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ci�t a�D�orm�� ,,o�'�� -----� — DEPART'MENT OF COARMUNITY&I3EVELOPMENT SERVICES ._.;�"" � 21825 E.Cop�ey Drive I (909)860-3195 Fax(909)861-3117 �'� PRESS '`%v����� BUILDINGI'ERMI'f'APPLICATION FIRMLY o ADDRIESS�L/�� / ���(�✓7�' �G��'�1I] DATE "P � � NUMBER�7'� # y. APPLICATION PERMIT P/C °-° APN LOT TRACT ISSUE TYPE OCC �� DATE CONST. GROUP p OWNER _!"'/itCl.�o9� C6.��u�-�i2".+ 0 ADDRESS T'�' � J ZONING SETBACKS z CITY +o�"fI /G��' ZIP 7EL. FRONT Ryy ❑ o APPLICAN7 TEL. REAR ❑ z SIDE/SIDE STREET RW ❑ Q CONTRACTOR � "'����.:�� ",� SIDE C ADDRESS � �' �`� PROPOSED USE � da'' '7�d �'�"-``� � CITY vtl '�-�"a " ZIP +�-� TEL. � � o ' e,^ o ARCH/ENG/ ����� ��'_.�a✓ f_"�'..�' f � � z DESIGNER. w NO.DWEL. NO. NO. d, ADDRESS v� UNITS STORIES BEDROOMS �; CIN ZIP TEL. cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALU�ITION � Q�� OWNER-BUILDER DECLARATION SFR/A�D/REM � ', Q��' 1 HEREBV AFFIAM IINOER PENALTV OF PERJURV 7HAT I AM EXEMPT FROM THE CONTRACTORS LI- G8f2Q0/C3�POfI . W', CENSELAWFORTHEFOLLOWINGREASON�SEC.7031.58USINESSANDPPOFESSIONSCODE:ANYCITYOfl � (n i U..COUMVWHICHREQUIRESAPERMITTOCONS7FUCT,ALTER,IMPROVE,DEMOLISH,ORREPAIPANYSTRUC- , W,',, 'TURE,PRIOR TO RS ISSUANCE,ALSO REQUIHE5 TNE APPLICANT FOR SUCH PEflMITTO FILE A SIGNE� w Patio/Deck � ��.,�,STATEMENT hiAT HE OR SHE IS LICENStp PURSUANT TO THE PROVISIONS OF THE COMRACTCRS LI- � �,�CENSE LAW(CHAPTER 9(COMMENCING.WITH SECTION 7WC)OF�IVISION30P THE BUSINESSAND PRO- POD�Spa , ��. FESSIONSCODE)ORTHATHEORSHEISE%EMPTiYHEIiEFROMAN�7HEBA5ISFORTHEALLEGEDFXEMP- (� V'�."TI�N.ANYVIOLATIONOFSECTION7031.58YANVAPPLICANTFORAPERMITSU9JECTSTHEAPPLICANTTO Z Re-Roof �'�.AqVIL PENALTY OF NOT MORE iHAN FIVE HUNDRED�OLLARS(SSoa).j: �'��'', ❑I,ASOWNEROFTHEPROP,�cflTV,ORMVEMPIAYEESWITHYJAOESASTNEIR50LECOMPENSATION, � Commercial - � Z�i�,.WILL�O THE WOAK,AND THE STRUCTURE IS NOT INiENDED OR OFFERED FOR SALE(SEC.7044,BU51- J �;i'�,.NE55 ANO PROFESSIONS CODE:THE CONTRACTbRS LICENSE LAW�OES NOT APPLY TO AN OWNER OF � .''PROPEflTY WHO BUILDS Ofi IMPFOVES THEREONI AN�WHO DOES SUCH WORK HIMSELF OR HERSELF OR CC'!I�'�'THROLIGHHISORHEROWNEMPLAYEE$,PpOVIDEDTHATSUCHIMPROVEMENTSARENOTINTEN�EDOR CO � ''�,pFFEREDFORSALE.IFHOWEVER,THE6UI�DINGOPIMPROVEMENTI550LDWITHINONEYEAROFCOMPLE- Z,��,"j.TIDN,THE OWNER-9UILDEfl WILL�HAVE THE BURDBd OF PROVING il?AT HE OR SHE DID NOT BUIID OR ���,'�,'IM PROVE FOR THE PURPOSE OF SALE). ❑I,AS OWNER OF THE PROPERTY,AM'eXCLUSNELV COMRAC71N6 W ITH LICENSED CONTRACTORS , �Ii'��:TO CONS7PUCT THE PROJECT(SEC.7049,BUSIryE55 AND PROFESSIONS CODE:THE CONTRACTORS LI- V8IU8�IOf1 ADJ.AREA � W�'�,��CENSELAWOOESNO7APPLVTOANOWNEROFpPROPERTYWH09VILO50RIMPROVESTHEREDN,HND --- �I,'��,WHDCONTRACTSFORSUCHPROJECTSWITiACONTFACTOR(SjLICENSEDPURSUANT70THECONT(iAG QUANTIIY DESCRIPTION FEE � Y� TORS LICENSE LAW.). � 0'. ❑I AM EXEMPT UNDER SEC. 6.&P.C.FOR7HI5 REA60N Q �S" ?�, U LL' DATE OWNER F- O, w LICEN$ED CONTRACTORS DECLRRATION � ¢,, W CL�", INEREBVAFFIRMUN�ERPENALT'(OFPERJURYTHATIAMLICENSeDUNDERPFOVI510NSOFCHAPTER � d���e(COMMENCING WITH S'eCTION 7000)OF DIVISION 30F iHE BUSMESS AND PROFESSIONS CODE,AN� Z X MY LfCENSE IS IN FULL FORCE AND EFFECT, ' P�' — � � IICENSE CLASS{��f��� LIC.NO,� ��y��,��( O �g� �/' � � _.m..w. ' � ��DATE. ��' �� °^'} CONTRACTOR ��I/�+ �.<^�/'/`gf{'[ � ' "^'� i9 a W � WORKERS'COMPENSATION DECLARATION Q � ��.� ������� �.r� � �I HEREBYAPFIRM UNDER PENALTY DF PERJURV ONEOFTHE FOLLOWING DECLARATIONS: Z �. _IHAVEANDWILLMAINTAINACEflTIFlCATEOFCONSENTTOSELF-INSUREFORWORKEftS' � ,. 2 ..__�.,,, ¢ , CAMPENSATION,AS PROVIOED 9YSECTION 3�o00F THE LABOR CO�E,FOR THE PERFORMANCE U Q oFTHE WOflK FOR WHICH 7HIS PEflMITI5155UE0. � � Q�� _I HAVE AND WILL MAIMQIIS WORKERS'COMPENSAiION INSURANCE,AS flEQUIRED BV SECTION 3]ooOFTHELABORCOD�,FOR�THEPERFOflMANCEOFTHEWORKFORWHICHTHISPERM1T15 ISSUED.MYWOFIICE.�S'CQMPENSATON�NSURANCE,CARPIE A�N�POLICYNUMBERARE: CONSTRUCTION —� / �"' .b 0�� s . 4j�� CARRIER �^"� �'�'�"� ("'-"� CW� ` PLAN REVIEW . � POUCYNUMBER��, C���eJ ELECTRIC B � (fF1133ECTK7NNEmNO'T9EOJMPLE(EDOFiHEPERMRISFORONEHUNDRED00LLAR5�$10�ORLESS). PLUMBING Z� I CERTIFYTHAT INTHE PE9FORMANCE OFTHE WORK FOR WHICH THIS PEPMIT IS ISSUEO,l MECHANICAL C�}, SHALL NOT EMP�OY APJV RERSON IN ANY MANNER SOAS TO BECOME SUBJECT TO THE � WORKERS'COMPENSASIQ'NLAWSOFCALIFORNIA,ANDAGREETHATIFISHOULDBECOME INSPECTIONFEE � SUBJECTTOTHEWORkERS'COMPENSATpNPROVISIONSOFSECTION3�ooOFTHELABOR �'� o } � �� s�+°' = CO�E,ISHALLFORTHWITHCOhIPLYWITHTHOSEPROVi510N5. ISSUANCE �i'!�.� /.T".T."'� � k '���Y (Q � ��... ,l� _. .. y �� DATE:___._ APPLICANT: � SMIP �'"- a� (�g� 's �'� WARNING FAILURETO SECURE WORKE,flS'COMPENSATION COVERA6E IS UNLAWFUI,ANO SHALL BE ENERGY P/C � H�� �n�l, �f_R�.J � � � SUBJECTANEMPLOYEftNCRIAAMALP�NALTIES'ANOCIVILFINESUPTOONEHUNDREDTHOUSAND ENERGYPERMIT � { J��. DOLLARS(blao.000),INA��ITION70THECOSTOFCOMPENSATION,DAMAGESASPROVI�EDFORIN f �s . SECTION37060FTHELABORCOdE,INTEREST,AN�AiTORNEY'SFEES. a ` �� RETENTION FEE: k f = d CONSTRUCTIONLENDINGAGENCY PRE-ALTFEE: �� - a---�-a^-^--�""�=-""�M O - � I HERE9vAFFIP,N UN�ER PENALT'/OF PERJURY7HATTHERE IS ACONSTRUCTION LENDING AGENCY fOR THE PEF�ORtv1ANCE OF THE WORK FOR W HICH THIS PERMIi IS i55UE6(SEC.3097,CIV.C.]. Z 111 � . LEN�ER'S NAME ' N . LENDER'SADDRE55 � W�� ICERTIFYTHATIHAVEREADTHIS;APPLICA7iONAN�STATETHATTHEA80VE1NFORMA'.IONISCOFRECT. TOTAL FEES �� c ,�� p_�,', I A6PEE TO COMPLY W1TH ALL CITY ANO CDUNTY ORDINANCES AND STATE LAWS RELATING TO B111L�WG �.�''.�., CONSTRUCTIDN,AN�HEREBYAUiHOR2EREPRESENTATiVESOFTHiSCOUN7VTOENTERUPONTHE - Z' ABOVE-MENTIDNEDPROPERTVFOR NSPECTIONPURPOSES. COMMENTS - � _��:�� ��� ����- � _. m' PERMITTEE ME(PRINT) � �.��,�" s���-�� y � S ATU OFPERMI EE DAiE � ���0' ��VALIDATION ��, RECPT.�O. 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