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HomeMy WebLinkAbout16114 % � I ` --��'� D PARTM NT OF COMMUNITY&DEVELOPMENT SERVICES � , _ W 21660 E.Copley Drive Suite 190 ! (909)860-3195 Fax(909)861-3117 Pf�E$$ � ��'�'�'� BUII.DING PERMIT APPLICATION - __ _ ���� �� FIRMLY } JOBSITE APPLICATION` \ l PERMIT i � p!C o ADDRESS ��Z�� G'..��'S'jl.�f�VL� DATE � I � `J I NUMBER ( l p � APN LOT L�C3 TRACT .�]`�_�y"7 �SSUE TYPE OCC � DATE CONST. GROUP � OWNE�� t�. o ADDRESS l�f c."� j��^A! l�e,..r,nt�6� ZONING SETBACKS W CITY �rj/tf'!h� ZIP�' , TEL.�I"(�il•-7Y��.`�'�'f FRONT RW ❑ APPLICANT �FF-P►1r'. TEI. J�.,�'►1e REAR ❑ SIDE/SIpE STREET RW ❑ CONTRACTOR � � P �" C°�a� SIDE p c� ADDRESS '' o CIlY ZIP '��ZTEL.9�'7�9"�R�J"� PROPOSED USE _ S�v'ldE��7��3�� � ARCWENG! DESIGNER ' ' �7R��� �"' G�rr ADDflE S /���"'7 TW,S'� r NO.DWEL. NO. NO. UNITS STORIES BEDROOMS � CITY - ZIP�3Z.7Cb,s"TEL.��y�-.5��,1�t7 7 v> DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION Q OWNER-BUIL�ER DECLARATION SFR/ADD/REM O p I HEREBV AFFIRY UNDER PENALTY OF PER,IURY THAT I AIA EXEMPT FROM THE CON7RACTORS LI- Gefa 6/C3 oR W CENSEL0.WFOqTHEFOILOYVNGREASON(SEC.703158USINESSAN�PROFESS{ONSCODE:ANYCITVOR [n 9 � C� COUNTI'NMICHREIXIIRESAPERMRTOCONSTFUCT,ALTER,lA1PROVE,DEMOLISH,ORREPAIRANYSTRUC- W p32i0/DBCk � TURE,PRIOR TO RS ISSUANCE,ALSO REQUIRES 7HE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED W STATEMEM iHAT HE OR SHE IS UCENSm PURSUANT TO THE PROVI910N9 OF THE CANTqACTORS LI� CENSE LAW(CHAPTER i(COMMENCINO WITH SECTION 7000)OF DIVISION 30F THE BUSINESS AND PRO- LL' POOUSPd FESSIDNSCODE�OqTHATHEORSHEISEXEMPiTHEREPROMANDTHEBA5I5FORTHEALLEQEDEXEMP• C7 TION.ANYVIOLATpNOF5EC710N7031.58YANVMPLICANTFORAPERMITSUBJECTSTHEAPPLICANTTO Z Re-RoOf � A CIVIL PENALNOF NOT MGHE THAN FNE HUNDRED DOLURS(S5oo).�: ❑I.ASONRJEFOFTHEPROPERTY.ORMYEMPLAYEESWITHWAGESAS7HEIRSOLECOMPENSATION, COIni718fCial � WILL 00 THE WOpK,AND�HE STRUCTURE IS NOT MiENDED OR OFFEREO FOR SALE(SEC.7044,BU51- �J � � NESS AND PROfESS10N5 OOOE:THE CANTRACTOPS LICENSE LAW DOES NOT APPLV 70 AN OWNER OF j OpOPERiY YIHO BUILDS OF IMPROVES 7HEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR � THROUCiFI HIS OR HEFONRI EMPLOYEES,PROVIDED THAT SUCH ILIPROVEMENTS ARE NOT MTENDED OR m �j OFFEREDFOHSA�EIF,HOWEVERTMEBUILOINGORMPROVEMENTISSOLDWITHINONEYEAROFCOMPLE- Z TION,THE OWNER-BU0.DER NfILL HAYE THE BUHDEN OF PROVINO THAT HE OR SHE 01�NOT BUILD OR � IMPROVEFORTMEPURPOSEOFSALE�. W ❑I,RSOWNE(tOFTMEPROPERTV,AMEI(CLUSIVELYCANTRACiINGWITHUCENSE�00MflACTOflS � TO CONSTRUCT THE PRQIECT(SEC.7044,BUSINESS AND PROFESSIONS CODE:7HE CONTRACTORS LI- V81UaSiOn ADJ.AREA CENSE UW DOES NOTAPPLY TO AN OWNER OFAPROPEHTY WHO BUILDS Ofi IAIPROVES THEREON,AND � WFIOCONTRACTSFORSUCHPRO.IEC7SWITNACONTRACTOR�S)LICENSEDVURSUANTTOTHECONTqAC- QUANTITY DESCRIPTION roas uc�sE uw.} FEE � ❑I AM F�fEMPT UNDER S�C. B.6 P.G FOR 7F715 REASON Q � U W � DATE OWNER U �¢ LICENSED CONTRACTORS DECLARATION W 2 1 HEREBYAFFIRAI UNDER PENALTY OF PERJURV THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER � � Y(COMMENCINO WIiN SECTION 7000)OF DNISION 3 OF THE BUSINESS AND PROFESSIONS CODE,ANO Z MY IICENSE IS IN NLL FORCE D EFFECT. m � UCENSE CIASS_„)�,_ LiC.NO._ I �• •J � v DATE /•'"F7 ar"v� I CONTRACTOR " y � d W � WORKERS'COMPENSATION DECLARATION � � I HEflEBYAFfIRM UNDER PENALTY OF PERJURY OIVE OF TME WLLOWING DECLAftAT10NS: Z � __IHAVEANDWiLLMAMTAINACERTIFICATEOFCANSENTTOSELF-INSUREFORWORKERS' _ � COMPENSATqN,AS GROVIDED BV SECTION 37uD OF THE LABOR CODE,FORTHE PERFORMANCE U Q OFTFiEWORKFORWNiCNTMISVERMITISIS5UE0. � � _IHAVEANDWILLMAIM(AINWORKF.RS'CAMPENSATIONINSURANCE.ASREOUIREDBYSECTIDN Qn 37o00FTHElA80R CODE,FOR THE VFRFORMANCE OFTHE WORK FOR WHICHTHIS PERMIT IS ISSUED.MV fRS'OOM NSATIONINSURANCECARRIERANDPOLICYN MBERARE/: CONSTRUCTION � CARRIER r4 'l Iq e nS lCC7• PLANREVIEW � POLICYNUMBER Lyr�' C- Y��L��-� ELECTRIC '4. � (nusSEc�aNNc�ha78Eca.1PLErIDOFiriErEw,rrswRonlEMX�DREooawaslstao)on�ESS�. PLUMBING , �� Z I CERIIFV THAY IN THE PERfORMANCE Of THE WORK FOR WHICH THIS PERMIT IS ISSUED,t MECHANICAL („y- SI-IALLNOT EMPLOYANY GERSON IN MIY MANNEA SOAS TO BECOME SU6JECT TO THE p p � WORKEflS'COMPENSATIONUWSOFCALIFORNIA,ANOAGREETHATIFISHOULDBECOME INSPECTIONFEE �� -� ��...�.e✓ SUBJECT TO 7HE WORKERS'GOMPEN5ATION PROVISIONS OF SECTION 3700 OF TME LABOR � / `'�j'� �j CO�E,I SH,AgLLFOR'fHWITH COMPLY WITH SE P VISIONS. �` /� ISSUANCE � �.Jv p DA7E: I"� �7"�I APPLICANT. ���p�—���.J 4.G�� SMIP ,. . �. ' � e'.� J WARNINO:FAILURETOSECUREWORNERS'COMPENSATIONCOVERAGEISUNLAWFUL,AN�SHALLBE ENERGYP/C � • ' � 5lJ9JECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL RNES UP TO ONE HUNOREO THOU50.ND �5 A �i�'°�q e�;'o`-.'#(fy;^�t�'+,'�';�,�y:�,Y A OOLUIRS(it00,000j,INADDIT�ONTOTHECOSTOFCAMPEN5A710N,DAMAGESASPROVIDEDFORIN ENERGYPERMIT a,� ,y,¢ ¢ SECTION37aeOF'fHELABORCODE,INTERES7,ANDA7TORNEI^SFEES. RETENTIONFEE: ��J�'�g�'''�-��j��<��;��3d"�6�.:•�� OCONSTRUCTION LENDINGAGENCY PRE-ALT FEE: � 1 HERE87 AFFIRM UNOER PENALTY OF PERJUFY THATTHERE IS A CONSTRUCTION LENOING AGENCY FOR TME PERFORMANCE OFTHE WORK FOR WHICH THIS PERMIT IS ISSUEO(SEC.30B7,CIV.CJ. Z ^ //� /,�,�} �y /� � LENDER'SNAME ��L.719� / Pi.PL�/- ��"�I�r �'CDC�N' F— LENOER'SAODRESS � /� W t CERTIFY THAT I MAVE READ THIS APPLICATqN AND STATE THAT THE ABOVE INFORMATION IS CARRECT. TOTAL FE ES ,S V � tAGFlEE TO CAMPLV WITH ALL CfTY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDINO � CONSTRUCTION,AND HEREBY AUTHOPIZE REPRESENTATNES OFTHIS COUNTV TO ENTER UPON THE Z ABOVE-MENTWNEO PROPERTY FOR INSPECTION PURPOSES. COMMENTS � J � m PERMITTEENAME(PRWT) 'Q � � SIONATUflE OF PERMITTEE DATE = RECPT.NO. 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