HomeMy WebLinkAbout17449 _�,� _ crrY oF D�o1•rD B� EXPI Fi ED
DEPARTMENT OF CONIIv1UMTY&DEVELOPMENT SERVICES
Q_ � 21825 E.Copley Drive
(909)860-3195 Fax(909)861-3117 JUN 17 2002 `' pRESS
'`-����w BUILDING PERMIT APPLICATION FVRMLY I
� JOBSITE � �
APPLICATION PERMIT P/C
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� ISSUE TYPE OCC
APN LOT ,T�tACT DATE CONST. GROUP
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cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION
p� OWNER-BUILDER DECLARATION SFR/ADD/REM
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I HEREBV AFFIRM UNDER PENALTV OF PERJURY THAT I AM EXEMPT FROM THE CONTHACTORS LI- Geffl9B/C2fpOR -
W CENSEUWFORTHEFOILOWINGREA50N(SEC.7031.SBUSMESSANDPflOFESSIONSCODE:ANYCITYOR (n
U COUNTVWHICHREOUIRESAPERMITTOCANSTRUCT,ALTER,IMPROVE,DEMOLISH,ORREPAIRANVSTRUC�
w TURE,PRIOR TO ITS ISSUANCE,AL50 RE�UIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNEO w Patio/Deck
S7ATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF 7HE CON7RACTORS LI�
� CENSE LAW(CHAPTER e(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO- � POOUSPB
FESSIONS CADE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BA515 FOR THE ALLEGED EXEMP�
� TION.ANV VIOLATION OF SECTION 7031.5 0Y ANY APPLICANT FOR A PERMIT SU&IECTS THE APPLICANT T0 Z Re-Raof
A CIVIL PENALTV OF NOT MORE THAN FIVE HUNDRED DOLLARS(S5o0).):
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❑I,ASONTJEROFTHEPROPER7V,ORMVEMPLOYEESWITHWAGESASTHEIRSOLECOMPENSA710N, Q
Z WILL DO THE WORK,ANO THE S7RUC7URE IS NO7 IN7ENDED OR OFFERED FOR SALE(SEC.7oI1,BU51� J COrtIrtlBfCiel l
� NESS AND PROFESSIONS CADE:THE CANTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF �
PROPERTY WHO BUILDS OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
� THROUGHHISORHEFiOWNEMPLOVEES,PROVIDED7HA75UCHIMPROVEMEN75ARENOTINTENDEDOR m
� OFFEREDFORSALE.IFHOWEVERIHEBUILDINGORIMPROVEMENTISSOLDWITHINONEVEAROFCOMPLE-
Z TION,THE OWNER-BUILDER WILL HAVE 7HE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
� IMPROVE FOR THE PURPOSE OF SALE�.
w ❑I,ASOWNEROFTHEPROPERTV,AME%CIUSNELYCONTRACTINGWITHLICENSEDCANTflACTORS
� 70 CONSTRUCT THE PR0.IECT(SEC.70l1,BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI- VelUBilOf1 ADJ.AREA
W CENSE UW DOES NOTAPPLV TO AN OWNER OF A PROPER7V WHO BUILDS OR IMPROVES THEREON,AND
� WHOCANTRACTSFORSUCHPR0.IECTSWITHACANTRACTOR(S)LICENSEOFURSUANTTOTHECON7RAG QUANTITY DESCRIPTION FEE
Y TORS LICENSE LAW.).
� ❑I AM ExEMPT UNDEFi SEC. B.8 P.C.FOR THIS REASON Q
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DATE OWNER U
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� LICENSED CONTRACTORS DECLARATION w
� I HEREBY AFFIRM UNDER PENALTY OF PERJURV 7HAT I AM UCENSE�UNDER PROVISIONS OF CHAP7ER �
d 9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND Z
� `X MV LICENSE IS IN FULL FORCE AND EFFECL m
� LICENSE CLASS_ LIC.N0.�� j
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U DATE � '� CONTRACTOR
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� WOFKERS'COMPENSATION DECLARATION � I
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� I HEREBV AFFIRM UNDER PENALTV OF PERIURY ONE OF THE FOLLOWING DECURATIONS: Z I
Z _I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF�INSURE FOR WORKERS' _ '
Q COMPENSATION,AS PROVIDED BV SECTION 3700 OF THE LABOR CODE.FOR THE PERFORMANCE W i
OF THE WORK FOR WHICH THIS FERMIT IS ISSUED. �
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w _I HAVE AND WILL MAIN7AIN WORKERS'COMPENSATION INSURANCE,AS REOUIRED BY SEC710N
Q 370o OF THE LABOR CODE,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS 2/�� �d
ISSUED.MY WORKERS'COMPENSATIO I ANCE CARRIER AND POLICY NUMBERARE: CONSTRUCTION I�1�/.
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] CARRIER 7 PLAN REVIEW
0 POLICV NUMBER � Q��� � ELECTRIC 7 L /
� (iHIS5ECi1CXJNE�NOTBE00MPLEfEDOFTI-IEPERMfTISFORONEFR1t�DREDDOLLFAS�S100)ORLESS} PLUMBING I J C�'�//^\ � �
Z I CERTIFV THAT IN THE PERFORMANCE OF THE WORK FOH WHICH THIS PERMIT IS ISSUED,I MECHANICAL I \
(.r} SHALL NOT EMPLOV ANV PERSON IN ANV MANNER 50 AS TO BECOME SUBJECT TO THE �
(/� WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGHEE THAT IF I SHOULD BECAME INSPECTION FEE I 4 'L U 1
SUBJECT TO THE WORKERS'CAMPENSA710N PROVISIONS OF SECTION 370o OF THE LABOR I t`
� CODE,I SHALL FORTHWITH COMPLV WITH THOSE PROVISIONS. ISSUANCE
� SM�P �D�CT_ , �
p DATE: APPLICANT: �,��
J WARNING:FAILURETO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALLBE ENERGY P/C ��"'-'��-•`'�--�-
J SU&IECT AN EMP�OYER TO CRIMINAL PENALTIES AND CIVIL FMES UP TO ONE HUNDFED THOUSAND
� DOLLARS(f100,000),INADDITIONTO7HECOSTOFCOMPENSATION,DAMAGESASPROVIDEDFORIN ENERGYPERMIT
J SECTION 3708 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. RETENTION FEE: �.�`
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� CONSTRUCTION LENDING AGENCY PRE-ALT FEE:
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� I HEREBY AFFIRM UNDER PENALTV OF PERIURV THAT THERE IS A CONSTRUCTION LENDING AGENCV
n- FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.J097,CIV.C.).
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� LENDER'S NAME
H LENDER'SADDRESS
� TOTAL FEES /[f f 3�
� 1 CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CARRECT.
� I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS REUTING TO BUILDING � / /
� CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTV TO ENTER UPON THE �
Z ABOVE�MENTIONED PROPERT FOR INSPECTION P� COMMENTS
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� SIGNATUREOFPERMITTEE DATE �
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RECPT.NO. 0 PAID BY � VALIDATION
~ WHITE—De anment Co YELLOW—Finance Co PINK—Assessor Co GOLDENROD—File Co GREEN—A licant's Co
P PY, PY, PY. PY, PP PY
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FTGS/F�RMS/STEEL FHA REQMTS 1
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ELECTRIC GROUND ' � ; UNDER FLQOR DUCT '
GROUND PLUMBING � j UNDER FLOOR-CUt�!C7UIT . I � -
---- -----:- _________......_.__
SLAB GRADE i __ _ FIREPLACE FOUND�TION _ __ __
TEMP POWER FIREPLACE BOND BEAIL4 �
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WATER SERVICE � MID HT. BOND,BEAM �
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ROOF SHEATHtNG ��-�'il ��- ,
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F'RA�UIIPJGNENTILIATION I . ' � FINA�BO(�D BEAM ;
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ROOF COVER ; i PRE-GRA�ING � � _
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ROUGH HEATING BENCHi�I� [
ROUGH ELECTRIC � ____ R�UGH GRADING
--- ----�-- ----._....___ ___-- ----._._____ _.- ----....._ _
ROUGH PLUMBING i FINISH GRADING _ _
SHOWER/TUB TEST , POCJ� ELECTRlC
EXT. LATH/SIDING , POOL FENCING
WALL IIVSULATION I POOL FINAL
GEILING IN�ULATION ' OFF SITE IMPS.
-- — ' ---.- --.._______ ----._ —.. ---..______...._____._ _____
DRYWA�L NAI�IIVG j DEDICATIONS i
SEWER FINAL ENC�. ;
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SEPTIC TANK LAPJQSCAPE/IRRIG.
SEEP PIT/L.L. ON SITE I��,qPS. �
GAS AIR TEST FINAL ZONING '
FINAL CONST. � �IRE DEPT. FINAL ��
FINAL HEATING HEALTH DEPT. FINA� ;
FINAL ELECTRIC , DEV. FEES PAID _ �_
FINAL PLUMBING ENERGY i
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