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--�---��` -- DEPARTMENT OF COMMUNTI'1'&DEVELOPMENT SERVICES
21825 E.Copley Drive �
(909)860-3195 Fa�c(909)861-3117 PRESS
�`'-��^� BUILDING PERMIT APPLICATION FIRMLY
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I HEREBV AFFIqM UNDER PENALTV OF PERJURY THAT I AM EXEMPT FROM THE CONTHACTORS LI- Gef890/C2fPOft
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I Z 7URE.PRIOR TO ITS ISSUANCE,ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT 70 FILE A SIGNED
w STATEMENT THAT HE OR SHE IS UCENSE�PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI� w
� � CENSE LAW(CHAPTER 9(CAMMENCING WITH SECTION 7000)OF DIVISION 3 OF 7HE BUSINESS AND PRO- � POOUSpB
FESSIONS CODE)OR THAT HE OR SHE IS EXEMP77HEREFROM AND THE BASIS FOR THE ALLEGED EXEMP� (�
� TION.ANV VIOLATION OF SECTION 7031.5 BV ANY APPLICANT FOR A PERMIT SU&lECTS THE APPLICANT TO Z Re-Roof
A CIVIL PENALTV OF NOT MORE THAN FIVE HUNDRED DOLIARS(5500).):
Z ❑t,ASOWNEROFTHEPROPERT',ORMYEMPLOYEESWITHWAGESAS7HEIRSOLECOMPENSATION, � Commercia� -�
WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SAIE(SEC.70da,BUSI� J
N NESS AND PROFESSIONS CODE:THE CAN7FAC70R5 LICENSE lAW DOES NOT APPLV TO AN OWNER OF �
PROPERTY VhiO BUILDS OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF Ofl HERSEIF OR
Q THROUGH HIS OR HER OWN EMPLOYEES,PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR m
w OFFEREDFORSPLE.IF,NOWEVERTMEBUILDINGORIMPROVEMENTISSOLDWITHINONEYEAROFCOMPLE-
0 TION,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
Z IMPROVE FOR THE PURPOSE OF SALE).
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� TO CANSTHUCT THE PRQIECT(SEC.7014,BUSINESS AND PROFESSIONS CADE:THE CONTHACTORS LI- V8IU8tlOf1 ADJ.AREA
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� WHOCANTRACTSFORSUCHPRQIECTSWITHACANTRACTOR�S)LICENSEDPURSUANTTOTHECONTRAC- QUANTITY DESCRIPTION FEE
Y 70R5 UCENSE LAW.).
¢ ❑I AM EXEMPT UNDER SEC. B.8 P.C.FOR THIS FEASON Q
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DATE OWNER �
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� LICENSED CONTRACTORS DECLARATION w
. � I HEREBY AFFIRM UNDER PENALTY OF PERJURV THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER �
d B(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINE55 AND PROFESSIONS CADE,AND Z
X IAY LICENSE IS IN FULL FORCE AND EFFECT. ^
� LICENSE CLAS�Sis��� LIC.NO. �`�'" G j
V DATE S v'1'�!� CON7RAC70R •�7t`�•L O!w 1�1�� d
� � �� WOAKERS'COMPENSATION DECLARATION Q
� I HEREBYAFFIRM UNDER PENALN OF PE0.IURV ONE OFTHE FOLLOWING DECLARATIONS: Z
Z _I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORNERS' _ ,
Q CAMPENSATION,AS PROVIDED BV SEC710N 370o OF 7HE LABOR CODE,FOR THE PERFORMANCE �U
Q OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. �
W X I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REOUIRED BV SECTION
Q 3700 OF THE LABOR CODE,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED.MY WOHKERS'CA/MPENSATION INSURANCE CARRIER AND POLICV NUMBERARE: CONSTRUCTION
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j CAqRIER sI1/4�.�Ce PLAN REVIEW �
Z POLICY NUMBER Q/�I� A� U� ELECTRIC
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� (iHISSECiXXJNE�NOTBE00MPLETEDOF71iEPEW�1fTISFORONEHUPDREDDOl1PAS(S10o)ORLESS} PLUMBING ��
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Z I CERTIFY THA7INTHE PEFiFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I MECHANICAL
C7 SHALL NOT EMPLOV ANV PERSON IN ANY MANNER 50 AS 70 BECOME SUBJECT TO THE
�j WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME INSPECTION FEE
= SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR i '
CODE,I SHALL FORTHWITH COMPLV WITH SE PROVISIONS. ISSUANCE � I
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p D�� � f Gi APPLICANT: Q l� �t � SMIP
J WA I :FA U TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL BE ENERGY P/C
LL SUBJECTANEMPLOVERTOCRIMINALPENALTIESANDCIVILFINESUP700NEHUNDRED7HOUSAN� ENERGYPERMIT
DOlLAFS(S7oo.000�,IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN ,�1
� SECTION 37080FTHE LABOR CODE,INTEREST,ANDATTOHNEV'S FEES. RETENTION FEE: �_ �+
� CONSTRUCTION LEND�NG AGENCY PRE-ALT FEE:
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� 1 HEREBV AFFIqM UNDE{i PENALTY OF PERJURV THAT THERE IS A CONSTRUCTION LENDING AGENCY
� FOR THE PERF-0RMANCE OF THE WORK FOR WHICH 7HIS PERMIT IS ISSUED(SEC.3097,CIV.C.). .
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� LENDER'S NAME
H LENDER'SADDRESS
� TOTAL FEES � S�
� I CERTIFV iHAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
w I AGREE TO COMPLV WITH ALL CITV AND COUNTV ORDINANCES AND STATE LAWS RELATING TO BUILDING 1
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� CONSTRUCTION,AND HEREBV AUTHORRE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
Z ABOVE�MENTIONED PROPERTY FOR INSPEC710N PURPOSES. COMMENTS
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� SIGN RMI DATE
= RECPT.NO. PAID BY VALIDATION
~ WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—Applican s Copy
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GROUNQ PLUMBING / / � �ta� ' UNDER FLOOR CU(�ID�IT i �
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SLAB GRADE �__._ �_�IREPLACE FOUi�DATION-� ;
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TEMP POWER -_-�_ __ _ _f�IREPLAGE BOND B�AM �
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WATER SERVICE � ' MID HT. BOND BEAM ___ ___
ROOF SHEATHfNG � 8 Ff. BOND BEAM �
FRAMING/VENTILIATION F1NAL BOND BEAM j
ROOFCOVER PRE-GRADING j ___ � -----
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ROUGH HEATING BENCNING I
ROUGH ELEGTRIC ROUGH UFiADING � � ��
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ROUGH PLUMBING � F1NiSH uRADING
SHOWERITUB TEST POOL ELECTRIC
EXT. LATH/SiDING � POOL_FENCING _ , _
WALL INSULATION POOL FINAL
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CEILING IN�ULATION � OFF SITE IMPS. ;
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DRYWALL NAILING DEDICATIONS
SEWER FINAL ENG. -- ------------- --
SEPTIC TANK LANDSCAPE/IRRIG.
SEEP PIT/L.L. ON SITE IMPS.
GAS AIR TEST FINAL ZONING
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FINAL CONST. i , �?RE DEPT. FINA!_
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FINAL HEATING j HEALTH DEPT. �INAL
FINA�ELECTRIC DEV. FEES PAID �
FINAL PLUMBING � ENERGY i
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