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� ---��` --- DEPARTMENT OF COIvIIvIUNTI'Y&DEVELOPMENT SERVICES
21825 E.Copley Drive ,J U N 18 1002
�- (909)860-3195 F�(909)861-3117 I� PRESS
�`'�YN����� BUILDING PERMIT APPLICATION FIRMLY
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I HEREBY AFFIRM UNDER PENALTV OF PERJURV THAT I AM EXEMPT FROM THE CANTRACTORS LI- Gef89B/CBfpOR
W CENSELAWFORTHEFOIIOWINGREA50N(SEC.7091.SBUSINESSANDPROFESSIONSCODE:ANYCITVOR (n
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Z TURE,PRIOR TO ITS ISSUANCE,ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT 70 FILE A SIGNED
w STATEMENT THAT HE OH SHE IS LICENSED PURSUAN7 TO 7HE PROVISIONS OF THE CONTRAC70RS LI� w '
� CENSE LAW(CHAPTER e(CAMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO- � POOVSp2
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A CIVIL PENALTV OF NOT MORE THAN FIVE HUNDRED DOlURS(5500)J:
❑I,AS OWNER OF THE PROPERTY,OH MV EMPLOYEES W ITH WAGES AS THEIR SOLE COMPENSATION,
Z WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED fOR SALE(SEC.70�d,BUSI� � COrt1RIBfCifl1 �
N NESS AND PROFESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF �
PqOPERTY WHO BUILDS OR IMPROVES THEfiEON,AND WHO DOES SUCH WORK HIMSELF Oii HERSELF OR
2 THROUGHHISOHHEROWNEMPLOYEES,PROVIDEDTHATSUCHIMPROVEMENTSARENOTINTENDEDOR m
Q OFFEREDFORSILEIF,HOWEVER,THEBUILDINGORIMPROVEMENTISSOLDWITHINONEVEAROFCOMPLE-
Z 710N,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THA7 HE OR SHE�ID NOT BUILD OH
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w ❑I,ASOWNEROFTHEPROPERTV,AMEXCLUSIVELVCANTRACTINGWITHLICENSE�CON7qACTORS
� TO CANSTfiUCT THE PRQIECT(SEC.7014,BUSINESS AND PROFESSIONS CADE:THE CONTRACTOFS LI- V8IU8SIOf1 ADJ.AREA
W CENSE LAW DOES NOTAPPLY TO AN ONRJER OF A PROPERTV WHO BUILDS OR IMPROVES THEREON,AND
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� LICENSED CONTRACTORS DECLARATION W
� I HEREBY AFFIRM UNDER PENALTV OF PERJURV THAT 1 AM LICENSED UNDER PROVISIONS OF CHAPTER � J I I
d e(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINE55 AND PROFESSIONS CODE,AND Z V
X MV UCENSE IS IN FULL FO CE ND EFFECT. �.}� /�
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� WORKEFiS'COMPENSATION DECLARATION ¢
NI HEREBV AFFIRM UNDER PENALN OF PERIURV ONE OF 7HE FOLLOWING DECLARA710N5: Z
Z _IHAVEANDWILLMAINTAINACERTIFICATEOFCONSENTTOSELF�INSUREFORWORNERS' _
Q COMPENSATION,AS PFOVIDED BV SECTION 37000F THE LABOR CODE.FORTHE PERFORMANCE w
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. �
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w I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REOUIRED BY SECTION
Q 3700 OF THE IABOR CODE,FOR THE PERFORMANCE OF THE WORK FOR WHICH 7HIS PERMIT IS
ISSUED.MV W E CAMPENSATIO IN URANCE CARRIER AND POLICV NUMBER ARE: CONSTRUCTION
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Z 1 CERTIFV THAT IN THE PERFORMANCE OF 7HE WORK FOR WHICH THIS PEHMIT IS ISSUED,I MECHANICAL
C.'} SHALL NOT EMPLOY ANY PERSON IN ANV MANNER SO AS TO BECAME SUBJECT TO THE
� WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME INSPECTION FEE
? SU&IECTTOTHEWORKERS'COMPENSATION VISIONSOFSECTION37000FTHELABOR /��
COD ,I SHAL FORTHWITH COMPLV WITH T paoviSioNs. ISSUANCE i\7.J
� SMIP
p DATE: rT�oZ APPLICANT:
J WARNING FAILUPE 705ECURE WORKERS'COMPENSA710N COVERAGE IS UNUWFUL,AND SHALLBE ENERGY P/C
� SUBJECTANEMPLOYERTOCRIMINALPENALTIESANDCIVILFINESUPTOONEHUNDREDTHOUSAN� ENERGYPERMIT
DOILARS(f700.000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN /�
� SECTION 3708 OF TNE LABOR CADE.INTEREST,AND ATTORNEY'S FEES. RETENTION FEE: I� O V
� CONSTRUCTION LENDING AGENCY PRE•ALT FEE:
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� I HEREBY AFFIfiM UNDER PENALTV OF PERJURV THAT THERE IS A CONSTRUCTION LENDING AGENCV
� FORTHE PERFORMANCE OF7HE WORK FOR WHICH THIS PERMI7IS ISSUE�(SEC.9o97,CIV.C.). .
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� LENDER'S NAME '
� LENDER'SADDRE55
w I CERTIFY THAT I HAVE ilEAD THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. TOTAL FE ES ��l �
� I AGREE TO COMPLY WITH ALL CITY AND CAUNTV ORDINANCES AND STATE UWS RELATMG TO BUILDING
� CONSTRUCTION,AND HEREBV AUTHORIZE REPRESENTATIVES OF THIS COUNTV TO ENTER UPON THE
Z ABOVE�M TIONED PROPERTV FOR INSPECT ON PURPOSES. COMMENTS
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Uj SIGNATUREOFPERMITTEE DATE
= RECPT.NO. PAID BY VALIDATION
~ WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENRO�File Copy,GREEN—Applicant's Copy
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FTGS/FORMS/STEEL � ; FHA REC�MTS
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ELECTRIC GROUND � � UNDER FLOOR DUCT
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GROUND PLUMBING , _ ____ ! UPJDER_FLQOR CU�IDUIT ! �,
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SLABGRADE _ _ _ FIREPLACE FOU�IDATION_ i __
TEMP POWER (. _� FIREPLAC� BOND B�AM i _ _._
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W,4TER SERVICE � I MID HT. B�ND BEAM
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ROOF SHEATHING + 8 FT. BdND BEAM i _
FRAMIfVG/VENTILIATION ! FINAL BQND BEAM !
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; PRE-GRADIfJG --_._........._.__...
ROOF COVER � ___
ROUGH HEATING BENCHING I
ROUGH ELECTRIC __ � ROUGH GRADING
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ROUGH PLUMBING i __ � FINISH Gr�ADING _ ____
SHOWER�fUB TEST i PO�L ELECTRIC
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EXT. LATH/SIDING i POOI FENCING
WALL IIVSULATIOPU ` POOL FINAL �
CEILING IN�ULATI�N � I �FF SITE IMPS.
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DRYWALL NAILING DEDICATiONS
SEWER FINAL ENG. i
SEPTIC TANK LAf�DSCAPE/IRRIG. (� f _
SEEP PIT/LL. UN S{TE I�tiPS. �
GAS AIR TEST FINAL Z�NING
FINAL CONST. FlRE DEPT. FINA�
FINAL HEATING NEALTH QEPT. FINAL
FINAL ELECTRIC � DEV. FEES PAID �
FINAL PLUMBING , � ENERGY
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