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COMMUNITY DEVELOPMENT DEPARTMENT ��T �/��;✓ :,,._� . 2166DE.Copley DriveSuite 190 O�! �, an PRESS (909)8603195 Fax(909)8613I17 ��""�"" BUILDINGPERMITAPPLICATIQN ��uQ� FIRMLY ' � JOBSITE ""'� ,�y APPLICATIQ�j (� PERMIT �j ,,/�t P7C ,r�� �/ o ADQRESS �.�3 ��, ��Y.Q��{9C"r�`' Z-�!'�"� DATE [ ��'-Z � NUMBER L �` #' 6 �'�O ( c� ISSUE TYPE OCC APN LOT TRACT DATE CONST. GROUP p OWNER �I(L'���V2� �� o ADDRESS ZONING SETBACKS oCITY i�+uWja-s��� � 21P TEL�!� � ' 3�+ FRONT RW ❑ APPLICANT ��+#,f�����'�_�-��� TEL.-�� REAR ❑ � SIDE/SIDE STREET RW ❑ z ¢ CONTRACTO 1 �Y'�C�� Z"L+����� SIDE ❑ ADDRESS 3'3 :��'2� r� o CITY �QI��'�°'✓.� ZIP p7 TEL.g�p ��G?7�`� PROPOSEDUSE ����� �C..I�IZ���� o ARCWENG/ iz DESIGNER NO.DWEL. NO. - NO. a ADDRESS UNITS 'STORIES BEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR P5F ADJ.AREANALUATION � OWNER•BI;ILDER DECLAftATION SFR/ADD/REM O p I HEHEBY AFFIRM UNOER PENALTY OF PER.NRV THAT I AM EXEMPT FflOM THE CANTMCTORS L4 Gdl'8<JB/CelpOlf W CENSELAWFORTHEFOLLOWMGREASON(SEC.7037.SBUSWESSANOPROFESSIONSCODE:ANYGTYOR (n U WUNTVWHICHRC-0UIRESAPERAAITTO�NSTRUCT,ALTER,IMPflOVE,DEMOLISH,ORREPAIRANYSTRUG W 3Ii0/DBCI( �� � � - � -Z TURE,PRIOR TO ITS ISSUMICE,ALSO RE�UIHES THE APPLICANT FOR SUCH PENMITTO FILE A SIGNED W STATFMENT THAY HE OH SHE IS LICENSED PUHSUANT TO THE PROVISIONS OF THE COMRACTORS LI-� W � CENSE UW{CHAPTER 9(COMMENCING YATH SECTION 7000)OF DIVISION 3 OF THE BUSW ESS AND PR6 �� PooUSpa � � 0 FESSIONSCODE)ORTHATHEOfl3HEI3IXEMPTTHEHEFROMANDTHEBASI3FOR7HEALLEGED,EXEMP• . V TION.ANYVIOLATIONOFSECTION7031.SBYANYAPPLICANTFORAPERMITSU&IEC'TSTHEAPPLICANTTO Z Re-Roof A CIVIL PENAlTV OF NOT MORE THAN FIVE HUNDRED DOLLAflS(55W).�: 2 ❑I,ASOWNEROFTHEPROPERTY,ORMVEMPIOYEESWITHWAGESASTHEIRSOLECAMPENSATION, � Commercial - � WILL DO THE WORK NN�THE STHUCTURE IS NOT IMENDED OR OFFERED FOR SALE(SEC.7044.BUSI- J � NESS AND PROFESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES NOT APPLV TO AN DWNER OF ? J PROPEHTY WFIO BUILDS OR IMPROVES 7HEREON,AND WFIO DOES SUCH WORK HlMSELF OR HEiiSELF ON [ � � THflOUGHHISOFHERONMEMPLOYEES,PROVIDED7HATSUCHIMPROVQAENTSARENOTIMENDEDOR m �S �����y QOFFEREDFOR3ALEIFFIOWEVER,THEBU�L�IN�ORIMPROVEMENTISSOL�WRHINONEYEAROFCOMP�E- c Z TION,THE OWNER-BUILDER WILL HAVE TiE BURDBJ OF PROVNJG THAT HE OR SHE DID NOi BUILD OR � IMPflOVE FOR THE PURPOSE OF 5ALE). W ❑I,ASOWNEROFTHEPROPER7I;AMEXCLUSNELYCONTFACTINGWITH-LICENSEDCONTRACTORS , p� � TO CONSTRUCT THE PRQIECT(SEC.7044.BUSWESS AND PROGESSIONS CADE:THE CONTRACTORS L�- VetU8t1011 /. C�V� ''�ADJ.pREA W CENSELAWDOESNOTAPPLYTOANOWNEROFAPROPERNWHOBUILDSORIMPFOVESTHEREON.AND - � WHOCONTRACTSFORSUCHPR0.IECTSWITHACONT(1ACTOR�SJLICENSEDPURSIIANTTOTHEGONTRAG QUANTITY DESCFIPTION � FEE � � TORS LICENSE UW.). ' . � ❑I AM E%B.iPT 11NDEfl SEC. B.&P.C.FOfl THIS REASON Q � U g�p 8 - � � - ..�aL9` �t'ssi'�6vS DATE OWNER V - � W � LICENSE�CONTRACTORS DECLARATION W � ¢ � I HEflEBYAFFIRM UNDER PENAI_TY OF PERJURY THAT I AM LICEN$ED UPDER PROVISIONS OF CHMTER � . � e(COMMENpNG WITH SECTION 7000)OF DIVISION 30F THE BUSINESS AND PROFE9310N5 CODE,AND Z MY LICENSE IS IN FULL FOflCEAND EFFECT. �1 o - - � LICENSE�S��C a L� � UC.NO. ��G + �+ � _ V DATE 17 � CONTRACTOfl � �E�� ��'Z�'�� �- . W � WORKEflS'COMPENSATION DECLARATION ����1� ¢ � 1 HEflEBYAFFIRM�NDER PENALN OF PEHJURV ONE OFTHE FOLLOWING DECLARATIONS: 1A . z Y Q 0 _IHAVEANDWILIMAINTAINACERTIFlCATEOFCONSENTTOSELF-INSUREFORWOFlKERS' _ � COMPENSFTION,ASPflOVIDEDBYSECilON97aoOFTNELABORCODE,FORTHEPEflFORM/WCE , , U a OF7HEWORKFORWHICHTHISPEPMITISISSUED. � -�- � � �� � � � 0 w _I HAVEAND WILL MAINTAIN WORKEHS'COMPENSATION INSUqANCE,AS RE�UIRED BY SECTION � - ' �// ./'1 Q 370o OF TME LABOR CODE,FOR THE PERFOHMANCE OF 7HE WORK FOR WHICH THIS PERMIT IS � 2) / -�/ ISSUED.MY WOflKEflS'COMPENSA710N INSURANCE CAHRIER AN�POLICY NUMBERAflE: CONSTRUCTION v�' !r J j CARR�ER PLAN REVIEW Z ro��cr NunasER ELECTRIC � ¢ � (f}tl55ECTIDHNE�NOTBEOq�MIEfmOFTiEPERMffISPoF1IXJEHUrDRED001.lAFlS�5f00)OFiLESS} P�UMBWG Z I CERTIFYTHAT IN THE PERf-0RMANCE OFTHE WORK FOR WHICH THIS PERMIT IS ISSUED,I MECHANICAL (� SHALLNOTEMPLOYANYPERSONINANYMANNERSOASTOBECOMESUBJECTTOTHE � WORKEHS'COMPENSATIONLAWSOFCALIFORNIA,ANDAGREEiHATIFISHOULDBECOME INSPECTIONFEE _ - � , SUBJECT70TFlEWORKERS'COAAPENSATIO ROVISION'OFSECTION37OOFTHELABOR � � CADE I SH FORTHWITH COMPLV WITH SE PRO ,NS. y ISSUANCE � Q �y / SMIP `p DATE: � 6 APRIGANT: � - f� .d' .,��� - � J ' WARNING:FAILURE TO SECUHE WOpKERS CCOAPENSATlO VERAGE IS UNL4WFUL,AND SHALlBE ENERGY P/C - LL . SU&IECTANEMPIOYERTOCRIMiNALPEWLTIESANDCNILFME6UPTOONEHUNDREDTHOU6AND ENERGYPERMIT € } DOLLARS(5100,000),IN ADUITION TOTHE COSTOF�MPENSATION,DAMAOESAS PROVIDED FOH IN � 'J� SECTION37080FTHELABORCODE,INTEREST,AnDATfORNEY5FEE5. RETENTIONFEE: � � � - �e� a CONSTRUCTION LENDING AGENCY PRE-ALT PEE: O � I HER�Y AFFIRM UNDEH PENALTV OF PERJUflY THAT THERE IS A CONSTRUCTION LENDING AGENCY , FORTHE PEHFORMANCE OFTHE WORK WR WHICHTHIS PERNIT IS ISSUED(SEG 3ae7,dV.G.). . Z � W � LENDER'S NAME ' ��_ � !— LENDER'SADDRESS W ICEflTIFYTHATIHAVEREADTHISAPPIICATIONANDSTATETiATTHEABOVEiNf-0RMATpNISCORRECT. TOTAL FEES � � d IAGflEETOCOMPLYWITHALLGITYANOGOUNTY6Fl�INANCESA(JOSTATELAWSRELA7INGTOBUILOING � ' � . . � CONSTRUCTION,ANDHEREBVAUTHORIZEREPRESEMATIVESOFTHISCOUN7YTOENTERUPON7HE � � � . . . � Z ABOVEMEMIONED PROPERTY f-0R INSPECTION PURPOSES. COMMENTS � � l:J i��NrCAJ� ��Cs�ud.'� m PER E N ip MT�� ���C��� . Q � � �SIGNATIkiE F EqM(TTEE � - ' ATE� -' �, , _ � RECPT.NO. 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