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DEPARTMENT OF COrM�tUNTTY&DEVELOPMENT SERVICES
21825 E.Copley Drive
' (909)860-3195 Fax(909)861-3117 • .IUN 1 9 2002 PRESS
'"-.��»'�� BUILDING PERMIT APPLICATION FIRMLY
JOBSITE APPLICATION Q � j� PERMIT P/C
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I HEREBV AFFIRM UNDER PENALTY OF PERJURV THAT I AM E%EMPT FROM THE CONTRACTORS LI- G8f0J0/CBfPOR
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U CAUN7YWHICHREOUIRESAPERMI7TOCANSTiiUCT,AL7ER,IMPROVE,DEMOLISH,ORREPAIRANVSTRUC-
w TURE,PRIOR TO ITS ISSUANCE.ALSO REOUIRES THE APPLICANT FOR SUCH PERMI7 70 FIIE A SIGNED w Patio/Deck
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CON7RAC70R5 LI-
� CENSE LAW(CHAPTER B(COMMENCING WITH SECTION 7000)OF DIVISION J OF THE BUSINESS AND PRO� � PooUSpa �.
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Z )OI,ASOWNEROFTHEPROPERTV,ORMVEMPLOVEESWI7HWAGESASTHEIRSOLECAMPENSATION, 0 COrt1rtlBfCi81 -
WILL�THE WORK,AND THE STRUCTURE IS NOT INTENOED OR OFFERED FOR SALE(SEC.70u,BUSI- J
� NESS AND PROFESSIONS CODE:THE CANTRACTORS LICENSE LAW DOES NOT APPLV TO AN OWNER OF ?
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Q THROUGHHISORHEROWNEMPLOVEES,PROVIDEDTHATSUCHIMPROVEMENTSARENOTINTENDEDOR m
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� TO CANSTHUCT THE PR0.IECT(SEC.7014,BUSINE55 AND PROFESSIONS CODE:THE CONTRACTORS LI� V8IU8�IOf1 ADJ.AREA
W CENSEUWDOESNOTAPPLVTOANOWNEROFAPROPERTYWHOBUILDSORIMPROVESTHEREON,AND
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� ❑I AM EXEMPT UNDER SEC. B.8 P.C.FOR THIS REASON Q
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� LICENSED CONTRACTORS DECLARATION —i
� I HEREBY AFFIRM UNDER PENALTV OF PERIURV THAT I AM LICENSED UNDER PFOVISIONS OF CHAPTER ��� �
� e(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND Z
`X AIV LICENSE IS IN FULL FORCE AND EFFECT. m �
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� LICENSE CLASS IIC.NO. j ,
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� WORKERS'COMPENSATION DECLARATION Q
� I HEREBV AFFIRM UNDER PENALTY OF PERJURV ONE OF 7HE FOLLOWING DECURATIONS: Z
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� I HAVE AND WILL MAINTAIN A CERTIFICATE OF CANSEN770 SELF-INSURE FOR WONKERS' _
COMPENSATION,AS PROVIDED BY SECTION 3700 OF THE LABOR CODE.FOR THE PERFORMANCE U
¢ OFTHE WORK FOR WHICH THIS PERMI715ISSUED. W �
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w I HAVE AND WILL MAINTAIN WORNERS'COMPENSATION INSURANCE,AS REOUIRED BY SECTION
Q 37000FTHE LABOR CODE,FOR THE PERFORMANCE OF THE WORN FOR WHICH THIS PERMIT IS
ISSUED.MY WORKEFiS'CAMPENSATION INSURANCE CARRIER AND POLICY NUMBEFiARE: CONSTRUCTION
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� CARRIER PLAN REVIEW
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Q �� (fHISSECiK7NNE�NOTBECOMPLEfIDOF7HEPERMfTISPoRONEFiIR�DREDDOILAfLS(5700)ORLESS} PLUMBING
' Z I CER71FY7HA71N THE PERFORMANCE OF 7HE WORK FOR WHICH THIS PERMIT IS ISSUED,I MECHANICAL
�•} SHALL NOT EMPLOY ANY PERSON IN ANV MANNER 50 AS TO BECOME SUBJECT TO THE
� WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME INSPECTION FEE
= SUBJECTTO THE WORNERS'COMPENSATION PROVISIONS OF SECTION 370o OF 7HE LABOP , I
CODE.I SHALL FORTHWITH COMPLV WITH THOSE PROVISIONS. ISSUANCE
� SMIP
p DATE: APPLICANT:
J WARNING FAILURE TO SECURE WORKERS'COMPENSATION COVEFAGE IS UNUWFUL.AND SHALL BE ENERGY P/C I
� SUBJECTANEMPLOVER70CRIMINALPENALTIESANDCIVILFINESUPTOONEMUNDREDTHOUSAND ENERGYPERMIT
DOLLARS(S7ao,0oo),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN
J SECTION 3708 OF THE LABOR CODE.INTEREST,AND ATTORNEY'S FEES. flETENTION FEE:
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� CONSTRUCTION LENDING AGENCY PRE-ALT FEE:
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� I HEREBV AFFIFiM UNDEfi PENALTY OF PERJURY THAT THERE IS ACONSTRUCTION LENDING AGENCV
� FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUE�(SEC.3087,CIV.C.).
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� LENDER'S NAME
F= LENDER'SADDRESS �'
� ICERTIFYTHATIHAVEREADTHISAPPUCATIONANDSTATETHATTHEABOVEINFORMATIONISCORRECT. TOTAL FEES � ��
w 1 AGHEE TO COMPLV WITH ALl CITV AND COUNTV ORDINANCES AND STATE LAWS RELATING TO BUILDING
� CONSTRUCTION,AND HEREBV AUTHORIZE REPRESENTATIVES OF THIS COUNTV 70 ENTER UPON THE
Z, ABOVE�MENTIONED PROPERTV FOR INSPECTION PURPOSES. COMMENTS
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� SIGN R F MITTEE DATE J �
— RECPT.NO. PAID BY !/ VALIDATION
~ WHITE—DepaAment Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENROP—File Copy,GREEN—Applicant's Copy
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ROUGH PLUMBING (—�_�-�ol , i FINISH GRADiNG --- -_-------- —�--_. __._..
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EXT. LATH/SIDING POOL FENCING
WALL INSULATI�PV � POOL FINAL j
CEILING INSULATlON ' OFF SITE iMPS. � � .•
DRYWALL i�AILING DEDICATIOIVS
SEWER �INA�ENG.
SEPTIC TAfVK LANDSCAPEIIRRIG. �
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SEEP PIT/LL. ON SI7E IMPS.
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FINAL CONST. FiRE DEPT. FINA.�
FINAL HEATING I HEALTH D�P f. �INAL
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FINAL ELECTRIC DEV. FEES PAID
FI(VAL PLUMBIIVG ENERGY
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C�Ni�flENTS
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