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HomeMy WebLinkAbout16635 (39) �� ,�' � crrY oF��torm a� � °'=�' --�-- DEPART'MENT OF COMMUNITY 8c DEVELOPMENT SERVICES � I � �_ . � 21825 E.Copley Ilrive ,(909}860-3195 Fa�t(909)861-3117 PRESS ''%•v��' 'BUILDING PERNIIT APPLICATION FIRMLY o� JOBSITE �� f � '� ���A����� L APPLICATION �d ���NUMB R ���� #/C `✓1` . ADDRESS L� t�T't � DATE o ISSUE TYPE OCC `.° APN � L`O�T„� TRACT pATE CONST. GROUP p OWNER K-a.�l1�r+�-r� i3-�`�L1� o ADDRESS �A'�'�/I.2�--� � ZONING SETBACKS Z CITY �9�LN�fl, �ZfP TEL. FRONT RW ❑ � APPLICANT TEL. REAR ❑ � SIDE/SIDE STREET RW ❑ Z m CONTRACTOR C�� SIDE ❑ oADDR SS ,� �, Ca�t�.t1�X�i+4-1 pROPOSEDUSE L�ZJI���,�� �ZG% CITY ZfP�� TEL. ���P��°� �' ARCHlE G/ �z �ESIGNER��f.� N�.DWEL. NO. NO. o_ ADDRESS �A�+^�� UNITS STORIES BEDROOMS a' CITY ZIP TEL. c�i� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-BUILDER DECLARATION SFR/ADDlREM O ' � 1 HEREBY AFFIRM 11NDER PENALTY OF PER9URY THAT I AM EXEMPT FFOM THE CONTRACiORS LI- G8f8QB/C8(�OII W CENSELAWFORTHEFOLLOWINGPEASON(3EC.7031.58'JSINESSANDPflOFES510N5CODE:ANYCITYOq (/� , ' U CAUNTYWHICHREOUIRESAPEpMIT70CANSTRU�T.ALTER,IIAPROVE,DEMOLISH,ORREPAIRANVS7RUC- W P8f10/D2Ck W TURE,PRIOR TO ITS ISSUANCE,ALSO R,E�UIRES�,THE APPLICANT FOR SUCH PERMIT TO FILE A SIG�EO W .� STATEMENT THAT HE OR SHE IS UCEN$ED PURSUANT TO THE PROVISIONS OF THE CONiRACTOflS LI- � CENSE LAW(CFIAPTeR 9(COMMENCING;WITH SECTION 7aD0)OF OIVISION 3 O�THE BUSINESS AN�PRO- � P001/Spe �FESSIONSCADEJORTHATHEORSHEISE%EMPTTHEREFROMAN�THEBASI5FOPTHEALLEGEOEXEMP- (� � TION.ANYVIOLATIONOFSECTION7031.5BYANYAPPLICANTFORAPERMI75U&IECTSTHEAPPLICANTTO Z Re-Roof '�ACIVIL PENALTV OF NOT MOAETHAN FIVE HUNDf�ED�OLLARS(y5o0),): O ❑I,ASOWNEqOFTNEPROPEHTY,�RMVEMPLOVEESWITHYJAGESASTHEIRSOLECOMPENSATION, 0 COfI1RIBICIflI ` Z .'WILL DO THE WOPoC,AND THE STRUCTURE IS F70T INTENDED OR OF�ERED FOfl SALE�SEC.7044,BU51- J �, �NESS AN�PROFESSION6 CODE:THE CONTRACTORS LICENSE LAW�OES NOi APPLV TO pN OWNER OF � PROPEliTYWH06111L�50flIMPROVESTHEflEON,'ANDWHO�OESSUCHVlOflKHIMSELFORHERSELFOF m � '�.THROUGHHISORHEROWNEMPLOYEES,PROVIDc'OTHATSUCHIMPROVEMENTSARENOTINTENDEDOR - � „OFFEREDFORSALE.IF,HOWEVER.THEBUIL�INGOpIMPRDVEMENTISSOLDWITHINONEYEAROFCOMPLE- Z ".TqN,THE OWNER�9UIL�ER WILL HAVE THE 911q0EN OF PflOVING THAT HE OR SHE 01�NO7 Bt11L0 OR _ 'IMPROVEFOfiTHEPURPOSEOFSALE). ' ❑I,AS OWNEAOF iHE PROPERTV,AM EXCLI�SIVELYCONTRACiING WITH LICENSEU CONTRACTOFS �� '.'.i0 CANSTRUCT iHE PROJEC7(SEG 7a44,B1151NFrS5 AND PROFESSIONS CODE:THE CONTRAGTORS LI- VeIUHtI0f1 ADJ.AREA W ,CEN3ELAWDOESNOTAPPLYTOANOWNEflOFAPROPERTYWHOBUILDSOFIMPROVESTHEREON,AND �� �,'�WHOCONTRACTSFORSUCHPROJEC7S{VITHACGN7RACTOR(S}LI�NSEDPURSUANTTOTHECONiRAC- QUANTITY DESCRIPTION FEE �, TOfiS LICENSE LAW.). � ❑I AM E%EMPT UN�ER SEC. ' B.&P.C.FOR7HIS RElSON U � � LL �FTE OWNER' � Z - W �� � LICENSED CONTRA!CTORS DECLARAT70N w � IHEREBYAFFIRMUNDEqPENALTYOfPERJURVTH,ATiAMLiCENSEDIJNDEqPflOVI510N50FCHAPTER � (y, 9(COMMENCMGWITHSECTION700a)OF�DIVISION!30FTHEBUSIA'ESSANDPROFESSI�NSCO�E,ANO Z W '� MY UCENSE IS IN FULL FORCE AND�EFPECT. m �� LICENSECLASS�e��, LIC.NO. �(�9"�� � � . �t y� / � V ' �A7E fA'�2��—�(9� GbNTRAGTOR '�/"� CO 4. W ' d� WORKEFS'COMPENSATION�ECLARATION -� Q � 'IHEREBVAFFIRMUNDERPENALTYOFPERJURYONEOFTHEFOLLOWINGOECLARATIONS' Z � _IHAVEANDWILLMAINTAINACERTIFICATEDFCONSENT70SELF-INSUREFOflWORKERS' _ COMPENSATION,AS PROVIDED BY SECTIO"N 37Do OFTHE LABOq CODE,FOR THE PERFORMANCC U ¢ OFTHE WOqK FOR WHICH iH15 PERMIT IS ISSUED. � W. _I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE.AS REQUIRE�BY SECTION Q 37aoOFiHELFBORCODE,FORTHEPcRFORMPNCEOFiMEWOflFCFOflWHICHTHISPERM1T15 P ISSUED.MYWORKEf75'COMPEN5ATIONINSURANCECARRIERANDPOLICYNUMBEf1ARE: CONSTRUCTION ��� ) �l� Q y cqARiea , PLAN REVIEW 0 P041CY NUraeER ELECTRIC Z' d Q [�FiI5SECIIONNEmNOTBECOMf'L[fEDOFTF{EPERMTISWRONEhIUNDRED00LLAR5(5700)ORLESS). PLUMBING @'',�-�,,_+'�,'�.�' Z�� ICERTIFVTHATINYHEPERFORMANCEOFfHEWORKFORNMICHTHISPERM1iI5Ic5llE0,l MECHANICAL (�_[_""..�. `�� (!7'. SHALL NOT EMPIOY ANY P'eFiSON.IN PNY MbNNER SOAS TO BEGOME SUBJECTTO THE �a� ���� � � WORKERS'COMPENSATIONLAWSOFCALIFORNIA,ANDAGREE7HATIFISHOULDBECOME INSPECTIONFEE �-�-- _. Sl10JECTTOTHEWORKERS'COMPENSATIG�JPflOVISIONSOFSECilON37000F'NELA90R � ,n ['� � COOE,I SHALL F R7NWITM COMPLY WITHTHOSE PROVISIONS. ISSUANCE � � C.�"'�' � DATE: t� � APPLIGANP. — SMIP C. O ` # . �. WARNING FAIWRETO SECURE WOHKERS'CO ENSATION COVEfi IS UNLr1WFL1L,AND SHNLL 9E ENERGY P/G � SUBJECTANEMPLOYERTOCRIMIN LPENAI ESA�I�CIVILFINESUPi00NEHUNDREDTHIXISANO �.T � � pOLLARS(S��,o00�,INADDITIONTOTHECOSiOFGOMPENSATION,�AMAGc5A5PROVIDEOFORIN �NERGYPEAMIT ��4� �-. J� SECTION370BOFTHELAHOftCOOE;,MT�qEST,ANO�,ATTORNEY'SFEES. �����""`""`'^` ''-'� —'- � � ° RETENTION FEE: _. o"'�_.�. CONSTRUCTION LENDING AGENCY PRE-ALT FEE O � IHEREBYAFFIRMUN�ERPENALTYOFPERJUftVTHATTHEREISACONSTRUCTIONLENDINGpGENCY FOR THE PERFORNANGE OF THE WORK FOfl WHIGH',THIS PEFiMIi15 ISSUED(SEC.3091,CIY.C.�. . Z I W �. LENDER'S NAME � I'— LENDER'SAODRE55 �' ICER71FYiHATIHAVEREADTHISAPPLICATiONAND'�STATETHATTHEABOVEINFORMATIONISCORREGT. TOTAL FEC�-ryS _ �p/ �� �,�y\ w IAGREETOCOMPLVWITHALLCINANDCOUNTYOijDINANCESANDSTATELAWSRELATINGTOBUI.DING � pb� FB a M1��O/ �� �� � <,J 1 Y �°/� �� GONS7RUC710N,ANOMEFEBYAUTHORIZE.REPRESEN7ATIVESOFTHISCIXINTYTOENTERUPONTHE �' ABOVE-MEMTIONED PROPERTV FOR INSP TION PURPOSES. 1'�� � � � z� { COMMENTS � �.', ��fY✓L�5 �..!» .rq�:' - _ ' m PERMITTEENAM NT) � �y (f)�.� /l- � � �ry.;, GNATUREOF PERMITTE ' AiE ���y _ - - - RECPT.NO. _ l! PAID BY ___ VALIDATION ~ � WHITE—DepaAment Copy.YELLOW—Finance Copy,PiNK—Assessor Copy,GOLDENROD—File Copy,GREEN—ApplicaM's Copy . ,...;,. . _ _ .. . ., � - ,: _ . ;�,,> �� ,s, ,TK �, ..� . ✓ f.._. .t ..€C .. 3�. ,€.� �l.; M.,.��.: k . .,..Y i . � x. .'� �5 ' . 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