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HomeMy WebLinkAbout18763 - 1520 AUTUMN HILL RD CiTY OF I7TAMOND BAR — ��' - DEPAR'i'ME�''I'OF COMMUNTfY&�DEVELOPMEN7'SERVICES 21825 E.Capley Drive (909)860-3195 Fa�c(909)861-31 t7 PRESS "'%��*'� BYJILUING PERMIT APPLICATION FIRMLY � JOBSITE _�_--. APPLICATION �'b t� � PERMIT P/ � ADDRESS � � DATE � NUMBER N � AFN LOT TRqCT � bATE �v � v� ONST. G OUP � OWNER �r r— Q "- AD�RE Zc� �E1 o j��l � '� ZONING SETBACKS z CITY _ � ZIP TEL.�q��3/3a FRONT �pW �`j g REAR ❑ APPLlCANT TEL._ SIDEJ53pE STREET RW ❑ � CONTRAC'fOA a SIDE ❑ � ADBRESS // Q CITY - +`� ZIP TEL. PROPOSED USE � ARCH/�NG! _..�_ ,_ w DESIGNER NO.bWEL. NO. NO. 4 ADDRESS UNI75 STORIES BED OOMS � CITY ZIP cn cn DESCRIPTlON SQ.FT. FACTOR PS ADJ. 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Iil?s-as�sa PPLICANT TEL. - CONTRACTOR /Z o, ADDRESS CITV-n.v-T ZIP EL i- RCWENG/ ESICrNER DRESS CITY ZIP W N ER-BUI�DERDEC LARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY TNA71 AM EXEMPT FROM THE RAC70R5 L4 CENSEIAWFOR7HEFCLLOWINOREASON(SEC.7W1.SBUSINESSANOPROFESSION DE:ANVCITY R COIIN7YWrNCHREWiRESAPERM1T7000NS7 UCTA�7E IMPROVE.DEMOIIREPAIRANYS7 UC i 7URE.PRIOR TO ITS ISSUANCE,ALSO EOU'IRES THE APP�ICANT FOR SUC RMIT 70 FI�E A SIGNE STATEMENT THAT HE OR SHE IS�ICENSED PURSUANT 70 THE P OV151 OP THE CONTRACTORS L CENSE LAW CHAP7ER B CCMMENCWG WI7H SECTION 7.1 OF DIVI 3 DF THE BUSINESS AND PRO FESSK)NSCCDE/ORTHAT HEORSHEZSFXFMPT THEREFROMM EBASTS FORTAEALLEGED EREMP. TION.ANYVIOLA7K7NOFSECTION703'I.SBY NYAPP�ICANT F PERMIT SUBJECTS fHEAPPLiCAN7T ACIVILPENALTY OFNOTMORE 7HANFIVE HUNDRED DO�$SCO,: O�ASONNEROF7HEPROPERTY ORMYEMP�OY WITH WAGES ASTHEIR SOLE COMPENSATIO WI�L DO THE WORK AND THE STRUCTURE 15 NOT I NDED Op OFFEREO FOR SA�E(SEQ 70< BUSI NESS ANUPROFESSION CODE:7HECONTRACT SIICENSEIAWDOES N07APPLY70ANOWNERO PROPERTY W OBUI�DSORIMPROVES THER ANDWHODOESSUCH WORKHIMSE�F ORHERSE�FO THROWN HISORHEROVMEMP�OYEES,VIDEDTHAT SUCH IMPROVEMENTSAREN071NTENDED O OFFERED FORS.ILE.IP,HOWEVERTHE DINCORIMPROVEMENTISSOIDWITHINONEYEAROFCOMPIE 7K7N 7HEOWNER•BURDERWIL�THEBURDEN OFPROVING-HA7HEORSHEDIDNOTBUIL00 IMPROVE FORTHEPURPO5EOF E DIASOWNEROP7HEPPERTYAME%CLUSNELYCONTRAC7INCWITHLICENSEDCONTRACTOR 7000NSTRUC7THEP SEC.7044,BUSINESSANOPROFESSIONSCV70E:7HECON78ACTORS�i CENSEIAWDOESNJT LY70ANOWNER OFAPROPERTYWHOaUI�DSORiMPpOVESTHEREON N W7SOCON7AAC7SF UCHPAOZECTSWZTHACCNTRACTOR(SZLZCENSED PURSUAN770TAECONTSSA 70R5 LICENSE OIAM EMP7UNDER SEC,a.APQFORTHIS REASO D OWNE LICENSED CONTRACTORS DECLARATIO 1 HEREBY AFPIRM UNDER PENALTY OF PERJURY THAT 1 AM LICENSED UNDER PROVISIONS O CHAPTE B(COMMENCING WITH SECTOR 70.ro)OF DIVISION S OF THE BUSW ESS AND PPOFESSIONS COD AN MY LICENSE IS IN FULL FORCE AND EFFEC LICENSEC�ASS LIC.NO DATE d CONTRACTO WORKERS'COMPENSATION DEC�ARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOL�OWMG DEC�ARATION I.VEANDWILLMAINTAIN ACERTIFICATE OFCONS F.INSUREFORV V KERS PGHSA . ROVSOEOBYSECTSOyS "1 7HELSHp FOR7HEPERFORMANC OF RN FOR H THIS P tiSISSUED 7 HAVE AND WI�L MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REOUIRED BY SECTIO 3700 OF THE IABOR CODE,FOR THE PERFORMANCE OF THE WORK FOR WHICN 7HIS PERMIT I ISSUED.MV WOSKERS'COMPENSATICN INSURANCE CARRIER AT PO�ICY NUMBER ARE CARRIER CL.=-- PO�ICY NUMBE QIC55EG7aNNEEOM070EGOtmE7EDOFTHEPERMiTS wRGN in.m EOeousJrs ImIONLESS ICERTIFY THAT INTHEPERFORMANCEOFMEWORK FORWH HISPERMI7 SSUE SHAL�NOTEMPLOY ANYPERSON INANYMANNERSGA57 COME BUBI O�H V ORKERS'COMPENSA710NLAWS OFCpLIFORNIp,pNO ETHAT 1F1 O�OBECOM SU61E 770THEWORKEHS'COMPENSA7 is OF SECTO OOOFTHEIABO CODE$H FORTHWITH CGIAPLV WIT DATE: D L. APPLZCAN WARNING.ILURETOSECURE WORKERS'COMP TIONCOVERAGE IS FUL,ANDSMALL B SUSJEC7ANEMPLOYERTOCRIMINALPENA�T1 CIVI�FINES UPTOONEHUNDRED THOUSAN DO�IAR51S1N.Cw INADDITICN70THEC0 F OMPENSATION DAMAGESASPROVIDED FORI SEC71'JN3709pFTHELABOR CODE,INTER,A pTTORNEYSFEE CONSTRUCTION LENDING A C IHEREBYAFFIRM UNDER PENALTY OFPERJURY THAT7HE ACONSTRUCTION LENDINGAGEND FGRTHEPERFORMPNCEGPTHEWORK FORWHICH T ERMITISISSUED ISEC.3067 CNC.1 LENDER'SN LENDER'SADDAE55 T TI T HAN N AND STATE THI THI MOVE INFORNATION'S CORRECT PRE S S HAT T'Fy RRR TFY TNAT THS T,Fy 11 F APPLICATION I'O t(I-DATE O 1 E PERM�T � NUMBER TYPE F ISSUE G^'^',y���..i DATE o-�_-e CONST._ F THA C ZONZNG SETSACKS FRONT SSDE/SIDE E STREET � � RW GMV RW O O IIILL�-J . JIII REAR ° sxns LV EE,.-NF���TH�� PROPO ED USE JNTY OROINMCES AND STATE 5 RELATING TO B TRUGT ON NO.DWE�. ur i - T UCT CT„ DC C TR oiC 'T R EBV A EPRESENTATINES OF THIS COUNTY TO ENT PON E T ii �E ZN'D "YS CT SES RIN 7) IGNA7U ERMIIE DATE O. 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