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i —�'`'-----� CPI'Y OF DiAiv10NU BAR � ' COMM�JNITY I��VELOPMENT Di'sPARTMENT � � -,.,�; 21GGD F..Coplcy Drive Suite 190 �� ��� ��ES.�. (909)860-3195 Fax(909)86L3117 �'•"�'1� BUiLlliNG YERMIT APP[.ICATION � FIRMLY � JOBSITE +' y �;l,T'�° �, 7� L'���� �'� �. APPLICATION C�` 7� - PERMIT L-7 C � ADDRESS_ ar4✓ 1�'" /l.;�r•� __ DATE_.._,�__,�_._ NUMBER� �r _".. # '._"__ � issuE rvPe occ - APN_,_ LOT TRACT__.______ _.._ DATE_..._,_ ___. CONST. ...----- GROUP .,_. p OWNER �.--- -- - - ---- p ADDRESS�J , . ► �" �/171C�_'aJ�,�_.�' ZONING SETE3ACKS w ' - FRONT - ---._. L]--.— L�� S DE/SIDE STREET '— --- RW.---- -... z CITY � ZIP__ _��_ TEL. RW---- o APPLICANT _. �� TEL, t�S. ^'- -- Z _ J— - -- ¢ O , ` SIDE ---..---_ Q CONTRACTOR --- �'�/1.�,='-- - --- —._ I�_...._—..._.. --- O ADDRESS '��_ � ' �". ._C�� --- PROPOSED USE.__._ -- --- --- ----�- CITY_���,` ZIP���TEL.� �=�L� .� � ARCH/ENG/ — --- ---- �z DESIGNER _ ------. -- N0.DWEL. N0. NO. n� ADDRESS_ - ---- UNITS. 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FACTOR PSF ADJ,AREANALUA7IDN ? � OWNER•Bl,'ILDER DECLARA710N SFR/AUD/REM O - p' I HEREBV AFFIPM UNDEfI�[NAf TV OF PERJURV iHAT I AM E%[MVT FHOM THE CONTRACTORS LI� Gdf890/CafpO(I W CENSEIAWFOFlTHLFOLLOWMGHEA50N(SEC.'Io31.581151NF..SSANDPqOFESSIONSCqOt:ANYCITYOR (n U Cn�UNTYWI-IICHRE�UIRESAPERMITTOCONSTRUCT,ALTER.IMPROVL.�EMOI.ISH,OHqEPAIFANY;i'RUC- W PafiO/DOCk Z' TUqE,PRIOR TO ITS ISSUANCE.A150 HE�UIRES THE APPI.ICAN�l�OR SUCH PEflldlT TO�Rc A SIGNE� w STATFMENT THAY HE OR SHE IS UCENSED Pt1HSUAhI'1'O THE PROVISIONS Uf i fIE CONTR�CTJRS LI- w �.; CEYSF lAW�CNAPTER 9�COMMENCING Y!I�H SEC,TION 7000)OF DIVISIDN 3 0f-THE�USINe"SS ANf7 PR0- � Pool/Spa FESSIONS CODE�OR TI1qT f IE Ofi SFIt IS EXEMf'T THF;ftEFHOM AVD TNE BA515 FOR TM[aLl f:GF:U tXEMP� � TION.ANVV�OLATIONOFSEC710N7031.513YANY�PVI.ICANTFORAPEfiMITSUPJECfSTHEAPPLICANTTO z fie-Roof O ACIVIL PENALTY OF NOT MOIiC TI1AN FIVE Hl1NDRE�D�LLAfiS(E50D).): — i'II,ASOWNEROFTHEPqOPERTY,O(1MYf:MPLOYEESWITHWA6ESASTHEIfiSOLECOMPENSATION, 0 Commercfal Z. WIIL DO 1'l1E WORK,ANO THE STfil1CTUl7E I.S NOT INTENDED OR O�FIRI�f)FON SALE(SEC.]Und,t3U51- � J ._— _ NESS AN�PROFESSIONS CODE:THE CAYTRACTORS LIGCNSE LFY�OOES NOT APPI.Y 70 AN OWNER OF ' � PROPF'RTYWHO�UILDSORIMPROVES�H[RCON,ANDWIIOOOESSUCHWOfiKHIMSf:IFORHERSELFOR � �� 1'IIROUGHHISORHEF70WNEMVI.0YEE5.PROVIDE�THATSUCI�IIMPIIUVEMEN�SAflENOTINTEN;IEDOR m " w OfFEFE'DFORSAI.E.IF,HOVIF,VER,THEBUIL�INGORIMPHOVeMENTISSOLDWITNINO4LVEAliOFCOMPIE� �'. TION,THL OWNER-BUILDER WILL HAVE'lli[AUHUEN OF PROVING THAT HE O(i SHE DID NOT BUIL�OR � ��' IMPROVE FOR iF!E PURf'OSL Oi=SAIE). �' W� !.iI,ASOWNF.f10FTIiEPFOPERTY,AMFXCLI.:SIVL=LYCONTR�C?INGWITHI.IC[NSEDCONTRACTORS , � TO CON57RUCT THE PROJ[C7(SF'G lOdq CYUSINE55 ANO PRO�fSSIONS COf7E'iHE CONTRACTUHS LI- V2IUfftI0f1 _ ,__. _.____ADJ.AREA_...._-. . � W'- CENSELAWDOESNOTAPI'LYTOMIOWNEHOFAPPOP[IITYYVhIOBUILUSORIMPROVE3THEREON,AND ' ' � �- -""—"'" -'-'— ' _�� WHOCONTMCiSFORSUCHPPOJECTRYlITHACOYTHACTpR(S)LICENSFDPURSUANTTOTHECONTRAC- ' QUANTI�TY DESCRIPTION FEE r� TOflS LICENSE LAW.]. � _— } �� ❑I AM EXEMPT UNf1ER SY.C..___"""_ _.._...- . U �. 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U� DATE_�..1_L___1g__CONTHACTOR_._.._. .. _ " a ' _'� W �`� WORKEHS'COMPE�SATION DECLARATION � ���, IHEREBVAFFIR�UUNL)GFiVENAITYOFPERJURVO�EOFTriEtOI.L()WMGDECLARATI045� Z �' _IHAV[ANUWILLMAIYTlIINACERTIFlCATEO�CONSE:N'fTOSELF�IN5UftEfORWORKfRS' Z COMPENSATION,ASPROVIDF.�AYSCCTION3]o00fTIlELABORCODE,�OfiTIIF.P[NF'OR67ANCE U � OfT1iEWORKFORWHICHhIISPERA�ITISISSUEU. � �.: n;]�A' V-' �HAVEANDWILLMAINiAIYWORKf:RS'GOMPFNSAilONMSURANCE,ASFlfqUIFlCDUYSECTION y � Q 37000F TI1E LABOR CO`JE.fOH TN[pERFOHMANCE OF THE WDRK fON WHIC!f THIS PERMIT IS ' _ ISSUED.MY WORK�F:R.S+'(+bMPENSATION MSURANCE CARRIER ANu POLiCY NUM�ERARE: CONSTRUCTION _,_,_,__,__._ _. _. ,_ _ __ 'i j CAHHIER._. G'"" t�G--L���� .C„r • � .. PLANNF..VIEW -.---,. ��'p �t -. .__....— ... ....._..... .._.. ....--- -- . �� aoucvNu�ae�n_.... T„�.�. '_��_L�. ELECTHIC � ..._......... ' —... .: —... ..—......_ ...—_ _ ; Q � ? ti (pCS5ECf10tJNEmNOTAE(XN.�PLEfE�OFRA=PER+NTtSfORIXJEHUPD�9F00q1Afi5(SIW)OHLE55�. PLUMBING __._...____... __._.._ .,_. �'�� ... w �--- Z" I CERTIFYTHAT IN THL P[FlFORMANCF.OF'(IIL WOHK FOR WHICHTHIS PEFiMI�IS ISSUED,l MECHANICAL '�� (7 SHALLNOTFNPLOVANVPERSONINANYMAN4ERSOASTOB[COMFSU�JF_CTTOTHE .•• - - ��t— �� � ��,. ' (n . WORKERS'COM.PENSATIONLAWSOfCAI.{�OHNIP,ANUAGHEEiHA'IFISHO(iIDUECUPAt INSPECTIONFEE '�"�. L� � �� � SUBJ CT TNLWOHK�HS'COMPF:NSATIONPROVI.IONSO�SECTi0�9]ODOFiHELABUR � COD ISH��LL(FO�FlTHWI'�lICOMPLVWITH iOSEPROVISlO$, ISSUANCE I � � ./�JY _ ___��C� Y - - SMIP �� . � p UATE:� �{.__�� _ APPLIGANT: . _.__ -..... —...—._-... _....._._'._ :: -_._"—._._. W ENERGY P/C � "'� ` � J WARNING:FAILUf1[TO SECURE WOHKERS'COM7ENSATION COVERAG[IS UNLAWFl/L,A�D SHALL BF -� ���-�- � '. ' . . . . ...... . �y Sl10JEGTANEMPLOYERTOCRIMINALP[NAI.TI[SANDGIVILFINESl1PTOONEHUN�RFD7110U5AND ENERGYPERMIT -� �,� ''-�6 " DOLLARS(StOo,oro),IN AUDITION TO TH[GOSTOf f,OMPENSATION,�AMAGF.S AS I�HOVIUEU FOR IN � � .... ..__.. ._ .,-_" _'.-.._ . ___._-' � SECTION37090FTH.F.I.ABORCOUE,INTG(7[57,ANDA1'iORNEYSFEES. RETENTIONFEE: _ ' '.' .-...... __-...—_..__... ,. . _"'_'_ pCONSTRUCT�ON LENDING AGENCY PRE-ALT FEE: ' � � IIiCREBVAFFIHMUN�ERPENALTYOFPERJURYTH?T1'IIEHEISAf.O45THUCTIONLENDINCAGI�NCY ' d FOH THF PERFORM�NGE OF THE WORK fOA W111Q 1 I1115 PCRMIT I51S5UED(SEC.3097,CIV C.). — ""'--' ' � ' "--'--' '-"""-"'—"'-"""" �� Z W -... __...-_.. _. ....__. _ -"__ �. _.-__ � LF.NUER'SNAME_"....._ _...__-..._"_ '....._.._ ,. ..__,.-._ -_— F- LENDER'SADDRESS__.. . ___._.___.-- __-- - �7 � ICFflTIFYThIATIH�VEHEA�THISAPPI.ICATIONANU57ATE1kIAThIEABOVEINfOf1ldATIONISCOHHECT. TOTAL FEES � ,f� � W I AGFEE TO COMPLV WIiH ALL CIiY AND COUNTV OROIVANCCSANU ST1TF L�1W5 RELATING TO AUILUI4G � CONSTHUCTION,AN�HEREBYAUTHOHIZE,,ttiL'PIiES[NTA71V[SOFTI{ISCOUNTYTOENIflVUI'OhTIIE �BOVE�M'cNTiONLD PfiO�EHTY�OR INSP�`710N PUHPOSES. ����- � C�L�.�,�.+l'�., � � � y I COMMGNTS��,L.Yd;P•'�...__C_�(_�F7 '!.7i�'G�-�—.. _ ;. ' 0 � �/� �, �}C�4C_.. G - --- - ', c� ✓ `7( '�! !!1 �_ _ _. . , - ---. _.__._ ' � PERAAITTEFti HINI d . _. . ...... . .. . .-. .-. . _ �- .__ � ...... __ - / : �! � SICNATUfi[OFPERMITfEE DATE (� Lj- �� ; = RECPT.N0._��_7 _ PAID BY ..._I.��VALIDATION._. ~ WHITE---DepaAment Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENROD-1=ile Copy,GREEN—Applicant's Copy � f �����w�Sa£�&���3�"�'��.��.��..,,, '�.._,._.,, i !.. i _'.._... 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