .,.�, . , ' , . w �� LICEN Eq CONTRACTOAS DECLARATlON � CC t HEREBI'�AFFIRbA UNDER�PENALT OF PERJURYTHAT I AM LICFNSE�UNDER AROVISIONS OF CHAPTER � . Q..� 9�COMMENCINGWITHSECTION700)OFDIYISION30FTHEBUSINESSANDPAOFESSIONSCODE,AND z `X�,., MVLICBdSEISINFt1L�FORCEAN¢,EFFECT.� m d. LICENSE CLASS L4C.NO. � � �j� �'�:���ATE CONTRACTOR a W , � , NlORK'�RS'COMPENSATION DECLAFATION Q .a . .' �.�. U � ' I�HERE6YAFFItiMUNOERPENALT OFPERJURYONEOFTHEFOLLOWMGDECLARATIONS: Z Z� �. _IHAVEANDWILti'�,MAINTAI ACERYIFICATEOFCONSENTTOSELF-IN5UREFORWORKERS' 2 COMPENSAiION;AS Pq0 I�ED BY SECTION 370o OF THE LABOR CODE,FOR THE PEflFORMANCE U ¢ OFiHE�WORKfQ�WH�C THISPERMITISISSUEO. � 0 �.� �'; IHAVEANdWILIIiMAINTAI �WORKERS'COMPENSAiIONINSURANCE,ASRE�UiREDBYSECTION Q '. 37a00FTHELABORCODE,�'.FORTHEPERFORMANCEOFTHEWORKFORWHICHTHISPEPMITIS ISSUED.MY WOF�KEiiS Cc�MFENSATION INSUqANCE CARRIERAN�POLICY NUM6ERARE: CONSTRUCTION j�� CARRIER � �I PLAN REVIEW zPouCYNUMBER;,'�� I ELECTRIC Q: . . �� �.. � Q (IHISSECiIONNEEQ.NOTB�COMPLEfE�OFhIEPERMRISFORONEHUNDPED00LLARS(S10G)ORLESS). PLUMBING Z' . ICEflTIFYTHATI�J��SHEP FORMANCEOFhiE\NORKFORWHICHTHISPERMI'ISISSUED,I MECHANICAL ����� g � � '6,} SHALL NOT EMPIbY ANY' ERSON IN ANY MANNER 50 AS TO BEGOME SUBJECT TO THE a""�"""' � � WORKERS'COMPENSW71 N I.AWS CF CAIIFORNIA,AND AGFEE iHAT IF 1 SHOU:.D BECOME p INSPECTION FEE �� � �' . _� , 'SUBJECTTO TFiE�WOqKE S'COMPENSA710N PROVISIDNS OF SECTION 37000F 7HE LABOR � "-y"y!'- ::''�� � �� `y �l���P''`�\ WDE,ISHALLFY7FSTHWI bOtdPLVWIiHTHOSEPROVI510N5. ISSUANCE �� �""� �� , . . .�. �. � SMIP : p OATE: �� A PLICANT; ! —� WARNING:FAILURETOSECU�E ORKERS'COMPENSATIONCOVERAGEISUNLAWFl1L,ANDSHALLBE ENERGYP/C � � � i J' SUBJECTANEMPLOVER���TQCRIMNALPENALTIESAN�CIVILFINESUPTOONEHUNOREDTHOUSAND � LL� ENERGY PERMIT i ' DOLLARS(EtUO 000),IN,qD�1TION O THE COST OF COM?ENSATION,DAMAGES AS PROVI�EO FOR M �� SEGTION37o90FTHELA6qfi�.W E,INTE�EST,ANOATTORNEV'SFEES. RETENTIONFEE: 'jT' F . ' . :-.-_..--"F'--_"_ _.".„. d' � �CO STRUCTION LENDING AGENCY PRE-ALT FEE: ��"' O �; I HEREBY AFFIaM UNDER PENALT(((fff OF PERJURY THATTHERE IS ACONSTRUCTION LENDINO A�ENCY FOR THE PERFORMANGEOFTHE�VYORK FOR WHIGH THIS PERMIT IS ISSUED(SEC.309'!,GIV.C.�. . Z' W, �','. LENOER'SNAME F- LEN�EFi'SADORESS� �:� L 7 �-� ICEflTIFYTHATIHA�/EFifiia�.THISAPPLICATIONAND5TA7ETHATTHEA60VEINFORMAilONiSCORRECL TOTAL FEES /'"� g ��. IAGREETOCOMPLYWIThIALLCITYANDCOUNTYORDINANCESANOSTATELAWSRELATINGTOBUILDING ��, CONSTRUCTION,ANOHERE6VAUTHOA2EREPRESENTATIVESOFTHISCOUNTYTOENTERUPONTHE �. ABOVE�M NTIQNEDPROPERTYf PINSPECTIONPURPOSES. COMMENTS 0 �'. ��,� i�'�f �� .�'W��� a� PERM �NAME(PftIN`f�r�' /f � �`'`1/� ' �ii /��f �j/ ) Cn.'� 7 ' �Jg' (�/ E Uj.' SIG�, P FM ,F�� OATE � ,.O _;, � � RECPT.i\O. 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