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^ ���' — DEPARTMENT OF COMMUNTI'1'&DEVELOPIv�NT SERVICES �C-j \�
21825 E.Copley Drive y
(909)860-3195 Fax(909)861-3117 PRESS
"'%«M�� BUILDING PERMIT APPLICATION � FIRMLY
I JOBSITE
� APPLICATION PERMIT P/C
o ADDRESS ��4� S. Grand DATE � o NUMBER #
� APN V@YI��1 TRACT ISSUE O TYpE pCC
DATE CONST. GROUP
p OWNE�rIZOCI
o ADDRESS OCIe Verizon 8 ZONING SEfBACKS
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o APPLICANT• TEL. REAR ❑
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� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION
p� OWNER-BUILDER DECLARATION SFR/ADD/REM
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p I HEREBV AFFlRM UNDEfl PENALTV OF PERIURV THAT I AM E%EMPT FROM THE CONiRACTORS�I- G8f8 B/C8 ff
W CENSEUWFORiHEFOLLOWINOqEA50N(SEC.7a31.6BUSINESSAND7ROFE5510NSCODE:ANYCI7VOR (n 9 �
C-� COUNTVNMICHRE-0UIRESAPERMRTOCONSTRUCT,ALTER�./PROVE.DEMOLISH,ORREPAlRM1VSTRUC� w
w TURE.PHIOR TO RS ISSUANCE,AL50 REWIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED w Patio/Deck
� STATEMENT 7HAT HE OR SHE IS LICENSED PUFSUANT TO THE PROVISIONS OF THE CONTRACTORS LI-
g CENSE LAW(CHAPTER e(COMMENCINO WITH SECTION 7000)OF DIVISqN 3 OF TFIE BUSINESS AND PRO� � POOUSPB
� FESSIONS CODE)OR THAT HE OR SHE IS E%EMPT THEREFROM AND THE BASIS FOR THE ALLEOED E%EMP- (�
V TION.ANY VIO�ATKKJ OF SECTION 7031.5 BV ANV APPLICANT FOR A PERMIT SU&IECTS THE APPLICMIT T0 Z Re-Roof
� A CML PENALTY OF NOT MORE THAN FNE HUNDRE�DOLURS(f500)J:
� ❑I,ASONMEROFTHEPROPERTV,OflMYEMPLOVEESWITHWAGE5A5THEIq50LECAMPENSATION, 0 COrtIfTIBfC18I
Z WILL DO THE WORK,AND iHE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC.70N,BUSI- J �
� NE55 AND PROFESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES NOT APPLV TO AN OWNER OF �
, PROPERTV WFIO BUILDS OR IMPROVES THEREON,AND NMO DOES SUCN WORK HIMSELF OR HERSELF OR
w hIRWGHHISORHEROWNEMPLOVEES,PROVIDEDTHATSUCHIMPqOVEMENTSARENOTINTENDEDOR m
Q OFFEAEDFORSALEIF,HOWEVER,7HEBUILDINOORIMPROVEMENTISSOLDWITHINONEYEpROFCOMPLE-
Z TION,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
� WPROVEFORTHEPURPOSEOFSALE).
w ❑I,AS OWNER OF THE PROPEHTV,AM E%Cl.USNELV COMRACTING WRH LICENSED CONTRACTORS
� TO CONSTRUCT THE PR0.IECT(SEC.7oN,BUSINESS M!D PROFESSIONS CODE:THE CONTRACTORS LI� VBIU8ll0(1 ADJ.AREA
W CENSELAWDOESNOTAPPLVTOANOWNEROFAPROPERTVWFIOBUIIDSORIMPROVESTHEREON,AND
� N7/OCONTRACTSFORSUCNPR0.IECTSWITHACANTMCTOR(5)LICENSEDPURSUANTTOTHECONTRAC� QUANTITV DESCRIPTION FEE �
Y TORS UCENSE UW.).
� O I AM EXEMP7 UNDER SEC. B.8 G.C.FOR hl1S REASON Q
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� DATE OWNER �
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Q� LICENSED CONTRACTORS DECLARATION w
2 I HEREBV AFFIRM UNDER PENALTV OF PERIURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER �
� G(COMMENCINO WfTH SECTION 7000)OF DIVISION 7 OF THE BUSINE55 AND PROFE5510�5 CODE.AND Z
X AIY LICENSE IS IN FULL FORCE AND EFFEC7. �
� LICENSE CLASS UC.NO. S l�S �
U DATE � CONTRACTOR � �- d
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� WORKERS'COMPENSATION DECLARATION a
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� I HEREBV AFFIRM UNDER PENALTY OF PERIURV ONE OF THE FOLLOWING DECLARATqNS: Z
Z� �I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSEM TO SELF-INSURE FOR WORKERS' a
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COMPENSATION,AS PROVIDED BV SECTION 3700 OF THE LABOR CODE,FOR THE PERFORMANCE U
Q OFTHE WORN FOR WHICH THIS PERMIT IS ISSUED. �
w I HAVE AND WILL MAMTAIN WORKERS'COMPENSATION INSURANCE,AS REW IRED BV SECTION
Q 37000F THE LABOR CODE,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS 87�'Z O
ISSUED.MY WORK�FB$'COMPENS}•TION INSU � CARRIER AND POLICV NUMBER ARE: CONSTRUCTION
j CARRIER 'C��eS 1 �� � I R S d rQM�-C_ PLAN REVIEW
Z POLICV NUMBER_��31 D O O a"' �2��O( � ELECTRIC
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� (n+sSEcila�lr+�rqreE�ErmoFniEPEar.rrswaor�tu�ooaltasRtoo)oa�Ess1 PLUMBING
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Z I CERTIFV THAT IN THE PEi1FORMANCE OF THE WORK FOR WHICH THIS PEFiM1T IS ISSUED,I MECHANICAL
�} SHALL NOT EMPLOV ANY PERSON IN ANV MANNER SO AS TO BECOME SUBJECT TO THE
(/) WORKERS'COMPENSATION LAWS OF CALIFORN10.AND AGREE THAT IF I SHOUID BECOME INSPECTION FEE
� SUBJECT TO THE M/ORKERS'COMPENSA710N PROVISIONS OF SECTION 3700 OF THE LABOR j �_�r�i Z S.O O
� CO�E I S ALL FORTHWI7H COMPIY WITH TH E PROVISIONS. ISSUANCE �..
p DATE:� APPLICANT: ���� SMIP i •SO
w ENERGY P/C
J WARNING:FAILU E TO SECURE WORNERS'COMPENSATION COVERAOE IS UNLAWFUL,AND SHALL BE
� SU&IECTANEMPLOYERTOCRIMWALPEN/�LTIESANDCNILFINESUPTOONEHUNDREOTHOUSAND ENERGYPERMIT S
DOLLARS(f1oo,000),IN ADDITION TO 7HE COST OF COMPENSATION,DAMAGES AS PFOVIOED FOR IN
. J SECTqN 3708 OF THE LABOR CODE,INTEREST,AND ATTORNEV'S FEES.
aC RETENTION FEE:
O CONSTRUCTION LENDING AGENCY .a�—=
PRE-ALT FEE:
� � I HEREBV AFFIRM UNDER PENALTY OF PERIURV THAT THERE IS A CONSTRUCTION LENDING AGENCV
� FOR THE PERFOFMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.3097,CIV.CJ.
Z
W
� LENDER'S NAME
1-- LENDEfYS ADDRESS
�
w I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. TOTA L FE ES � ����7 O
� I AOREE TO CAM7LV WITH ALL CRY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDINO
� CONSTRUCTION,AND HEREBV AU7l10RIZE REPRESENTATIVES OF THIS COUNTV TO EMER UPON THE
Z ABOVE�MENTIONED 7ROPERTV FOR INSPECTION PURPOSES.
�L COMMENTS
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m `PEq/�ITTEE N (PRINT) - �
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� G�I IJ i�URE OF PEFiA111TEE T�
� � � RECPT.NO. PAID BY VALIDATION
WHITE—DepaAment Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENRO�File Copy.GREEN—Applicant's Copy
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GROUND PLUMSWG UNQER FLOOR CUMDUIT I
SLAB GRADE FIREPLACE FOUNDATION
TEMP POWER ! FIREPLACE BOND BEAM
WATER SERVICE MID HT. BOND BEAPA �
ROOF SHEATH[NG 8 FT. BOND BEAM
FRAMINGNENTt�lAT10N FINAL BOND BFAPvi
ROOF COVER PRE-GRADING
ROUGH HEA7ING BENGHING
ROUGH ELECTRIC ROUGH GRADING
RtJUGH PLUIVIBING FINISH GRADING
SHOWER/TUB TEST POOL ELECTRIC �
EXT. LATHlSIDING PDOL FENCING
WALL It�SULATION POOL FINAL
GEII.N'VG I�lSULATIO(V QFF SITE IMPS.
DRYWALL NAILING DEDICATIOfVS
SEWER FINAL ENG. �
SEPTIC TANK LANDSCAPE/IRRiG.
SEEP PIT/LL. ON SITE IMPS. �
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FINAL COfVST. � ' F�RE DEPT. FINAL ��
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FIi�AL ELECTRIG DEV. FE�S PAID
FINAL FLUMBING , ENERGY.
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