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HomeMy WebLinkAbout16742 (44) � - - — _ _ � CIT�'OF D�OND BAR FN ;;'i; ---��'-- DEPARTMENT OF COMNTUNITY�c DEVELOPMENT SERVICES I a , 21825 E.Copley Drive � ��w (909)860-3195 Fvc(909)861-3117 P���SS ""%.����' BUILDINGPERMITAPPLICATION FIRMLY JOBSITE ���� APPLICATION F ; . '�`�~ � PERMIT "'� � I P/C o AD�RESS� � �� ��� DATE I���' ���Iy �� NUMBER �II C? 14 �����# c� ISSUE IYPE OCC APN LOT TRACT DATE CONST. GROUP p OWNER ��L �G1�i���� ADDRESS p� t> �°�✓�� ��° ZONING SETBACKS OCITY����:P� ' ZIP�'� TEL. FRONT RW ❑ APPLICANT TEL. REAR ❑ � SIDE/SIDE STREET RW ❑ a CON7RACTpR ��� I�i�- C��'.+��'1`se�«��F�-9�T j SIDE ❑ p� ADDRE S eI'�t°'�� M"1' .h�'F�I �°� � CITY 1D ZIP ��� TEL. `'�f`BG^^5���+ PROPOSEDUSE o ARCH/ENG/ z DESIGNER NO.DWEL. NO. NO. a' ADDRE$S � UNITS STORIES OEDROOMS � CITY I ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � i � OWNER-BUILDEFI DECLARA710N SFR/ADD/REM O p I HEfiEBY AFFIRM UNDER PEIJALN OF PERJURY THpT I AM EXEMPT FROM THE CONTRACTORS LI- Garyge(C2fF10f[ W �CENSELAWFORTHEFOLLOWINGREASON(SEC.�c31.5BUSiNESSANDPROFE5510N5CODE:ANYCITYOR (n U COUNTYWHICHREOUIRESAPERM`TTOCONSTRUCT,ALTER,PAPROVE,DEMOLISH,ORREPAIRANYSTRUC- W Patio/Deck 'W�., 7UFiE,PRIDR TO ITS ISSUANCE,A�50 REQUIRES YHE APPLICANT FOfl SUCH PERMIT i0 FILE A SIGNED W � STATEMENT 7HAT HE OR SHE IS LICENSEO PUflSUANT TO THE PflOVISIONS OF THE CONTRACTORS LI- ���' CENSE LAW(CHAPTER 9(COMMEf�CING WITH SECTION�000)OF DIVISION 3 OF THE BUSINESS AND Pfl0- �' POOVSPB 'FESSIONSCODE)ORTHATHEOR$HEISEXEMPT7HEFEFR041ANDTHEBASISFORTHEALLEGEDEXEMP- � � TION.ANYVIOLATIDNOFSECTION�031.SBYANYAPPLICAMFOFAPEflMiTSUBJECTSTHEAPPLICANTTO Z Re-Roof ACIVILPENALTVOFNOTMORET NFIVEHUNCRE�DOLLARSiSSoo).): ,0 ❑I,ASOWNEqOFTHEPROP RTY,ORMYEIdPLOYEESVlITHSNAGESASTH'eIR50LECOMPENSATION. ❑ QpmmOfCial - � ,-Z�. �,WILL DO iHE WORK,AND THE ST UCTURE IS NOT INTEN�E�OR OFFERE�FOR SALE(SEC.7044,BUSI- J ,�. NESS AND PflOFESSIONS CODE:'�IHE CONTRAC?ORS LICENSE LAW DOES NOT APPLY'O AN OWNER OF � � PROPEflTYWHOBUIL�90FIMPflOVESTHEREON,ANDWHODOE55UCHWORHHIMSELFORHEFSELFOR m �' TXROUGHHISORHEROWNEMPL�VEES,PROVIDE�THATSUCHIMP�OVEMENTSARENOTINTENDEOOfi . �W', OFFEREOFORSALE.IF,HOWEVEfi, HEBUILDINGDRIMPflOVEMENTI550L�WITHINONEYEAROFCOMPLE- �0�� ,TION.THE OWNER-BUIL�Efl WILL AVE THE BURGEN DF PPOVING THAT HE OR SHE DID NOT BUILD OR Z IMPROVEFOFTHEPURPOSEOF�LE). - �' ❑I,ASOWNEROFTHEPROP RTY,AMEXCLUSNELYCONTFACTINGWIhILICENSEDCONTRACTORS . � TO CONSTRUCTTHE PROJECT(SEC.7044,BUSINESS�0.ND PROFESSIONS CO�E:THE CONiRACTORS LI- VaI112IiOf1 ADJ.AREA �- W ' CENSELAWDOESNOTAPPLYTO NOWNEROFAPflOPERT'WHOBUILDSORiMPROVESTHEREON,AN� ' � WHOCONTRACTSFOqSUCHPRO�ECTSWITHACONTPACTOR(S)LICENSEOPURSUANTTOTHECONTflAC- QUANTITY DESCRIPTION F X TORS LICENSE L4W.�. f��I'�9 � ❑I AM EXEMPTUNDER SEQ��, B.&P.C.FOR THIS REASON U (*/C9��T�-�Ers � � _--__ R LL � DATE OWNEF U W � LICENSED CONTRACTORS DECLARATION i j d � I HEREBYAFFIRM UNDEfl PENALT�"Of PEAJURYTHAT IAM LICENSE�UN�ER PROVISIONS OFCHAPTER � d 9�COMMENCINGWITHSEGTfON70oo)OFOIVISION30FTHEBLISINESSAN�PROFESSIONSCDDE,AN�] z W MV UCENSE IS IN FULL FOfiCE AND EFFECT. m � LICENSECLASS �4i�'� L1C.N0. ���I'�"�� � �, �}, � U �ATE B%'����— CONTRACTOR n- W �, ,� WORKERS'COMPENSATION DECLARATION Q . .t7',�s e♦ � i. / . � U (' E�P �'ii' . , � I HEREBYAfFIRM 11N�ER PENALTY OF PEflJURYONEOFTHE FOLLOWING DECLARATIONS: Z � Q Z IHAVEANDWILLMAINTAIM ACERTIFICATEOFCONSENTTOSELF-INSUREFORWORKERS' _ , COMPENSATION,ASPROVIDEDBYSECTION370oOFTHELABORCODE,FORTHEPERFORMANCE U � ¢ OFTF7EWOFKFORWHICMTHISPERMITISISSUEO. . � � � � �1 HAVE AND WILC MAINTAIM�WDRKERS'COIAPENSATION INSURANCE,AS REal11RE�BY SECTIDN ..�.q,,,�. . Q 370oOFhiELABORCODE,FORTHEPERFORMANCEOFTHEWORKFORWHICHTHISPERMiTiS ¢{'� �x"" ISSUEO.MY WORKERS'CbMPENSATION INSURANCE CARRIER AND POLICY NUMBERARE: CONSTRUCTION ,s.� � ���.._. � i � ��'.e. �cJ,✓d]� _� - -_ cnRaiea� PLAN REVIEW � f d POLICYNUM6ER �� � � ELECTRIC Z ¢ (THI3SECTKKJNEmNOTB�`COMPLEfEDOFTI-EPERMfI'ISWRONEHUNDREDWLL4R5(5100)ORLESS). PLUMBING � Z I CERTIFV THAT IN iHE PSRFORMARCE OP THE WORK FOR WHICH THIS PERMIT IS ISSUEO,I MECHAMICAL .,(� SHALLNOTEMPLOYANYPER50NINANYMANNERSOASTOBECOMcSU&IECTT4THE .��„ � � .� WORKERS'COMPENSATION LAWS OF CALIFOPNIA,AND AGREE THA71F I SHOUL�BECOME . FEE t —� SUBJECTTO THE WOftKE�4S'COMPENSATION PROVISIONS OF SECTION 37oa CF THE LA60R ;s CODE,ISHA�LLf�OR�T'H�'WITHCOMPLYWITHTHOSEPROVI510NS. � SSUANCE . ������, p DATE:�..����/ APPLICANP. — SMIP � �� ENERGY P/C � WARNING:FAILURETOSECUREWORKEFiS'COMPENSATIONCOVERAGEISUNLAWFUL,ANDSHALLBE �, SUBJECTANEMPLOYERTOCRIMINALPENALTIESAN�CIVILFMESl1PTOONEHUNDREDTHOU5AN0 �\ OOLLARS(51 oo,noa),IN AO�IiION�TO THE COST OF COMPENSATION,DAMAGES AS PROVIDE�FOR IN —��I � SECTION37080FTHELABORCODE,INTEREST,ANDATTORNEY'SFEES. .. ETENTIONFE ' � CONSTRUCTION LENDING AGENCY� � � PRE-ALT FEE: O � IHEREBYAFFIRMUN�ERPENAL DFPERJURYTHATTHEREISACONSTRUCTION�ENDINGAGENCV FOR THE PEflFORMANCE OF THE�YJORK W R WHICH THIS PERMIT IS ISSUED(SEC.3097,CIV.C.). Z W = LEN�ER'S NAME � 1— LENDER'SAODRESS �- ICERTIFYTHATIHAVEflEADTHi$APPLICATIONANDSTATETHATTHEA90VEMFOflMATIONISCORRECT. TOTAL FEES '� W I AGREE 70 COMPLY WITH ALL CITYAND COUNTY OqDINANCES AND 57ATE L4WS RELATING TO BUILDING 4 CONSTAl1CTION,AN�HEFIEBYAL�THORIZEFEPRESENTATIVE50FTHI5COUNTYTO'cNTERUPONTHE ZABOVEMENTIONED PROVERTV F'OR INSPECTION PU4iPO5ES. � COMMENTS � J � m PERMITIEENAMEIPRINTj � - Q � � SIGNATUFEOFPERMITTEE � DATE = RECPT.NO. _ _ PAID BY VALIDATION ~ WHI7E—De artment Co YELLOW—Finance Co PINK—Assessor Go GOLDENROD—File Co GREEN—A IicanTs Co P PY. PY. PY. PY. PP PY ...,. _. . , ._ . , ,r, .: ti . , _ ;,, . . � ,; ,;,..a•:,,,: , �..;.� b .,...,�,; y ��y � , °� � . , ;. x � ' � � x. 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