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HomeMy WebLinkAbout10060 (7) ( CTT'Y OF DIAA�IOIVD BAR �xP�I��D � COMMUNTI'Y DEVFLOPMENT DEPARTME �,.� 21660 E.Copley Drive Suite l90 PRES•S• � (909)860-3195 fax(909)SG1-3117 ��l �3 ��9�MLY � ,"'"°~ BL7TLDING PERMIT APPLICATION � N JOBSITE 1 ` APPLICATION • PERMIT P/C d o ADDRESS . DATE_ �'�� �`���y ,NUMBER����� # � � APN__ LOT TRACT `�. 4 �SSUE TYPE OCC DATE__ _CONST. GROUP p OWNER f� E-``��%��„ � u' ADDRESS � CU .S��c ,�G(o�% ZONING SE76ACKS w / FRONT RW C] Z CITY�!�/a,� / �.. ZIP TEL. �' �� ( � APPLICANT '��1� ��UG�^' TEI_._� 'S �/_W REAFi ❑ SIDEJuIDE STREET RW ❑ ma CONTRACTOR �� <'�� ����- SIDE CI _ � ADDRESS L�('.�'1 r l��t�1(7 � CITY S�U:,-� �-` ZIP�7 C'Srl TEL. f"�,('J�`v�f`I�� - PROPOSED USF���,,�--y"`� L' y' � � ARCH/ENG/ z DESIGNER � w — NO.DWEL. NO. NO. t� � a ADDRESS UNITS / STORIES Z"' BEDROOMS ! i � CITY Zip TEL. ' i N ----- cn DESCRIPTION SQ.Fl: FACTOR PSF ADJ.AREANALUATION i p� OWNER•BCIL�ER DECLARATION SFR/ADDiAEM � � O p I XEFEBY AFFIAM UNDEH PENALTY OF PFRJUHY 1HqT I AM EXF.MPT FROM THE CANTRACTORS LI� GdfaJe/C9fpOh W CENSEUWFOFTHEFOILDWINGREA504(SEC-7031.SBUSINESSANDPROFESSIONSCODEANVCITYOR (n � U COUNTVWHICHflEQUIRESAPERMITTOCONSTRUCT,ALTFR,IMPROVE,DEMOL1�i3ORRF.PAIRANYSTRUG W PytiO/DBCI( Z TUfiE.PflIOR TO ITS ISSUANCE.AL50 RE�UIRES TME APPLICANT FOR SUCH PERMIT TO FILE A SIGNEO �. STATEMENT 7HAY HE OR SHE I5 LICENSED PURSUANT TO THE PFOVISIONS OF THE CONTPAC7oR5 u- � :ti � CENSE LAW(CHAPTER B�COMMFNCING WITH SECTION�on0)OF DIVISION 3 Of THE BUSME55 RND PRO- POOUSPB � p FESSIONSCODE)ORTl1ATHEOfl5NE15E%EMPTiMEFiEFFOMANDTHE8P.515FORYHEALLEGEDEXEMP- (� -- U TION.ANVVIOLATIONOFSECTION7031.SBYANYAPPLICANTFOHAP[ftMIT5U61EC7STH[APPLICAN770 Z qe-ROof '�� A CIVIL PENALTV OF NOT MORE THAN FIVE HIJNDRF_D DOLLARS�i500).): � OI.ASOWNEROFTHEPROPERN,ORMYEMPLOYEESWITHWAG[SASTHEIFlSOLECAMPf;NSATION, O COf11f11BfCi8I � Z WILL DO THE WORK,AND THE S7RUCTURE IS h0T M(ENDF:O OR OFFERED FOR SAIE(SEC.70d4,6tJSl� J .j � NESS AND PROFESSIONS CODE:THE CONTFACTORS LICENSE LAW DOES NO'f APPLY TO AN OWNER OF PROPER7YWHOBUIL0.40RIMPROVESTHEREON,ANONMODOLSSUCMWORKHIMSELFORHERSELFpp , � THROUGHtfJ50RHEROWNEMPLOYEES,PROVIDE�THA75UCHIMPROVEMENTSARENOTINTENDE�OR m i Q OFFEqEOFORSPLE.IF,HOWEVER,THEBUILDIN00HIMPROVEMENTI550LDWITHINONFYEAROGCAMPLE- _� TION,THE OWNER�9UILDER WILL HAVE THE BURDEN OF PflOVINO THAT HE Ofl SME 010 NOT DUILD OR � � IMPROVE FOR THE PURFOSE OF SALF..), ,,, ❑I,AS OWNER OF 7HE PpOPERTY,AM F.XCLUSIVELY CONTRACTIUG WITH LICENSF.0 CONTRACTORS + � TO CONSTflUCT THE PqqIECT(SEC,7a4,OUSINE56 AND PROFESSI4N5 CO�E:THE CONTMC70R5 ll- V8IU8IIOf1 �J ADJ.AREA___ :7 PW GENSELAWDOESNOTAVPIYTOANOWNEROFAPFlOPEHiYWHOdUIlA50RIMPflOVESTHEREON,AND �- � F NM1IOCANTRACTSFOHSUCHPROJECTSYJITHACONTFAC?Oii�S�LIC[NSFOPl1HSUANT?OTFIECONTF7AC- QUANTITY DESCRIPTION �EE Y TORSLICENSEUW.). , � J Q IIIAMEXEMPTUNDERSEC.____.____,____.,_._,,..A.APC.FON7HISpEA50N Q . : �. _--_""..._...."_""__ � :. LL' DATE OWNER ,__.____ � — Z W �� Q LICENSED CONTRACTUflS DECLARATION W ft I HEREBYAFFIflM UNDER PENPLN OF PEFUURY THpT I AM LICENSED UND[fl PROVISIO4S OF CHAPTER � � 9(COMMENCINGWITHSECTION]Oo0)Oi�IV1510Y70F7H[BUSINESSNN�PflOFE5510N5CADE.AN� z � X MY LICENSE IS IN FULL fOflCE AN�EFFECT. � LU ''f� ��(��O � LICENSEC' S5 �__�J��__ LiC.NO.� ��Q,_Q�_.�:`_._ __�1 j � V; DATE � �' �__ _ CONTRACTOR_�__� ��✓UI� n. W �_ �" ___—__ � � WORKERS'COMPENSATION DECLARAI'ION a . �; 1 NEREBYAFFIRA1lJNDER PENALTV OF PE0.IURY ONF,OFTHE KOLLOWING DECLARATIONS: Z ;i � � � Q Z _IHAVCANDWILLIAA;NTAINACEHTIFICRTFOFCONSENTTOSF.LF-INSUNC:�ORWORKFHS' y � '� d_ WMPENSATION.ASPqOVID[OdYSF.CTIONJ'looOFTHElA80RC(�E,FONTHEPERFOqMANCE �U� _ � Q - OF THE WOFK FOR WHICH T4{�5 PERAAIT IS ISSIIFO. � w �'`I HAVE AN�Will MAINTAIN WORNFRS'COMPENSATION�NSURANCE.AS HEqUIFiED BV SeC'.ION (, Q 370o OF THE LiBOR CODE,FOR THE PERFORMMICE OF THE YlORK FOR WHICH THIS PEFMIT IS p��.`"'�y [; �i�Y�� � {''^ { �� ISSUED.MYWORKEflS'CCMPENSATIONINSURANGE ARRIERAN�POLICYNUM9ERARE: CONSTFlUCTION ' `" ' e'��"�� `/ ,.��J� 3 J - .n � �_ y ' _____�_t � j c��aiEA...__.���'_�.!L`�!��' . . PLAN REVIEW . -- � POLICYNUMBEfi __-....._.._�-.-..-._'_._._...'_"__—__'__ ELECTRIC ¢ n (IHISSEC110NNE�NOTBEOCM'LEfEDOfTNLPERWTISFORONEFN1nDtiF.DDOLW"i5(E7W)ORLF.SS). PLUMBING ___ Z I GEflTIFY THAT IN TME PERFOFlMANCE OF iME WOPK('OR WHICFI THIS PERMIT IS ISSUEU,1 MECHANICAL _.____ _ C7 SHALLNOTEMPLOYANYPERSONINANYMANNEHSOASTOBECOMESUfi,tECT70'SiE � � WORKF.RS'COMPENSATIONLAWSOFCAIIFORNIA,ANDAGREETHATIFISHOULUBECOMF: INSPECTIONFEE ___ ---__ _ . = SU&IEGTTOTHEWORKEHS'LOMP[NSATIONPiiOVI510N50F5ECTpN:f7000FTNELABOR " COO,i 5 ALL FORTHWITHCOMPLY WITM THOSF.PFlovi�. � ISSUANCE "� �• � o. ��. �e1 G�..�- � _ :. p DATE:� APPLICANT: � �SMIP ___'._.._.._--'_........_..._.._ '_."__`_' ° . W 1 � � ,_"'�j WAflNING FAILURETO SECURE WOPKEFi5'GOMPENSfTIDN fqVERAOE IS UNtAWFUL,AND SHALL BE ENEHGY P/G . __ LL SUBJECTAN[MPIOVER TO CRIIdINAL PENALTIES AND CIVIL FINES 11P'fOONE Hl1NDR[0 THOUSAN❑ ENERGY PERMI7 DOLLARS(5700.000j.IN ADDITIONTO THE COSTOF COMPENSATION,DAMAGES AS PNOVIDEU FOR IN ¢ SECTION37080FTHELA60flCODE.INiEREST,ANDATTOflNGY'SFEES. RETENTIONFEE: __,_„______ , O CONSTRUCTION LENDING AGENCY PRE-ALT FEE: � _._....----.....---- � IHEREBVAFFIqMUNDEHPF.NALTVOFPERIURYTHpTTHEflEISACONSTRUCTIONLENDINGAGENLY _ _ _ FOR THE PERFORMANCE OF 7HE WORK WR WHICH THI5 PERMIT IS IS5UED(SEC.3091,CIV.CJ. 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