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HomeMy WebLinkAbout17223 � c��oF nza�olvn aax ,� � ----�'-- DEPARTMENT OF COMMUNTI'Y�DEVELOPMENT SERVICES �� I - 21825 E.Copley Drive (909)860-3195 Fax(909)861-3117 PRESS '''%�r�� BUILDING PERMIT APPLICATION FI R M LY o� JOBSITE /7/�f^U� ���J.� �' DATE'CATION�b � �f' NU g R l ��-'�p/C ADDRESS_ 6U"J �. � ISSUE TYPE OCC APN L T • TRACT DATE CONST. GROUP � OWNER � � � �i 0 o ADDR SS �i ZONING SETBACKS Z CITY P TEL � FRONT _ RW ❑ o APPLICANT TEL. SI�SIDE STREET RW ❑ z ¢ CONTRACTOR SIDE ❑ ADDRE S � CITY �� ZIP TEL �I'� �, ' PROPOSED USE o ARCH/ENG/ W DESIGNER NO.DWEL. NO. NO. � ADDRESS UNITS STORIES BEDROOMS = CITY ZIP TEL. cn ua DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION' � OWNER-BUIL�ER DECLARATION SFR/A�D/REM O I HEREBY AFFIRM UN�ER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTHACiOflS u- GaragelCarport d � W. CENSELAWFOqTHEFOLLOWINGqEA30N(SEC.7031.SBUSINESSANDPROFESSIONSCODE:ANYCITYOR U CAUNTYWHICHREQUIRESAPEFiMITTOCONSTflUCT,ALTER,iMPFOVE,DEMOLISH,OflPEPAIRANYSTRUC- W , TURE,PRIOR TO ITS ISSUANCE,IjL50 RE�UIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED w Patio/Deck - � �. SiATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO iHE PROVISIONS OF THE CONTRACTORS LI- LL � . CENSE LAW(CHAPTER 9(COMMENCING WITH SECTION 7W0)OF DIVISION 3 DF THE BUSMESS AND PflO- POOUSpa O..',�FESSIONSCODE)DRTHATHEOR$HEISIXEMPiTHEREFROMANDTHEBASISFORTHEALLEGEDEXEMP- (� , U'�, TION.ANVVIOLATIONOFSEC710N7031.SBVANVAPPLICANTFORAPEftMITSUBJECTSiHEAPPLICANTTO Z Re-Roof '� ACNIL PENALTY OF NOT MOPE THAN FNE HUNDRED DOLLARS IE500).): �� �. ❑I,ASOWNEROFTHEPROPEftTY,ORMYEMPLOYEESWIiH.NJF,GE5A5THEIRSOLEGOMPENSATION. 0 Commercial . = Z WILL DO THE WORK,AND THE STpUCTURE IS NOT INTEN�ED OR OFFERED FOR SALE(SEC.7044,0U51- J � � �. NESSAND PROFESSIONS CODE:THE WNTRACiORS UCENSE LAW DOES NOT APPLY i0 AN OWNER OF � ".PtiOPERTY WHO OUILOS OR IMPROVES THEREON,AND WHO DOES SUCH WOSK HIMSELF OR HERSELF OR � �'� THflWGHHI50RHERONlNEMPLOYEES,PROVIDEDTNATSUCHIMPROVEMENTSAqENOTINTENDEDOR CO 'Q '; OFFEflE�WRSN.E.IF,HOWEVER;THE9UILDINGORIMPROVEMENTISSOLOWITHINONEVEAROFCOMPIE- �. "TION,THE OWNEH-9UILAER WILL'�iHAVE THE BURDEN OF PROVING THAi HE OR SHE DIO NOT BUILD OR = IMPflOVEFOflTHEPUfiPOBEOF$ALE). w ❑I,ASOWNEROFTHEPFOPEFN,AME%CLUSIVELYCONTRAGiINGWITHLICEN5E000NTRACTORS � '��TO CANSTRUCT THE PRQ1ECi(SEC.7044,BUSINESSANO Pfl�FE5510N5 CODE THE WNTFACTORS�I� VBIUallOfl ADJ.AREA � W �CENSELAWDOESNOTAPPLYTOANOWNEROFAPHOPEHTYWHOBUILDSOfiIMPROVESTHEREON,AND F� WHOCONTFACTSFORSUCHPROilECTSWITHACONTRACTOR(S)LICENSEDPURSUANTTOTHECONTRAC- QUANTITY �ESCRIPTION � FEE � Y TORSLICENSELAW). ' � ❑I AM EXEMPT UNDER SEC. B.&P.C.FOR THIS REASON J � U � 2 � .DATE OWNER U Z � LICENSED CONTRACTORS OECLARATION W � ¢ � .I HEflEBYAFFIFiM UNDER PENALTY OF PERJURV T:iAT 1 AM LICENSED UNDER PROVISIONS OF CHAPTER � /�� tn 0. ,9(COMMENCINGWI7HSECTION70oo)OFDIVISION30FTHE6USINESSANDPR FE 10 CODE,AND Z �"i,J�� w ?C MY UCENSE IS IN FULL ORCE ANp EFFECT. /� � .LICENSEC S LIC.NO. 1���O r �' � DATE CONTRACTOR a i]J � ��� WORKERS'COMPENSATION DEC � Q � `�c., V � ' IHEREBYAFFIRMUNOERPENALTYOFPERJl1RYONEOF7HEFOLLOWINGDECLARATIONS: z z _IHAVEANDWILLMAINTAINACERTIFICATEOFCONSENTTOSELF-INSUREFORWORKERS' _ Q COMPENSATION,ASPflOVI�E09Y5ECTION37000FiHELA30RCO0E,FORTHEPERFOflMANCE U Q OF THE WORK fOR WHICH THIS PERMIT IS ISSUED. � � �_1 HAVEAND WILLMAINTAIN WORKER5 COMPENSATION INSURANCE,AS FiE�U1RED BYSECTION Q 37ooOFTHELABORCODE,FORjHEPERFORMANCEOFTHEWORKFORWHICHTHISPERMITIS ISSUED.MY O EAS' OMPENSATIO INSU�R�5g.n.�CECARRIERAN POUCYNUMBE RE: CONSTRUCTION j CARRIER ������n�,�t��� 1 ?}I'�P i8°�/� �� PLAN REVIEW � P�LICYNUMBER..._.11\� ei--t Q,l �t �� ELECTRIC ¢ FY p � � (iHISSECTIONNE�NOTB€NMPLEfE�OFTFIEPERMfiISWRONEHUNDREDDd1ARS(y100)OqLE55). PLUMBING �{.+�- Z ICERTIFYTHATINhIEP�RFORMAKCEOFTHEWORKFORWHIC THISPERMITISISSUED,I MECHANICAL (� SHALL NOT EMPLDYANY PEft50N IN ANV)AANNER S S O 0 OME SUBJECT TO THE � WORKERS'COMPENSATIONLAWSO�CAIlFOPNIA, PE HATIFISNOULDBECOME INSPECTIONFEE = SU9JECTTO THE WORKEli3'COMPENSATIQY P SECTION 3�Da OF THE IABOR D�1 AL OR W17Ji COMPLY WITHT 5. ISSUANCE s � Q SMIP p DATE� � • O� APPLiCANT J WARN�:F�LURE SECV W RK RS'COM NS RAGEISUNLAWFUL,ANDSHALLB'c ENERGYP/C LL SUBJECTANEMPLOVERTOCRIMINALPENALTIESA�CI INESUPTOONEHUNUREDTHDUSAND ENERGYPEAMIT OOLLARS(E700,000),IN ADDITION�TO THE COST OF COMPENSATION,DAMAGES AS PflOVIDEO FbR IN � SECTION37080FTHELABORCODE,INTEREST,ANOATTOqNEY'SFEES. RETENTIONFEE: a CONSTFUCTION LENDING AGENCY I PRE-ALT FEE: O � IHEREBYAFFIAMUNDERPENALTYOFPERJURYTHATTHEREISACONSTRUCTIONLENDINGAGENCY FOR THE PERFORMANCE OF THE WORK FOF W HICH THIS PERMIT IS ISSIJE�(SEC.3097,qV.C.). . Z W �'�, LEN�ER'S NAME - 1-- LENOER'SADDflE55 � TOTALFEES �@, � I CERTIFY THAT I HAVE READ THIS APPLICAiION AN�STATE THATTH�ABOVE INFORMATION IS CORRECT � ��_ @ � W I AGREE TO C0IAPLV WITH ALL CITY AND COl1N7Y ORDINANCES AND STATE LAWS RELATMG TO BUIL�ING �'�� d � CONSTRUCTION,ANDHEREBYAUTHORIZEREPFESENTATIVESOFTHISCOU�VTVTOEKTERIJPONTHE Z�. ABOVE-MENTIONED PflOPERTV FOR INSPECTION PU POSES. COMMENTS � WA r J � m� PERMITTEE NAME(PRINT� � a !� ��d� — � � SIGNATUrIEOFPERMITTEE DA = RECPT.NO. PAID BY VALIDATION ~ WHITE—Department Copy,YELLOW—Finance Copy,PMK—Assessor Copy,GOLDENROo--File Copy,GREEN—ApplicanPs Copy , .._. .. _.. ._. .. . _ , _... � — . . . . .. . �- .-.:.y .:",..' t�.;:��, K. . ...,. P' "":P, y�.yi.�,.-. .,..;'-: , .«,..a-.� .,_. - � - .- . � . ....... ......_. .. ,. . ' . , . . e s ... 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