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21825 E.Copley Drive r.„ - - ' ''
(909)860-3195 Fa�c(909)861-3117 - • PRES$
����M�� BUILDING PERMIT APPLICATION FI R
� JOBSITE � Q� # APPLICATION' R �l PERMIT /C
o ADDRESS,�/ [�(/ �_L'S�/ CkTr �UI� DATE V �� "I NUMBER � #
TYPE OCC
� APN LOT TRACT D TEE CONST. GROUP
p OWNER � �,.�
� ADDRESS � ZONING SETBACKS
0
Z CITY �� ZIP TEL. FRONT RW ❑
o APPLICANT TEL. REAR �
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� CONTRACT " SIDE �
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� CITY L YI' � � ZIP EL. / - PROPOSED USE
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z DESIGNER � e � V1 � f.� �
a ADDRESS ` NO.DWEL. NO. NO.
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� DESCRIPTION SQ.Fl: FACTOR PSF ADJ.AREANALUATION
p� OWNER•BUILDER DECLARATION . .
p SFR/ADD/REM
p I HEREBv AFFl{UA UNDER PENALTV OF PERIURV 71MT I A!A EXEMPT FROM THE CONi{7ACTORS LI- G8f8gB/CBfpOrt
W CENSEUWFORTHEf-0LLOWINOREASON(SEC.7a31.6BUSINE55ANDPROFESSIONSCADE:ANYCITYOR (n
U COUNTVWHICHREWIRESAPERMITTOCONS7RUC7,ALTER,IMPROVE,DEMOLISH,ORREPAIRANYSTRUC� W P3t10/DBCK
Z TURE,PRIOR TO ITS ISSUANCE,ALSO REOUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED w
w STATEMENT 7HAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI-
� CENSE LAW(CHAPTER V(COMMENCWO WITN SECTION 7000)OF DIVISION J OF THE BUSINESS AND PR0. �- PooUSpa
�� FESSIONS CODE)OR THAT HE OR SHE IS EXEMPT hIEREFROM AND THE BA515 FOR THE ALLEGED E7(EMP� (�
TKKJ.ANVVIOLATIONOFSECTION7o31.5BVANYAPPLICANTFOflAPERMITSU&lECTSTHEAPPUCAN7T0 Z Re-Aoof
� A CIVIL PENALTV OF NOT MORE THAN FNE HUNDRED DOIURS(f500).):
Z ❑I,ASONRJEROFTHEPROPERTV,ORMVEMPLOVEESWITHWAOESASTHEIRSOLECOMPENSATION, � Commercial _
WILL DO THE WORK�ND 7HE STRUC7URE IS NOT IN7ENDED OR OFFERED FOR SALE(SEC.7oa1,BUSI� J
� NE55 AND PROFESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES NOT APPLV TO AN OWNER OF � �
PROPERTV VlFIO BUILDS OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
w THROUGH HIS OR HER OWN EMPLOVEES,PFiOV10ED 7}/NT SUCH IMPROVEMENTS ARE NOT INTENOED OR m J
Q OFFEREDFORSALEIF,HOWEVERTNEBUILDINGORIMPROVEMENTISSOLDWITHINONEVEAROFCOMPLE�
Z TION.THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVINO THAT HE OR SHE DID NOT BUILD OR
= IMPROVEFORTHEPURPOSEOFSALE).
,w ❑I,AS OVJNER OF THE PROPERTY,AM E%CWSIVELV CANTRACTINO WRH LICENSED CONTMCTORS
� TO CONSTRUCT THE PR0.IECT(SEC.701a,BUSINE55 AND PROFESSIONS CODE:THE CONTRACTORS LI- V8Il10fI0l1 ADJ.AREA
W CENSELAWDOESNOTAPPLVTOANOWNEROFAPROPERTVWHOBUILDSORIMPROVESTHEREON,MJD
� N710CANTMCTSFORSUCHPR0.IECTSWITHACONiRACTOH�S)LICENSEDPURSUANTTOTHECONTMG QUANTITY DESCRIPTION ' FEE
Y TORS LICENSE LAW.).
� ❑I AM E7(EMPT UNDER SEC. 8.8 P.C.FOR THIS REASON Q
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� DATE pWryEq ¢
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� LICENSEO CONTRACTOFS DECLARATION w
� 1 HEREBY AFFIRM UNDER PEN�LTV OF PER1UfiV THAT I AM LICENSED UNDER PROVISqNS OF CHAPTER �
� 9(COMMENCINO WfTH SECTION 7000)OF DIVISION 3 0F THE BUSINESS AND PROFESSKKJS CODE,AND Z
LLI MV LICENSE IS IN FULL FORCE M1D EFFECT.
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� LICENS LASS �� LIC.NO. �
V DATE CONTRACTOR a
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� WORKERS'COMPENSATION DECLARATION Q � Q � ��r
� 1 HEREBV AFFIRM UNDER PENALTV OF PERIURV ONE OF iHE FOLLOWINO�ECLARATIONS: Z
� _I HAVE AND WILL MNINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORNERS' _ �
� COMPENSATION,AS PROVIDED BV SECTION 3700 OF THE LABOR CODE,FOR iHE PERFORMANCE U
Q OF 7HE WORK FOR WHICH THIS PERAl1T IS ISSUED. �
w �I HAVE AND WILL MAINTAIN WORKEPS'COMPENSATION INSUHANCE,AS REOUIRED BV SECTION
QQ 7700 0F THE LABOR CODE,FOR 7HE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED.MYv/��E�R�S'c�/p�PENSATION INSURANCE C�-AyRR--IE.F AND POLICV NUMBEF ARE:A CONSTRUCTION
� CARRIER �F r1/G�ll�' N9 �� -L-YI S�(!`9H tC C�C� pLAN REVIEW
0 POLICV NUMBER /►W G'O� �O�J
Z ELECTRIC
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� (iHSSECIIONN�NOTBENI.�LETEDOFTHEPEPAYTLSFORONEMI�OREDDOLLAFiS�S10o)ORLESS� PLUMBING
Z 1 CERTIFY THAT IN THE PERFORMANCE OF THE MlORK FOR WHICH THIS PERMIT IS ISSUED,1 MECHANICAL �
L} SHALL NOT EMPLOV ANV PERSON IN ANV MANNER 50 AS TO BECAME SU&lECT TO THE
N WORKERS'COMPENSATION UWS OF CALIFORNIA/W D AGREE TMAT IF I SFIOULD BECOME INSPECTION FEE
SUBJECTTOTHEWORKERS'COMPENSATIONPR VISIONSOFSECTION37ooOFTHEIABOR /�j�
-�j CAEISHALLFORTHWITHCOMPIVWITHTHO PR SqNS. ISSUANCE . tJLJ
� SMIP
p DATE: • APPLICANT: `
J WARNINO:FAILURE TO SECURE WORKERS'CAMPENSATION COVERA6E IS UNUWFUI,AND SHALLBE ENERGY P/C
�y SU&IECTANEMPLOVERTOCRIMWPLPENALTIESANDCMLFINESUPTOONEHUNDNEDTHOUSAND ENERGYPERMIT
DOLLARS(5700.000).IN ADDITION TO THE C0.ST OF COMPENSATION.DAMA(iES AS PROVIDED FOR IN
� SECTION 3708 OFTHE LABOR CODE,INTEREST,ANDA7TORNEV'S FEES. FETENTION FEE: •
OCONSTfiUCTION LENDING AGENCY PRE-ALT FEE:
� I HEREBV AFFIRM UNDER PENALTV OF PERIURV THAT THERE IS A CONSTRUCTION LENDINO ADENCV �
FOR THE PERF-0RMANCE OF THE WORK F-0R WHICH THIS PERMIT IS ISSUED(SEC.JOG7,CIV.C.�.
Z
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� LENDER'S NMIE
F— LENDER'SADDRESS
� TOTAL FEES . Qd�
� I CERTIFV THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CARRECT.
w I AOREE TO COMPLV N7TH ALL CITV AN�COUNTV ORDINANCES AND STATE LAWS RELATINO TO BUILDING
� CANSTRUCTION,AND HEREBV AUTHOR2E REPRESENTATNES OF THIS CAUNTV TO ENTER UPON THE �
� ABOVE-MENTIONED PROPERTY fOF INSPECTION PURPOSES.
Z COMMENTS
� n�S
m PERMITT NAME INn G'
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N FEOFPERMITTEE A E
= RECPT.NO. PAID BY VALIDATION
~ WHITE-0epartment Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENRO�File Copy,GREEN—Applicant's Copy
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SET BACK FLOOR JOIST
FTGS/FORMS/STEEL FHA REQMTS � '*. �
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ELECTRIC GROUND UNDER FLUOR DUCT .
GROUND PLUMBING UNDER FLOOR GURIDUIT �
SLAB GRADE FIREPLACE FOUNDATIOA! 4
TEMP POWER i FiREPLACE BOND BEAM
WATER SER�/iCE I MID HT. BOND BEAM ' � �
ROOF SHEATHING 8 Ff. BOND SEAM
FRAMINGNENTILIATIOfV � FINAL BOND BEAM L_�__
ROOF COVER PRE-GRADING �
ROUGH HEATING BENCHING ^
ROUCH ELECTRIC RC�UGH GAADING
ROUGH PLUMBING �� FINISH GRADING
SHOWER�TUB TEST i POOL ELECTRIC
EXT. LATH/SIDING POOL FENCING
WALL INSULATION � POOL FINAL
CEILING INSULATION OFF SlTE IMPS. _�
DRYWALL NAILIiVG DEDICATIONS
SEWER FINAL ENG.
SEPTIC TANK LANDSCAPE/IRR(G.
SEEP PIT/L.L. ON SITE IMPS.
GAS AIR TEST FINAL ZONWG
FINAI.CONST. . FIRE DEPT. FINA!
FINAL HEATiNG HEALTH DEPT. FINAL
FIM1IAL ELECTRIC DEV. FEES PAID�
FINAL PLUh/IBING ENERGY
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COMMENTS
SEPTlC TANK SIZE
SEEP PIT/U SIZE -
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