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Home My WebLink About18415 CITY OF D ND BAR �' 1 �'� DEPART�OF COMMUNITY&DEVELOPMENT SERVI� -� � I �'��?�� 21825 E.Copley Drive (909)860-3195 Fax(909)861-3117 PRESS BUILDING PERMIT APPLICATION FIRMLY o� JOBSITE (J/ ��-�"/ r � . APPLICATIO PERMIT �� PIC ADDRESS�_JL�'�//�l�l�/_ �'� DATE �'�G—UZ-- NUMBER q o� ISSUE TYPE OCC APN___ LOT TRACT _ _ DATE CONST. GROUP p OWNER �"�'Z �1L� G1n/�[ S — Q ADDRESSlS�� C�tL1.1�✓C+-iv (�1'S r—�� ZONING SETBACKS g CITY d �a�..+.� I) RI�I ZIP�17G�7EL. FRONT qW ❑_ REAR -� APPLICANT TEL` SIOE/SIDE STREET RW ❑ z ¢ CONTRACTOR �+� Fr�tiI S.v� SIDE o ADDRESS�C�[�lwdytr.Z,i G✓f T�-�^ ` PROPOSED USE Vl/ CITY �.�� l�vt-- ZIP 9�24 r TEL 39 "¢'S' _ oARCH/ENG/ — w DESIGNER — NO.DWEL. O. a ADDRESS UNITS STORIES BEDROOMS � CITY ZIP T�L_ � cn DESCRIPTION S�.FT. FACTOR PSF ADJ.AREANALUATION Q OWNER-BUILDER OECLARATION SFFUADD/REM O W CI HEREBY AFFlRM VNDE�3 pENALTY Of PERJURV-HAT I AM FXEMPT FROM THE CONTRACTOqS LI- ('jyf2J8{Caf�JOR ENSEUWFORTHEFGLLOWINGREASON�SEC.7031.SB115MES5AN�FAOFE551GN5CODE:ANYGITYOR (,() ZCOUNTYWHICHRE�UIFESA7EqMITTOCANSTP.UCT,ALTFR,IMoqpy[,OcMOLISH,CRREPAIHANY�TRUC� W pg�10/DBCk TVRE,PRIOR TO ITS ISSUANCE,ALSO RE(]UIRES THE APPLIGANT FUR SUCH PEHMIT TO�I�E A SIGNEC w STAiEMENT THA1 HE OR SME IS LICENSED PVRSUANT TO iHE PROVISIONJ DF THE CONTi7ACTOR&LI- w � CENSE lAW(CHAVTER 9(COMMENGING W��M SECTIOH]ooG�OF�IVISIGN 7 C�F THE BUSINE55 AND PRO� LL, P�oVSPa FESSIONSCODE�OFlTHATHEOqSNEi&E%EMPTTHGREFFOMANOTHEBASISFOFTHERLLE3EDE%EMV� (� � TION.ANVVIOLATIONOFSECTION7031.SBYANVAPPLICAN�FORAPERMITSU9JE(:fSTHFAGPI.ICANTTO Z Re-Roof � � A CIVIL PENALTV OF NOT MORI:TNAN FIVE HUNf]HED DGLURS(5500))'. ' ^1,AS OWNER OF 1HE PROPEPTY,OF!AY EMPLOYEES W i7H WA�ES AS 7 HE I9 30LE CGMPENSATiON, Z � Commercial WILL DO THE WORK.AND 7HE 51 RUCTUfiE ly NOT IN'ENf]E�04 OFFE0.ED FOH SALE;SEC.]OdO.BJCI� J � NESS AND PflOFE5510N5 CODE:THE CONTRACTORS LICENSE LAW 00'cS NO�APPiY�O AN OWNER OF � VRO?ERTV WFO BUILDS OR IMPqpyES THEAEON,AND WNo DOES SUCH WGRN HIMSELF OR HEASELF OF � THROUGHHISORHEROWNEAIPLOYEES,vROVIDE�TMAT�UGHIMPROVEMENiSARENOiINiENDEDOR m w OFFEREDFORSALE.IF,HOWEVLR.TNEBUIIDINGORIMPROVEMENTI5501�'N'TNINONEYEARDfCOtAPLE- � TION,THE OWNER�BUILDER WiLL HAVE TME BUROEN OF PROVING'.HAT HE OR SV1E�IO NOT BUILD OR Z IMPRO'JE FOfl THE PURPOSE GF SALE). _ ❑1.AS OWNER OF iHE PFiOPERTY.AM E%GlU51VELY CONiRRC71NG W��H LICFNSE�CONTRACTORS W � TO CONSTRI�CT iHE PRQIECT(SEC.]06e,BUSINESS AND PROFESSIONS COOE:THF C04TRACTORS LI- V21U8IIOf1 � ADJ.AREA W CENSE LAW OOES NOTAPPLY TORN OWNER OFA PROPERTV WHO dUII.�S OF IMPFOVES THEREON,AND — � WFqCONTRACT5FOF5UCHPFtOJEGTSWITNACONTRACTOR�S)I.ICFNSCD?URSUANTTOTHEGONTRAG QUANTITY DESCRIPTION FEE Y TORS LICENSE LAW j. � �I AM EXEMPT UNDER SFC. B.8 P.C.FOR THIS REASON Q � V � ¢ DATE _ OWNER _ _ � Z w � LICENSED CONTRACTORS DECLARATION W � 1 HEREBV I1FfIRM UNDER PENALiY OF PERJURV THAT I AM LiCENSED JNDER PROVi510N5 OF CHAPTER � p_, B(COMMENCIHG WITH SECTION 7U00)OF DIVISION 3 UF THE BUSiNE55 AND PPOFESSiONS CDDE.AND z `X MY IICENSE IS IN FULI FORCE A'VO EFFEC7 m 0 LICENSE CLASS(�.,J� tT��LIC.NO �� j r J V DATE_�� __ CONTqACTOR___ a W a� WORKERS'GOMPENSATION DECIARATION Q = U � INEREBVAFFIRMUNDERPENALIYOFPERJURYONEOFTHEFOLLOWING�ECLARATIONS: Z Q � �HAVE�NCwIlLMA1NTAIVRGEV7�IFICATEOiCONSENT705ElFJNSUqEFORWORKERS' � COMPENSATION,AS Pq�V10ED 9Y SECTION 31ooOF THE IABOH CODE,fOR THE PERFORMANCE U a OFTHE WORK FOR WHIC��THIS PERAl17IS ISSUEO. � � W _ I HAVE AND WILL MAINTAIIJ WORKERS'GOMPENSATInN INSURANCE.AS RFOUIRED BY SECTION l` Q �3�Oo Of THE LABOR GODI:.FOR lHE PERFGRMANCE OF THE WORK FOA WHICH TH15 PERMI*IS �U, U� ISSUE�.MY�jggK-EF�S_'G_)MPEN$TION 1N5U4ANCE AR EP ANO�OLIC rvuM�anAE: CONSTRUCTION � CnRRiEF�Z�N��7 �h` — PLAN REVIEW -- --_- Z POUCY NUMBEfl Q_��L(�2 S - I ELEC,Tfll('. __ _ __ Q 'D Q (iN1.CSECTKXJNEEDNOTBEWh1PLEfEDOFTHEVERMITISFOkONEMJ�ORED00114RS(f�0])OFLES3). PLUMBING _ W MECHANICAL Z I CEiiTIFv TNAT�N THE PEI�F00.MANCE OF THf WORK FOfl WMCH THIS PERMIT IS 15SUEU,I _ C�3 SHALLNOIEMPLOVANYFERSONINANVMANNER50ASTp8ECAM'cSUBJE�TTOTHE � WOHKERS'COMPENSATIOiVLAW50FCALIFORNIA,ANDAGFEETMATIFISHOUlDBECOME INS�ECTIONFEE _ � SUB.IECT'CTHEWOFK�FS'COMGENSATIDNPRO'J SOFSEG110N37000i?HEUBOf1 � � � GOOE.I SHA�L FORTHWIThI COMPLY WITH TH0 O`JISIONS ISSUANCE __ � i� �-o? AFPLICANT SMIP ��_ p DATE. W ENEAGY PiC � WARNING'.FAIIURE TO ScCUFE WORKERS' MPENSATION GOVERAGE IS UNLAWFUL,AND SHALL BE - -- LL SUF3JECT AN EMPLOYER TO CRIIdInAL 7E LTIES AND CIVIL FINES UP IOONE HUNDFED TMO'JSANO ENERGV PERMIT DOLLARS({t00.00C),IN ADDITION TJ THE COST OFCOMPENSATION,DAMAGES AS PROVI�E�FOR IN — ---- J SEC110N 3lDe OF THE LABOR CODI:,INTEREST ANDA�70RNE�'S FEES. RETENTION FEE: Q —" d CONSTRUCTION LENDING AGENCY PRE-ALT FEE: __ . _... O � I HEREBYAFFIRM�NDER PENALTV OF PERJURY THAT THEFE IS ACONSiFUCTION 1EN01NG AGENCv d WR THE PENFORMANCE DF THE WORK FOR WI�ICH THIS P'cRMIT I5155VEC(SEC.309],CIV.C.7. � Z W —- __ —_ � LENUEN'S NAME_ __ __ — F=- LENDFR'S AODRESS . -- � � � � TOTALFEES � I GEflI iFY TMAT I HAVE READ THIS A�'Cf ICATION nN0 STATE-HAT TME ABOVE INFORMA710N IS�ARRECT � I AGREE TO COMP�Y WIT LL CITY 4ND COUNTY OROINANCES ANO STFIE lAWS RELATING TO BUI'.OING � CONSTRUCTION.A� AEBYAUTfORREFEPRESENTATIVESOFTHISCWNTVTOE�3iERUP�)NTHE Z ABOVE-MENTIO PROPERTY F R INSP CTION PURPOStS COMMENTS _ _._ � _�.��- - J � m M'TTFF N (P �) Q � _ � � �'_"-_ ^�� SIiaN iRE EE �A�E l.� = RECPT v0. PAID BV l VALIOATI�N _ ~ WHITE-De artment Go YELI.OW-Finance Co PINK-Assessor Co GOLDENRO�File C p DY. PY. PX oPY.GREEN-ApplicaM's CoDY � � o��s� �-��'�'��^�+ <F� f � � �"�"� a��'` �i � , � �, � �a� a �� .� ; � .. t� i li " �:�� K . . . ��' �� . ��r; � � . . � . . .. ... . _. .._ . _.. . . . . ... . . . .. . .. ... .. ., .... ... ... ._. . ..._ ..,. ._... ._.... .. . .. : � . �, ) �^� j �� __ _ t,.�-U�t>r`G.'t�,,,� Z'j�rt7�'1� �; , <. .» ° , _ ! __ � _ ; ,� °�;, ��.�� _ _ _ _ � a;� yi�V ' � _ � �i , : . ��-%'�Z�z..� �.�.��- �r�.�-�,� ��a- ��-�j��3. �L�� __. _ _ _ _ __ ___ . _., _ _ . __ _ _ _ . _ ;. _ _ _ ._ __ _ ; __ _ ___ _ __ _ _ __ _ , °' � ��,�� .., „ � y , _ _ . Jt � ,,s.�. .,� � +�� 1�, � _ _ _ _ .. _ h g �' � , _ _ _ _ _ . _ � j�4 1 4 � � ' . . �s h ' v ... . . . .. . .. . . . . . _ .... . . . .... ... ' _ 11��1'�: _ ._. , . _._ . _ � � � W�' � ., ��,.. y.i,.�,!. ' ..... . . . .... .. .... ........ ... . .. . .. . . ... . ...... ....... ... ... .. .... .. .. .. . . ...... . .,;�.:�. . �64 CITY OFD ND BAR DEPAR OF COMMUNITY&DEVELOPMENT SERVI 21825 E.Copley Drive (909)860-3195 Fax(909)861-3117 BUILDING PERMIT APPLICATION PRESS FIRMLY JOBSITE ADDRESS J_1L-C/' i_c J'/ APN LOT TRACT OWNER I"L'--II C'i.-i Pe-L ADD ESS/1-C-4_&e-y c-cif CITY;,R V X4 ZIP 17Gr TEL._ APPLICANT TEL. CONTRACTOR +� �(SwU ADDRESS Lc'4L1Li#. ,-L4.71,&45T��-_ CITY 6401-ZIP I: r TEL. ARCH/ENG/ DESIGNER ADDRESS CITY ZIP TEL. 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 REQUIRESA PERMIT TO CONSTRUCT,ALTER,IMPROVE. DEMOLISH,CR REPAIRANY ITRUC. TUBE,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 TS THE APPLICANT TO A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS($503)) ^I,AS OWNER OF THE PROPERTY,OR MY 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). ^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 BUII.DS OR IMPROVES THEREON,AND WHO CONTRACTS FOR SUCH PFIOJECTS WITH A CONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAC- TORS LICENSE LAW). L,I AM EXEMPT UNDER SEC. 8.&P.C. 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 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND MY LICENSE IS IN FULL FORCE AND EF E CT F LICENSE CLASS C 3�- NO LIG r3 DATE._" (P-0 Z CONTRACTOR WORKERS'COMPENSATION DECLARATION I HEREBYAFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS: HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS' COMPENSATION,AS PROVIDED BY SECTION 3700 OF 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 LABOR CODE., FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. MY ERS'C)MPENS TION INSURANCE AR ER AND AOLIC NUM ARE: CARRIER /^' POLICY NUMBER 0 Z-V?-(Z L J (THIS SECTION NEED NOT BE COMPLETED OF THE PERMIT IS FOR ONE HUNDRED COLLARS(5100)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 SO AS TO BECOME SUBJECT TO THE WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME SUBJECT TO THE WORKERS'COMPENSATION PROS CF15 OF SECTION 3700 OF THE LABOR CODE.I SHALL FORTHWITH COMPLY WITH THO OVISIONS. DATE: " -AFPUCANT WARNING. FAILURE TO SECURE WORKERS' MPENSATION COVERAGE 15 UNLAWFUL,AND SHALL BE SUBJECT AN EMPLOYER TO CRIMINAL PE LTIES AND CIVIL FINES UP 70 ONE HUNDRED THOUSAND DOLLARS($100,000). 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 HEREBYAFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC 3097,CIV. C.) LENDER'S NAME LENDER'S ADDRESS I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT AGREE TO COMPLY WIT LL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING CONSTRUCTION.AN REBY AUTI-ORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE 77TIQN PROPERTYF PURPOSES. �P �� SIGN IRE EE DATE APPLICATIONS PERMIT I% Lj P/C DATE"-G-V Z--NUMBER# ISSUE TYPE OCC DATE CONST.GROUP ZONING SETBACKS FRONT RW^ REAR Fj SIDE/SIDE STREET RW^ SIDE PROPOSED USE N0. DWEL. 0_ UNITS STORIES BEDROOMS DESCRIPTION SQ. FT. FACTOR PSF ADJ.AREA/VALUATION SFR/ADD/REM CO Garage/Carport W Patio/Deck LL PooVSpa Z Re-Root Commercial Z) Valuation ADJ.AREA QUANTITY DESCRIPTION FEE J cc I- U w Z CL Q z z u w )I r\II S CONSTRUCTION V•V PLAN REVIEW ELECTRIC PLUMBING MECHANICAL INSPECTION FEE ISSUANCE SMIP ENERGY P/C ENERGY PERMIT RETENTION FEE: PRE-ALT FEE: TOTAL FEES 14 00 COMMENTS RE PT N.O. PAID BY VALIDATION WHITE-Department Copy,YELLOW-Finance Copy, PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy