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^--1� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
' 21660 E.Copley Drive Suitc 190 PR ESS
�� (909)860.3195 Fax(909)861-3117
`��. BUILDING PERMIT APPLICATION FIRMLY
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Z TURE,PRIOR TO ITS ISSUANCE,ALSO RE�UIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
w STATEMEM THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CON7RACTORS LI� W �
� CENSE UW(CFIAPTER Y(COMMENCINO NATH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PR0. � PooVSpa
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� IMPROVE FOR THE PURPOSE OF SAL�.
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� I HEREBV AFFIRAI UNDER PEN/�LTV OF PEiUURV THAT I AM L�CENSED UNDER PROVISIONS OF CHAPTER �
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� WORKERS'COMPENSATION DECLAHATION Q
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� I HEREBY AFFIRM UNDER PENALTV OF PERRIRY ONE OF THE FOLLOWING DECURA710NS:
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� �I HAVE AND WILL MAINTNN A CEHTIFICATE OF CONSENT TO SELF-INSURE FOH WORNERS' _
� COMPEHSATqN,AS PROVIDED BV SECTION 9700 OF THE UBOR CODE,FOR THE PERFORMANCE W
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. �
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w I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REOUIREO BY SEC710N � ~ /
Q 37000F THE LABOR OODE,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ��
ISSUED.MY WORKER'COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE: CONSTRUCTION
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Z I CERTIFVTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I MECHANICAL
(} SHALL NOT EMPLOV ANY PERSON IN ANY MANNER 50 AS TO BECOME SUBJECT TO THE
� WORKERS'COMPENSATION UWS OF CALIFORN10.AND AGREE THAT IF I SHOULD BECAME INSPECTION FEE -
S SUBJECTTO THE WORKERS'COMGENSA710N PROVISIONS OF SEC710N 3700 OF THE LABOR
CODE, SHALL FOqTMV17H COMPLY WITH TIiOSE PROVISIONS. ISSUANCE
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� SUBIECTMIEMPLOVERTOCRIMINALPENAL71E5ANDC ILFINESUPTOONEHUNDRED7HOUSAN ENERGYPERMIT
DOILARS(f7oo,o00).IN ADD�710N 707HE COST OF COMPENSATION,DAMAGEu AS PROVIDED WR IN
� SECTqN 3708 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. - RETENTION FEE: �
d CONSTRUCTION LENDING AGENCY pRE-A T F E:
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� I HEREBV AFFIHM UNDER PENALTY OF PERIURV THA77HERE IS A CANSTRUC710N IENDING AGENCY
FOR 7HE VERFORMANCE OF THE WORK FOR WHICH THIS 7EHMIT IS ISSUED(SEC.3oY7,CIV.C.).
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� LENDER'S NAME �
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Q I CERTIFY iHAT I HAVE READ THIS APPLICATION AND STATE T1A7THE ABOVE INFORMATIDN IS CORRECT. TOTAL FEES / Y/- � �
W I AGREE TO COMPLV H7TH ALL CRV AND COUNTV ORDINANCES AND S7A7E LAWS REUTINO TO BUILDING L
� CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUN7V 70 ENTER UPON THE �
ZABOVE•MENTIONED VROPERTY FOR IHSPECTION PURPOSES. CO TS h
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FTGS/FORMS/STEEL FHA REQMTS
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GROUND PLUMBING UNDER FLOOR CUi�IDUIT •
SLAB GRADE FIREPLACE FOUNDATION � •• ��
TEMP POWER FIREPLACE BOND BEAM
WATER SERVICE MID HT. BOND BEAM �
ROOF SHEATHING 8 FT. BOND BEAM
FRAMINGNENTILIATION FINAL BOND BEAM
ROOF COVER PRE-GRADING
ROUGH HEATtNG BENCHING
ROUGH ELECTRIC ROUGH GRADING
ROUGH PLUNIBING FINISH GRADING
SHOWER/TUB TEST POOL ELECTRIC
EXT. LATH/SIDING P�OL FENCING
WAL�INSULATION POOL FINAI.
CEILING INSULATION OFF SITE IMPS.
DRYWA�L NAILING QEDICATIONS
SEWER � FINAL ENG.
SEPTIC TANK _ LANDSCAPE/IRRIG.
SEEP PIT/L.L. - � - ON SITE IMPS.
GAS AIR TESI" FINAL ZONING
FIPVAL CONST. FIRE DEPT. FINAL
FINA�HEATING HEALTH DEPT. FINAL
FINAL ELECTRIC DEV. FEES PAID
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