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Home My WebLink About17790 (40)4 CITY OF' MOND BAR W,;—c DEPART21i,_1'1T OF COMMUNITY & DEVELOPMENT SERA . :;S E. Copley Drive (909) '�(909) 860-3195 Fax (909) 861.31l7 BUILDING PERMIT APPLICATION JOBSITE ADDRESS �% • . !S APN LOT TRACT OWNER �fiX Z cr V-,L' ADDRESS 4 7 c ..Yn,u;+- ti +L- CRYI�� .,,_.,/ >Gh:- ZIP Y TEL.=. APPLICANT TEL. CONTRACTOR ADDRESS Lkt CITY: ARCFUENG! DESIGNER ADDRESS CITY ZIP TEL. OWNER -BUILDER DECLARATION 1 HEREBY AFFIRM UNDER PENALTY OF PERMAY THAT I AM EXEMPT FROM THE CONTRACTORS LL CENSE LAW FORTHE FOLLOWING REASON (SEC. 7031,S BUSINESS AND PROFESSIONS COCE: ANYGTY OR COUNTY WHICH REOUIRESA PERMIT TO CONSTRUCT, ALTER IMPROVE. DEMOLISH• OR REPAIRANY STRUC• TIRE PRIOR TO ITS ISSUANCE. ALSO REWIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED STATEMENT THAT HE CA SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LF CENSE LAW (CHAPTER 9 (COMMENCING WITH SECTION 7000) OF DIVISION 0 OF THE BUSINESS AND PRO. FESSIONS CODE) OR THAT NE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THEµLEGED EXEMP- TION. ANY VIOLATION OF SECTION 7031.5 BY ANYAPPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO A CINI PENALTY OF NOT MORE THAN FIVE HUNDREO DOLLARS ($Wet): O L AS OWNER OFTHE PROPERTY, OR MY EMPLOYEES WITH WAGESAS THEIR SOLE COMPENSATION, WILL DO THE WORK. AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 704A SUSI• NESS AND PROFESSIONS CODE: THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF LN PROPERTYIOBUILDS OR IMPROVES THEREON.AVD 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 BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAROFCOMPLE- TION. THE OWNER -BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE 010 NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALn O L AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WATH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (SEC. 7044. BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LI• CENSE LAW DOES NOTAPPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON. AND WHO CONTRACTS FOR SUCH PROJECTS WITHACONTRACTOR(S) LICENSED PURSUANT TO THE CONTRAC. TORS LICENSE LAW.). O 1 AM EXEMPT UNDER SEC B L PC FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER IT (CDMMENCINO WITH SECTION TWO) OF DIVISION O OF THE BUSINESS AND PROFESSIONS CODE AND MYUCENSE IS INRAJ. FORCE AND EFFECT. LICENSE CUSS C a'1--CI� U0. NO. % 0 DATE JQ — cl l CONTRACTOR WORKERS' COMPENSATION DECLARATION 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS: _I NAVE AND WILL MAINTAN A CERTiRCATE OF CONSENT TO SELF -INSURE FOR WORKERS' COMPENSATION. ASPROVIDED BY SECTION7700 OF THE LABOR CODE. FOR THE PERFORMANCE �OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. Y 1 HAVE AND WALL MANTAN WORKERS- COMPENSATION INSURANCE, AS REOURED BY SECTION 3700 OF THE LABOR CODE FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. MY WORKERS -COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE. CARRIER •T, r�y�' 1 POLICY NUMBER •S J ^ ,�/ (R6SECA ON NEEDNOTBE OCAilmOF" PERMIT IS FOR ONE HLAMO DOLLARS 3100) OR LM% I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT 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 LABOR CODE.1 SHALL LIJFORTHWITH COMPLY WITH THOSE PPRONSIONS. DATE::: ^ 'F-�il APPLICANT: _ ` 4 S L•-t!L 0 WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL BE SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS (st WOW)• N ADDITION TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR IN IO SECTN 3703 OF THE LABOR CODE. INTEREST, AND ATTORNEYS FEES. CONSTRUCTION LENDING AGENCY 1 HEREBY AFFIRM UNDER PENALTY OF PERAIRV THAT THERE IS A CONS rFIUCTICN LENDING AGENCY FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC. 3097, CIV C.I. LENDERS NAME LENDERS ADDRESS I CERTIFV THAT 1 HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. 1 AGREE TO COMPLY VATW ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING CONSTRUCTION, AND HE REBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ABOVE MENTIONED PROPERTY FOR INSPECTION PURPOSES. I of '' it PERwme NA^•M/^��IMIT SIONATUREOF PERMITTEE DATE 01PRESS FIRMLY APPLICATION, DATE/S�'J" PERMIT -+ PIC NUMBER 74� M ISSUE TYPE OCC DATE CONST. GROUP ZONING SETBACKS FRONT RW ❑ REAR ❑ SIDEISIDE STREET RW p SIDE 0- PROPOSED USE • /ice EV`N f� .» : , J 1'T•11 I.J rl F-/> nn `.i-, NO. DWELL NO. NOrI (. i'L Flap UNITS STORIES BEDROOMS f DESCRIPTION SO. FT. FACTOR PSF ADJ.AREAAfALUATION SFRIADDIREM TA GaragwCarport WPatioiDeck PoOVSpa Z Re-RDDI I., -- CI Commercial In Valuation " -7 ADJ.AREA QUANTITY DESCRIPTION FEE J Q U Q F— U W J w 0 Z CO J U Z Q 2 U W CONSTRUCTION PLAN REVIEW ELECTRIC PLUMBING MECHANICAL INSPECTION FEE ISSUANCE T 1 - SMIP ENERGY PIC ENERGY PERMIT RETENTION FEE: k PRE-ALT FEE: TOTAL FEES j YL7 L� COMMENTS A RECPT. NO. PAID BY L L t VALIDATION )t WHITE —Department Copy, YELLOW—FnanCe Copy. PINK —Assessor Copy. GOLDENROD —File Copy. GREEN—ApplicanCs Copy �s �� 11� ��y�. � � ?�c