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21825 E.Copley Drive i I I N 1� +AttiM;H
(909)860-3195 Fax(909)861-3117 JU ��+"��' pRESS
"�»�� . BUILDING PERMIT APPLICATION FIRMLY
� JOBSITE � T � e APPLICATION `I � (\ PERMIT � P/C
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�, ISSUE TYPE OCC
APN LOT TRACT DATE CONST. GROUP
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p� OWNER•BUILDER DECLAAATION SFR/ADD/REM
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p I HEREBY AFFIRM UNDER PEWLLTY OF PERIURV THAT I AM E%EMPT FHOM THE CONTRACTOflS LI- G0f9g6/CBfpOR
W CENSEUWFORTHEFOLLOWINGREASON(SEC.7031.6BUSWESSANDPROFESSIONSCODE:ANVCITVOR (n
U �p�JpJJyWr{ICHREOUIRESAPERMITTOCONSTRUCT,ALTER,IMPROVE,DEMOLISH,ORREPAIRANYSTAUG
w 7URE,PRIOR TO RS ISSUANCE.ALSO REOUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIONED w Patio/Deck
� STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PFOVISIONS OF THE CONTMCTORS LI�
� CENSE LAW(CHAPTER o(COMMENCINO WITH SECTqN 7000)OF DIVISION 3 OF THE BUSINESS AND PRO- � POOUSPB
� FESSIONSCODE)ORTHATHEORSHEISEXEMPTTHEREFROMMlDTHEBASISFOR7HEALLE6EDE%EMP- (�
TqN.ANV VIOUTION OF SECTION 7031.5 BV ANV APPLICANT FOR A PERMIT SU&IECTS THE APPLICANT TO Z Re-Roaf
A CIVIL PENALTV OF NOT MORE THAN FNE HUNDRED DOLI.ARS(5500�.):
� OI,ASONRJEfiOFTHEPROPERTV,ORMVEMPLOVEESWITHWAGESASTHEIRSOLECAMPENSATION, � COfflfflBfClal
Z WILL DO THE WORK,AND 7HE STRUCTURE IS NOT MTENDED OR OFFERED GOR SALE(SEC.7W�,BU51- J
� NESS M!D 7ROFESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES NOT APPLV TO AN OWNER OF �
PROPERTY NTiO BUILDS OR IMPHOVES THEHEON.M1D MMO DOES SUCH WORK HIMSELF OR HERSELF OR
� 7HROUGH HIS OR HER OWN EMPLOVEES,PPOVIDED 7HAT SUCH IMVROVEMENTS ARE NOT INTENDED OR m
� OFFEREDFORSALEIF,HOWEVER711EBUILDINGORIMPROVEMENTISSOLDWITHINONEVEAAOFCOMPLE-
Z TKKJ,THE OWNER�BUIIAER WILL HAVE THE BURDEN OF PROVINO THAT HE OR SHE DID NOT BUILD OR
� IMPROVE FOR THE PURPOSE OF SALE).
W ❑I,ASONMEROFhIEPROPERTV,AME%CLUSIVELYCONTRACTINOWITHLICENSEDCANTRACTORS
� TO CANSTRUCT h1E PRQIECT(SEC.701�,BUSINESS AND PROFESSIONS CODE:THE CONTRACTOqS LI- V8IU8fI0f1 ADJ.AREA
W CENSEIAWDOESNOTAPPLYTOANOWNEROFAPROPERNWHOBUILDSORIMPROVESTHEREON,AND
� WHOCOMRACTSFORSUCHPROJECTSWI7HACONTRACTOR(S)LICENSEDPURSUANTTOTHECONTRAG QUANTITY DESCRIPTION
Y 70RSLICENSELAwJ. � FEE
� ❑1 AM EXEMPT UNDER SEC. B.6 P.C.FOR THIS REASON Q
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LL DATE OWNER ~
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� LICENSED CONTRACTORS DECLARATION � w
� I HEREBY AFFIqM UNDER PENALTV OF PERJURV 7HAT I AM LICENSED UNDER PROVISIONS OF CHAPTER �
� 0(COMMENCINO WITH SECTION 7oao)OF DIVISION 3 0F THE BUSINESS AND PROFESSIONS CODE,AND Z
��� MY UCENSE IS IN FULL FORCE AND EFFECT. m
� LICENSE CLASS GJ � LIC.NO. �
WDATE �I^G� G/ CONTRACTOR d
� WORKERS'COMPENSATION DEC RAT10N a
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' � I HEREHV AFFIRAI UNDER PENALTV OF PERJURV ONE OF 7HE FOLLOWING DECURATIONS: Z
Z� _I MAVE AND WILL MAINTAIN A CERTIFICATE OF CONSEN7 TO SELF-INSURE FOR WORKERS' ¢
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COMPEN ,AS PROVIDED BV SECTION 370o OF THE LABOR CADE,FOR TME PERFORMANCE `U
OF OqK FOR WHICH THIS PERMIT IS ISSUED. �
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w I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE.AS flEWIRED BV SECTION
Q 37000F THE LABOR CODE,FOR THE PERFORMANCE OF THE WORK FOR WHICN THIS PERAIIT IS
ISSUED.MV WORICERS'COMPENSATqN INSURANCE CAqRIER AND POLICY NUMBERAAE: CONSTRUCTION
� CARRIER V�AT 1�n li1-L �j�^ PLAN FEVIEW
� POLICV NUMBER s�c ;d�Iq��9 `
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Z I CERTIFV THAT W THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I MECHANICAL
('} SHALL NOT EMPLOY ANY PERSON IN ANY MANNER 50 AS TO BECAME SU&IECT TO THE
(/� WORKERS'COMPENSATIONLAWSOFCALIFORNIAu.'DAOREETHATIFISHIXILDBECOME INSPECTIONFEE
SU&IECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTKKJ 3700 OF iHE IABOR
O CODE,I SHALL FORTHWITH COMPLV WITH TH V ISSUANCE .:� �e-s a-��—
p DATE: `I��L APPLICA : � SMIP ���T��� � I � I� �
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J WARNIN�:FAILURE TO SECURE MIORICER OMPENSATqN COVERAGE IS UNLAWFUL,AND SH�LLBE ENERGY P/C
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� SU&IECTMIEMPLOYERTOCRIMINALPENALTIESANDCIVILFINESUPTOONEHUNDREDTHOUSAND ENERGYPERMIT
DOLLARS(f ta0,o00),IN ADDITION TO THE COST OF COMPENSATqN,DAMAGES AS PqOVIDED FOR M �
J SECTION 37ae OF 7HE UBOR COOE.INTEREST,AND ATTORNEI"5 FEES.
OOC RETENTION FEE: �T
CONSTAUCTION LENDING AGENCY PRE-ALT FEE: B T � �`w �
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� I HEREBV AFFIqM UNDER PENPLTV OF PERIURV THAT THERE IS A CANSTqUCTION IENDING AGENCY
FOR THE PERFORMANCE OF THE WORN FOR WHlpi THIS PERMIT IS ISSUED(SEC.3097,CIV.CJ.
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� LENDEH'S NAME
� LENDER'SADDRE55
w I CERTIFV THAT I HAVE READ TNIS APPLICATION AND STATE 71iNT THE ABOVE INFORMATqN IS CARRECT. TOTAL F E ES ,-`l
� I AGREE TO COMPLV WITH ALL CfTY AND CWNTV ORDINANCES AND STATE LAWS RELATING TO BUILDING I I V!
� CON UCTION,AND HEREBV AUTHORIZE REPRESEMATIVES OF 7HIS COUNTV TO ENTER UPON THE
Z VE� TqNED PROPERTV FOR INSFECTION PURPOSES. COMMENTS
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� ATUR TTEE DATE �
= RECPT.NO. PAID BY VALIDATION
~ WHITE—DepaRment Copy,YEILOW—Finence Copy,PINK—Assessor Copy,GOLDENRO�File Co GREEN—
py, Applicant s Copy
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GROUND PLUMBING � UNDER FLOOR CU�!DUIT •
SLAB GRADE � FIREPLACE FOUNDATION '
TEMP POWER FIREPLACE BOND BEAM
WATER SERVICE MID HT. BQND B�AM ' '
ROOF SHEATHIIVG ����/o� �, �� 8 F—C. BOND,BEAM ' i
FRAMItVGNENTILIATIOfV FINAL 80ND BEAM
ROOF COVER PRE-GRADING
ROUGH HE�471NG BENCHING
ROUGH ELECTRIC ROUGH GRADING
ROUGH PLUMBING FINtSH GRADING
SHOWERlTUB TEST POQL�LECTRIC
EXT. LATH/SIDING POOL FENCtNG
WALL INSULATION POOL FINAL
CEILING IN�UTATION OFF SITE IMPS. �
DRYWALL NAILING DEDICATIONS
SEWER FINAL ENG. '�
SEPTIC TANK '-. LANQSCAPE/IRR[G.
SEEP PIT/L.L. � ON SITE IMPS.
GAS AIR TEST FINAL ZONING
FINAL CONST. FIRE DEPT. FINAL
FINAL HEATING HEA�TH DEPT. FINAL
FINAL ELECTRIC DEV. FEES PAID
FINAL PLUMBIMG ENERGY
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