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HomeMy WebLinkAbout16725 (39) i - ._ ___ _ -- , _ . CITY OF Y3IAMONi3 BAR � --I��' --- DEPARTNBENT OF COMMUNTTY&DEVELOPMENT SERVICES �` .`� , �I 21825 E.Copley Ihive � (909)&603195 Fax(909)861-3117 PRESS '''-.yw�'��' BUILDINGPEiiMITAPPLICATION FIRMLY o ADDR'ESS���! / l..d`l�/V W�O �J [�1.� DATEICATION � � �� NUMB R � �,C � ISSUE ~ TYPE OCC APN LOT� TRACT DATE s � � CONST. GROUP p OWNER MO/1�/� �.�� � ADDRESS � C�r Q� ZONING SETBACKS z CITY �'1 ZIP 7 TEL O FRONT RW ❑ � APPLICANT TEL. — REAR ❑ � SIDE/SIDE STREET RW ❑ z ¢ CONTRACTOR "'V I7 �` SIDE ❑ � ADDRESS?-�_�j�_ ` ^ � PROPOSED USE � GITY �'_ �� ZIP 4r�o�3 TE ,���5"'�G-33 J w ARCH/ENG/ � �z', I DESIGNER NO.DWEL. NO. NO. �, ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OV�NER-BUILDER DECLARATION SFR/ADD/REM � O �0 I HEREBV AFFIRM UNDEfl PEPIALTV OF PERJUPY THAT I AM EXEMPT FROM THE CONTRACTORS LI- � Garage/Carport W CENSEL4WFORTHEFOLLOWINGAEASON(SECJ031.SBUSINESSANDPROFESSIONSCDDE:ANYqTYOR Z �COUNTYWHICHREOUIRESAPERMITTOCON5TRUCLALTER.IMPROVE,DEMOLISH,DRREPAIRANYSTRUC- W PdtlO/DeCk TURE,PRIOR TO ITS ISSUANCE,ACSD Flc'�111FES THE APPLICANT FOR SUCH PERMIT'O FILE A SIGNED W STATEM6NT THAT HE OP SHE IS LICENSED PURSUANT TO THE PFOVISIONS OF THE CONTRACTORS LI- W ,� CENSE LAW[CHAPTER 9(COMMEI�,CING WITH SECTION 7000)OF DIVISION 3 OFTHE BUSWESS AND PRO- � PooUSpa FESSIONSCODE)ORTHATHEORS�HEI3EXEMPTTHEREFROMAND7HEBASISFORiHEALLEOE�EXEMP- � � TION.ANYVIOLATIONOFSECTION7031.SBYANYAPPIICANTFOflAPERMITSU&lECiSTHEAPPLICANTTO Z Re-Roof A CNIL PENALiY OF NOT MORE TH,4N FIVE HUNDREO�OLLP,RS(SSOOj.): Q � ❑I.ASOWNEROFTHEPROPERTV,ORMYEMPLOYEESWITHYJAGESASTHEIRSOLECOMPENSATION, � Commeroidl �- Z WILL�O THE WOqK,ANO THE ST lICTIJRE IS NOT INTEN�ED OR OFFERED FOft SALE(SEC.7044,B1/51- J NESS AND PROFESSIONS COOE:T E CONTRACTOaS LICENSE LAW DOES NOT APPLY TD AN OWNER OF � PROPERNWF'�OBUILOSORIMPRq ESTHEREON,ANDWHODOESSUCHWORKHIMSELFORHERSELFOR m �' THROUGHHISORHEROWNEMPLQYEES,PROVILIEDTHATSUCHIMPflOVEMETITSARENOTINiENDEDOR ' ��Q� OFFERE�FORSALE.IFHOWEVER,THEBUILDMGORIMPflOVEMENTISSOLDWRNINONEYEAPOFCOMPLE- ,:�. TION,THE OWNE�BUILDER WILL HAVE THE BURDEN OF PROVING 7HAT HE OR SHE 01�NOT BUILD OR ,� MIPROVEFORTHEPURPOSEOPS�.LEJ. . ��W ❑I,ASOWNEROPTHEPROPERTY,AMEXCLUSIVELYCONTRACTINGWITHLICENSEDCONTRACTORS ',�� TO CONSTFUCT THE PRO.IECT(SF�C.7Ubd,9USINESS AND PROFESSIONS CODE:THE CONTRACTORS LI- V81U8IIOf1 ADJ.AREA W�. '�CENSELAW�OESNOTAPPLVTONNOWNEROFA;PROPERTYWHOBUILOSORIMPROVESTHEPEON,AN� ��.� 'WHOCANTRACTSFORSUCHPROJECTSWRHACONTRACTOfl(5)LICENSEDPURSUANTTOTHECONTRAG QUANTITY DESCRIPTION FEE Y 70R5 LICENSE LAW.). _ '�� ❑IAM EXEMPTUNDERSEC. 0.&P.C.FORTHIS REASON Q � � U Li. � DATE � OWNER U z w � LICENSED CONTRACTORS DECLARA710N w �Q 1 HEREBY AFFIRM UNDER PENALTI�OF PEFJURY THAT:I AM LICENSED lJNOER PROVISIONS OFCHAPTEA � � 9(COMME�CING WtTH SECTIIXJ 7GOOj OF DIVISION 3 OFTHE BUSINESSAND PROFESSIONS CODE,AN� z ,`X, MV LICENSE IS IN FULL FORCEAND EFFECT_ m 0 .IiCENSE SS��LIC.NO. � � �U� DATE ��� �w��Y..R� � CqVTRACTOR _ , _� , -�4 a W � WORKP,RS'COMPENSATION DECLARATION U (�� ,� � I HEREBYAFFIRM UNOER PENALTI(OFPERJURYONE OFTHE FOLtAWMG�ECLAFATIONS: � Q 0 IHAVEANDWILLMAINiAINACERTFICAiEOFCONSENTTOSELFINSUREFORWORKERS' S CAMPENSATION,AS PROVIDED 6V SECTION 37o00FTHE LABOR CODE,FOR iHE PERFORMANCE U �¢' OFTHEWOHKFORWHICFITHIS�ipERMITI5ISSUED. � 0 � _I HAVEAND WILL MAINTAIN WOFIKERS'COMPENSATION INSURANCE,AS REQUTAE�BY SECiION Q37DOOFTHELA60RCODE,FOR!THEPERFORMANCEOFTHEWORKFORWHICHTHISPERMITIS J ISSUED.M\'WORKERS'C�MPENSATIONWSURANCECARRIERANOPOLICVNUMBERARE: CONSTRUCTION j cnRAieR � �, PLAN REVIEW ���Z POLICYNUMBER ELECTRIC ¢ � (tHISSECTIONNEmNOTBECOMRLEfEDOFiFiEPERMRISWRQVEHUNDREDD�LLAFl5�510%ORLESS). PWMBING :Z' ICERTIFYTHATINTHEPEpFORMANGEOFTHEWORKFORWHICHTHISPERMITI5155UE�,l MECHANICAL � 1. �(� SHALLNOTEMPLOYANYPEFiSONINANY',MANNERSOASTOBECOMcSUBJECTTOTHE � /'%'y�, 7 � WORKEaS`COMPENSATIONLAII'SOFCAfLIFOFNIA,ANDAGREETHATIFISHOULDOECOME �NSPECTIONFEE s�=•.—,.� � � ~ CO�E,ISHALLFORTHIMTHCOMPLVWITFVpNPftOVI510N5CFSECTION37000FTHELABOR - - - � �-��� `� 4 � SUBJECT TO THE WORKEAS'COMPENSA7, � THOSEPROVISIONS. ISSUANCE ��[]�� �OO� � p DATE: APPLICANT: �� SMIP F3 ' `"°" �' —� WARNING:FAIW RE i0 SECURE WORKB�RS'COMpENSATION COVERAGE IS UNL4WFUL.AND SHALL BE ENERGY P/C R � -� DOBLARS(E1oo,oCo�NA��ITIONrE�TECOSTpANDGVILFINESllPi00NEHl1N�RE�THOUSAN� ENERGYPERMIT ��'�'* � ) �COMPENSATION,OAMAGESAS PROVIDE�FOR IN e EREST,ANDATTORNENSFEES, RETENTIONFEE: -�""-��'—�-=- - J SECTION37oeOFTHELABORCOq __ � �d COIJSTRUCTIONLEN�INGAGENCY - PRE-ALTFEE: O ,� IHEREBYAFFIRFAUN�ERPENALTj'OFPERJURVTHATTHERGISACONSTRUCTIONLENDINGAGENCV � FOR7HE PEFFORMANCE OF THE WORK FOR WHIICH THIS PEflMIT I5155UED(SEC.3o9],CIV.C.). W S LEN�ER'S NAME � � I F LEN�ER'SAODFESS '� � � IGEflTIFYhiA71HAUEREADTHISAPPLICA710NA�NCSTATETHATIHEABOVEINFOflMAT10NISCOflRECT. TOTAL FEES � �� W IAGREETOCOIdPLYWITHALLCITYNN�COUNTY�OR�INANCE5AND5TAiEL4W5RELATINGiOBUIL�ING 4 CONSTRUCTION,AND HEREBY AUI�HORIZE REPRESENTATIVES OF THIS CDUNTV To EMER UPON THE �' ABOVE�MENTIOIVEOPROPERTYFpHINSPECTI NiPURPO5E5. � ?' 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