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HomeMy WebLinkAbout17292 (23) ctr�r oF n�orm B�t �'= - � — DEPARTMENT OF COMMI.JI�tITY&DEVELOPMENT SERVICES I � 21825 E.Copley Drive (909)860-3195 F�(909)861-311'7 PRESS ""%»�"��' BUILDING PERMIT APPLICATION FIRMLY �� JOBSITE APPLICATION PERMIT �J O� PJC o I ADDRESS�I Z.�c�C� "T�LU'l, PS?+L✓"'� DATE_ �� �� �� NUMBER ��` (Z# ��/ o�' ISSUE /� TYPE OCC APN LOT TRACT DATE I� v CONST. GROUP O OWNER �C1C3�I p� ApDRESS �Z.Z,io1 l7 `�'L.U l. �A�. ZONING SETBACKS z' CITY �, �. ZIP �I'�LS TEL.�(p'1� Sf6I'S �" FRONT RW ❑ � APPLICANT TEL REAR ❑ � SIDE/SIDE STREET RW O � CONTRACT�R C200EtvJ�- �,TtlanD�JaS�.OS SIDE ❑ ADDRESS��'1� CL R `{ PROPOSEDUSE � � R�IC'�F � cirr P��Ace,N,tiA—._ ZIP�`Z�`7QTEL.^I[4/—�R3—`77! � ------- C� ceT +�St"Ac(. 31 � w ARCHIENG/ --__."--'_::�,..�,._, �✓J � 1/,f,�AC�S.�7W++�P' � ADDIRESS NO.DWEL. NO. �_ NO. � CITY ZIP TEL. UNITS STORIES _i BEDROOMS � DESCFIPTION SQ.FT. FACTOR P5F ADJ.AREANALUATION OOWNER-BUILDER DECIARATION SFR/ADD/REM Q I HEREBV AFFIRM UNOER PENALTY OF PERJURY T'.IAi I AM E%E�APT FROM 7HE CONTRACTORS LI- � GaragelCa.ryort W CENSELAWFOqTHEf-0ILAWINGREP.SONfSEC.7031.5BU51NE5SANDPROFE5510NSCODE:ANVCiTYOR U COUN7VWHICHREOUIpESAPERMITTOCONSTRl1CT,ALTER,IMPqOVE,�EMOLISH,ORREPAIRANYSTR�'C- W PatiOIDBCk WTl1RE,PRIOR TO ITS ISSUANCE.ALSO REQUIRES TI1E APPLICANT FOR SUCM PEFMIT TO FILE A SIGNED W � STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTOAS L!- � CENSELAW(CHAPTER9(COMMENCINGWITFiSECTIO�'I00o)OFOIVISION3OFTNEBUSINE55ANDPRO- � POOVSpB O FESSIONSCODE)ORTHATHEORSHEISEXEMPTTHEREFROMANDTHEBASISFORTHEALI.EGEDEXEMP- (� i_ V TION.ANYVIOLATIONOFSECTION7031.SBVANYAPPLICANTFORAPERMITSUBJECTSTHEAPPLICANTTO Z R8-ROOf � � ACIVILPENALTYOFNOTMORETHANFIVEHUNpREDDOLV+RS(ESoo).�: � ❑I,ASOWNEROFTHEPROPEATV,DR6IVEMPIOVEFSK'ITHWAGESASTHEIRSOLECOMPENSATION, � COf11rtf0fC18I Z WILL�O TME WORK AND THE STRUCTURE IS NOT INTENtl'eD CR OFFERED FOR SALE(SEC.7044,BUSI� J NESS AND PROFESSIONS COOE�.THE CONTRACTORS LICENSE LAW�OES NOT APPLV TO AN OWNER OF � PROPERTYWHOBUI�DSOPIMPROVESTHEREON,AN�WHODOESSUCHWORKHIMSEIFORHERSELFOR ' � THflOUGHHI50RHEROWNEMPLOVEES,GROVIDEDTHATSUCHIMPROVEMENTSARENOTMTENDE�OR m W OFFERE�WRSPLEIF,HOWEVER,iHEBUII�INGOiiIMPROVEMENTIS50L'JWITHINONEYEAROFCOMPLE� � TIDN,THE OWNER-BUILDER WILL HAVE 7HE BURDEN OF 7aOVING THAT NE OR SHE DIO NOT Bt,IL�OR Z IMPROVEFORTHEPURPOSEOFSAIE). � �I,ASOWNEROFTHEPROPERTV.AMEXCLUSIVELYCONTRACTINGWITNLICENSEDCONTRAGTORS / � TO CANSTPUCT TNE PROJECT(SEC.7044,BUS�NE55 AND PROFES910N5 CODE:THE CONTRACTOflS ll- 'VeIUeIIOR_y2L ADJ.AREA W CENSELAWOOESNOTAPP�VTOANOWNEFOFAPROPERTVWHOBUILDSORIMPROVESTHEREON,AND � WHOCONTFACTSFORSUCHPROJECTSWITHACANTRACTOR(SILIGENSEDPURSUANTiOTHECONTRAC- qNTITY DESCRIPTION FEE Y 70RS LICENBE LAW.). � ❑I AM EXEMPT UNOER SEC. 9.&P.C.FOR THIS REASON U � � � DATE OWNER v Z W � '� LICENSED CONTRACTORS DECLARATION w �' 'I HEREBYAfFIRM UNDER PENALTV OF PERJUFVTNAT IAM LICENSED UNDER PROVISIONS Of CHAPTER � d i 9�COMMENCING WITH SECTION 7000)OF OIVIS�:ON 3 OF THE BUSMESS ANO PROFESSIONS CODE,AND Z X 'MY UCENSE IS IN FULL FORCEANO EFFEC7. m 0 rLICENSECLASS L� '"'� LIC.NO. � �'✓o� --q--- � ���� (]'�. J w (�ATE `�! � � '—�' � CONTRACTOR �IY�.�e/'�al.J� � 0- . �� � WORKERS'COMPENSATION�ECLARATION Q � � �IHEREBYAFiIRMUNDERPENALTYOFPERJUFYONEOFTHEFOLIDWINGDECLAfiATIONS: U C/� Q � �,INAVEANDWI:LMNINTAINACERTIFICATEOFCONSENTTOSELF-INSUREFORWORKEFS' 2 GOMPENSATiON,ASPROVIOEDBYSECTION3'looOFTHELA80RCODE,FORTHEPERFORMANCE U ¢� ' OFTHE WORK FOR WHICHTHIS PERMIT IS ISSUED. � I �� {�IHAVEANDWILLMAINTAINWORKERS'COMPENSATIONINSURANCE.ASREdUIREDBYSECTiON �'\�] //�� Q 370a OFTHE LABOR CDDE,FOP THE PERFORMANCE OF 7HE W�FK FOR WHICH THiS PEPMIT IS 'l l�/� L�V 0� ISSUE�.MVWORKERS'COMPENSATIONINSURANCECARRIERANDPOUCYNUMBERARE: CONSTRUCTION �i � j �� CARRIER` PLANREVIEW � � POLICV NUMBER ELECTRIC Q � (iHISSECfIONNEmNOTAE�IAPLEYEDOFTHEPEF3vif11SFORONEHUN�REDDOl1ARS(E100)ORLESS). PLUMBING W ICEP,TIFYTHATINTHEPERFORMANCEOFiHEWORKFORWHICH7HISPERMITISIS5UE0,i MECHANICAL Z (S SHALLNOTEMPLOYANVPERSONINANYMANNEFSOASTOBECOMESUBJECTT07HE � WORKERS'COMPENSATIONIA.WSOFCALIFORNIA,ANDAGFEETHATIFISHGUIOBECOUE IN$PECTIONFEE I SUBJECTTO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 370oOFTHE tABOR '— - ~ I COOE,ISHALLFORTHWITHCOMPLVWITH'HOSEPAOVISIONS. ISSUANCE � � 1 �} p bATE:�_�Z 3��`APPLICANT. SMIP ♦�v W ENERGY P/C J AHNING:GAILURE TO SECl1RE VJORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL @E � SUBJECTANEMPLOYERTOCRIMINALPENAITIESANOCIVILFINESUPTOONEHUNDPEDTHOUSANO ENERGYPERMIT DOLLARS(=100,000),IN ADDITION'O THE COST OF CONPENSATION,DAMAGES AS PROYIDED FOR IN q„� � SEGTION 37ae OF THE LABOR CODE,INTEREST,AN7 ATTORNEI"S FEES. RETENTION FEE: W CONSTRUCTION LENDING AGENCY pqE•ALT FEE: d O � IHEREBVAFFIqMUNDERPENALTVOFPERIURYTHdTTHEREISACONSTRUCTIONLENDINGAGENCY FOR iHE PERFORMANCE OFTHE WOflK FOR WHICH THIS PERMIT IS ISSUE�(SEC.3o9'!,CIV.C.i. Z w 2 � LENDER'S NAME � � F_- ' �ENDER'S ADDRE55 ___.._. WICERTIFYTNATIHAVEREADTMISAPPLICATIONANDSTATETHATTHEABOVEINFORMATIONISCORRECT. TOTAL FEES � `7� � ! � � IAGREETOCOMPLVWITHALLCITVAN�CO�NTVOFDINANCESANOSTATELAWSRELATINGNBUILDING CONSTRUCTION,AND HEREBY AUTFIORIZE REPRESENTAT:VES OF 7HI5 COUNTV TO ENTER UPON THE ZABOVE-MENiIONE�PROPERTY FOR INSPECTION Pt1RPOSES. COMMENTS_._..___ � ��. �. � e �- m PE MITTEE NaNE(PRIM) — Q �„ � 3- � r IGNAiUREOFPERMITTEE DATE = RECPT.NO. 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