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.____ _ ___ . . .__.i—._. ..._. . . . .. 8 �����°���1''��� -----�'�`c- --- I3EP�iT'I�NT OF�ONIMLINITY 8�DEVEL�PMENT SERV�CES � � 21�25 E.Copley FJrive ,�`� � ^` (909)$60-3195Fax(909)86d_3��7 ( P ESS ',v��.., �u�a...����� �a��L�c��ox � I R M LY Q ADDRESS���% � r���,,,��i(1��i�� DATE CATION / ��'"l�� yUMBER � #/C ly / o ISSUE ' TYPE OCC °-° APN LOT TRACT DATE GONST. GROUP p OWNER � ADDRESS ZONING SETBACKS Z CITY ZIF TEL. FRONT RW ❑ � APPLICANT TEL. REAR ❑ � SIQE/SIDE STREET RW ❑ ¢ CONTRACTOR � �t SIDE ❑ o ADDRESS/� PROPOSED USE o CI7Y��-�11�t'� ZIP EL. o ARCH/ENG/ �z DESBGNER N0.DWEL. NO. NO. a ADDRESS UNiTS STORIES BEDROOMS � CITY ZIP TEL. c�n D�CSCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWPJER•BUlLDER DECLARATION SFR/ADD/REM O ' � I HERE6Y AFFIqM UNDER P�NALTY OF PEFJURY THAi I Aht EXEMPi FROM THE COPITRACTORS Li� Gd189BJCB�POtI W CENSEL4WFORTHEFOLLOWING(7EASQN(SEC.�a31.58USINESSAN�PROFESSIONSCO�E:ANYCITYOR (n U COUNTYWHICHREOUIRESAPERMITiO FON5TRUCT,ALTEA,IMPROVE,DEMOLISH,0�9REPAIRANYSTRUG �J,J PafiO/D@Ck � w Tl1RE,PRIOR TO ITS ISSIiANCE.ALSD REOUIPESTHE APPLICANT FOR SUCH PcAM1T i0 FILE A SIGNEb W � STATEMENi THAT HE OR SHE IS�ICEN$EO PURSUANT TO THE PftOVI510NS AF iHE CONTRACTORS LI- � � CENSE LAW(CHAPTEFi 9(COMMENCING WITH SECiION 7000J OF DIYISION 3 OF THE BUSINE55 ANO PRO- POOUS(JB FESSIONSCO�E)ORiHATHEORSHEISIXEMPThiEREFROlAANDTHE6ASISFOR?HEALIEGE�EXEMP� (� � TION.ANYVIOLATIONOFSECTIOh7031.5BYANYAPPLICANiFORAPEFIMITSUBJECTSTHEAPPLICANTTO Z Re-Roof � ACNILPENALTYOfNO7MOREYIiANFIuEHUNDREDDOLLAftS(E5oo).): � ❑I,ASOWNEROFTHEPROP�RTY,pRlAYEMPLOYEESWITHWAGESASTHEIRSOLECOMPENSATION, � COfIlfllBfCifll ' Z WILI DO THE WORK,AND THE STRUCTURE IS NOT INTEM1DED OR OFFERED FOR SALE(SEC.7044,BUSi� J � NESSAND PROFESSIONS CODE:THE CANTRACTORa'LIC=MSE LAW�OES NOT APPLV TO AN OWNER OF � PqOPERTY WHO OU�LDSOR IMPF�VES"(HEREON.AN�WHO DOES SUCH WORK HIMSELF OR HERSELF OR CG '7HROUGHHISORHEROWNEMPL�OVEES,PROVIOEOTHATSUCHIMPROVEMENTSAFENOTINTENDE�OR � � OFFEREDFORSALE.IF,HOWEVER,''�1}1E0llILDINGORIMPROVEMENTi550LDWITHINONEYEAROFCOMPLE- iION,THE OWNER-BUILDER WILL'HAVE THE OURDEN OF PROVING THAT HE OR SHE DID NOT 6UIL0 OR = IMPflOVEFORTHEPURPOSEOF$ALE�.��, fl I,AS OWNEp OF THE PRORERTV;'AM EXC WSNELY CONTRACTING WITH LICENSEO COldTRACTORS '� 'i0 CONSI'RUCT THE PROJECT(S�C,7a,44,BUSINESS AND PFIOFESSIDNS CODE:iHE CONTRACTORS LI- VdI1ldllafl ADJ.AREA W �CENSELAWDOESNOTFPPLYlO1WOWNEftOFAPflOPERTYWHOBUILDSCFIMPROVESTHEREON,AND ,� WHOCONTRACTSFORSUCHPROjECTSWITHACONTRACTOR(5)LICEtiSE0Pt/RSl1ANiTOTHECONiRAG QUANTITY DESCRIPTlON FEE , Y TORS LICENSE LAW.). ��^ � J ' (� � � o ❑I AM EXEMPTUNDER SSC.�. B.8 P.C.FOR TNIS REASON Q � U � � �JATE '� OWNER U 2 W � LICENSED CONTRACTORS DECLARATION W � I HEPEBYAFFIRM UNDER PENALTj'OF PERJURY 7HAT I AM LICENSED 11NDER PPOVISIONS OF CHAPTER � � 9(COMMENCWGWITHSECTION]fpD)O�DIVISION30FTH�BUSINESSANDPROFESSIONS��� Z X MY LICENSE IS IN FULI FOftCE AN(7 EFF�CT. � LICENS/F�CLASS^ry���'p LIC.NO. ��ea��� � � V DATE!�%`�O`V� GONTflACTOR�i�� a W .� WORKERS'COMPENSATION DECLARgTBON � � U � 1 HEPEBYAFFIRM UNDER PENALTY OF P'ERJURV ONE O'r THE FOLLOWMG�ECLARATIOPIS: Z 0 _IHAVEANOWILLMAINTAINACERiIFICATEOFCONo'ENTTOSELF-INSUREFORWORKERS' y ¢ COMPENSATION,ASPROylOE�,$YSECTION37ooOFTHELA80RCODE,FORTHEPERFORMANCE `U OF THE WORK FOF WHICW THISi��PERMIT IS ISSUED. � 0 I � IHAVEANDWILLMAINTAINWOF�KERS'CObtPENSATIONINSURANCE,ASREQUiREDBYSECTION Q 37ooOFiHELABORCO�E,FORiTHEPERFORMFPJCEOFTH=WOFKFORWHICHTHISPERMITIS ISSUED.MV WFORKERS'CqMPEMS�AT�roN,INSU�RyANCECARRIERAND POLICV NUMBERARE: CONSTRUCTION j CARRIERI7__. �' P� Y a PLANREVIEW - d POLICY N BER '�.�_�� � ���'�f.��L ELECTRIC �`��� �, ,yT ��c � (iHISSEC BE��mOFiHE��ORONEHUNORFDDCLLARS($100;ORLESSI. PLUMBING Z ICERTIFVTHAiIN7HEPEPFORrMNCEOFiHEWORKFORWHICHTHISPERMITISISSUEO,I MECHANICAL (°5 SHALLNOTEMPIOYANYPERScYNINANYMANNER50A5T06ECOMESUBJECTTOTHE � WOaKERS'COMPENSATIONLAL�ISOFCALIFORNIA,PNDAGREETHATIF�SHOULDBECOME INSPECTIONFEE SU�JECTTOTNEWORKERS'COMPENSATIONPROVISIONSOFSECTION37000FTHElA80R ^ 1C'r> = COOE,I SHALL FORiHWITH COMPLY WITHTHOSE PROVISIONS. ISSUAUCE �.1�d V 4 SMia � , WAqNING FAILl1RETO5EWRE WDRKIEIqNT; "" �� " W �ATE: A � . -•'\. �� 1 : � , RS'GOMPENSATIONCOVERAGEISUNIAWFUL,ANDSFiALLBE ENERGYP/C =__ '"-'�..w : jy SUBJECTANEMPLAVERTOCRIMINALP�NALTIESAN�qVILFME5l1PTOONEHLINDRE0TH0'JSAND ENERGYPERMIT � e � COLlARS(Etoo,o00),IN AODITION'(O?HE COST OF COMPFNSATION,DAMAGES AS PROVIOED FOfl IN J " SECTION37060FTHELABOFCObE,IN�iERE5iAN0ATTORNEY5FEE5. RETENTIONFEE: � � ' aCONSTf�L1CT10N LENDING AGENCY pRE-ALT FEE: � . FORTHEPERFORMANCEOFTHEWORtlEfl.iUFYTHATTHEREI5AC4N5THUCiIONLENUINGAGENCY �"�T' � � I HEREBYAFFIRM UNDER PENALTY�F�1�',FOR 4VHICHTHIS PERMITIS ISSl1EG(SEC.3G9],CIV CJ. � -.:...�...e..�-..�.�.._"�._.g�m.�,�..� W � � LEN�ER'S NAME I— �� LENDER'SADDFE55 �I � ��. IGERTIFYTHpTIHAVEREA�THISAPPL�GATIONANDSiATETHA7THEABOVEINFORMATIONISCORFECT. TOTAL FEEu �°i� � w � IAGREETOCOMPLVWITHALLCITYANf1ICOl1NTYOR�INANCESAN�STATELAWSRELATINGTOBi11LDING � . CO(dSTflUC710N,ANDHEREOYAUiHOR`bEREPRESENTATIVESOFTHISCOVNTYTOENTEFUPONTHE � ' ABOVE-MENTIONED PROPE FOB INS�iPecTion auRaoses. 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