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Home My WebLink About18879 (21) - �'` CiTY OF D1�OND BAR � -� � DEPARTM�'OF COIvIIvfUNIT�C&�DEVELOPI�NT SER� �-.--' C' 21825 E.Copley Drive (909)860-3195 Fax(909)861-3117 BUILDING PERMIT APPLiCATION PRESS y JOBSITE /j,�+ APPLICATION FIRMLY o ADDRESS `�� '� ��" DATE PERMIT � NUMBER � g�C �� N . LC>T TRACT _ DA EE v � ONST. GROUP O OWNER p ADDRESS� �'7 L-L�{1r� b� ZONING SETBACKS oCITY `��'iJ+•.0 �/}y� ZIP��7��TEL. 'pi�'v�-��7 FRONT RW u APPLICANT " TEL. REAR � � SIDE/SI�E STREET SIDE RW � ¢ CONTRACTOR_ C � ADDRESS � C�N ZIP TEL. PROPOSED USE �/ 0 w ARCH/ENG/ z DESIGNER D'rx�lMt_ �1�� a ADDRESS L" NO.DWEL. NO. • � CITY(.�irflT�'nCiL ZIP�'[�Y�TEL. 2 ' �-'t UNITS STORIES NO. --.___BEDROOMS � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION O OWNER-BUILDER DEC�.ARATION SFR/ADD/REM (� p I HEREBY AFFIRIA UNDER 7ENALri OF GE0.IURY TMAT I AA1 F%EMPT FROM TNE corrra.croAs u� Garage/Carport W CENSEUWFORTMFGOLLOWMGREASON�SEC.10]1.SBUSWESS.nN�FROFE551ON5CODE:ANYC�TVOR (n U COUNTYWHICMREOUIRESAPERMITTOCONSTRUCT,ALTER.It,IUROVE.DEMOL�SH,ORREPAIRMJYSiRUG w7URE,PRqR TO ITS ISSUANCE,AL50 REOUIRES THE APiLICANT FOR SUCH PERMIT�O FILE A SIGNED W Patio/Deck � STATEMENT THAT ME OR SME IS IICENSED PURSUANT TO THE PROYISIONS OF'ME CONiqACTOHS LI� � CENSE LAW(GNAPTEH 9(COMMENGING W�TM SECTION�000)OF OIVISION]CF THE BUSINE55 AND PRO� � Pool/Spa � FESSIONSCODE�ORTMATHEORSMEISEREMPtTNF_qEFROMANUTNEBASISFOFTMEALLEGEDE%EMP� (� U TION.ANVVIOLATIONOFSECTION7031.SBVANVAPPUCM!'FOFAPERMITSU9JECf5MF.�PFUCANTTO Z qe-Root � A CIVIL PENALTY OF NOT MORE TMAN FNE HUNDRED DOLURS fi5a0�.�: ' � r]I.ASOWNEROFTHEPROPERTY,OAAIVEA.1ClOYEESW�TNWAGE5A51NEiR50lECOMPENSAi�iON, � Comme�dal Z NnLL DO THE wORN,AND iHE STRUCTURE iS NOT INTENDGD ON OFFERFD FOH SALE(SEC.70u,BU51� J � NESS ANO PROFESSIONS CODE:THE GONTRACfORS LICENSE UW GOcS NO'APPiV TO Ah OWNER OF � PROFERN VMO BUILOS OR IMPROVES TMEREON,ANO WNO DOES SUCH WORK HIMSEIF Ofi MEiiSEIF OR w THiqUGM MIS OR HER OWN EMVLOYEES,PROVIOEO THAT SUGH IMPpOVEMENTS�RE NOT IN7EN�E0 OR m Q OFFEREDFORSILLE.IF,HOWEVER,THE9UILOINGONIMP(iOV6MENT1550LOWITHINONEVEAqOFCOMPLE� Z TION,TME OWNER-BUILDER WILL MAVE THE BUADEN O�PqOVING'HA1 NE OH SHE DID NOT BUILD Ofl � IMPROVE FOR THE GUFOOSE OF SALE�. � � W �.�I,ASOWNEROFTMEaROPERTY.�ME%CLUSIVELYCONTRACTINGWITHLICENSE�CONTiUCTORS - � TO CONSTRIIGT THE VR4IECT(SEC.]Ou,B1151NE55 ANO PROfE5510N5 CADE:THE CANTRACTORS ll- VdIU3llq1 ADJ.AREA W CENSELAwDOESNO'AVVlYiOANOV/NEROF/.CqOVEPTVWMOdUl1.O50RIMPAOVESTHEREON,MlD � WNOCAN7RACTSFORSUCHPROdECTSWITMACANTRACTOR�S�LIGEhS[OPVRSUMlTTOTHECONTPAP QUANTITY ESCRIPTION Y TOqS LICFNSE�AW.j. FEE Q ❑I AM E%EMPT 11NDER SKC. B.6 P.C.FOfl THIS qEASON Q V/ �I� 0 tJ�i� S(� � U � DATE OWNFR � � LICENSED CONTRACTORS DECLARATION w ¢ � I HEREBV AFFIRM UFDcR PENALTY OF PE0.IURY TMAT I AM LICENSEO UNDEN PRO�h510N5 OF CMAPTER � �J��12 c} d Y(COMMENCING WITH SECTION la0a)OF DIVISION�Of THE BUSINESS AND FP.OFESSiJNS CO�E.AND Z / �� G••1 w Mv LICENSE IS M FULL FORCF AND EFFEGT. m � I.ICENSE CLASS � _� '� / Lv � ��N� �3 4 = / r.� �U U DATE �O_�� CONTPACTOR_ � a W • . � WORKERS'COMPENSATION DECLARATION -� �. �.�.r.�'_ � � M .�J ry � V iar/.�+'V �iJJU!•. � IMEFlE81'AF�IRMUNDERPENRLiYOFPERIUFVDNEOFTHEFOLLOWINGDECURAT10N5: Z � _INAVEANOWILLMAINTAINACERTIiICATEOFCpJSENTTOSELF.iNSUREfGRWOqKERS' a Z = � COMPENSATION,�S PROVIDED BV SECTION�)oonF THE UBOR COOE,FOH iME PERFORMANCE U OF TME WOFK FOR WHICHTHIS PEfiMIT IS IS5UED. W � � w _I H�VE AND Y/iLL MAINTniN WORNERS'COMPENSATION INSURANCE.AS REOUIRED BY SECT:ON Q ]7000F TNE�'.ABOR CODE.FOR TME PERFORMANCE O�THE WORK FOR WHICH TMIS PERMIT IS r_�``�y/., ISSUE�.MY WORKERS'COMPENSAT:ON INSURANCE CARqIER AND POUCY YUMBER ARE: CONSTRUCTION �r j �(� j� S�,�t//1/G CARiiIER y /� ^��[�'J��'�-/• PLAN REVIEW POLICYNUMBERY�'7 d� U/V I� Vv(.I[� �(7 C/� � 7 � EIECTRIC ��`�7 •-"'� � (n�IS5ECT10NNE�NDTBEaCMPLEfEDOFTHEPERMiSFCFOrvEMX�DREDOal.wS�ftm)ORLESS�. PIUMBING a"xl �� w �� Z I CERTIFV THAT IN TNE PERFORMMICE O�TNE WORN FOR WHICH iH15 PERMIT IS ISSUED.1 MECHANICAL C�S SIiALL NGT EAIP�OV ANY PEFSON IN ANY MANNER 50 AS TO BECOME SUBJECL:O'HE (n WORKERS'COMPENSA?ION LAWS OF CALIFORNI�,AhD r1GflEE THAi IF i SNOUL�BEGOME INS?ECTION FEE � SUBJECTTO iHE WOFKERS'COMPENSr1TION PROVISIONS OF SECTION 31000F THE UBOR � � CO�E.I SHI,LL FORTNWITM COMP�Y WITH TH(?SE PROVISIONS. ISSUANCE � �v ^s jI�J p �A7E��_�7 ��7(ppLlCaNi�LS `^ SMIP � � /� W • • — �—ii— aJ J WARNINC.:FAI�URE TO SECURE WORKEFS'COMPENSFTION GOVER�GE IS VNUWFUL,AND 5NA�L BE ENERGV P/C ♦` � ^ J � SUBJCCTqNEMPIOVEN?OCRiMINALPENALTIESqNDCIYILFINE5UP100NEHl1NOFE0TMOU5�ND ENERGVPERMIT �� J OOLURS�St0o.o0a�,M q00IilONTO THE COSTOF COMPENSATIqJ.DAMAGES AS PROVIDED FOR IN � SEC'ION l]OB OF T4E LABOF C�DE,iNTFqEST,ANO ATTORNE�'S FEES. RETENTION FEE: Q QO�NSTRUCTION LENDING AGENCY PqE-ALT FEE� � �HEREB�AFFiR�nUNDERPENA�TVOfPERJURYinr1TTHEHEISACONSTFUC'IONLE401NG�GENCY � FDR'LIE PEHFORMANCE OF THE WOFK F09 WHICN TMIS PERMIT IS ISSUEO(SEC 1091,CIV G�. � Z W �l /� j LENDEII'S NAM- •_ r7' _ S f- IENDER'SAO�FE55 ' � TOTAL FEES % �� , � . w I CERTIFV iHAi i HAVE READ iH15APPLiCAT�ON ANC ST�T�TMRT TnE AEiOVE INFL RMAiION IS CORPECT ' � i AGREE TU CDMPLV WITH qLl CITV AND COUN�V pqDINANCES RNO SlqtE LAWS NELATING'O BUI�DING �� CONSTRUCTiON.PND MEREBY AU:HOR�ZE REPRESENiAiIV`e5 OF THIS COUNTV TO ENTER UP(1N TME �J Z 4k30vE�MENT'VNED FFOFERTV FOR INSPECTipN PURPOSES. c p � COMMEN75 , 1_)• '� _ �.�('../4'/� � _ II v m PERNITTtEN�M" -- '� /� �� — Q �� ' � SIGNAiURF .. � ��..-- 7ATE � RECPT.NO. _ PAID BY VALIDATION WHITE-Department Copy,YELLOW-Finance Copy,PINK-Assessor Copy,GOLDENFiOD-Flle Copy,GREEN-Applicanfs Copy ilnn iil . --"-"'...'-..�.. � � --�� _�� _ �' �y �� '�✓ m C� `�p��,, _� �, ,, �� -�l �"� �'-�''�'�� v�� -�o-hl-�/ „ ' ��/ �'� .��:n� � �°�� ' ,� � -��-��-I� . ._�.. , „�.��,��_�..._...�.. CITY OF LMOND BAR DEPARTMMW OF COMMUNITY&DEVELOPMENT SER 21825 E.Copley Drive (909)860-3195 Fax(909)861-3117 BUILDING PERMIT APPLICATION JOBSITE ADDRESS APN LOT TRACT OWNER 1'7 GL's{QJ� t)7 ADDRESS CITY(NiVA-3 B-0 151 i'ZIP 9 i 7(D3TEL. 'P APPLICANT TEL. CONTRACTOR ADDRESS CITY ZIP TEL. ARCH/ENG/ "RVI DESIGNER 05K-Y ADDRESS CITY L. '*r'll iL ZIP I .TEL 2-1 OWNER-BUILDER DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI' CENSE LAW FOR THE FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE:ANY CITY OR COUNTY WHICH REQUIRES A PERMIT TO CONSTRUCT.ALTER,IMPROVE. DEMOLISH,OR REPAIR ANY STRUC. TURE. PRIOR TO ITS ISSUANCE,ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI- CENSE LAW(CHAPTER 9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO. FESSIONS CODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP' TION.ANY VIOLATION OF SECTION 7031.5 BY ANY APPLICANT FOR A PERMIT SUBJEC is THE APPLICANT TO A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS(5500)): ^I,AS OWNER OF THE PROPERTY,OR MV EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION, WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC. 7044,BUSI. NESS AND PROFESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF PROPERTY WHO BUILDS OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR OFFERED FOR SALE. IF, HOWEVER,THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF COMPLE- TION .THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALE). 0 I.AS OWNER OF THE PROPERTY.AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT(SEC. 7044, BUSINESS AND PROFESSIONS CODE.THE CONTRACTORS LI- CENSE LAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO dU'II.DS OR IMPROVES THEREON.AND WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAG TORS LICENSE LAW) ^I AM EXEMPT UNDER SEC. B&PC. FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER 9(COMMENCING WITH SECTION 70(0)OF DIVISION 3 OF THE BUSINESS AND PP.OFESS-IONS CODE,AND MY LICENSE IS IN FULL FORCE AND EFFECT. 6 I LIC N0. LICENSE CLASS DATE�/0 i d CONTRACTOR_ WORKERS'COMPENSATION DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS. I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS COMPENSATION.AS PROVIDED BY SECTION 37000E THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION 3700 OF THE BOR CODE. FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED MY WORKERS NSAT SURANCE CARRIER AND POLICY NUMBER ARE: C OM PE IONN I N 'C / MP CARRIER)C/"' ! �� POLICY NIJMBER,?-?g (THIS SECTION NEED NOT BE COMPLETED OF THE PERMIT IS FOP ONE MX'ORED DOLLARS(f100)OR LESS). I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN ANY MANNER 50 AS TO BECOME SUBJECT TO THE WORKERS'COMPENSATION LAWS OF CALIFORNIA.AND AGREE THAT IF I SHOULD BECOME SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR CODE.I SHALL FORTHWITH COMPLY WITH T HgSSE PROVISIONS HW / OATS/Q-Z(ppLICANT WARNING FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL.AND SHALL BE SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS 10100.0001.IN ADDITION TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR,CODE. INTEREST.AND ATTORNEY'S FEES. CONSTRUCTION LENDING AGENCY I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE OF THE WOPK FOR WHICH THIS PERMIT 15 ISSUED(SEC 3097,CIY CI LENDERS NAME r� LENDER'S ADDRESS I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING CONSTRUCTION.AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE MENT:ONED PROPERTY FOR INSPE CTION PURPOSES ABOVEE. + lt PERMITTEE NAM^ SIGNATURE DATE WHITE-Department Copy,YELLOW-Finance Copy, PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy ilnq 8-1 APPLICATION PERMIT R P/C DATE NUM v 0 If BER ISSUE a i TYPE 0 OCC DAT E CONST GROUP ZONING SETBACKS FRONT RW REAR SIDE/SIDE STREET RW 0 SIDE C PROPOSED USE N0. DWEL. N0. NO UNITS STORIES BEDROOMS DESCRIPTION SQ. FT. FACTOR PSF ADJ.AREA/VALUATION SFR/ADD/REM W Garage/Carport W Patio/Deck LL Pool/Spa 0 Z Re-Root 0 Commercial m Valuation 22 ADJ.AREA QUANTITY ESCRIPTION FEE J 4/m d�nor sv. cc: U w W U 47 /C/YTZJ2 Z LJ- a Z U w CONSTRUCTION •�J PLAN REVIEW ELECTRIC PLUMBING MECHANICAL INS?ECTIO N FEE ISSUANCE 7(, SMIP to ENERGY P/C ENERGY PERMIT RETENTION FEE: PRE-ALT FEE: TOTAL FEES% '-7 COMMENTS 1 ,-�• 1 G 144 Jc, RECPT N0. PAID BY VALIDATION 7