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DEPARTMENT OF COMMUNTTY&DEVELOPMENT SERVICES
21825 E.Copley Drive ,J�N 181002
'� (909)860-3195 Fa�c(909)861-3117 ���� PRESS
��"��� BUILDING PERMIT APPLICATION FIRMLY
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p I HEREBY AFFIRM UNDER PENALTY OF PERNHV THAT I AM EXEMPT FROM THE CONTRACTORS LI- G9f8QB/CBfpOft "
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W NRE,PRIOR TO ITS ISSUANCE.ALSO RE-0UIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIONED w Patio/Dedc
� STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF iHE CONTRACTORS L6
� CENSE UW(CHAPTER B(CAMMENCWO WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO- � POOI/SP8
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U TION.ANV VIOLATION OF SECTION 7031.6 BV ANY APPLICANT FOR A PERMIT SUBJECTS THE APPUCMfT TO Z Re-Roof
A CML PENALTY OF NOT MORE THAN F1VE HUNDRED DOLLARS(S60o).):
� ❑I,ASOWNEROFTHEPROPERTY,ORMVEMPLOVEESWITHWAGESASTMEIRSOLECOMPENSATION, � COfTIfflBfClal
Z WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC.7044,BUSI� J .
� NESS AND PROFESSIONS CADE:THE CONTRACTORS LICENSE UW DOES NOT APPLV TO AN OWNER OF �
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Q THROUGH HIS OR HER ON?J EMPLOVEES,PROVIDED THAT SUCH IMVROVEMENTS ARE NOT WTENDED OR m I
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Z TION,THE OWNER�BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE�ID NOT BUILD OR
� IMPROVE FOR THE PURPOSE OF SALE).
w ❑I,ASONTIEROFTHEPROPERTV.AME%CLUSIVELVCqNTqACTWOWITHLICENSEDCONTRACTORS
� TO CONSTRUCT THE PRQIECT(SEC.70N,BUSINESS AND PROFESSfONS CODE:THE CONTRACTORS LI� V81U8Ii011 ADJ.AREA
i W CENSELAWDOESNOTAPPIVTOANONTJEROFAPROPERTVWFqBUILD50RIMPROVESTHEREON,AND
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❑I AM EXEMPT UNDER SEC. B.8 P.C.FOR TMIS REASON J
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2 1 HEREBY AFFIfiM UNDER PENALTY OF PERIURV THAT I AM LICENSED UNDER PROVISIONS OF CNAPTER �
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� WORKERS'COMPENSATION DECLARATION Q
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� I HEREBV AFFIRM UNDER PENALTV OF PERIURV ONE OFTHE F-0LLOWING DECLARATIONS: Z
0Z I HAVE AND WILL MAINTPJN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR NbRNERS' a
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COMPENSATION,AS PROVIDED BV SECTION a7oo OF THE LABOR fADE,FOR THE PERFORMANCE U
Q OFTHE WORK FOR WHICH THIS PERMIT IS ISSUED. �
w _I HAVE M!D WILL MAINTNN WORKERS'CAMPENSATION INSURANCE,AS REOUIRED BY SECTION
Q 3700 OF TME LABOR CADE,FOF h1E PERf-0RMANCE OF THE WORK FOP WHICH THIS PERMIT IS
ISSUED.MY RKERS'COMP ATION IN URANCE CARRIER AND POLICV NUMBER ARE: CONSTRUCTION
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Z I CERTIFV h1AT IN THE PERFORMANCE OF THE WORK FOR WHICH TFIIS PERMIT IS ISSUED.I MECHANICAL
C.'} SHALL NOT EMPLOV ANV PERSON IN ANV MANNER 50 AS TO BECOME SU&IECT TO THE
(n WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AQREE THAT IF I SHOULD BECOME INSPECTION FEE
SU&1ECT TO THE WORKERS'COMPENSATION PLiOVI510NS OF SECTION J�00 OF THE LABOR
�j CAD ,I SHALL FORTHWITH COMPLV WITH T PFOVISIONS. ISSUANCE
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p DATE: ��lfo/DZ APPLICANT: SMIP
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� WARNINO:FAILURE TO SECURE WORKERS'COMPENSATION CAVERAGE IS UNUWFUL,AND SHALL BE ENERGY P/C
� SU&IECTANEMPLOYERTOCRIMINALPENALTIESANDCIVILFINESUPTOONEHUNDREDTHOUSAND ENERGYPERMIT
OOlLARS(f 100.aoo),IN/�DDITION TO THE COST OF CAMPENSATION,DAMAOES AS PROVIDED FOR IN
J SECTION 37oe OF THE LABOR COOE,MTEREST,AND ATTORNEI"S FEES.
OC RETENTION FEE:
OCONSTRUCTION LENDING AGENCY PRE-ALT FEE:
� I HEREBV AFFIiiM UNDER PENAL7Y OF PERIURV THAT THERE IS A CONSTRUCTION LENDINQ AGENCV
� FOR THE PERFORMANCE OF THE WOPK FOR WHICH THIS PERMIT IS ISSUED(SEC.3oe�,CIV.C.).
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� LENDER'S NAME
� LENDER'SADDRESS
w I CERTIFV THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORAIATION IS CARPECT. TOTAL FE ES ���
� I AOREE TO COMPLV WITH ALl CITV AND COUNTV ORDINANCES AND STATE UWS REUTING TO BUILDING
� CONSTRUCTION,AND HEREBV AUTHORIZE F7EPRESENTATIVES OF THIS COUNTV TO ENTER UPON THE
Z ABOVE-MENTqNED PROPERTV FOR INSPECTION PURPOSES. '
0 � S� � COMMENTS
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� SIQNATUREOFPERMITTEE DATE
� RECPT.NO. PAID BY VALIDATION
WHITE—Department Copy,YELLOW—Finence Copy,PINK—Assessor Copy,GOLDENRO ile Copy,GREEN—Applicant's Copy
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FTGS/FORMS/STEEL FHA REQMTS
ELECTRIC GROUND UNDER FLOOR DUCT •
GROUND PLUMBING UNC�ER FLOOR CU�IDUIT
SLAB GRADE FIREPLAGE�FOUPJDATION
TEMP POWER FIREPLACE BOND BEAM
WATER SERVICE MID HT. BQNQ BEAM `
ROOF SHEATHIIVG 8 FT. BO.ND�BEAM
FRAMINGNENTILIATtON FINAL BOfVD BEAM
ROOF COVER PRE-GRADING
ROUGH HEFlTING BENCHItJG
ROUGH ELECTRIC ROUGH GRADING
ROUGH PLUIVIBING FINiSH GRADING
SH(7WER/TUB TEST POOL ELECTRIC i
EXT. LATH/SIDING POOL FENCING
WALL INSULATION POO�FINAL
CEILIIVG IPVSULATION OFF SITE IMPS.
DRYWALL NAILItVG DEQICATIONS
SEWER FINAL ENG. i
SEPTIC TANK LANDSCAPE/IRRIG.
SEEP PIT/I�.L. ON SITE IMPS.
GAS AIR TEST FINAL ZONING
FINAL CONST. FIRE DEPT. FINAL
FlNAL HEATING HEALTH DEPT. FINAL
FINAL ELECTRIC DEV. FEES PAID
FINAL PLUP/iBIt�IG ENERGY
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COM�ENTS
SEPTIC TANK SIZE
SEEP PIT/U SIZE
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