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HomeMy WebLinkAbout16931 (39) _ - -.� �_ -- - - -- --- - �_ �i'I'Y��IDiA.t�1�ND�� _l�`�.__— DEP.�'I'P�A1"��F�OMArSL'Y+TT�I'6z DEVELOPIvfENF 3ERVICES ---- �I � 21825 E.Cmpley i3rive � (909)86�-3195 Fax(909)�61-31 P7 PRESS �,,,,,�ri�..,.. �t��,��v��E�����,t��Tl��v FIRMLY � JOBSITE +�ry } � � �� APPLICATION, PERMIT / P/C o ADDRESS�II✓��,�,�����J A""Ti�l� DATE �`J NUMBER �✓�� # � ISSUE TYPE OCC APN LOT _ TRACT_ DATE CONST. GROUP p OWNER _ LL ADDRESS ZONING SETBACKS z C17Y ZIP TEI.. FRONT RW q Qp APPLICANT 7E�� S CE/SIDE STREET RW p q CONTRACTOR =�U � SIDE ❑ ADDRESS � PROPOSED USE o CITY � � ZIP��TEL.+'.����t�/ wo ARCH/ENGI iz DESIGNER NO.DVJEL. NO. NO. � ADDRESS UNlTS STORIES BEDROOMS _' CITY ZIP TEL. � � CESCRIP710N SQ.FT. FACTOR PSF ADJ.AREA/VALUATION. OOWNER-BUILOER DECLARATION SFR/ADD/REM p I HEFEBV AFFIRM UNDER FENALTY OF PERJURY THAT I AM EXEMPT FROM THE COIJiRACTORS LI- � Garage/Carport 'W' CENSELAWFORTHEFOLLOWING'REASpN(SEC.7�31.56USINESSAN�PflOFESSIONSCODE:ANYCITVOR �U' COUNTYWHICHRE�UIRESAPERMITTOCONSiRUCT,ALTER,IMPROVE,DEMOLiSH,ORREPAiRAiYYSTRUC- W Patio/Deck '��. „TURE,PRIOR TO IiS ISSUANCE,ALSO REQUIPE$THE APPUCANT FOFi SUCH PERMIT TO FILE A SIGNED � � STATEMENT THAT HE OR SHE IS�ICENSE�PURSUANT TO THE PROVISIONS OF THE CO�TRACTORS ll� '��, !.'CEN9ELAW(CHAPTER9(COMMENCINqWITHSECTION70ooJOFDIVISION30FTHE6USINESSAN�PAO- V" POOVS{18 '�FESSIONSCAOE�ORTHATHEORSHEISEXEMPTTHEREFROM1AAN�THEOASISFORTHEALLEGE�EXEMP- (� ,'�� .TION.ANYVIOLATIONOFSECTION7031.58YANYAPPIICANTFOflAPEftMITSUBJECTSiHEAPPLICANiTO Z Re-Root � ,�' "q�CIVIL PENALT'OF NOT MOFE TWAN FIVE HUN�RED�OLLARS(SSoo).J: ,I � "��I,ASOWNEROFTHEPROP�R7Y,bRMYEMPLOYEESWITH-WAGESASTFiEIRSOLECOMPENSATION, � COR7rt10fC181 -' ,,Z' '.WILL DO THE WORK,AND THE sTRUCTURE Is NQT INTENDED OP oFFEFED FOR SaLE(SEC.7o4a,BUSI- J �NES$ANO PROFESSIONS CDDE:THE WNTRACTORS LICENSE LAW DOES NOTAPPLY TO AN OWNER OF i ��. :�'PROpERTyWH06UILDSORIMPROVESTHEREON�ANDWHODOESSUCHWORKHIMSELFORHERSELFOR � �,2'. :,TFROUGHHISORFIEROWNEMPLOYEES,PROVIDE�THATSUCHIMPROVEMENiSARENOTINTENUE�OR m Q�.,...OFFEFiED FOR SALE.IF,HOWEVER,THE 6IJILDINGOR IMPROVEMENT ISSOLD WITHIN ONE VEAROFCOMPLE .Z,,; ',TION;THE OWNER-BUILDER WILL HAVE�THE BURDEN DF PROVWG THAT HE OR SHE DID NOT BUIL�OF �;;",IMPROVEFORTHEPVFP09EOFSALE).' '0 I,AS OWNEH OF THE PROPER7V,�pM EXCLl1SIVELV CONTRACYING WI7H IICENSEb CONTFACTDRS �,'�,', ��Tq CONSTP�CTTHE PROJECT(SEC.7op4,BUSINE55 PN�PROFE9SIONS CODE:THE CONiRACTORS LI- VHIIJeIl01l ADJ.AREA_,____, ��'W'',:� ���CENSEL4W�OESN�TAPPLYTOANtiWNEROFAPROPERTYWHOBUiL�50R7MPROVESTHEREON,AND � '�'T''���'i;WHPGONiRACTSFORSUCHPROJECTSWITHACONTRACTOR(S�LICENSEDPURSUANTTOTHECONTflAC- QUANTITY DESCRIPTION FEE '�~� �.70RS UCENSE LAWJ. �, J �0;,:'. ' ❑IAlA ExEMPT UN�ER SEC. B.&P.G FORiHiS REASON U �' � ��' DATE � ' OWNEq �" U ',',Q��, � LICENSED CONTRACTORS DECLARATION W CC�'.I HEREBY ArFIFiM.UNDEfi PENALTYOF PERJURY THAT I AM UGcNSED UNDER PROVISIONS OF CHAPTER � �1 1 '['L,���9�COkMENCINGWITHSECTION70o0)OFDIVISION30FTHEBUSMESSANDPROFESSIONSCODE,A�'D Z ' -�6�� � �- � r�X MY LICENSE IS IN.FULL FORCEANO EfF�GCT. m L1J g � y � I LlCENSE GL4S5�p`�(,�✓ LIC.NO. ���+"F`� � .V "'�DATE� �'�'1����FS/ �.� CONTRAC70R Q�`V °�' �'_� � LLI' '��� �WORKERS'COMPENSATION DECLARATON a "���' ''IHEREBVAFFI(iM.UNDERPENALNOFPERJURVONEOFTHEFOLLOWMGDECLARATIONS: Z Q �'�, ��IHAVEANDWILLMpFJTA1NACERTIFlCATEOFCONSENTTOSELF-�NSUREFOPWORKER6' _ � CAMPEN�ATION,ASPROVIDE�BVSECTION3]ooOFTHELAeORCODE,FORTHEPERFORMANCE U Q� ' OF1'HE WORK FOR WHICH THIS PERMIT IS ISSUED, � �C:1 '��. . . . � .;��„�'� _�_IHAVEANPWILLMAINTAINWORKERS'COMPENSA'fIONINSURANCE,ASREOUIREDBYSECTiON L ' 3700�OFTHEUIBOFCO�E',FORTHEPERFORlAANCEOFTHEWORKFOFWHICNTHISAERMITIS ���'" ' ISSU�O.MVWORKERS'COMPENSATIONINSUFANCE�p,RPoEPANDPOLICYNUMflERARE: CONSTRUCTION �j. �� cnpaieA.' � ��Y'�,�g ��y �(,���- PLAN REVIEW ' �' . POLICYNUMB�'R �y� O '1�'�,,,�� `�G'� ELECTRIC � , � (IFBSSECIIONNEmNOTBECOMPLEfE00FTHEPERMfTISWRONEHUNDRE�WU.ARS[$tOo;ORLE55�. PLUMBING W . . . 9'f�'—� ,`� �'�" ��. I CEH7IFYTHAT IN iHE PERFORMANCE OFTH'c WORK FOR WHICH THIS PERMIT IS ISSUED,l MECHANICAL @'s- �,�.=�.� i� ��� 1~o f.�� SHpLLNQT EMPLOV ANY PER50N IN ANY MANNEA 50 AS i0 BECOME Sl1BJECT TO THE � "''�� ,�q� �— [/}�. � W,CjRKER5'COMPEN5ATIO�JLAWSOFCAL�FORNIA,ANDAGREETHATlFISHOULD6ECOME INSPECTIONFEE p� �'ry� eg /CJc �J9.IECT�TOTHENlORKEP�S'GOMPENSATIONPftOYISION50FSECTION3�DOOFTHELABOF �SSUANCE � ��1� E '8° /� �# "� �� COpE 1 SHALL FORTHWITH COMpLV WIiH'THOSfEf P�ROVISIONS. �p �ATE: . j APPUCANT . .�i. _ .. SMIP jt w � �� � ENERGY P/C 1'�'��>- ,�. J WARNING�A�_UI�E70 SECURE WORKERS COMPENSAT�ON COVERA�E IS 11NLAWFUL,AN�SHALLBE tl � �y '�.SUBJEGYiU4EMPLOYERTOGRIMINALP2NALTIESANDGIVILFNESUPTOONEHUNOREDTHOUSAN� ENERGYPERMIT �"�'�`"N'^ ' ' .OOLLARS(9�100.Od0�,IN A�DITION TO THE COST OF COMPFNSATION,DAMAGES AS RROVIDE�FOR IN p '. �� ,�SECTION3T�80F'THELA80flCO�E,INTEREST,ANDATTORNEY'SFEES. RETEIY�IONFEE: !' �' ��' �� �� � . CONSTRUCTIOW LENDING AGENCY PFE-ALT FEE � �',IHEREBYqFFIRMUNDERPENAL'Y.OFPERJURVTHATTHEREISACONSTRUCiIONLENDINOAGENCY I d'� F-0RTHE PERFOflMANCE DF 7HE WORK FOR WHICH THIS PERMIi IS ISSl1ED(SEC.3J97.CIV.C.� - �, . LAl —_ S.. 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