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_�� CITY OF DIAIvIONb BAI� � DEPARTMENT UF COMMUMTY&DEVELOPMENT SERVICES _ � . 21660 E.Copley Drive Suife 190 ,.....•� (909)860-3]95 Fax(909)861-3117 PRESS '"+� �, , BUILDING PERMIT APPLICATION , _ : RIRMLY �� JOBSITE � [` ���q n� APPLICATION��i��,e��p NUMBF14� ��/C ADDRESS ����', JL�.-IAG�--- �/s o DATE /S o , . � ISSUE ; TYPE '., ,, ' OCC °O RPN LOT 'i� TRACT . �-' 'Q?� DATE ` OONST. ' GROUP o OWNER - LL ADDRESS '�� L. ZONING SETBACKS , � CITY �, ZIP . TE'L� ` � O� , FRONT ! RW l_' APPUCANT TEL. REAR ''' C SIDE/SIDE STREET RW p �o� ADD ESSTOR S�L�, �3� SIDE ❑ ^ , �,:,a� _ o CITY ZIP TEL. PROPOSEDUSE ��� w kRGH/EMG/ �'Ty%�j��NR"���"'(?`�7L✓t� ,p -.i � 'DESIGNER NO.DWEL. "�� NO. ^ NO. a ADDR � , IES ^,.,- .. BEDRQO � CITY I ZIP''` TE - UNITS STOR MS .. O � �.. OWNER,BUILpEROFGLARATION . �.. � � � 3FR/ADDIIREMN *SQ.�FT.�'" FACTORPS . E{WALUATION'� r F ADJ.AR � i „p; . 1 HEREBY AFFIRM UNDER PENPLTY OF PEfiJURY THAj i Pld EXEMPT FROM THE CONTRACTORS LI- .Gg�eg81@'dt}701t. � � W CENSEUWFOFITHEFOLLOWIN�REASON(SEC.�o37.58USINESSANDPROFE5510NSCADE.ANyqTVOR " �� ' � C] COUNTVWHIOHREd11RESAVER �?T�'�NSTAUCTALTER'�IMPHOVE,�EMOLISH,ORpEP.41RANYSTRUC- . � q ..,.� ,� W �STA EMEN7�TiiAT HE Op SAHE ISIL�ICENSED PURSUANT OLT�HENPRqVISIONS OF RHE CONTRA 70R5 LI�- ��w� POoUSpa � �' '�� ���, �. � FESSIONS�E)ORTHATHEOd5NE15EXEMPTTHEREFROMANDTHEBA515FOR7NEALLEGEDEXEMP• � ` y� � .. ,,,� CENSElA�N CHAO7EN9 CAMMENCWGWITHSECTION7W0 OF�IYISION30FTHE8USMESSANpPFo- , + 'TION.ANVVIOUTIONOF6ECTION7091.SBVANVAPPLIGWTFORAPERMITSUBJECTSTHEAPPLICANTTO .:.Z Ffe-Fjppt � �; ' J1CMC'VENALTYOFNOTMORK_'��iHANFIVEHUN�RE�00LLAR5(f500�.J: ' � ~ � ❑I,ASONMEHOFTHEPRO�'EHTY,DRMYEMPLOYEESWITHWAGESASTF7EIRSOLECAMPENSATION, '�'(� �'�� C1 Commerciai � i i ;Zn, ,tlJILL DO THE WOpN,ANO SH&SjHUCTURE I5 NOT INTENDED OB OFPERFD FOR SAIE.�SEC.7049,BU51- J �NES4 ANO PROFESSI�NS CO�E:7NE CONiHACTOflS LICENSE LAW DOES N�T APPLY TO AN OWNER oF � �°'�,��`, i ��� PROPEP7YWHOBUIlD30RIMPROVESTHEHEOry;ANDMMO00ES3UCHWORKHIMSELFORHEfiSELFOp�� � �'�W�/ M1''�,' � � �-'� � ��'(r" �iHRd'JGHHISOR�HEROWNEM QYEES;VROVIDEDTHATSUCHIMPHOVEMENTSARENOTINTENOE�OR�.� m ' ��� �W� OFFEREDFORSALEIFHOWEVE�Tr1EBUILOINGOfliMPROVEMENTISSOLDWRH�NONEYEAROFCAMPLE• � � ����0���'�-TION THE OWNEp-BUI Efi WI� HAV THE BURDEN OF PROVMG THA7 HE OR SHE DI�NOT BUILO OR ., .. � . IMPRDVEWRTHEPURPOSE � � � '��� � � � . lD oFIS/uE1. '. i ' ❑I,ASOVMEROfTHEPROPERTY,AMEXCLU5IVELYCONTRACTMGWITHLIGENSEDCONTRqCTORS ��� F ���', �TO CON6TIiUCT TFIE PRO.IECT�&EC 704�,BUSINE55 AND PROFES610NS CO�E�7HE CONTPACTORS LI- .-VdIU8Si0I1 �d ���/�p,J./if;E/i � � �� W' CENSELAWWESNOTAPPLYT ANOWNEROFAPROPERTYWH09UIL�SORIMPROVESTHEREON,qN� � � - ���5 WHOCONiRACT5FOR5UCHPR�.lECTSWRHACONTRA¢70R(S}4CENSE�PURSUANTTOTHECANTHAG� QUANTITY DESCRIPTION � � " ' � - � � FEE �: TORSUCENSELAW.y. ',,' r _ .. . . .. ,, ❑1 AM IXEMPT 11N�FA gEC. B.&P.Q FOR THIS REA90N� Q .,,0 .I.. . . V .. , , ��, LL' ,� . 1L' . . . . . � DA7E OWNER U ' � OI 1 _ r �, UCE�rvSEO CONTRACTORS DECL4RATION � W , ii. � IHEREBYAFFIRMUNDERPEN ITYOFPERIURYTHATfAMLICENSEDUNDERPROVI310N50FCHAPTER �� � . ' I��: �'��(L�, B�CDMMENCIN4.WffHS6C7101Ji00o),OFDIVISION30FhiEBUSINE55ANDPROFE5510NSCADE,AND .Z ..0: �,�I 'EFFECT. � ,p ttt }�-� � ., ... , ��. LICENSE CLAS I�,/ '_LIC.NO. L +sr���°"We/ �. .�. . . . ..' x MY LICENSE IS IN FULL FOHCE �����~��� �DATE � � CONTRACTO�! � � a � ���q,{� 7�-�yp W; I I.t21�'ll.��i�..d SY� .. . . �'� WOR�(ERS'COMPENSA?ION DECLARATION Q w 9..i�eti,�'� � � . (ii'1� �.,�', I HEREBV AFFIRM INJDER PBNP,LTV OK 7ERJURV ONE OF THE FOLIOWING UECLARATIONS: - Z� ' ' ' ' � � ' ��� `I HAVE AND WILL MAINTAIN ACERTIFICATE OF CONSENTTOSELF•INSURE FOR WOpKEP,S' z . COMPENSATION,ASP'AOVIDEDBYSECTION37000FTHELABORCODE,FORTHEPERFORMANCE `U �; OFTHE WORK FOR WN�CNTHIS pERM1T IS ISSUED. � 4 W' �IHAYEANDWILLMAINIAINWOflKERS'COMPENSRTIONINSURANCE.ASREQUIREDBYSECTION 87000FTHEl.qBOflf,�DE,FORTHEPERFORMANCEOFTHEWORKFORWHICHTHISPEqMR15 �� ' ��P'1 � �.SSUED.NY WOFIKEFIS COMPENSA ION INSURANCE CARRIERAND POLICV NU.iBERAPE: CONSTRUCTION j td � CARRIER�� l PLAN REVIEW �, �py l�y�/y ,�� POLICY NUMBEFi_�i���? - ELECTRIC �S�.S�I.ye.IDyt V v' O (iHISSECMINNE��BE00NPLETFDOFTHEPERhYfISFOROPEHJnUREDWUARS(StoqORLESSF PLUMBING _ _�i t7p sV�Lj��}}''j Z � 1 GERTIFV THA71N TH�PERFORMANCE OF THE WORK FOR N'HICH THIS PEPMIT IS ISSUED,I MECNANICAL l`�J' 16 L�"{J (•j��� SHALL NOT EMPLOV ANY PEf1SON IN ANY MANNEA SO AS TO BECOME SUBJECT TO THE � � WORKEHS'COMPENS�iIONLAW50FCALIFORNIA,ANDAGREETHATIFI5H0ULO8ECOME INSPECTIONFEE � SU&IEGTTOTHEWO KF�RS'COMPENSATIONPROVISIONSOFSEGTION 7000FiHELA60R �J �°`� � COD ISHALLfORTH�WI7HCOMPLYWITHTHOSEPRO SION � ISSUANCE �c+� J I �{� ..�rj' OATE:�I...APPLICANT: ' - . SMIP _ _ � "'f�r�G.� ��'� WARNINO:FAIlURETOSECUIEMlOflKERS'CAMPENSATIONCOVEfiAQEISUNLAWFUL, NOSHALLBE ENERGYPlC ��yj� SU&IECTANEMPLOYEATOG IMINALPENALTIESANDCIVILFINESUPTOONEHUPIDRE�THOUSAND ENERGYPERMIT ���I� ' DOLLARS�5100,oa0),INADDITONTOTHECOS'fOFCAMPQJSATIIXJ.OAMRGE5A5PROVIDEDFORIN /�'+ a� �� S�CTIDN37o80FTHELABOPCQDF,INTEftEST,ANDATTORNEY'SFEES. � RETEMIONFEE: Ii3I�l.0 O �ONSTqUCTION LENDING AGENCY - PRE-ALT FEE: � � . 4IHEREBYAFFIRMUNDERPE ALTYOFPERJURYTNATTHEREISACONSTHUGTIONLENDINGAGENCY ' ' � � FORhIEPERFORMANCEOF HEWORKWRWHICH'fHISPERMITI5155UE0(SEC.3aW,CIV.C_j. . . LL! /p ' ���� LENDER'SNAME ��,- �� /�� , � � , '� LEN�ER'SMDRESS ��, w I CEHTI'rY THAT I HAVE READ fI HI5 APPLIGATiON AND SfPTE THAT TME ABOVE INPoRMATION I5 CARRECT. TOTAL F E ES ����C�9' ����' �I���X✓.: ¢ IAGREETOCANPLVWITHAILpTYAN�COUNTVOROMANCESANDSTATELAWSRELATINGTOBUILDING � CONSTRUCTION,ANDHERE�XA,IflHORIZEPEPRESEMATNESOFTXISC�UNiVTDENTERUPoNTHE . . . � � ABOYEMENTIONED PROPEWTY FOR INSPECTION RPoses. COMMENTS - � �4�-� ��'l�e � .� PEiiAIITTEE E( . I� . '..•q§ .. (q Vr �jj� SMaNATUREOFPER6A11TEE� DA � � ' �� RECPT.N�. PAID BY ` YALIDATION._ - �� - �� � � WHITE--De aRmen[Co -YELLOW—Financa Co PINK—Assessor Co GOLDENROD—File Co GREEN— � , P PY. Py. Py. py, ApPlicani's CaPY .. ... . . . .. . . , . . , . . . . kX-. . _ . . . � ��� � ��� x�.: '. . , . , ' , ,. . . . �.' . �6 ffi`�fi �W#'k!S �����Rv . . . � �� �p '..- y.. ,� #�:;�f<< , � � � " '. '&� � kY�, � , �...� . R � ,iH - R`�_... �.� . . �F .� �. 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