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HomeMy WebLinkAbout17024 (39) �I'�'�I�F I31�Iv1�NI3�3P� :� ---�``-- DEpAdt"fivpENT OF CO � TY�DE6iELOPA�NT SEi2VICES I ��. 21825 E.Copley Fhive Y (909)860-3195 FaY(409)861-3I17 PRESS "',vr..". ����1vc����A�PLaCATioN FIRMLY � JOBSITE �� APPLIC O PERMIT '''y.�`+'`,� P/C������ o AD�RESS��� �T�� DATE NUMBER 4dJ/'✓ # om ISSUE TYPE OCC APN LOT TRACT pATE � � � CONST. GROUP °C OWNER OO ADDRESS Z� ����` ZONING SETBACKS I o CITY L� �� ZIP���'jTEL��"ZZ��ICf FRONT RW ❑ APPLICANT TEL. REAR ❑ � SIDE/SIDE STREET RW ❑ ¢ CONTAACTO "al•/��NIG� SIDE � � ADDRESS � PROPOSED USE ! �_ CITY ZI TEL. , Q ARCH/ENG/ W DESIGNER NO.DWEL. NO. � ADDRESS UNITS STORIES BEDROOMS � CITY Z!P TEL. � �ESCRIPTION SQ.FT. FACTOR PSF ApJ.AREANALUATION � � OWNE7-BUILDEF DSCLARATION SFR/ADDlREM O p I NEREBV AFFIRM L1N�ER PENALTY OF PERJURV THAT i AM EXEMPT FROM THE COMRACiORS LI- � Garage/Carport '� W GENSEL4WFORTHEFOLLOWINGREASON(SEC.7a31.5BU51NESSANOPROFESSIONSCODE:ANYCITYOR ', U �OUNTVWHICHREWIRESAPERMITTOCONS7AUCT.ALTER,IWPROVE,CEMOLISH,ORREPAIRANVSTRUC- �J,j palVO/DOCk � TURE,PRIOF TO ITS ISSUANCE,AL50 FlEQl11RE5 THE PPPLICANT FOR SUCH PEflMR TO FIL:A SIGNEO W STATEMENT THAT HE OR SHE IS UCENSEU PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI- W � CENSE LAW(CHAPTER 9(COMMENCING�WiTH SECTION 1oDo)OF OIVISION 3 OF THE BUSWESSAN�PP.O- u' ROOVSpa � 'FESSIONSCODE)ORTHATHEORSHEISEXEMPiiHEREFROMAMDTiiEBA515FORTHEALLEGE�EXEMP- '(� � TION.ANYVIOLATIONOFSECTION7a37.5BVANYAPPLICANiFpRAPERMITSU&IECTSTH'eAPPUC.4NT70 Z Re-Roof � ACIVILPFNALTYOFNOTMORETHANFIVEH(1NDRED�OLLARS�SSua).J� o ❑I,ASONRJEROFTHEPROPER7Y,ORMYEMPLOYcESWITHWAGE5A5THElA50LECOMPENSATION, � COf17lPIBfCiel - Z WILL DO THE WORK,AND THE STRUCTURE IS NOT INiENDED Oq OFFEflE�FOR SALE(SEC.7o4d,BUSI- J NESS AN�VROFESSIONS COOE:THE CONTRACiORS LICENSE LAW O�ES NOT APPLY TO NN OWNER�F . � PROPERTYWHOBUILDSOflIMPROVESTHEREO�,ANDWHODOES^uUCHWORKHIMScLFORHERSELFDR = � � THROUGH HIS OR HER OWN EMPLbVEES.PFOVID£D THAT SUCH IMPROVEMENTS ARE�'OT INTENDED OR m OOFFER6DFOft5ALE.IF.HOWEVFA.?HEBUIWINGORIMPROVEMEN'ISSOIOWRH:NONEYEAROFCQMPLE- Z TION,THE OWNER-BUILUER WILL HAVE THE 6URDEN OF PROVING THAT HE OR SHE DiD NOT EUIL�OR = IMPROVE FORTHE PURPOSE oF SALE). ❑I,AS OWNEROFTHE PqOP�RTY,AM EXCLUSIVELYCONTRAGiWG WITH LICENSED CONTRACTORS � TO CONSTRUCT THE PROJECT(SEC.7a44,BUSINESS AN�PROFESSIONS CODE:THE CONTRACTORS(J- VeIUdlI0f7 � N]J.AREA W. CENSELAW�DESNOTAPPLYTOpNOlVNEROFAPROPER7Yl'dHOBUILD50RIM7ROVE5THEREON,AND � WHOCONTRACTSFOflSUCHPflCJECTSbYITNACONTRACTOR(S�LICENSEDPUFSUANT70?HECONiRAC- QUANTITY DESCRIPTION FEE � TORSLICENSELAW.�. � ❑I AM EXEMPT UNDERSEC. 0.S P.C.FOR THIS REA60N Q I � Q � � DATE .�OWNER � � . .�_.� . _.._ __ .._.__ ..__..__..__. _ .._ .0 . W � � LICENSED CONTFiACTORS DECLARATION W ¢ 'I CL IHEREBVAFFI67MUNDERPENALTYOFPERJURYTHATIAMLICENSEDUN�ERPROVISIONSOFCHAPTER � . � 9(WMMENCING WI7H SECTION 7000J DF DIVISION 30F THE BUSINESS PND PROFESSIONS CODE,AN� z 'X MY LICENSE IS IN FULL FOPCEAN�EFFECT. m � LICEYSE� LIC.NO. � j ~ J U DATE - CONTRACTOR 0- �W I � �� J WORKERS'COMPENSATION�EC�I A Q � I HEREBYAFFIRM UNDER PENALTV OF PERJIIRY ONE OFTHE FOLLOWING DECL4RATIONS U � Q � _,_IHAVEAN�WILLMAIMAINACERTIFICAiEOFCONSEkTTOSELG-INSl1REFOPWORKEflS' _ COMPENSATION.ASPROVIDEDBYSECTION3�ooOFTHELABORCODE,FORTHEPERFOFMANCE U � OFT E WORK FOR WHICH THI3 PERMIT IS ISSUE�. � � W I HAVEAND WILLMAINTAIN WORKERS'COMPENSATION INSL'RANCE,AS REOl11RE0 BY SECTION - T� \ Q 3]o00FTHELABaRCO�E,.FORTHEPERWRMANCEOFTHEWOFKFORWHICHiHISPFAMITIS X � ) ISSUED.MYWOR AS'COMPENSAiION��BA�N CECAFRIERANQPOLICYNUMBERARE: CONSTRUCTION r� ( �'g �7 � �'°� � CAFRIEP ➢--lJl3D�A ____ PLAN REVIEW Y r'� I C.._ � � PoucYNUMeEa ��;�L, m ELEGTRIC _ � ¢ (fHISSECTIONNEmNOTBE�I.IPLFE�OFTHEPERMTISFOqONEHUNDREDWLIARS(5100)ORLESS). PLUMBING � z I CERTIFYitVii IN iHE PERFORMANCEOFTHE WOFK FOR WHIGH THIS PERMIT I51551JED,i MECHANICAL ('3 SHALLNOTEMPLOYANYPERSONINANYMANNERSOASTOBEGOMESUBJECTT07H[ � WORKERS'CpMPENSATIONLAW50FCALIFORNIA,AN�AGREETHATIFISHOULD9ECOME �NS�ECTVONFEE _ _.___. _ � �SU EGT T THE WORKEflS'COMPENSAiON PftOV151 NS OF SE TION 3�0o OF TH'c LABOR ' P'�g%! � GO E,I SH 4 FORTHV/ITHCOMPLY W SE PR� ISION ISSUANCE ��l f p DATE: APPLICANT; � � SMIP n ( s'�� WWARNING:FAiLURE TO SECUftE WORKER�'COMPENSATION COYERAGE IS UNLAWFUL,AND SHALL �NERGY P/C � SU9JECTAN EA�PLOVER TO CRIMRJAL PENALTIES ANO CIVIL FINES�P TO IXJE Ht1N�RE�THOUSAN ENERGY PERMIT DOLLARS(5100,000�,IN ADDITION 70 THE GOST OF GOMPENSATION,DAMAGES AS PROVID�FOR I '——�� J SECTION3'lOeOFTHELA�ORCODE,INTEREST,ANDATfORNEY'SFEES. RETENT(ONFEE: � pW., CONSTRUCTION LENDING AGENCY PRE-ALT FEE: O � IHEREBYAFFIRMUN�EflPENALTYOFPERJUqYTHATTHEREISACONSTPUCTIDNLENDINGAGENCV ' d FORTHEPERFORMANCEOFTHEWORKFORWHICHTHISPERMIii5155UeD(SEC.309"l.GIV.CJ. Z W � LENDER'SNAME ___ . � LENDEF'SAD�RE55 �7 � ICEFTIFYiHATIHAVEREADTHISAPPLICATIONANDSTA7ETHATTHEABOVEMFORMATIONISCORftECT. lOTAL�ELS ` �� m`� `J w I AGREE 70 COMPLV WITH ALL CITV AN�COl1NTV ORDINANCESAN�STATE L4WS RELATING TO BUIL�MG � � � CONSTRUCTION,FND YEREBV AUTHDRIZE PEPRESENTATNES OFTHIS COUNTY TO ENTEq UPON 7HE k� zA8 VE-MENTIONEDPROFE YFORINSPECTIONPURPOSES. 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