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FACTOFi PSF ADJ.AREANALUATION p� OWNER-Bl:ll.DER DECLARATION SFR/ADD/REM � O p I NERfBY AFFVW WDER PE WLLTY OF PEiWRY T/1AT 1 MA EXEMPT FHOM TNE CONiMCTORS LF G918Q9�C.9fpOR � W CENSEUwFORT1IEFOLLOWWGREA50NISEC.7071.5BU51HE55/NOPROFESSIONSCODEANYCRYOR (n U COUNTYYMIp1RE0U1PE5ADERMITTOGONSTRUCT,ALTE0.M�VROYE,DE1.10L15H2ORREPNRANYSiRUC• W patio/Deck , � TURE,iRIOR TO ITS ISSW WCE,ALSA REOUIRES TME 11PPLICANi FOR SULN PERMR TO fRE A SIONED W ' ' � STATFMEHT 7iUT ME OR SHE B UCENSEO iURSUANf TO THE PROVISIOHS OF THE CONTMCTOqS L4 LL . . � tENSE UW(C/iMTER C(CUYMENCNO MiN SECf10N 70001�DIVISqN]OF THE BUSINE95AN0 PRO- POOUSpB _ FESSIONSCODE�ORTU7HEORSHEISE%EMPTTHEAEFROAIANDTNEBASISFORTMEALLEGEDE%EMP• (� T1DN.ANVViOLATiDNDFSECT10N7071.68Y/NYAPPLIC/JJTFORAPEIWIT6UBJEGTSTMEAPPIIC�NlTTO - Z Re-Roof � ACIV4VEWLLTYOFNOTMORETFIANFNEHUNDHEDDOLURS(i5ao).y � OI.�SOM�NEHOFiHEVROPERT'/,OqMYEMPLOYEESWIMW�GE5A5ME1flSOLECOMPEN5AT10N, (`,pR71fIB�C�AI � WILL DO iHE YYORI(,Mq THE STRUCTUHE IS NOT W7ENOED Ofi OFFER[D FOR SALE(SEC.70M,BUSI• � N NE53 AND VROFESSIONS CODE:TNE CONTMCTOR4 UCENSE LAW DOES NOTAP7LY TO AN OKNEN OF � OROPENTYN110BUROSOFtACRDVE3TMEREON.IIWNMODOE55Ud1YKMNHIAISELFOqHERSELFOR = � � � TNROUGHNISORNERONMEMPLOYEES,VROVIDEDTHAiSUCHMPROVFMENTSARENOTMFNDEDOR m . . , � OLTEREOPoRSALEF,IqwEVERTMEBULDN�00RIYPROVEUENTlS60lDWITMNONEYFAROFtOMPLE� � z TION,TME OwNER-BULDEH W1LL HAVE TF1E BUROEN OF iROVINO THAT ME OR SHE MD NO7 BUM OR � W VROVE FOR iHE PURPOSE OF S�LLE). �� �y,� 04ASOYMEROFiHEPROPEHTY.MIE%0.USIVELYCOHiMCTP1(31YIiHLICENSEDCONTMCTORS TO tONSTHUCT THE VROJECT(SEC.TDN.BUSINE55 l,ND PROFESSIOHS COOE:THE CONTMCTORS LI• V8IUBIIOf� 1 AQI.AREA CENSE UW DOES NO7APVLY TO AN OWNER OF A PAOVERTY MT1D Bl11lDS DR M7f10VE9 MEREOH.AND WHOCOMMCTSFORSUCHVROJECTSNnTHACONTRACTOR(S)IICENSEDPURSUANTTOTHECONTMG pUAMITY � DESCRIPTION � FEE � � � OHSLICENSEIAW�. IMIE%EMPiUNDENSEG B.�i.C.fOfiTWSREASON � ! 3 � _ ' LL � I � s DATE ONMER Z W ¢ LICENSED CONTFiACTORS OECLAAATION W , OC IHEHE9Y11fFWMUNDERPEW�LTYOFVEiWHY7MATIMILIGENSEDUN0ERP1iOV15iON50FCHMTER Vr 1 �.. �ICOMyENCINO WRH SECTqN 70001 OF DNISqN]OF THE BUSR�E53 AND iROFESSqNS COOE,IWD Z X W UCENSE IS W FIAL FORCE AN�EFFECT. m Lll � � UCENSECLASS LIC.NO. � V DATE CONTRACiOR � w � � WORKERS'COMPENSATION DECLARATION � � INEREBYAFFIRAIUNDERVENALTYOFiEM1RY0NEOFTIEFOLLOWwOOECUMTIDNS: Z . � _INAVEANDNnLLWUNTAWAGERT1i1CATEOFCONSENTTOSELF�INSl1REFdIWORKE0.5' S COYPENSATqN,AS PROVIDED BY SECTION]70o OF THE LABOR CODE,FOR THE PERFORMANCE W OF THE WORK fON WMIp1 TN15 PERMIT IS ISSUED. • . . � � .. • � 0 � . W _IHAVEANDNALLWINTAPIMIORKERS'CdIPENSATIONWSURANGE,/15RE0UIRE0lYSEC710N �'� . � /��.� / Q �70o OF THE IABOR COOE.FOR THE PERFORMANCE OF TME WORR FON WNtp/M15 CERMRIS , � ISSUEO.MYIMDPo(ERS'COYPENSA7qNIN5URANCECARRIERAN[1POl1C'/MIMBENME: CONSTFI N' . . � cnawEn PLAN REVIEW. '� � I � PoLICYMI1�BEfl � (I}�sEcrcNNEIDru7eECM�IErEnaF7lfvEwwrsxaa�HLfaiEnOatlisR+�)altFssl PLUMBING � Z ICERTIfYTMATNTMEPERFORMANCE0FIHEWORKFOi1W111CNiM5VERYRt5155UED.l MECHANICAL .(7 SNALLNOTEYPLOVINYVERSONWANYYuINENSOASTOBE�MESUaIECTT�THE � VVORNERS'COUPENSATqNLAwSOFCWFOfiNI,�ANDAGREETM�TIFISNWLDBCCOuf IN� NFEE - � SV&IEGT f0 T7E VIOiUtERS'WYPENSATqN PROVISIONS OF SECiqN 77oD OF T1E IABOR -rj 000e,�srw.�roaramrncourtrrnn+naserHo�nsans. ISSVANCE � MIP •��� p DATE: APPIICANf: � ENERGY P!C WAfWIN6:FNLURE TO SEWRE WORKERS'COIAPENSATqN COVERAOE IS UN.AWFUI.AND Sh1ALL BE � bU9JECfIWEA1PlOYERTOCRMANALVENILLTIESANDCMLFNESUPTODNEIUNDREDT/�W5M10 ENERGYPERMIT DOIURS 1ff00.0001,W ADD�TION TO 1HE COSTOF COMPENSATION,OAMA�ES AS PRONDED FOR IN � BECT�ON17oeOFTMEUBOiiCO�E.WTEREST,ANDATTORNEY5fEE4. � RETENTIONFEE: � � oW., ' ' CONSTRUCT�ONLENDINGAGENCY PFiE-ALTFEE: O ' Q INEREBYAFFIRMUNOERPENALTYOiiEMJRYTHIRTHEREISACONSTRUCT10NlFNDW4ACENCY � � FOR iHE CERFORYANCE OF iME W011N FOR WMf1i 7HI5 PERMITIS ISSUED(SEC.70i7,qV.C.). . , � ' � LENDER'4NAYE ' . C LENDER'SADORE55 � ICERTIFY7HATINAVEISEhDT/15APPlICATqNANDSTATET17AiTHE11B0`/EWFOAAIATqNISCORHECT. TOTAL FEES ,, � IAfiREETOCON7LYYATHALLCRYIW�COURYORDUUNCE5MIC5TATEUW5REU7WOTO8UILOINO . � CONSTRUGTqN,ANDMEREBYAUT1qRIZENEGRESENT�71VE50FiNI5COUNTYTOEMTERUPONTIE � ABO�(E�NEMqN DVHOVERT'FORWSVECTIONR1RV05 r COMMENTS _ �� � /V4 z�t c-c� [ m Pe��/6-J^,,�TT6G NAYE(DRI / ,�/ ' � � Jf l-7� �C�'4Y1 i.�//v•/ N tU OF ERMITTEE . • DA7E � � . . - .` .. RECPT.NO. PND BY VALIDATION � . � �/ - WHITE—D�partment Copy,YELLOW--Finenee Copy,PINK—�seeua Gopy,GOLDENROD--File Copy,GREEN�11pp�CenCe Copy / . ( , .,�.. ;r,..��•..fi. '� '�7,: � ';rj ,.a,:.:%� � �� �:..rt.,��n,-, •,r.i'•��vt,: tY„� r,.,:.r. ,.".v:.�;. �,�.,..; .. . '�+�'��i , .. , .j;:..h:' '.�r•,:.;'r:•o�.+�Y�• , YyS.�. .f�� '�°{••''.i' ��(".2i.,�,�•.n.�ir+w'.,- �'1.t.�,rrr. ,:r.;�:: ..+.• �::. �:�«, n... i i ' '"` C F DIAib'tOI�ID:_��.R� �.���� _ -�� �:. • - � ..,_:. . � .,.� .. ..� :,�� .: ..,.:�.:_,�.� '� . ' �� � ': .�:. ; i � cCTIOt�! REC�i'�D, ��,' ` %' . '� �,_ .''.: . .. ';'!�.'. 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