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. ._ . ._. .. .._......__'__._._.".__I .. .._._.._ . . CIT'Y OF d3I�MONI)BAR — �" DEPARTMENF OF COMMLINITY&DEVELOPMENT SERVICES I ^*I � --- 21825 E.Copley Drive �' (909)560-3195 Fa7c(909)861-3117 PRE$S '<YK��� BUILDIIoiG PERMIT APPLICATIDN FIRMLY Q DDRIESS Z t��� �ij l.��dq� C�R..()���, ApPLICATION PERMIT � P/C� DATE �" �) NUMBER � # �''�� � ISSUE o� ,/� TYPE OCC APN LOT TRACT DATE �I I I V CONS7. GROUP p OWNER� Pt" O 1 =tM LL ADDRESS.�j '�4rLk1 PC.'f9'Z.R 5I'C • l�d _ ZONING SETBACKS w CITY RV� ,Z�p 7 26t� TEL. FRONT RW ❑ � APPLICANT t i,��, 7EL?[��'� 021{ S DE/SIDE STREET RW ❑ z ¢ CONTRACTOR I�. SIDE ❑ I' O CITY ESN ZIP TEL. d PROPOSED USE Z S -�Z+ � c� . o ARC NG/ � W DESIGNER NO.DWEL. NO.• NO. a ADDRESS UNIT � ,CITY ZIP TEL. S STORIES BEDROOMS �' cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREACVALUATION � OWNER-BUILDER DECLARATION SFRlADDlREM � O I p ' I HEREBY,4FFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CIXViRACTOHS LI- GSPflJB/CBfpOfl ' ' W �CENSELAWFORiNEFOLLOWING�REASON(SEC.T031.SBUSLNESSAN�PROFESSIONSCODE:ANYCITVOR (n �i � �COUNTYWHICHREQl11RE5APER�ITTOCONSTRUCT,ALTEfl,iMPROVE,DEMOLISH.OqREPAIRANVSTRUC- W PdllO/DBCk �, W TURE,PRIOR TO ITS ISSUANCE,qL 50 qEQUIRES hIEAPPLICANT FOR SUCH PERMITTO FILE ASIGNED � '.STATEMENT THAT HE OR SHE IS LICENSE�PURSUANT TO THE PROVISIONS OF THE CIXJT9ACTORS LI- � �CENSE LAW(CHAPTER 9(COMMENCING'.WITH SECTION]000)OF�IVISION 3 OF THE BUSINESS AN�PRO- � PooUSpa � � ;��fESSIONSCODE)ORTHATHEOR$HEISEXEMPT'HEREFflOMANDTHE8A515FORTHEAILEGEDE%EMP- (�} � � ��'�,TION.ANYVIOLATIONOFSECTIONj7091.cBYANYAAPLiCANTFORAPERMI7SUBJECTSTHEAPPLICANTiO Z RB-ROOf � '� A CIYIL PENAL7Y OF NOT MORE TF{AN FlVE HUNDFED�OLLAHS�55W).): Z. ❑I,ASOWNEflOFTHEPROPERTY,DRMYEMPiOYEESWITHWAGE5A5THEIRSOLECOMPENSATION, � COfitRl0�Ci81 - � ';.WILL DO THE WORK,AND THE SiRUCTURE IS NOi INTENDE�OR OFFEqED FOR SALE;SEC.7044,BU51- J - � �' �.NESS AN�PROFESSIONS CODE:THE CONiRACTORS UCENSE LAW DOES NOT APPLY TO AN OWNEH OF � ''"PROPERiY WHO BUILDS OR IMPROVES THEFEON,AND WHO DOES SUCH WDRK HIMSELF OR HERSELF Oq " � �:'�THROUGHHISORNEROWFIEMPLOVEE5,PROVIOEDTHATSUCHIMPROVEMENTSARENOTINTENDE�Op � O' ;OFFEREDFORSALE.IF,HOWEVER.�fHEBf11LDWGORIMPflOVEIfENTI550LDWITHINONEYEAROFCO;APLE- Z'. ,,TION,THE OWNER-BUIL�ER WILL fiA,VE 7HE�BUqOEN OF PROVING THAT HE OR SHE DID NOT BUI4D OR , ��. �IMPROVEFOPTHEPURPOSEDFS�LE�.' W� ", O I,AS OWNEF OF iHE PROP�RN,AM EXCLUSIVELV CONTRRCTING WI7H LICENSED CONTRACTORS � �'�.' '�.'70 CONSTRUCT THE PROJECT(5€C,704a,6USMESS AND PROFESSIONS CODE:iHE CDMRACTORS LI- VfllUdfl�fl ADJ.AREA_ ' _ ,�CENSELAWDOESNOTAPPLYIDqNOWNEROFAPRCAERTYWHOBUILD50RIMPROVESTHEFEON,AND ^_ , . �,' '�,:WHOCONTRACTSFORSUCHPRO.IiECTSWRHACONTRACTOR(5)LIC£NSEOPURSUANTTOTHECONTRAC- QUANTITY DESCRIPTION FEE � � � � '��TORS UCENSE LAW.). � ❑I AM EXEMPT UNOER SEC.� 0.9 P.C.FOR THIS REASON J� � U � � � OATE ,OWNER U 2 ' w � LICENSED CON7RACTORS DECLARATION W � Q � .IHEPEBYAFFIRMUN�ERPENPLiY�OFPEAJURVTHA7IAMLICENSEDUNDERPROVISIONSOFCW�PTER � � p,. �9�COMMENCMG WITH SECTION 7obo)OF OIVISION 3 OFTHE 6USINESS AND PROFESSIONS CODE,AND Z 'X.�MV LICENSE IS IIV FULI FOHCE AND EFFECT. � � o UGENSE CLASS�I171 � LIG.NO. � � ~ �DATE�� � A� � CONTRACTOR C a W p,{� � WORKERS'COMPENSATION DECIARATlO ����YJI Q - �. IHERE6YAFFIRMUNDERPENALTYOFPERJ1IRYONEOFTNEFOLLOWINGDECLARATIONS: z � �, _IHAVEANDWILLMMNTAINACERTIFlCATEOFCONSENTTOSELF-INSUREFORWOqKERS' _ Q COAIPENSA710N,ASPFiOVIDEDBYSECTION37000FTHEL4BORCODE,FORTHEPERFOaMANCE �U OF THE WORK FOR WHICH 7HI5 PEFiMIT IS ISSUE�. � 0 ����, �I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BYSECTION � � QQ 3]o00FTHELABORCODE,FDRTNEPERFORMANCEOFTHEV✓OFiKFOFWHICHTHISPEPMITIS ISSUED.MY WOPKER' 1�1 ENSATION INSURANCE CARRIEF AN�POLICY NUMBERARE: CONSTFaUCT1ON �� � � CARRIER ��jv�„t,' ✓� ' PLANREVIEW __y�O� Z POLICYNUMBEH �� Z ""°"'�"`"' � - - �^� ��.� ELECTRIC '�"`�" "\ ¢ . . - ,;.�� _ 0 (�HISSECTIONNEmNOTeE00MftETE�OFiNEPERMITISWRONEHU'�IJRE�DOLLARS(fi00)ORLE55) PLUM8ING ! � �"" W � Z�, I CERTIFYTHAT IN THE PLRFORMlWCE OF tHE WORK FOR WHICH iH15 PERMIT IS ISSUED,I MECHANICAL f �'C E�9_ 1 'G 7 fl P1� �J' SHA�LNOTEMPLOYANYPEqSON'�,INANYMANNERSOASi09ECOMESUBJECTTOTHE i 6jLT ' � YJORKER5LOMPENSATION�LAWS;OFCA FORNI ANDAGREETHATIFISFIOULDBECdME INSPECTIONFEE . � SUBJECiTOTHEWORKEflS'COMpENS IONPR ISIONSOFSE TIO 37000 THELABOR 1 ^ t�'r,}� � CO�E,I SHALI FORTHWITH COMP�V W THOS ROVISIONS. ISSLIANCE �y _ .�;J "�/�J O .,. '. ,'' . p DATE: APBLICANT: SMIP -id-��. —. _�.,_. ....: • e...�.._._. .....__ . .__.�_. .__._ ._......�. J WARNING:FAILURE TO SECURE WOpKERS'COMPENSATIDN COVERAGE IS UNLAWPJL,AND SHALI BE ENERGY P/C �y SUBJECTANEMPLDYEflTOCRIMIN/U.PENALTIESAN�CIVILFINESUPTDONEHUNDREDTHOUSAND ENERGYPERMIT - DOILARS�Eioo,000�,IN A�DITION Td,THE C057OF CDMPENSA710N,DAMAGESAS PROVIOED FOR IN �, SECTION3JOBOFTHELABOPCODE;INiEFiEST,ANDATTORNEY'SFEES. RETENTIONFEE: O , CONSTRUC710N LENDING AC�ENCY PRE-ALT FEE: � IHEREBYAFFIRMUN�ERPENALTYQFGERJURVTHATTHEREISACONSTRUCTIONLENDWGAGENCY . FOF1iHEPERWRMANCEOFTHEWQRKFORWHICHTHISPERMITISI55UE0I5EC.3o91,CN.CJ. . Z LL7. — � LENDER'SNAME - F- LEN�ER'SADDRESS / �n � ICERTIFViHATIHAVEREADTHISAPPLICATIONANDSTAiETHATTHEAeOYEINFOPMATIONISCARflECT. TOTAL FEES t (\�J �I', I AGREE TO COMPLY WITH ALL CITYljND CDl1NiYQR�INANCES ANO STATE LAWS RELATING TO E111L01NG �� � ) r/ �'.' CON3TRUCTION,ANDHEREBYAUTHPRRE�,REPflESENTATNE50FTHISCOUMYTOENTERUPONiHE z,. ABOVE�MENTIONEDPROPERTYFORINSPECTIaNPURPOSES, COMMENTS 0' �, ��_'g,t4-12� -�c)S`�i n/�- t 0� — -- -- — � PERMITTEE ME(PRI ) ' � ,�"� �, � � 9� I t��'J' Uj SIGNATU OFPERMITT —P� DAiE - _, � RECPT.NO. PAID BY VALJDATION � WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENR06—File Copy,GREEN—ApplicaM's Copy _ �., , � . , , r.,��.�:,��nrb.A , - .. . ,�::�..,� . ..�;:.� ,,:,;, ,,, �. . �. ,;. - � � �''� � ��,i� ra"�; �1 ��� °. � k '3 , �. ��.¥# � g� .# .Ei z.. ��. � �h �a.��4 r a:" ,.`� #'��s a s a e r:` � a'�`6 ? r ;k b '.�� '� :: a '� .� ; »�' , x,.� s .d�u � " � a � = M F s. a .�''k ��. a � �'� �^� �` a o '�a � ����..„ �s -; z- .i � � .„; � �' � � � � �t � �i r>" a ���� � - � �l � . _' x ''' o°�: ��.:,r�.�.�-. . �..��:',�..a...�,„r�.,< .. ,�. .s��.. n..._....���.� '`.,.� ...�`a� .. ,�,,. _� �„,.. .,��..�..�,.:'.; �, . . „"'.,._ ....� .� �.�.. � ° = m .�-c , � � ' ,F �:�# . .a�ti � �''�'. 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