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Home My WebLink About17663 crrY oF v�orm B�x ��C�I�� `----�� -- DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES 21825 E.Copley Drive �� , (909)860.3195 Fax(909)861-3117 .. , ' ' ' PRE$$ �'��" BUILDING PERMIT APPLICATION ^ �� FIRMLY o DDRIESS ��'��' ^'�arn'On�7 �G'� I✓I. � C' DATE CATION ��I ��' PERMIT P/C _` � �IUMBER I�Q�� # �� v� � APN LOT�� - TRACT ISSUE TYPE OCC p OWNER CJ1,.�L1 ('�p DATE CONST. GROUP p ADDRESS S� I�A� I_ Q' ZONING SETBACKS OCITY TCINto � ZIP q t?6s"TEL. 3 '�IC�-bIS�SY FRONT RW O APPLICANT TEL. REAR ❑ �� SIDE/SIDE STREET RW ❑ CONTRACTOR L�(, SIDE ❑ ADDRE,SnS � CITY _VI�Q.1+v►-ol I'Ia.. ZIP q►�6rTEL. PROPOSED USE N�W ��Al2 �)�T f}L OO D R oARCH/ENG/ z DESIGNER ' w NO.DWEL. NO. NO. a ADDRESS � CITY ZIP TEL. UNITS STORIES BEDROOMS � � DESCRIPTION SQ.Ff. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER DECLARATION SFR/ADD/REM O p I HEREBV AFFIRAI UNDER PENALTV OF PE0.0.1RV THAT I AM EXEMPT FAOM THE CONTRACTORS LI- G8f89B/CBfPOR W CENSE LAW FOR THE FOLLOW WO REASON(SEC.7031.5 BUSINESS AND PROFESSIONS CODE:ANV CITYOR (n C-� COUNTVWHIC}iRE�UIRESAPERMRTOCONSTRUCT,ALTER,IMPROVE,DEMOLISH,OHREPAIRANVSTRUG w w TURE,PRqR TO ITS ISSUANCE,ALSO REW IRES THE APPLICANT FOR SUCH PERMIT TO FlLE A SIONED w Patio/Deck � STATEMENT THAT HE OR SHE IS LICENSED WRSUANT TO THE PROVISIONS OF THE CONTRACTORS LI- � CENSE LAW(CHAPTER Y(COMMENCINO WITH SECTION 7000)OF DIVISION 7 OF THE BUSINESS AND PRO� � POOI/SP0 0 FESSqNS CODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEOED E%EMP- C7 U TION.ANV VIOLATION OF SECTION 7031.5 BV ANV APP�ICMlT FOR A PERMIT SU&IECTS THE APPLICANT TO Z Re-Roof � A CIVIL PENALTV OF NOT MORE THAN FNE HUNDRED DOLURS(f500)J: � ❑I,ASOWNEROFTHEPROPERTV.ORMVEMPLOVEESWITHWAGESASTHEIRSOLECOMPENSATION, � COffIrt18fC18I Z WILL DO TME WORK,AND THE STRUCNRE IS NOT INTENDED OR OFFERED FOR SALE(SEC.70a�,BU51� J l � NESS AND PROFESSIONS CODE:TNE CONTRACTORS LICENSE UW DOES NOT A7PLV TO AN OWNER OF � PqOPERTV WHO BUILDS OR IMPROVES THEREON,M1D WH0 DOES SUCH WORK HIMSELF OR HERSELF OR wTHROUOM HIS OR HEfl OWN EMPLOYEES,PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR m Q OFFEREDFORSPLEIF,HOWEVERTMEBUILDINGORIMPROVEMENTISSOLDWITHINONEVEAROFCOMPLE- Z TION.THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVINO THAT HE OR SHE DID NOT BUILD OR � IAIPROVE FOR THE PURPOSE OF SALE). W ❑I,AS OWNER OF THE PROPER7V,AM EXCLUSIVELV COMRACTINO WITH UCENSED CONTRACTOHS � TO CONSTRUCT THE PROJECT(SEC,7o�a,BUSINE55 AND PROFESSIONS CODE:THE CANTMCTORS LI- V8I118(10I1 ADJ.AREA W CENSE UW DOES NOTAPPLY TOM!OWNER OF A PROPERTY WFiO BUILDS OR IMPROVES THEREON,AND � WHOCONTRACTSFORSUCHPRQIECTSWITHACONTRACTOR(S)LICENSEDPURSUANTTOTHECONTRAG QUANTITY DESCRIPTION FEE Y TOqS LICENSE LAWJ. � O I AM IXEMPT UNDER SEC. B.6 P.C.FOR THIS REASON Q ?� U � DA7E OWNER V— Z U � LICENSED CONTRACTORS DECLARATION W � I MEREBV AFFIRM UNDER PENALTV OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER � � e(COMMENCINO WfTH SECTION 7000)OF DIVISKKJ 3 OF THE BUSINESS AND PROFESSIONS CODE,AN� Z �� MY LICENSE IS IN FULL FORCE AND EFFECT. m � LICENSE CLASS LIC.NO. � � U DATE CONTRACTOR d W � � WORKERS'COMPENSATION DECLARATION Q � U , � I HEREBV AFFIRM UNDER PENAL7Y OF 7ERIURV ONE OF THE FOLLOWING DECLARATKKJS: Z �Z _IHAVEANDWILLMAWTAINACERTIFICATEOFCONSENTTOSELF�INSUREFORWORKERS' ¢ Q COMPENSATION,AS PROVIDED BV SECTION 37ao OF 7HE LABOR CODE,FOR THE PERFORMANCE U OF THE WORK FOR WHlpi THIS PERMIT IS ISSUED. W � � w _I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE.AS REOUIRED BY SECTION Q 3700 OF THE LABOR CODE,FOR 7HE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ' �� ISSUED.MV WORKERS'COMPENSATqN INSURANCE CAARIER AND POLICV NUMBER ARE: CONSTRUCTION ��'l J -- j CAfiRIER PLAN REVIEW _� � V Z aa.ICV NUMBER ELECTRIC � ¢ � (IWSSECIqNN�NOTBE�.GLEfmOFhEPEHMrISFOqONEV4I�DREDDp1/3LS(tlao)ORLESS} PLUMBING ' W Z �CERiIFY TH�T IN THE PERFORMANCE OF THE WORK FOR WHICH iHiS PERMIT IS ISSUED,I � MECHANICAL U' SHALL NOT EMPLOV ANY PERSON IN ANV MANNER SO AS TO BECAME SU&IECT TO THE (/� WORKEHS'CAMPENSATIONUWSOFCALIFORN10.�DACtREETHATIFISHWLDBECOME INSPECTIONFEE � SUBJECTTOTHEWORKERS'COMPENSATIONPROVISIONSOFSECTbN37000FTHELABOR � CODE,I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS. ISSUANCE � p DA7E: APPLICANT: SMIP w ENERGY P/C �SO J WARNINO:FAILURETO SECUF7E WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL BE J � SU&IECTAN EMPLOVER TO CRIMINAL PENALTIES AND CNIL FINES UP TOONE HUNORED THOUSMID ENERGY PERMIT DOLLAAS(f 1 a0,000),IN/�DDRION TO THE COST OF COMPENSATION,DAMAOES AS PROVIDED FOR IN J SECTION 3708 OF THE LABOfl CODE,INTEREST,AND ATTORNEV'S FEES. OC RETENTION FEE: OCONSTAUCTION LENDING AGENCY PRE-ALT FEE: � � I HEREBV AFFIRM UNDER PENALTV OF PERJURV THAT THERE IS A CONSTRUCTION LENDM�AGENCV FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.3oe7,CIV.C.�. � Z W � LENDER'S NAME 1-- LENDER'SADDRESS w I CERTIFY TMAT I HAVE READ THIS APPLICATION AND STATE 7HAT THE ABOVE INFORMATION IS CARRECT. TOTA L FE ES �v�� I AGREE TO COMPLV WI7H ALL CITY AND COUNTV ORDINMlCES AND STATE UWS REUTING TO BUILDING (((''''''��(((��n � � CONSTRUCTVON,AND HEFEBV AUTHORIZE REPRESENTATNES OF THIS COUNTY TO ENTER UPON THE �/J/'� Q�� Z ABOVE�MENTIONE�PE�TVFOR��CTKKyPURPOSES�� COMMENTS `�� p i�� N�s s � m PERMITTEE NAIAE � Q � � SIONANREOF ERMITfEE DATE � � RECPT.NO. ' PAID BY VALIDATION WHITE-0epartment Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENRO File Copy.GREEN—ApplicanYs opy � c�911'�'( �Ir �8�6��G�4� (�l�[r� o��-��-o�� r��c�� , . °� ��i oQu��. ,oa�� ; oa�� o a . o .� � o � �, a �� SEf BACK FLOOR JUIST FTGS/FORMS/STEEL � FHA REQMTS ELECTRIC GROUND ^ � � UNDER FLOOR DUCT GROUND PLUMBING I UNDER F6_OOR CUMDUIT SLAB GRADE `i FIREPLACE FOUNDATION TEMP POWER FIREPLACE SOND BEAM WATER SEI�VICE MID HT. BOND BEAM � ROOF SHEATHING 8 FT. BOND BEAM FRAMIIVGNENTI�IATION FINAL BQND BEAM � ROOF COVER PRE-GRADING �� ROUGH HEATING BENCHING ROUGH ELECTRIC R�UGH GRADING R�UGH PLUfVIBING FINISH GRADING SHOWER/TUB TEST POOL ELECTRIC EXT. LATHJSIDING POOL FENCiNG WALL INSULATIOI� POOL FINAL CEILING INSULATiON OFF SITE IMPS. DRYWALL NAILING � OEDICATIONS SEWER FINAL ENG. SEPTIC TANK LANOSCAPE/IRRiG. SEEP PIT/L.L. ON SITE IMPS. GAS AIR TEST FINAL ZONING FINAl.CONST. , G!RE DEPT. FINA� FlNAL HEATING HEALTH DEPT. FINAL � FiNAL ELECTRIC DEV. FEES PAID i F1NAL PLUMBING ENERGY ' ��o � � COi�iNiENTS SEPTIC TAiVK SIZE SEEP PIT/U SIZE �� . a � �1 � �� ' � � �� . � � —