HomeMy WebLinkAbout17064 (19) �
_.._ CITY OF F QOND BAR ' �
- � � DEPARTIvli..�T OF COMMUNTCY&DEVELOPMENT SERV1c,�S �
�,�;. 21825 E.Copley Drive
� (909)8603195 Fax(909)861-3117 PRESS
"r� BUiLDING PERMtT APPLICATION FIRMLY
/ / Q '` APPLiCAT1QN PERMIT �,�1'Z-�1C,•�"•,� �""'?'�
oDDRIESS (O 9 I �T/�Z� 1� I�' L� DATE �''s"y '.o/ NUMBER_�___'-' ' J ^�'�,
o ISSUE TYPE OCC
`r° APN LOT TRACT DATE CONST. CaROUP
p OWNER G�LbQE�i ZONING SETBACKS
ADDRESS L G � C �N W FRONT RW �
gCITY O IP TEL. REAR �
APPLICANT /A ��fsGL.L?iTiZya�F� SIDE/SIDESTAEET RW ❑
z i^�=p�I.fi/.4 j�Q"XS{!�/E r 5f DE -'
_ Q CONTRACTOR� . E
� ADDRESS aN Lr C PROPOSED USE � ' � .
� an(Z.Goyj,�.4 ziP I TEL.C�Z�G7J7i��
� ARCH/ENG/
z DESIGNER ���,�EL.�^ NO.DWEL. N0. NO.
a ADDRESSG�i/t=�" T� � G'� UNITS STORIES BEDROOMS
� cirY GZl,c�'no��1 __ ziP�L?�f Te�b��'335H3G
N DESCRIPTION SQ.FT. FACTOR PSF ADJ.ASEANALUATION
� OWNER-BUIL�ER DECLARATION SFWAD��REM - � � � `
O
G] I HEREOY AFfIR1A V1d3ER PENALTV OF PEFiJUP.Y THAT I AM E%EMPT FqOM THE CONTqACTORS LI- G8f292IC8fp0�1
W CENSELAWFORTHEFOl40WINGREA50N(SEC.7a31.iBUSINE55ANJVROFE5510N5WDE:pNYCITYOR (�
C.J fAUNiYWHiCHftEQL11RESAPEflMITTOGON5TRt1GT,ALTEfl.IMPPOYE,DEMOLISH.OHREPAIRPNYSTRUC- W Patio/Deck
Z TUPE,PRIOFl i0 ITS ISSUANCE,AISD Rc�UIRES TFEAPPLICANT FOR SUCH PERMITTO FILE A SIGNEp (L
� STATEMENT THAT HE OR SHE1S llCeNSED?URSUA^f'.?C THE?HOVISIONS�f THE CJN?PACT095 lf- �y pDOUS D Cj
� CENSEIAW(CHAPTER9�COMMFNCIN�W!THSECiION'�MojOFDIVISION3OFTHEBUSINE55AN�PRO- � Pa
. O FESSIONSCO�E)OFTHATHEOFSHEISEXEMPTTHEREFROAIAN�THEBASISFORTNEALIEGEDEXEMP�
V TION.ANVVIOLA710NOiSECTiON�o31.50YAhYAPPLICANi FORAPfRMiTSU&IECTSTHEAPPUCANSTD Z Re-Roof
� ACIYIL PENALTY OF NOT MORE THAN FlYE HUNOREO OOLLARS(2500�.): � .
;� ❑I,ASOWNEROFTHEPFOPERTY,ORMYEMPIOYEESWITHWAGESFSTHEIfl50LECOMPENSATION, � COR1mBtCIflI
' Z WILL DO THE WORK,ANO THE SiRUCNaE IS NOT INTEN�E�OR 0'rFEP'c0 FOR SALE(SEC.7044,BUSI- J
� NESS M'D PROFESSIONS CODE-THE CON',PACTORS UCENSE LAW DOES NOT APPIY 70 AY OWNER CF �
Pq0?ERTYWtiOBUILCSOAIMoPOVESTHEREO�,Af�DYMO�0E35l;CHWORKH!MSELFORHERSE'�_FOF �
(r TNROIIGHHISORHEROWNEM7LQVEES.PqOVIDEDTHA75UCHIMPROVEMENTSARENOTINTENDEDOR . .
W ' OGFEFEDWRSALEIF,HOWEVcN.TFiE9UIlDPJGOFiMPROVEMEI:TI550LDWRHINONEYEAROPCOMFLE�
, ZTiOh.`HE OWNER�BUILDEfl N1LL FfAVE 1HE BURDEN OF PHOVING TMAT ME ON SME OiD NOT 3U1LD OR�
IMPPOVE FOR TME PURPOSE OF SALE�.
w ❑I,A501VNEROFTHEPROPERF'/.AME%CLUSIVELYCONTRACTINGWITM�LICENS�CONTIiACi0R5 l
[[ 'O CANSTRUC7 THE PROJECT(SEC.704G,BUSINESS AND PRQFESSiONS CODE:THE CONTRACTORS L1- VflWfliiDfl � � ADJ.AREA
� W CENSELAWDOESNOTAPPLY70ANONR7EROFAPROPEFTYWHOBUIl�SORNAPROVESTHEFEON.AN� '
� WHOCOVTRACTSFORSUCHORQIEGTSWITHACANTRACTOFI(5)LICENSE�PURSUANiTOTHECON?PAG QUANTITY �ESCRiPTICN FEE
r TORS LICENSE L4W.). ' '�
J �
Q C�AM£XEMPT UNDER SEG &5 P.C.FOR THIS REASON �
� �
LL �A7E OWNER V '
Z W
� LICENSED CONTRACTORS DECLARATION J
a W � .
[C IHEREBYAFF�RMUNDERPENALTYOFPEH.f�F7Y?HPTIAMLICENSECUNDEFiPRCViSION50FCHAP?fR .�. � }� ��`
. (� 9(COMMENG�NGWITHSECTIONlOW�qF�IVISION3OFTHEBUS�NESSANOPPOFE551aNSCO�E,AND z
X MVLiCENSEI5INFULIFORCEnNDEFfECT m . � �
� LICENSE CIAS.,Sq � � / UG.NO. ��D 7�O�' j j� �^a`�� � '� i I`�` l
U - �ATE � �^��4� �CONTRACTOR���� �g$' s S a � - � i �
W
� WORKERS'CCMPENSATIONDEGLARATION � j,,,,�-� .
� IHEREBYAFFIRMUNDERPENALT'/OFPEFJURYONEOFTHEFOLLOWING➢ECLARATIONS: . �
� Z
4
Q IHAVEANDWILLMAtP1TAINACERTtFICATEOFCONSENTlOSELF�iNSUfiEFORWORKERS' S
Q CAMPENSATION,AS 7POVIOED BY SECTION 370o OF THE LAB�R COOE.FOR THE PERFONMANCE W ,
OF THE WOFN FOii WHICH THIS PERMIT IS ISSUED. �
�
W
I HnYE AND WILL MAINiAIN WDRKERS'COMPENSATION INSURANCE,AS REOUIRED BV SECTI�N
Q 37000.='HE�BOfl CODE.FOH THE PERF0�8AANCE OF TNE W00.K FOR WHICH7HIS PERMIT IS ��`.��I �� l
ISSUE�.MY WORKERS'CAMPENSATI�N I45URANC'c CARftIER AN6 POUGY NUMBERARE: CO�STRUCTION �"'�
} ��.G Q�j� PLAN FEVIEW ' ! � -
CARRIEA n / —
ZOOUCVNUMBER G�NOb ��� �^I�� ELECTRIC � 1 �
Q �\l
� (I}iISSECiKY.NEEi�N�T9ECY7MREfEDOFiHEPERMf�S�OR�NEMINNIED!JCYIARS(EtCo)ORlES51. PLUMBING ,
W ICEflTFYTHATIN'HEPERFORMANGEOF�-HEWORKFORWHICMTHISPEFMITISISSUED.1 MECHANICAL . � � '� �'"
Z
� '�J' SFWILNOfEMP(.OYANYPEASONIN4NYMANNEflSOASTOBECOME5U0lECTTOTHE
� WORKERS'COMGE!1SATION LAWS OF CAIIFORNIA.AN�AGREE iHAT IF�SMOUI�BECOME INSPECI�ON FEE c,
. SU6JECTTOTHEWORKEflS'COMPENSATIGNPROVISIGNSOGSECiICN37ooOFTHELA80P , l,��J�\J�j
� CODE.I SHALL FOkTHWI?HCOMC.Y 1V!iN THOSE PROVISIONS. �SSUANCE - ,�
� GAL-/F Pd�f�"S���i' SMIP � -
� DATE: ����� APPL�CANT: �
� ENEAGY P/C
j.� WARNING:FAIUIRF TO SECURE WORKEAS'COMPENSATIOM COVERAGE IS UNLAWFUL,ANO SHALL BE
' � SUBJECT AN EMPLOYEq TO CRIA/INAL PEUAlT1ES AND CIVIL FlNES UP TO ONE�'NN�RED T110USAtifl . ENERGY PEFMIT .
DOILARS(S1aa.OD01.�N ADDITIONTO THE COSTOF COMPENSATION,OAMAGESAS PRONOE�FOFl IN -
J SECTION37080FTHELABORGODE,INTEREST,ANOAT`ORNEY'SFEES. RETENTIONFEE:
�
� CONSTRUCTION LENDING AGENCY
� PRE-ALT FEE: �'J � ` �--'
� IHEREBYAFFIRMUNDEPPENPLTYOFPEFJURYTtiATTHEREISACONSTqUt;TIONlEN01NGAGENCY
n- FOF TNE PERFORMANCE OF iHE WOaK FOF`MHIGH THIS PERMR IS IS5UE0(SEC.3091,GIV.C.i.
Z
W f
� LEN�ER'SNAME nL (�
F- LENOER'SAO�RE55_._. - ' /
� �. j'.
� % `-..� r
ICEFTIFYTHATIHAVEREADTHISAPPLICATIONANDSTATETHATTHEABOVEMFORMATIONISCORflECT. T�TAL FEES - Y�` I � y 2,j
� 1 AGflEE 70 COMPLV WITH ALI.GITY AN�COUNTV OFDINAVCES AND STATE LAWS RELATINF TO BI1IL�ING
CONSTRUGTION,ANDHEREBVAI;THOfltZcREPRESE�:TATIVE50FTHI5CDUN'YTOEN?�.AUPONTHE t �'�`�/Jj �LJ
z ABOVE-MENTIONED PROPERiV FOR iNSPECTION PURPOSES. COMMENTS i,��^ 4�! � � (�"� `
n f�� `--' �G'!'J W/f� �7 ..�i; 7 L%
� � _
m PErIM]�1`Ee NAME(FRINS�' ��w� . _
Q � � F�'��/
//
� ATUREOFPERM EE ' DATE .
= RECPT.NO. � PAI�BY VAUDATION
� WHITE—Oepartment Copy.YELLOW—Pinance Copy,PINK—Assessor Copy,GOLDENROD—File Copy.GREEN—Applicant s Copy
p� ,�z"r.��� �'; �7f-C�.�
� �
�
i�`�t!�� �.�s��,G���, Z:l�!-�z .���