HomeMy WebLinkAbout15784 I���i��
., �
_ 1,s.,�� CITY OF DIAMOND BAl� '� �..-
. .. DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES ' h,�'" /
21 Gb0 E.Copley Urivo Suite 290 -�'�
w (949)850-3195 F�(904}861-31i7 1 / PRESS
�'��°�� BUII.DING PERMIT APPLICATION �'f� FI R M LY
��„ JOBSITE ApPLICATICIN PERMIT P!C
� ADLIRESS���ic.*� �'C���7,`.__I t� DATE �� ��M NUMBE �� #
� ISSUE TYPE OCC
APN LOT TRACT
� DATE CONST. GROUP
p OWNER ��3+'�t_? �.. }�� V
p ADDRESS�,"� � i7.,rY,�s��.�„ �-ti, ' 20NING SETBACKS
�W � TEL.�' � -��►1�7• FRONT
CITY �.e�w.,..nx itial ZIP � c_ REAR RW C
APP�ICANT TEI. G
� SIpE/SIDE STREET RW �,
CdNTRACTOR SIDE �
c� ADDRESS � ���
,�,�, C�TY ZIP TEL.� _ Pf20POSEt7 t1SE �C.�G�C_ R�G.�✓3""�--
� ARCFitENGf n.111c A-+ai C^� („ , (j`
� DESIGNER NCI.DWEL. Nt7. NO.
� CIT`! �$� ZIP TEL. UNITS STORiES BEDROOMS
�s DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION
� qWNEft-BUILDER DEGLAFiAT1pN SfR1ADDIR£M
C} 1 MEREBY AiPiRM UNDEfl PENALTY OF pERJURY THA1 I M1 EXEMPT FFlf}M TNE CONTRACTORS ll� GdYdSB(C,.B�Q(2
tii CENSE UW FOR THE FOlIOriiNC3 REASOFi(SEC.7o3i 5 BUSME8SAN0 Pfl��ESSiONS CODG:ANY CtTYOR (n
C� CDUNTYWHICHRECNIIRESAPERMR7pCON5TRUC7,ALTEFi,IMPROVE,pEMOlISH,ORHEPAIRMlYSTRUG W PBfltl/DBCk
W TUflE,PRIQFi TQ ITS 4SSUANCE,M.SO REIX1iRES THE APPtlCAN i f6R SUGH PEftMIT TO F�E A 51GNE4 �
.� STATEMENi 1H�T HE OR SHE I6 tJCENSED pURSUANT Tq THE PtiOVISiONS UF iHE CONfRACTOPS Lb �
� CENSE UW(CHAP7ER o(COMMENCINO WI7M SECTNJN 7pU0)OF DIVISION 30F THE BUSINESS ANp PRp PoOUSpa _
FESSIONSCG56E}ORTNATNE6RSMEISEXEMPTTNEREfAUMANbTNEBASiSF6FiTHEALlE0E0EXEMP- (�
7qN.ANYVNJl.AT10NOFSECTIqN]o31.5BYANYAPPUCANTFORAPERMIT5U6JECTSTHEAPPLICANTTO Z Re-Roof
� ACIYi47ENA1.TY QF NOT MOqE7HAN FIVE HUNDRIX7 DOLLARS({500)):
� UI,ASOWT1Efl9FTHEPFiOPER7Y.ORMYEMPtOYEESWiTHWAGE5ASTH£IRSOtECQMGEfiSATtON, � COrtIRIBiCidl ^
YYILL 00 THE WORK,IWD 7HE 9TRUC7URE IS NOT IN7ENDED OR OFF�pED FOR SALE ISEC.]044,BU51- J
� 1�5$AND P(pF£$SlONS CA�E:THE WNTRACTORS UCEt15E IAW OOES IiOT APPLY TO AN OWNER pF �
PROPER7Y WfiD BUICDS pR IMPqQYE57HER£iNt.ANO WNO DOfiS SUCH WOtiK HIMSELF Ofl HERSEtf Ofl
� 1HNOUGH HIS OR HER OYM EMPLOVEES,PROVIDEp THAT SUCFI MAPRqVEMENTSARE NOi INTENDED OR m
t�FERE6FON SUE.�F NOWEYER TME6tNL01NG OH1tdPROVEMENT IS SQIA wi7'HtN ONE YE4�OFC4�MPLE�
TION,THE OMMER�HUILl]ER'MU HAVE THE BURDEN OF PpOYING 7HAT HE OR SNE DI�NO7 6Uftil OR
IMPROVE Fpp THE pURPGSE OF SALE).
yyj C7I,ASOY1NEFi4FTHEPflOPERfY,AFdIXCLUSiYELV4Y'3NTRRCTINC>WISi{tIGfNSEDtYJNTRACT4P5
(C TO CONSTRUCT TNE PRqJECT(SEC.7tlH,BUSINESS ANp PNOFESSKKJS CQDE�TNF fAN7MCTORSII- VffIU2tI0f1 ADJ.AREA_
LL! GEtiSEUWpOESNOTAPPIYTqANOWNERpFAPiiOPERT'WIibBU11,p50R1AApfM7VE57NEREGN,AND '—'—
N7K)WNTR,RCTS FOR SUCN PRCUECTS W[TN A CONTMCTORtS}{,ICENS£D PURSUANT TOTME CONTRAC-
QUANTITY 6ESCRIPTI6N
� TORS UCENSE UW.). + FEE
❑i AM EXEMPT UNDER SEC. 8.a P.C,ipR THts qEASON Q *� L j fG�� ( �
U p
u' o�rE,_��CJ—��i ownen ¢ J�Gt��. t C— � ic„
�+k[ UCENSEp CONTRACTORS DECLARATION w ��1 Z�- S '
CL IHEflEBYAFFiflMUNDERPENA{.TVOFPERJUR`lTNA7EAMLtCEN5E6t1NDERPROViS�ON50FCHAPTER �
� 0(COMMENCIN(3 WITH SECTION 7000)OF DIYISION 3 OF THE 9USINES$AND PROFESGIONS CA�6,AND Z
�}j� MXLICENSEISlNtULLWRCEANUEFFECT, � --- I
Q �
F llGENSE C(ASS LIC.NO. � �
U pATE _ CONTRACTOR^„ _ d �--
tl!
� WORKERS'COMPENSATION DECLARATION a -
� I HERFBv AFFIRM UNDER PEN�II.TY OF PERIURY ONE OF7HE FOLLOwMG DECLARATIONS: Z
� ,�_iHAYEtNpWiLLMeVNTAiNACERTiFiCATE(7FCONSEh'TT6SEt.F.iNS{IAEFORWQflKEftS' a
y� COMPENSATION,AS PRqYl0E0 BV SECTION 37D0 QF THE LABOR COpE,FOR TNE PEPFORMANCE U
Q 4F TH£WURK W4i W411CH TNIS PERM�T IS tSSI}E0. �
� __I MAVE M�WILL MAINTAIN WORKEpS'COMPENSATION INSUMNCE,AS REOUIFED BY SEC710N ���
� 3Ta00�TNE tAeOF COOE,FORTHE PERFOFMANCE OF THE Wf}PK FOR WHICH THIS PEflMiTlS
ISSUED.MY WORICERS'C'.OMPENSATIUN INSUMNCE CAftRIER AND PQLICV NUMB6R ARE�. CONSTRUCTION � �
> c�R�n�R _. PtAN REVIEW � f#�
� POLICYNUM@ER _ _ � _—'_ —...
ELECTRIC
Q (i1d5SECl'MJNNLEbN�TqE00MttFTF"DOF7NEPEWNTISRJqpdEMNiNiEDIX:M.INt.(5100)PRLESs} PLU—� MBING
ii.!
� I CERTIFV TMAT IN THE PERFORMANOE OF 7HE WORI(FQR WHICH THIS PERMIT IS ISSl1Ep,I MECHANICAL
SMALL ND'f EMPIOY ANY PERuQN fN ANY MANNEft 50 AS TO 6EfAME SVBJECT i0 THE "
(/J WQRKEAS'COMPEF}SATqN�hhWS OF C�V.IfORNiA,AND AGREE itiAi h"�I SHOULD BECOME iNSPECTION FEE �
SUWECT TO THE WORKERS'�"bMP�NSRTION Pft17N510N5 OF SECTICNJ J7p0 OF THE UBOR
� �E,E sttnu.FoarHw�r.�corav�v win{Trros�paov�smras. ISSUANCE �
� .... ...._.. �'—
p DATE:_ aaa�.ICANT: SMIP
..._.__ ..._ _. ......_
w ENERGY P/C S. �tr,,.,
J WARNING FAIWRETO SECUFiE WORKERS'GOMP6NSATION COVERAQE IS UNLAWKUL,AND SHAI.LBE — � .4
�y St�JEGF Ni EMPIOYER i0 CPoMINAI PENAL71E5 ANO CtYil FMES UP TO OME Fk1NDRE�TNOUSAND �� .-'�T:��
DOLURS j{1o0,000),IN AODRIONTO THE COSTOF CAMPENSATION.�AMAGE5 AS PROVIDED FOR IN �NEF2GY PERMIT �
J SECTbN 31tl8 OF THE LABOR WDE.INTERE3T,AND ATTORNEY'9 FEES. ' �
OC HETENTION FEE
OGONSTRUCTION LENDING AG6NCY pqE-ALT FEE: �f��' � __.,_
� 1 HER�V AFFIRM UNDER PENAITV OF PERIURv THAT TFtEPE IS A CONSTRUCTION tENDiNG AGENCY �
FOR THE PERWRMANC�OF TNE WORK FOR WHICH iHl5 pERM17151S5UED($EG.3081,CIV C.}. � .. ' ����—
Z
ISI
� LENpER'S NAME �_, ' �� , ' .. .
1— LENqER'SApDRE5S _..� _._
t .
�
W iCERTiFYTHATINAVER6Ai7THISAPPLiCAT'�ONANpSTATE711ATTHEA80YESNFORMATi�Ni5C09RECL TOTAL FE�S �7 � � �--f
d I AGREE TO CAMPLY WITH ALl CITY AND COUNTY OR�INpNCES pND STRTE LAWS flELATINO TO BUILDIN�
� CONSTRUCTIQN,ANOHERESYAJTHpRiZEREPflESEN7ATiYE50fTHiSCOtlNTYTOENTERU?�N7HE
Z neOVE-MENTIONEDPApPERTVFORINSPECTIONP�URP09ES. COMMENTS
d
� �, "�".� --
� P£RM E E{PWNTj
� � l`r� ' �G - c'J — �
� sroNa e eE axr� -
� RECPT NO. PAID BY VALIDA'fION
WH{TE—Dspartment Copy,VELLOW—Finarxa Copy,PlNK—Assessw Copy,G4LDENRt?6—Fiie Copy,GREEN—A�piicanPs Gopy
��°�`�` �� �€ ��1� ���
l�l�����'��� F���� �� � — -
` � � A +� ` s �rl • � �
; �;r-T n n, .
� _�S' , . i ^I Ji7�� �;�CY
_.__ _ .._.. i :
.__,�._ .__ _....
k�_��i������ 4 '�� . , F!��' �_...._.._ .— '_ —.. '�_�_._.... ._.... ,.
� �
, � . ri�
�. .. � �. ._ _ ._ _.." _
� i-' �- i}�I�_: -e�('Ic�' b � ,t`�-�� y ` {,.,-2 �, . _ _.. �_ . .�_ _..
_ _. __ �_ . ___....., _... �
1
� ('�,-' t ��1( � t a �: , ... __ ._ � _ _. . - _. _.' "'_ -.
[ °l, r. S {_.1�21J r-t •- Y.�i 1�;� , -
.._ _ . , . ... ___........_. ..__.._ _ ....__.__ { _ .....
._ ...._...
} �� , ...._ . .. _ _— _.#_..��_ .�..__ ....... .
7 �i,+._d�� f ¢�:q `? .. ."1 .s� (a�i C � .._,.�°t�€j3=c"���� .� ,.
_ ... . .._ ,__. _..,_.. _�_. .___......______.,._.__ ' _... __ _' " _.._. _.._ _._._,..._ _.. �.
�F'1i' t ��:��t� ", ; ,- - f _._
�--
_ �' t F , ' �r"�tf �_ �i;�iiC; ,�, .'��� ' �
�.__�_ :�'__ __ _ _. __._ _ � - ���
� k�I�7�t� '��t',t ;r � - — a+��� ;? �# _ �_ --� -- ...__ _ .._�_ _ _ _ �
� t _ ,
__ _ �_ �_.�_,_ .:
_ __ .._ __ ,
- _ .___ .__
g �:��k- t',9-�t..'1 } � �'�t � � � & r �x . . .._ . .___, _
� .._ _ _ . � — -___ __.._._ _ � � E ,° ___— _---- -___ a
�. �
s . �'� �
- _
� r �?FaM1�«iC;{I �tP,€�� � �!�; ` � __ ___ __
t--. ._ � _ _ ��` '�i � a.tg�1�,7 �``�;, e �
_,- -- -.__ _ .__ _ _ -- _.
� - _ _� _
.;r,r r .."''� °. < 4z� a <� �>"� .
_ _. __ . � w _.._._ �._,,._ _ ..____ ,_
��-5�f�<€ i --lC� �+.� � .._ .. .'_ ..---. _—__., ._ __._ .__ _.._ .,.__._._.. �.
. . . �;.... -� .iSe f
t -.__ .'. . � ._ .,w .........� �.�.._..._...._ __...._ ___.._.._�_._ ._. _ _.__ _ __.._ . _..
� --�.�� _.._..�_ a- . _._ .. ..._., ..
s ^?C�L3°��$`�t ' ��.���� ' �r � _.
�,
x,a._ F 1 �,�. t.� 1; ::kS ��x...E�r. �.
N_ _... -,._._ '_—_ _ ' ; "_._..._,.. . _._ " ___ ...... . —_. _.. . "__ " ..___ y'_— .'""'"" f '__"_"_"'" ..._..
�-+i.� .. y � ......
f'?'�..F f f� L�5... 4:�4;a ' 3—'� �3 Y .
. _. ._ . , .. _._. __ __. ___.... _ __..� �
',. . y' ..p—/'�...e -� '""r_. —...
��E`�•,�e , 1+:.,5 � � • €_i. ; •_f✓l�t'J t —_ .._� ,. . _,..
_ .. .._ , ,. _. . .__..... �__....._.. ...._.___....�_ _ "� � _._...._.__...,._.
p{ . ._._..._..._.� __....._�... __.._. .. .. _._.... '
:�. ., ,.�7i .. � x3i" 1 L�`��IYCwt � ...... �.
x_._'_ _ ... ...._ ""......... _ ` '_...._..._.. ...... __."_ .._ _.._.. ._____.._.__ ........_ ..
f �y`n,! t� ; t�T '. _ .._ �_..�...�_.�__�..._.__.._ ._.. .
. _ w"�� .���°�. � ',�{��i_ ____.
_ _�.. _ _ �_.W�- - -- _ __
-. , �, <�r .,• _ - � -- - - _�___ _ _ � _
3 , . . r,�r. _ " �� �_
. ti = ,. �, � , -
� ,; ... . , �� ,
_. ._ _.�____ _._ _..,�- ---_ �..
iF�° << , � • -,: . , . - - ...� __� w _.� �—_ .__ ...... .
� __ , _ __z}� ,;;.�t�`;
_ _ __. _ _ _._ , _ __ _______..
�:r'. ' � � ��a, � - - -----. -_ _ _._. _.
e •
, 3__ ;._ _.._ _ � __ _�_ .
- .. � . __ - _ _ . _— _ __ __
. _ ., ��� _ ,� � .��;_ �
_ _ _ . ___ __ .._ _ _ �...___ __
___ .__—_ _.� _. _ „ ._
_ _ _m _._� __ . _._._ _,. ___.._ _
� . � � ,;� --
_. � _ -"�, ,
_._ _ ____ -- -- ; _ __
�_w. _. -. _.___ �____ .-�__.�_ ......�__ . _
_� , ,. ,
�v�� �w . � � o .. s .__
__ � -. _. es�� ��:-�: � ,� { a
. __ _ ---
.�,����e" �:°'� �'�<� , ; __ �
¢ ___. _ . _ __ ,. �- __ �.__ _ __ _ ____ __. _ __
, _ __ _
g
� _....,._ _. __ _ _ _. _ __ _ _ . . _
t-__.' _. . _ _ --- - -- _ _ _ ___ ___
._ _.
__ __ _ _ ___ _._ -- _ :
� mt'; . -
__
, -�.�c�'3 i=, �:�;, :�. rs� ...... _..... _.... _... . . . ... . �
; ..� ,... ..._ .._. ... .. . .... ..
� ` ,`�°�') ,i*r,a E
5 r +^ ��
� _. ......_ . ._ _ ..... ..._ .. ._�._ ..
� � —. ..._ ..... .._.. ...... .... . ..
S
� . ..... .._..,,__,..,_ , .._,.._ ._.. ...,. .._. ..... . ..
� -..... _, , _....._. _ ..__ ...___.. __.. �
t� ii . .... ..__ . . .......
� � _ -
; ' �+i - _ __ - _ - _ �
� '' ii�� _ � - ��- -_--
'
� � � �
� , _._, __ . . _._.. _ _ _ __ _ _
� � - --� � -
4, - . . ..� ... _ __ . _..,.m.... _ .._.. _. ._ ...... _- ---.... .. .... ._._. _... ._. .... ...... . .... ..
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVE�OPMENT SERVICES
21660 E.Copiey Drive Suite 190
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
PRESS
FIRM�Y
APP�ICATION PERMIT 5_]� P/C
DATE u �v NUMBE#
ISSUE TYPE OCC
DATE CONST.GROUP
ZONING SETBACKS
FRONT RW^
REAR^
SIDE/SIDE STREET RW^
SIDE
�
/^'
PROPOSED USE Pop-0 h 0_
N0. DWE�. N0. NO.
UNITS STORIES BEDROOMS
DESCRIPTION SQ. Ff. FACTOR PSF ADJ.AREA/VALUATION
SFR/ADD/REM
0 Garage/Carport
W Patio/Deck
LL PooVSpa
Z Re-Roof
Commercial
5
Valuation AD).AREA
QUANTITY DESCRIPTION FEE
a 3 L
�-7S
pp
U h�r�E t'-C a
7
w 5'ueZ�S
W
LD
m
Z
W
CONSTRUCTION_
P�AN REVIEW ty� .
E�ECTRIC
�
P�UMBING
MECHANICAL
INSPECTION FEE
ISSUANCE
SMIP
ENERGY PJC'•,_
ENERGY PERMIT
RETENTION FEE:
PRE-ALT FEE:
Lz)
TOTA�FEES
COMMENTS
RECPT. NO. PAID BY VA�IDATION
JOBSITE
ADDRESS G c�
APN�OT TRACT
OWNER_�1Aj �-]12 ti
ADDRESS
"fe C aJ6Ciayr'C 1--A-
CITY i�c�wr.AA.Via,ZIP CA TE�.,"S'-1 147
APPLICANT TE�.
CONTRACTOR
ADDRESS
CITY ZIP TE�.
ARCH/ENG/
DESIGNER
ADDRESS
CITY ZIP TE�.
OWNER-BUI�DER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE�P,W FOR THE FOL�OWING REASON(SEC.7031.5 BUSINESS AND PROFESSIONS CODE: ANY CITY OR
COUNTY WHICH REQUIRES A PERMITI'O CONSTRUCT,ALTER,IMPROVE, DEMOLISH,OR REPAIR ANY STRUC.
TURE, PRIOR TO ITS ISSUANCE,ALSO REQUIRES THE APP�ICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI.
CENSE IAW(CHAPTER B(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO.
FESSIONS CODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE A�LEGED EXEMP-
TION.ANY VIOLATION OF SECTION 7031.5 BY ANY APP�ICANT FOR A PERMIT SUBJECTS THE APP�ICANT TO
A CIVIL PENA�TY OF NOT MORE THAN FIVE HUNDRED DOL�ARS($500).):
^ 1,AS OWNER OF THE PROPERTY.OR MY EMPLOYEES WITH WAGES AS THEIR SO�E COMPENSATION,
WI�L DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SA�E(SEC. 7044,BUSI-
NESS AND PROFESSIONS CODE:THE CONTRACTORS�ICENSE�AW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BUI�DS OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE IF, HOWEVER THE BUI�DING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF COMP�E-
TION,THE OWNER-BUI�DER WIL�HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUI�D OR
IMPROVE FOR THE PURPOSE OF SALE).
^I,AS OWNER OF THE PROPERTY,AM EXC�USIVE�Y CONTRACTING WITH �ICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC. 7044,BUSINESS AND PROFESSIONS CODE:THE CONTRP,CTORS LI-
CENSE t_AW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUI�DS OR IMPROVES THEREON,AND
MHO CONTRACTS FOR SUCH PRO]ECTS WITH ACONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAC-
TORS LICENSE�AW.).
^ I AM EXEMPT UNDER SEC. B. &P.C. FAR THIS REASON
DATE T)-?OWNER
LICENSED CONTRACTORS DEC�ARATION
I HEREBY AFFIRM UNDER PENA�TY OF PER7URY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
V(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND
MY�ICENSE IS IN FUL�FORCE AND EFFECT
LICENSE CLASS�IC. NO.
DATECONTRACTOR
WORKERS'COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENA�TY OF PER]URY ONE OF THE FO�LOWING DECLARATIONS:
I HAVE AND WIL�MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'
COMPENSATION,AS PROVIDED BY SECTION 3700 OF THE IABOR CODE. FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
-1 HAVE AND WIL�MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION
3700 OF THE IJ�BOR CODE,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WORKERS'COMPENSATION INSURANCE CARRIER AND PO�ICY NUMBER ARE
CARRIER
POLICY NUMBER
(TFBSSECigN NEEDNOT BE OOM,ETED OFTHE PERMIT IS FOR ONE I-LP ED DOL�ARS($100)OR LESS
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
SHAL�NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUB]ECT TO THE
WORKERS'COMPENSATION LAWS OF CALIFORNIA.AND AGREE THAT IF I SHOULD BECOME
SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE(ABOR
CODE,I SHAL�FORTHWITH COMPLY WITH THOSE PROVISIONS.
DATE: APP�ICANT:
WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERP,GE IS UN�AWFUL,AND SHAL�BE
SUBJECT AN EMPLOYER TO CRIMINA�PENALTIES AND CIVI�FINES UP TO ONE HUNDRED THOUSAND
DOLI�,RS($100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN
SECTION 3708 OF THE LABOR CODE,INTEREST,AND AITORNEY'S FEES.
CONSTRUCTION LENDING AGENCY
I HEREBY AFFIRM UNDER PENA�TY OF PER]URY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC. 3087,CIV. C.).
LENDER'S NAME
LENDER'S ADDRESS
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES.
ZUO-7---Z-
k PERMI E E(PRINT)
3 SIGNAT E EE DATE
r I
WHITE-Department Copy,YE�LOW-Finance Copy, PINK-Assessor Copy,GO�DENROD-File Copy,GREEN-Applicant's Copy
PiL