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HomeMy WebLinkAbout17275 (10) --. ._ � _ - - -- - — /�rj% CiTY OF I7iAR�IOND BAR �' ------�'°` --- ���AKTIVIE�FT OF C�MNIIJNTTY&DEVELOPMENT SERVICES � � - 2I825 E.Coplcy Brive (909)86Q-3195 Far.(909)861-311i PRESS �'-�K�� ' BUILDiNGPEItMITAPPLICA'I"ION FIRMLY � JOBSITE APPLICATION PERMIT �P/C o ADDRESS 1116 Cleghorn _ �,� �� �' `��� DATE NUMBER ° ii � ISSUE j� TYPE OCC APN LOT TRACT DATE l��� � �1 CONST. GROUP 0 owNeR �',��,xran�aks I H�A o ADDRESS F,7� i�1 �g8z���� $��, �1�1� ZONING SETBACKS o CITY(�lr'��'2fi16�?-� ZIP� TEL. �Q.(�-�1(1� FRONT RW ❑ APPLICANT TEL. REAR ❑ � SIDE/SlDE STREET RW ❑ ¢ CONTRACTOR ��,a�� �.qnf ('n_ SIDE ❑ � ADDRESS PROPOSED USE �'4ST O�� WOOC� shakes. Install 0 CITY���}�� ZI ��.� TEL��_ wo ARCH/ENG/ 7692 z��lgvSzc�A�i S�3z�g�ES � DESIGNER NO.DWEL. NO. NO. � ADDRESS UNITS STORIES �ti�g BEDROOMS � CITY ZIP 7EL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OOWNER-BUILDER�ECIARATiON SFR/ADD/REM p I HEPEBY AFFIRM UNDER PENALiY OF PERJURY THAT I AM E%EMPT FROM THE CONTRACTORS Li� GH(d(]E/CBfpOf[ W CENSELAWFOqTHEFOLLOWINGREASON(SEC.7031.58USINESSANDPkOFE5510NSCODE:APoYCf'VOR (n U COUNTYWHICHREOUIRESAPEflMITTOCONSTRUCT,kLTER,iMPflOVE,DEMOUSH,ORflEPAIRANYSTPUG W Patio/Deck � Z TURE,PRIOR TO ITS ISSUANCE,ALSO REOUIRES THE APPUCANT FOR SUqi PERMIT TO FILE A SIGNED �� STATEAIEM THAT HE OR SHE IS LICENSED PUftSUANi i0 THE PROVISIONS OF THE CDNiRACTOflS LI� W � � CENSELAW(CHAPTER9(COMMENCINGWITHSECTION7oo0jOF�IVI510N30FTHE3USINESSANDPqO� u' POOUSP8 �FESSIONSCODE)ORTHATHEORSHEISEXEMPTiHEREFROMAN�THEBA515FOFTHEALLEGEDE%EMP- (� �] � , TION.ANYVIOLATIONOF6ECTION7a31.6BYANYAPPLICANTFORAPERMITSUBJ6CTSTHEAPPLICANTTO Z Re-Raof JOOO A CIVIL PENALTY OF NOT MORE THAN FNE HUNDRED�OLLAFS(SSaO)J: Z ❑I,ASOWNEROFTHEPFOPEPTV,ORMVEMPLOVEESWITH.WAG65ASTHEIRSOLECOMP'cNSATION, � Commercial - WILL�O THE WOAK,ANO THE STqUCTURE IS NOi INTENDED OR OFFERED FOR SALE iSEC.7044,BUSI� J � �NESS ANO PROFESSIONS CO�E:TH[CONTRACTORS LICENSE lAW�OES NOT APPLV TO AN OWNER OF ? PROPERTY WHO BUIL�S OR IMPROVES THEREON,AN�WHO DOES SUCH WORiS HIMSELF OR HERSELF OR � 'THROUGHHISORHEROWNEMPLOVEES.PROVIDEDTHATSUCHIMPROVEMENTSARENOTINTEN�EOOR � � OFFEREDFORSALE.IF,HOWEVERTHEBUILDINGOFiIMPROVEMENTI550lDWITHINONEYEAROf-COMPLE �. TION,THE OWNE(i-BUIlOER WILL HAVE THE BUR�EN OF PROVING THAT HE OR SHE DID NOT BtJILD OR � ' IMPROVE FOR THE Pl1RPOSE OF SALE).', ❑I,ASOWNEROF7HEPROPERTY.AM EXCLUSIVELYCONTFlACTING WIiH LICEh5E0 CONTRACTOftS � TO CANSTRUCT THE PflOJECT(SEC.704a,9lJSINESS AND PROFESSIOIVS CO�E THE CONTRACTORS LI- VeIUeS1011 ADJ.AREA W , CENSELAWDOE3NOTAPPLYTOANOVJPJEROFAPROPERTYWHOBUIL�SORIMPAOVESTHEREON,AND ' �. ��WHOCONTRACTSFORSUCHPROJECTSWITHACONTRACTOF7(S)LICENSFOPUPSUANTTOTFiEWNTRAC- QUANTITY DESCRIPTION FEE Y � TORSLICENSEIqWJ. � ❑I AM EXEMPT UNDEfl SEC.. &S P.C.FOA 7HIS REA30N Q � U 1.1_ ¢ DATE � OWNEF V � LICENSED QONTRACTORS DECLARATION `j ¢ � I HEREBY AFFIflM UNDER PENALTY OF PERJUflY THAT I AM LICENSED UN�Efl PROVISIONS OF CHAPTER � . � 9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS PND PROFESSIONS GOOE,AND z �X MV LICENSE IS IN FUIL FORGEAN�EFFECT. m � LICENSECLASSC.—�A HTC LIC.NO. y.��S,LI��. j WDATE �_���,.�,'� CONTRACTOR D...,..1 D..,.-F ('..� a � WORKERS'COMPENSATION DECLARATION Q � U � I HEREBYAFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWMG DECLAR4ilON5: z Q 0 IHAVEPN�WILLMAINTAINACEHTIFICATEOFCONSENTTOSELF-INSUREFORWOPHERS' 2 COMPENSATION,AS PFOVIDED 6YSECTION 370o OF THE LABOR CODE,FOR THE PEflFORMANGE U Q OFTHEWORKFORWHICHTHISPERMITISISSUED. � � � ��.1 HAYE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REDUIRED BY SECTION ��� � Q 37aaOFTHEIABORCO�E,FORTHEPERKORMANCEOFTHEWOPoCFORWHICHTHISPERMITIS ISSUED.MY WORKFAS'COMPENSATION INSURANCE CARRIER AN�POIICY NUM6ERARe: CONSTRUCTION � �ARR,ER Superior National _ P�nN ReviEw � POLICYNUMBEfl �AT�,R�i���A ELECTRIC Q � (iHISSECTKKJNEmNOTBEO�'.APLEfEDOFTrIEPERMi15FORDNEHUf�DRE�00L1AR5($707)ORLESS). . PLUMBING _ Z 1 CERTIFYTHAi IN hIE PERFORMANCE OFTHE WORK FOFi WHICH TH15 PERMlT IS ISSUED,I MECHANICAL LS' SMALLNOTEMPLOYANYPERSONINANYMANNERSOASTOBECOMESUB�ECTT07HE � WORKERS'COMPENSAiIONLAWSOFCALI.=OFNIA,ANDAGREE7HATIFISHOULDBECOME INSPECTIONFEE � � SUBJECTTOTHEWORKEflS'COMPENSATIONP�90VISIONSOFSECTION37ooOFTHELABOR ISSUANCE � � � � CODE,I SNALL FORiHWITH CON?LY WITH THOSE PROVISIONS. � SMIP y • � p DATE: APPLIGANT: W �� ENERGY P/C --� WARNINGFAIWRETOSEC'JREVJORKEf15'COMPENSATIONCOVERAGEISUNLAWFUL,qNDSHALLeE J SUBJEGTANEMPLOYERTOCRIMINALPENALTIESANOCIVILFINESUPTOONEHUNDFEDTHOUSANO � DOLLAFS(51oo,�oa�.INAD�ITIONiOTHECOSTOFCOMPENSATION.DAMAGESASPROVIDEOFORIN ENEflGYPERMIT ' J SECTIDN37aeOFTHELABOPCODE,INT�REST,ANDATTORNEY'SFEES. RETENTIONFEE: � Q' � CONSTRUCTION LEN�ING AGENCY PRE-ALT FEE: O ' � IHERE9YAFFIRMUNDERPENALTYOFPERJURYTHATTHEREISACGNSTRUCTIONLENDWGAGENCV FOF THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.309�,CI V.C.), z w 2 LENDER'S NAME � F_— LENDER'SA�DRE55.. ' . /� � ICER7IFVTHATIHAVERLADTHISAPPLICA710NANOSTATE7HATTHEABOVEINFORMATIONISCORR'cCT. TOT/YL FEES ��"'� /,�, w I AGREE TO COMP4Y WITH ALL CITYANO C�UN1Y OFDINANCES AN�STATE LAWS RELAiING 70 BUIL�IYG " V � CONSTqUCTION,ANDHERE6YAUTHORI'LEREPRESENTATIVESOFTHISCOUNTVTOENTERUPONTHE - ' zA00VE�MENT NE�PROPEflTYFORINSpECTIONPURPOSES. �, COMMEN75___— _�. _— � � J; � — m PEflM1T E N A RINT� • '� /�, ¢ I� � _�—\� ��� . . V) � SIGNATUREOFPE MITTEE I DATE ��°J _ . fiECPT.NO.�.. _ PAID BY VALIDATION ~ WHITE—DeparlmenT Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOIDENROD ile Copy,GREEN—ApplicanYs Copy , ,.. _.... ., ,.�. „. . ,... _,. � ,,;.,. 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