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� � DEPARTMENT OF COI�RvtUMTY&DEVELOPMENT SERVICES
� 21825 E.Copley Drive 1
(909)860-3195Fa�c(909)861-3117 �UN 19 ZQO7 PRESS
��;���± BUILDING PERMIT APPLICATION FIRMLY
} JOBSITE 23640 Monument Canyon APPLICATION � PERMIT -, P/C
o ADDRESS— DATE � NUMBER�IY� #
� issuE TYPE occ
APN LOT TRACT, DATE CONST. GROUP
p OWNER Cimarron Oaks I HOA
p ADDRESS_�i75 W fnnthill Alvd �1(L4 ZONING SETBACKS
Z CITY�'.1 a rPmnn t ZIP 91 71 1 TEL"�Q9-�1 n3 FRONT RW ❑
� APPLICANT TEL. REAR ❑
� SIDE/SIDE STREET RW ❑
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Q CONTRACTOR Roval Roof Co. sioE ❑
� ADDRESS (�()g �_�.�E����
� cirr ziP TEL PROPOSED USE Tear off wood shakes. Install
oARC �� ��-76 new composition s ing es
iz DESIGNER NO.DWEL. NO. NO.
� ADDRESS
� CITY ZIP TEL. UNITS STORIES twn BEDROOMS
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cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION
p� OWNER-BUILDER DECLARATION SFR/ADD/REM
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I HEREBY AFFIRM UNDER PENALTV OF PERIURV THAT I M1 E%EMPT FROM THE fANTRACTORS LI� G2f89B/C8�0lI
W CENSEUWFOqTHEFOLLOWINGREASON(SEC.7o31.5BU51NE5SANDPROFE5510N5CODE:ANVCITVOR (n
U COUNTYWHICHREOUIFiESAPEFiMITTOCONS7RUC7,ALTER,IMPROVE,DEMOLISH,ORREPAIRANVSTRUC- W P3ti0/DBCk
TURE,PRIOR TO ITS ISSUANCE,ALSO REOUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNE�
W 57ATEMENT THAT HE OR SHE IS LICENSED PURSUANT 70 THE PROVISIONS OF THE CONTRACTORS LI� W
� CENSE LAW(CHAPTER 9(COMMENCING WITN SECTION 7000)OF�IVISION 3 OF THE BUSINESS AND PRO� LL' POOUS{70
Q FESSIONS CODE)OF THAT HE OR SHE IS ExEMP7 THEREFROM AN�THE BASIS FOR THE ALLEGED E%EMP� (�
U TION.ANY VIOLATION OF SECTION 7031.5 BY ANV APPUCANT FOR A PERMIT SUBJECTS THE APPLICANT TO Z Re-Roof
, � ACIVIL PENAl7Y OF NOT MORE 7HAN FIVE HUNDRED DOlLARS(f5oo�.g
� ❑I,ASONTlEFOF7HEPROPERTV,ORMVEMPLOYEESWITHWAGE5AS7HEIR50LECOMPENSATION, � COfi1R18fClal '
Z WILL DO THE WOHK,AND THE STRUCTURE IS NOT INTENOED OR OFFERED FOR SALE(SEC.70at,BUSI- J
� NESS AND PROFESSIONS CODE:THE CONTRACTORS UCENSE LAW DOES NOT APPLV TO AN OWNER OF �
PROPERTY WHO BUILDS OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OF HERSELF OR
� TMROUGM HIS OR HER OWN EMFLOYEES.PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR m
w OFFEHEDFORSPLE.IF,HOWEVER,THEBUILDINGORIMPROVEMENTISSOLDWITHINONEYEAROFCOMPLE�
� TION,THE OWNER�BUILDER WILL HAVE THE BURDEN OF PROVING 7HA7 HE OR SHE DID NOT BUI�O OH
Z IMPROVE FOR 7HE PURPOSE OF SALE).
Q� ❑I,AS OWNEF OF THE PROPERTV,AM EXCLUSIVELY CONTRACTING WITH IICENSE�CANTRACTORS
TO CANSTRUCT THE PR0.IECT(SEC.701�,BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI� V8IU8110f1 SOOO ADJ.AREA
W CENSEUW�OESNOTAPPLYTOANOWNEROFAPROPEFiTYWHOBUILD50RIMPROVESTHEREON,AND
. � NMOCONTRACTSFOflSUCHPRQIECTSWITHACANTRACTOR(S)LICENSEDPUFiSUANTTOTHECONTiiAC- QUANTITY DESCRIPTION FEE
Y TORS UCENSE LAW.). '
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O ❑I AM E%EMPT UNDER SEC. B.8 P.C.FOR THIS REASON
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DA7E OWNER U . �
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� LICENSED CONTRACTORS DECLARATION w
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CC I HEREBV AFFIRM UNDER PENALTV OF PERJURV THAT I AM LICENSED UN�ER PROVISIONS OF CHAPTER �
� D(COMMENCING WITN SECTION 7000)OF DIVISION 3 OF THE BUSINE55 AND PFOFESSIONS CODE,AND Z
X MY LICENSE IS IN FULL FORCE AND EFFECT.
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� LICENSE CUSS C-39 HIC �,�.No. 413057 �
U DATE 5—��—n� CONTRACTOR��a� Rnnf Co a
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� WORKERS'COMPENSATION DECLARATION Q
� I HEREBY AFFIRM UNDER PENALTY OF PEiiIURV ONE OFTHE FOLLOWING OECIARATIONS: Z
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� I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENTTO SELF�INSURE FOR WORKERS' _
a CAAIPENSATION,AS PROVIDED BV SECTION 3700 OF THE UBOR CODE,FOR TNE PERFORMANCE W
Q OF THE WORK FOR WHICH THIS GEFMIT IS ISSUEO. �
w 1 HAVE ANO WILL MAINTAIN WORKERS'COMPENSATION INSU(7ANCE,AS REOUIRED BY SECTION ///��� 7
Q XX 9700 OF THE LABOR CODE,FOR THE PERFORMANCE OF THE WORN FOR WHICH THIS PERMIT IS ,y-7/l C�
ISSUED.MV WORKERS'COMPENSATION INSURANCE CARRIER AND POLICV NUMBER ARE: CONSTRUCTION J /
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� CARRIER A M C PLAN REVIEW
ZPOLICY NUMBER ELECTRIC
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� (fH65ECTKXJNE�NOTBE(�'AW.ETEAOFTHEPERANTISFORONEHUI�DREDDOLLARS(f100JOR1E55} PLUMBING
Z I CERTIFV THAT IN THE PERFOFMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I MECHANICAL
CJ SHALL NOT EMPLOY ANV PERSON IN ANV MANNER SOAS TO BECOME SUBJECT TO THE
� WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME INSPECTION FEE ,
= SUBJECT TO THE WORKERS'COMPENSATION PPOVISIONS OF SECTION 37000F THE LABOR �'J'-
CODE,I SHALL FORTHWITH COMPLV WITH THOSE PROVISIONS. ISSUANCE �� I , � t
p DATE: APPLICANT: SMIP I I i�—'�/�� � � � �/� .. ,/O
� ENERGY P/C I�^ n
J WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL.AND SHALLBE I I J F 1 I O �
�y SUBJECTAN EMPLOVER TO CRIMINAL PENALTIES AN�CIVIL FMES UP TO ONE HUNDRED THOUSANO ENERGY PERMIT �
DOLLARS(f 1a0,o0o�,IN ADOITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN I ��
� SECTIONJ7080FTHELABORCODE,INTEREST.ANDATTORNEV'SFEES. HETENTIONFEE: � `+
� CONSTRUCTION LENDING AGENCY PRE-ALT FEE: I��r. � '
CC 1 HEREBV AFFIflM UNDER PENALiV OF PERIURV THAT THERE IS A CONSTRUCTION LENOING AGENCY ��-�_-'_���`�
� FOfl TNE PERFORMANCE OFTHE WORK FOP WHICH THIS PERMIT IS ISSUED(SEC.7091,CIV.C.).
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= LENDER'S NAME
�
� LENDER'SAD�RESS
� I CERTIFV THAT I HAVE REA�THIS APPLICATION AND STATETHAT THEABOVE INFORMATION IS CORRECT. TOTAL FEES /� „J7 " U
w I AGREE TO COMPLY WITH All CITY AND COUNTV ORDINANCES AND STATE UWS RELATING TO BUILDING '
� CONSTRUCTIDN,AND HEREBY AUTHORIZE REPRESENiATIVES OF THIS COUNTY TO ENTER UPON THE
� ABOVE-MENTIONED PFOPERTY FOR INSPECTION PURPOSES.
Z COMMENTS
� �/�
� 'JJon� Imbru�ri a
m PERMI E NAME(PRINT) �
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� SIGNA7URE OFRERMITTEE ��- DATE � �� ��^Z, VALIDATION
= RECPT.NO. PAID BY
~ WHITE—Depanment Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENRO�File Copy,GREEN—ApplicanYs Copy