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HomeMy WebLinkAbout17505 (23) CITY OF ISIAMOND BAPa f,�^f - �-- DEPARTIvIIENT OF COMMUNITY&DEVELOPMENT SERVICES `� iiusuu� 21825 E.Copley Drive (909)860-3195 Fax(909)861-3117 PRESS �"';.vNr�� Bu[i.nrlvGrEx��arpLiCaTiox FIRMLY � JOBSITE � � � � - ��(��/-t` '/� � APPLICATION PERMIT j P(C o ADDRESS_ V i � 1 DATE � �iC� I NUMBER/ i��� # om ISSUE TYPE OCC APN LOT� TRACT DATE CONST, GROUP p OWNER �IA.0 V( � �+---�- ADDRESS S- L/l.. + ZONING SETBACKS � oCITY d' ZIP TEL FRONT RW ❑ APPUCANT TEL. REAR ❑ o S SIDE/SIQE STREET RW ❑ Z a CONTRACTOR SIDE ❑ � ADDR S$ �y����� pR PO ED USE �'L' , o CI7Y 21 ���'„� TEL. � w ARCWENGI z DESIGNER NO.OWEL N0. p. �� oW_ ADDRESS UNITS STORIES BEDROOMS � I � CITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � � OWNER-BUILDEA�ECLARATIDN SPR/ADD/REM � � O � I HEREBY AFFIRM�UNDER PENALTY OF PERJURY THAT I AM EXETAPT FROM THE CONTRACTOpS LI- G8fa9B/Cefp�ft W CENSELAWFORTHEFOLLOWINGflEA50N�5EC.7031.5BLJ51NE55AN�PHOFE5510N5CODE'.ANYqTYOR ((� �', U COUNiVWHICHREIXJIRESAPEqMITTOCONSTPUCT.ALTERIMPROVE,DEMOLISH,ORREPAIRANYSTRUC• W Pat10/DBCk W ,TURE.PRIOR 70 ITS ISSUANCE.AL50 REQUIRES TNE APPLICANT FOR SUGH PERMIT TO FlLE A SIGNED W STATEMENi THAT HE OR SHE IS LICENSED PURSUANT TO THE PPOVISIONS OF THE CONTRACiOflS LI- �' CENSELAW(CHAPTER9(COMMENqNGWITHSECTION�aOo�OFDIVI510N30FTHEBUSINESSANDPRO- U' POOIISPB �FESSIONSCODE)ORTHATHE095HEISEXEMPTTHEFEFROMAN�THEBASISFORTHEAL�EGEDEXEMR C7 ��.� TION.ANYVIOLAiIONOFSECT10N7031.5BVANVAPPLICANTFORAPEqMIT5U6JECi5THEAPPUCANTTO Z Re-Hoof ACIVILPENALTY OFNOT MOPE iHAN FNE HUN�RED�OIlARS(5500).): ' � ❑I,ASOWNEROFTHEPflOPERtt,ORMYEMPLOYEESWITH3NAGESASTHEIfl50LECOMPENSpTION. ❑ Commercial - � Z 'WIIL DO 7HE WORK,ANO THE STRUCtURE IS NOT INTEIJ�ED OR OFFERE�FOR SALE(SEC,7044,BU51- �.J � NESSAND PROFESSIONS CODc':iHE CONTRAC70PS LICENSE LAW'�OES NOiAPPLV TO AN OWNER OF ? 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PLUMBING ZICERTIFVTHATMTHEPERFORMANCEO:THEVJaftKFORWHICHTHISPERMITI5155UE�.l MECHANICAL '�"�-� ' ��� ('3 SHAILNOTEMPLOYANYPER50NINANYMANNERSOASiGBECOMESUBJECTTOTHE ' ? � /�:^ , [/] WORKEFS'COMPENSATIONLAWSOFCAIIFORNIA,ANDAOqEETHATIFISHOULOBcCOME INSPECTIONFEE � SVBJECTTOTHEWORKERS'COMPENSATIONPROVISIONSOFSECTION �oaOFTHELABOR � '-' r9.c'y , � CODE,ISH�ALLJF'�ORiHWITHCOMPLVWITHiH VISIONS • ISSUANCE ' �. n,� Hi.-� a DATE:��7�PPLICANT: SMIP �� ����' �'� B � �'�' d J WAR�YING:FAILURETOSECUR6WORKERS'COMPENSATIONCOVER EISUNLAWFUL,ANOSHALLBE ENERGYP/C �y SU&IECTANEMPLDYEFTOCqIMINALPENALTIESANOCIVILFINES TOCNEHUN�RE�THOUSAND ENERGYPEAMIT 1�.�'T` ' OOLLAflS(51o0.000),INADDITIONTOTHECOSTOFGOMPENSA710N,DAMAGESASPROVI�E�FORIN '- __.__.,__ � !�„e':_ ___"ym_ ___' ' �,� �J SECTION3�o80FTHELFBORCOOE,INTEREST,PN�AttORNEY'SFEES, ' '--"`-' --�� '—""' RETENTION FEE: � CONSTRUCTION LENDING AGENCY PRE-ALT FEE: O � IHEREBYAFFIRMUNDEPPENALTYOFPERJUflVTHATTHEREISACONSiR'.1CTIONLENDINOAOENCY � FOR THE PEPFORMANCE OFhiE WORK fOR WHICH THIS PERM�T IS ISSUED(SEC.309�,CIV.C.). . , Z W 2 LENOEfl'SNAME � F— LEN�Eq'SApI]RE55 � ICERTIFVTHA7IHAVEREADTHISAPPLICA710NANDSTATETHATTHEABOVEMFORMATIONISCORRECT. 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