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HomeMy WebLinkAbout16833 (26) CITY OF IDIAhiIONL�BAIi _ I h ' -- -�'�'—- DEPARTMENT OF COMMUNTI'Y&DEVELOPMENT SEAVICES I � 21825 E.CopleyDrive (909)850-3195 Fax(9Q9)861-3117 �� PRESS '"`-.yr�'"' BUILDYIlTGPERI�IYTAPP�,ICATION FIRMLY o ADDRESS i �"v � l�"��"'� �' ` DATEICATION� /�' �'� NUMB R �_Vd'A J�#f C�'�.��� l o� ISSUE TYPE �',.�p OCC � APN LOT TRACT DATE CONST, GROUP p OWNER � � p ADDRESS v � �"�� ZONING SETBACKS z CITY ZIP C-^�' �EL. �r ��9`�T FRONT RW ❑ o APPLICANT �' --��� TEL. ` � SI E SIDE STREE7 RW ❑ z ¢ CONTRACTOR SIDE ❑ � ADDRESS y- � CITY 21P TEL. PROPOSED USE a`7 X' �Za !�s� S��l�-� �8 o 'ARCH/ENG/ � a DESIGNER • W NO.DWEL. j N . NO. � ADDRESS � ,CITY ZIP TEL. UNITS i STORIES BEDROOMS � cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� � ;AWNEFIrBUIL�ER DEGLARATION SFR/AD�/REM � � O � I HEREBY AFFIRM UN�Eit PENALTV OF PERJIJflY THAT I A!A EXEMPT FROM THE CONTRACTORS LI� G2f2gBIC2fPOf[ W CENSELAWFOftTHEFOLIOWINGREASON(SEC�031.58USBJESSHNOPROFESSIONSCO�E:ANVCITYOR (� .0 CAUNTYWHICHfiEQUIRESAPERMITTOCOhSiRUG,T,ALTER,IMPROVE,�EMOLISH,ORREPAIRANYSTRUC� W patio/Deck W TURE,PRIOR TO ITS ISSIJANCE, 50 PEQ�IRES THEAPPLICAN7 WR SUCH PERMITTO FILE ASIGNEO W STATEMENT THAT HE OR SHE IS�CENSED PLIRSUANT TO THE PROVISIONS OF THE CONTflPCTORS LI� � CENSE LAW(CHAPTER 9(COMME CMG.WITH S�C;�ION 700�)OF DIVISION 30F THE BUSWESSAND PRO� U' POOUSP2 FESSIONSCODE)ORTHATHE.OR'�,�HEISEXEMPYT(iEREFROMAND7HEBA515FORTHEALLEGEDEXEMP- (� � ,TION.ANYVIOLATIONOFSECTIQN7031.5BY'ANYAPPLICANTFORAPERMITSUBJECTSTHEAPPUCANTTO Z R2-ROOf � � ACIVIL PENALTY OF,NOT MOR�TWAN FIVE HUNqR�D DOLLARS($5oD).�: ❑I,AS OWNEFiOF THE PftOP�RTI',OR MY EMPLOYEES W ITH.WAGES AS THEIR SOLE COMPcNSATION, Z 0 Commercial � � - � WILI�O THE WbRK;AN�TH�S"CRUCTURE IS NO"�'WTENDEO OR OPFERED FOR SALE(SEC.7044,6US4 J � NESS AND PFOFE5SIONS CODE:jHE CONTRACTO�S LICENSE LAW DOES NOT APPLY TO AN OWNEP OF = �� �� , , �� � PROPERN WHO BUIL�S OR IMpqOVESTHEREON,AND WHO�OES SUCH WORK HIMSEIFOR HERSELF OR . � �THROUGH HIS OR HER OVJN EMPLOVEES,'PFOVID�b THAT SUCH fMPFOVEMENTS ARE NOT INTENOED OR m '� 'W '-0FFEREDFORSALEIf-,HOWEV�R7HE8ULDINGOFIIMPROVEMENTISSOLDWITHINONEYEAROFCOMPLE ' Z .TION,THE OWNER-BUILDER WILL�iHAYETHE.BUR6,�N OF PROVING THAT HE OR SHE DID NOT BUILO OR 'IMPROVEFORTHE�PURPOSEOF�$ALE). � ' � ❑I,AS OWNEFI:OFTHE PRO��RTV,AM EXCLUS�VELV CONTRAC7ING WITH LICENSED CONTFlACTOliS W � ��,TO CONSTRUCT THE RflOJECT(SEC.70'44,BU51NE55 AND PROFESSIONS CODE:THE CONTRACiORS�I� V81uaUUn ADJ.AREA � LLI CENSELAW�OESNOTAPPIYTO;WNOWNEROFAPFiOPERTYWHOBl11LD50PIMPROVESTHEREON,AN� — � F �.WHOCONSpACTSFORSUCHpRO�JECTSWITHACO��RACTOF�S)LICENSEDPURSUANTTOTHECONTRAC- QUANTITY �ESCRIPTION � FEE i Y '',TOPS LIC SE LAW.)'. � AM EXEMPT UNDER SEC. B.6 P.C.FOR7HI5 REASON Q � � � � �DATE ��� OW , U . Z '� ' � ' .- W . � -�CENSEQ CONTRAC,TORS DECLARATION � � I ¢ � '�I HERE FIRM UNDER PENAITN OF�PERJURY THAT I AM LICENSED UNDEF PROVISIONS OF CHAPTER � ��� . 'q, ,9(COMMENCM�WITH SECTIO,N�q00)OF'JIVISION'�3;OF THE BUSINE55 AND PROFESSIONS CODE,AND Z �X MY LICENSE IS W FULL FORCEAND EFFECT: m � UCENSE�CLASS LIG.NO. j � � J V OATE CONTRACTOR a . W � � WOflKERS'COMPENSATION DECLARAT70N Q �� 'IHEREBYAFFIRMUNDERPENAL'M�F�PERJIJRVONEOFTHEFOLLOWING�ECLAPATIONS: Z - ' z _IHAVEANDWILLMAINTAI ACERTIFICAiEOFCONSENTTOSELF-INSUREfORWORKERS' , _ . , , � �, Q CAMPBJSATION,AS PRO�I�E��y SECiION�l37oo DFTHE LABOR CODE,FORTHE PERFORMANCE . 'U Q OF7HE WORK FOR WHIC TWIS�.7EqM1T IS ISSUED. - ' � - F _IHAVEANDWILLMAINTqINWOfiKE(15'COMpENSATIONINSUqANCE,ASHEOUIRE�9VSECiION• � -.� Qn 37a00FTHELABOR�COOE.FORIiIiEPERFORMANCEOFTHEWORKFORWHICHTHISPERMITIS ISSUEO.lAVWORKEAS',C�MPENSATIONINSUFANCECARRIERAN�POLICVNUMBERARE: CONSTRUCTION Q � CARRIER PLAN REVIEW ,{� ZPOLICY NUMBER � ELECTRIC 1.J�+.Jry Q ,�V � (iHI55ECT10NNEmNOTB�NMPLEfE�OFiHEPERMITISFORONEHUMJREDD011ARS(5100)ORLESS). PLUMBING Z ICERTIFYTHATINTHE�PEflFORMANQEOF'THEWORKFORWHICHTHISPERMITISISSUED,I MECHANICAL (} SHALL NOY'EMPLOYANY'�EPSQN IN ANY MANNER SOAS TO BECOME SUBJECT TO7HE •S � WORKERS'GOMPENSATIONUWSOFCALIFORNIA,AN�AGREETHATIFISHOLLUBECOME INSPECTIONFEE . �-•--�-�- � SUBUECTI`07HEWORK�RS'COMPENSATIONPROVISIONSOFSECTION37oo0FTHELA60R /'� , � i �,j � CODE,ISHALLFORTHWI'�HCOMPLYWITHTHOSEPflOVISIONS. ISSUANCE ��4�✓.�`'��w i �__ � � ' SMIP �� i ��e p DATE: 'APPLICANT: ,V y� J WARNING FAILURETOSECUHE�WaRK@R5'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALLBE ENERGY P/C � fi.��' "� - � { � �y� SUBJECTANEMPLOYERTOCRIA�1NALPENqLTIESANDCIVILFINESUPTOONEHUNOREDTH0U5AND ENERGYPERMIT � r � . } -5T0=COMPEtvSATION,DAMAGES AS PiiOVIDED FOR IN J� SECTION3]OBOFTHELABORCOP, ERbST,ANDATTOftNEV'SFEES. RETENTIONFEE: � '3' a. GqNSTT �. �..u. .�'".' 100.000),IN O I O H C W RUCTION LENDING AGENCY PRE-ALT FEE: � �'''' - O � IHEREBYAFFIRMUNDERPENAL.?YOFPERJLIRYTMfATTHEPEIS.4CONSTRUCTIONLENDINGAGENCV FOR THE PERFOFiMANCE OF iME�i WORK FOR WHICH THIS PERMIT IS ISSUEO(SEC.30 W,CIV.C.). . 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