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HomeMy WebLinkAbout10182 (5) ;;: i � COMMUN[TX�DEVEL�n iviElv"I'DEPART ��P/�CI� � 21660 E.Copley Drive Suite 190 PRE�J+S (909)860-3195 Fax(909)R61-3ll7 Qj;f ,'} r� �'""°�w AUILDING PERMIT APPLiCATION � �ti u� 1000�'IRMILY � AD R'ESS � � ���� ��� � ' pAPE�CATION NUMBE �'"A #�_� $ ISSUE TYPE �°' > OCC � APN LOT TRACT_ ' DATE CONST. OUP p OWNER _ i: . "" ADDRESS t'12I . INI,O�12.t�kL G1LJ . ZONING SETBACKS J'` w " FRONT RW f:l Z CITY I.,A��� ZIP TEL. - o APPLICANT �� ir�q„(,�Jt►f� TEL. S DE/SIDE STREET RW CJ mCONTRACTOR SIDE ❑ j � ADDRESS rL (t l '����I PROPOSED USE ' � CiN��lF FGV�L��11� ZIP TEL.�(J��3 _ � o ARCH/ENG! - C I � DESIGNER NO.DWEL. NO. - NO. ADDRESS 1 4 bP'PL.6�WLY�� e UNITS_ 'STORIES BEDROO S y � CITV ZIP�,Sp. TEL. T ' � c�i�i DESCRIPTION SQ.Ff. FACTOR PSF ADJ.AREANALUATION I — OWNER-BL'ILDER DECLARATION i � SFR/ADD/FiEM 4 p I MEFEBV AFFIRM UNDEH PENALTY OF P[RJURV THAT I AM EXEMPT FROM THE CON7flACTOHS LI- G8f890ICdfPOfl W CENSELAWFORTNEFOLLOWINGREASON(SEC_7031.5�USINESSANOPROFF.SSIONSCOOEANYCITVOR (f� U COUN7YWHICHflEY�UIRESAPERMITTOCONSTRUCT,AITER,IA!PROVE,OEMOLISH,ORREPAIRANYSTRUC- W patio/DBCk Z Tl1qE.PRIDR TO ITS ISSUANCE,ALSO RE�UIRES 1'HE APPUCANT FOR SUCH PEFMIT TO FILE A SIGNED W STATEMENT THAY HE OR SHE IS LICENSED PURSUANT TO iHE PROVISIONS OF THE CONTRACTOflS LI� W � CENSE LAW(CHAPTER 9(CAMMENCING WITH SECTIO�700oj OF DIVISION 3 OF THE BUSINESS AND PRO- U' PooUSpa � FF.SSIONSLODE)ORTHATHEORSHEISEXEMPT7MFREFROMANDTHFBASISF�ORTH[ALLEGEDEXEMP• TION.ANVVIOLATIONOFSECTION7a31.5BYANVAPPLICANTFORAPERAIITSUBJECTSTHEAPPIICANTTO z Re-Roof � ACIVIL PENALTY OF NOTMORE THAN FIVE HUNDRED DOLIAfiS(f5oo).): Z~ OI.ASOWNEHOFTHEPROPEHTV,ORMYEMPLOYEF.SWITHWAGESASTHF,IRSOLECOM.PENSATION, �'�. � Commerciai � WILL�O THE WORK.ANU TFE STRUCTIJRF.IS NOT INTENDED OR OFFERED POR SALE(SECJat,AUSI- J � NESS/WD PROFESSIONS CODE:THE CONTRAC70R5 LICENSF LAW UUES NOT APPLY TO AN OWNER OF � PFiOPEfYTYWHOBUILD50FIMPROVESTHEREDN,RNDWHO00ES5UCHWOFKHIMSELFOqHEflSELFOR m � 7HRWGHHISORHEROWNEMPLOYEES,PHOVIDEDT11A75UCHIMoqOVEMENTSAR[NO7INTENDEOOR , . � Q OFFEREOFORSALE.IF,IiOWEVER,h1EBUILDINGORIMPROVEMENTISSOI�WITHIkONF.VEAROFCOMVLE- ` TION,THE OWNER-BUILDER WILL HAVE THE BUflDEN OF PflOVINa THAT HE OR SHE DID NOT BUILD OR = IMPHOVEFONiHFPUHPO5EOF5AL[�. w GI,A50WNEROFTHEPqOPEflTY.AMEXCLU5IVELYCONTRACTINGWITHLICENSEDCANTRACTOHS � TO CONSTflUCT THE PRQIECT(SEC,70a4,OUSINESS AND PRUFESSIONS CODE:THE CONTRACTORS LI- VillllallOfl _ ADJ.AREA W CENSELAWWESNOTqPPLYTOANOWNEROFqFROPFf7TYWHOBl1'LDSORIMPPOVES'fHERFON,AND — — - � WHOCONTRACTSFORSUCHPRQIECTSWITHACONTRACiOR(S�UCENEEDPUPSl1ANTiOTHECONTfiAG QUANTITY DESCRIPTION FEE Y TOflSUCENSELAW.), � ❑1 AM EXEMPTUNDER SEC. 8.&P.G FOR THIS REASON Q O � - -------------- -----.._.._...._.._..-------�---------- oC LL' DA7E OWN£R__...__ ' ~ — ......._'_'"'._,_..'__'.._.__._.._....."""_ . . Z LL � LICENSED CONTRACTORS DECIARAT�ON W ' s � � `_ , k 1 HEREBV AFFiRM 11N0EP PENALTV OF PERJURV THAT 1 AM LICENSED UNDEfl PROVISIONS OF CHAPTER � � 9(COMMENCINC WITH SECTION 700a)OF OIVISIOtJ 30F THE BUSINE55 AND PROFESSIONS CADL,MID z lX AIV LICENSE IS IN FULL FORCE AND EFFECi. � O Q m LICENSE CLASS "/ LIC.NO. / j � ~ DATE�_:.�_`�GONTHAGTOR P/ - a ��$- �•�� U w � � � WORKERS'COMPENSATION DECLARATION .i�` J � � I NEREBYAfFlHM UNDER PENALTV OF PF.RJURY ONE OFYHE FOLLOWIN6 DECLARA710N3� � Z � ,INAVEANDWILLMAINTAINACEHTIFICATEOFCONSEN7TOSELF�INSUREFOAWORKERS' ',a= � Z COMPENSATION,ASPflOVIDFDE3Y5ECTION3�ooOFTHELABORCO�E,FORTHEP[flFORMANCE U � OF THE WORK FOR WHICH THIS PERMIT IS ISSIIED. � � _ � W ___i HAVE AN�WILL MAINTAIN WORK[fi5'CAMPENSAiIOY 1NSURANCF.,A5 REOUIRED 0V SECTIQN ��a,g Q3700 OF THE LABOR CODE,FOFt THE PERFORMMC[OF THF WpHK FOR WH�CH THIS PERMIT IS _��` /J�J� _ ISSUE�.MY WORKERS'COMPENS�ATIO+N INSUFANCE CARRIER AND POLICY NUM�ER AR[: CONSTRUCTION y� � j �`CARRIER__�OI� ._..h l ��. Ge. PLANREVIEW � � . !3 ��J� � � � �- ------- Z l\POIICYNUMBEF /� S_��ly `��'_��!�"_"' � ELECTRIC --_- ¢ o �ssEcnorrr�[-0r�oTeEcarowiFreoorni[P[w�+rT�wraavE�ooa�u�siao)on�Ess} PLUMBING w Z ICERTIFVTHATINTHEPERFORMANGEOFTNEWOHKFORWHICHTMISPERMITISISSl1ED,l MECHANICAL __ _ (} SHALL NOT F.MPIOY ANV PEFSON IN ANY MIINNER SOAS TO BECOME SUBJECT TO TFIE � WORKERS'COMPENSATIONI.AWSUFCALIFORNIA,h�DACFEETNATIFISHOULDBECOME INSPECTIONFEE —y F- St1BJECTTOTHEWOFiKEflS'COMPENSATIONPflOVI51bNSOFSCCTION]]ooOFTHElA80R y� . � CADE,I SHALLFORTXWITH COMPIY W1T SL ROVISIONS. ISSUANCE _ f �� � V SMIP p DATE���_. APPLICAN. _ � � � � ENERGY P/C �/ J WARNING:FAILUFiE TO SECURE WORKERS'COMPEN5ATION CAVERAGE IS UNl'AWFUL,AND SHALL BE — � SUBJECTAN EMPLOVER TO CRIMINAL PENALTIES AN�CIVIL FMES 11P T0 ONE Hl1N�RED THOUSAND ENERGY PERMIT DOLLAfl3(S10o,000�,IN ADDITION TO THE COST OF CAMPF.NSATIDN,DAMAGES AS PF70VIDF.D FOR IN � SECTION37080FTHELABORCODE.INTEREST,ANDRTTORNEY'SFEES. RETENTIONFEE: ! d CONSTRUCTION LENDING AGENCY pRE-ALT FEE: O � i HEREBYAFFIFM UNDER PENIILTV OF PEfUURY THAT THERE IS A CONSTRUCTION LENOING AGENCY FOR THE PERFORMANCE OF THE WORK FOR WHIL41 THIS PERMIT IS ISSUED(SEC.3097,CIV.C.). 2 W _'_"— � LENDEWSNAME._"_.__' --_—__._....--'..'____ . � LENDFR'SADDRESS .._...._'_—_'—'"_'__'...__ � � ICEflTIFV7HATIMAVC-REAOTHISAPPLICATIONANDSTATETHAThIEABOVEINFORMATIONISCORRECL TOTAL FEES ,.� � I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AN�STATE lAWS fiF.LATING TO 6UILOING � � CANSTRUCTION,ANDHEREBYAUTHORIZF.REPRESEN7ATIVESOFTHISCOUNTVTOENTERUPONTHE Z A80VE�MENTIONEO PROPERTY FOH INSPEGTION PURPOSES. 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