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HomeMy WebLinkAbout14704 (34) 1 r �� _ CITY OF DIAIVIOND BAK t�� : DEPARTMENT OF COMMUNITY&DEVELOPMENT SEFtVICES 't �w 21660 E.Copley Drivc Suite 190 (909)860-3195 Fax(909)861-3117 PRESS '"�^ ' BIJII.,DING PERMIT APPLICATION FIRMLY � JOBStTE ey� Ql APPLICATION PERMIT /�` ' � AODRESS ,I�� a�r .��n��{��� I���� DATE �r'�� NUMBER�# v��Q� � ISSUE R TYPE OCC � APN LOT TRACT DATE CONST. GROUP p OWNER �SNIN(T(�Ai M�'T� t- �— — o ADDRESS L h���I ZONING SETBACKS w ' FRONT _ �nJ ❑ z CITY ZIP�yj_�_� TEL.� "' I '� g APPLICANT 1 � T L. t� REAR ❑ � p SIDE/SIDE STREE:T RW ❑ � CONTRACTO ('r.� SIDE _ ❑ ADDRESS � P PROPOSED USE���1�r:.��GL ��{� � CITY C A L G�� ZIP�TEL. a z DES GNER1 C L.�I. � � ������� NO.DWEL. NO. NO. a ADDRESS ��� y� ' �$� ____�� UNITS STORIES BEDROOMS � CIN ZIP TEL � cn DESCRIPTION SQ.FI: FACTORPSF ADJ.AREANALUATION Q OWNER-BUILDER DECLARATION � � SFR/ADD/REM � � O p 1 HEREBY AFFIRM UNDER PENALN OF PERJURY THRT t AM El(EMPT FROM hIE CONTRACTORS LI� G3fi190/C81p011 � W CENSEUWFORTHEFOLLOWINGREASON(SEC.7031.SBUSINESSAN�PROFESSIONSCOOE:ANYCINOfl (n U COUNfVWHICHpE0U1RESAPERMI77000N5THUC7,ALTER,IMPROYE.OEAIOLISH,ORREPAIRANVSTRUC- W PBIIO/�BCk z TURE,PRIOR TO ITS ISSUM'CE,/LLSO RE�UIRES THE APPLICANT FOR SUCH PERMIT TO FIIE A SIGNE� ' � STATEMENT TFIAT HE OR SHE IS IICENSED PURSUANT 70�THE PROVISICNS OF THE CONTRACTORS LI- W � CENSE LAW(CHAP7ER 9(COMMENCINO WITH 3ECTON 7aoo)OF DIYISION 90F iHE BU$INE9S AND PRO• � PoollSpa FESSqNSCODE)OFlTHATHEORSHEISEXEMPTTHEREFROMANDTHEBASISFOflTHEALLEGEDEXEMP- (� TION.ANVVIOLATqNOFSECTiON7037.68VANYAPPLICANTFORAGERMITSU&IEC75THEAPPLICANTTO Z Re-Roof � A CML PENPL7Y OF NOT MORE THAN FlVE HUNORED DOLLARS(SSoo�.): ^ ❑I,ASOW,NEROFTHEPROPERTY,ORMVEMPIAYEE&WITHWAGESASTHEIRSOLECAMPENSATION, Q COfl1/I1BfCIdI -' � WILL 00 THE WORK,AND 7HE STRUCTURE tS NOT INTENDED OR OFFERED FOR SALE(SEC.7044,8U51- J N NEwANDPROFESSWNSCODE:THECOMRACTORSLICENSELAWDOESNOTAPPLYTOANOWNEqOF � PROPERTY WN08UItD5 OR IMPROVES THEREON,AN�WHODOES SUCH WORK HIMSELF OR MERSELF OR Q 7HROUGHHISOR HER OWN EMPCOVEES.PROVIDED TMRT SUCH IMPROYEMENTS ARE NOT INTENDED OR C•� e� � OFFEREDPORSALEIF,HOWEVERIHEBUIL�INGOFi17APpOVEMEMI550LDWITHINONEYEAROFCONPLE- I ,!!7t i Z TqN.THE OWNER-BUIIDER WILL HAVE THE QURDEN GF PROVING THAT HE OR SHE DID NOT BUILO OR = IMPROVE FORTHE PURPOSE OF SALE�. ❑1,AS OWNEROF 7HE PROPERN,AM E7fCLUSIVELV CAMRACiING WITN 110ENSED CONTRACTORS �� � TO CONSTRUCT TFIE PRQIECT(SEC.70�4,BUSMESS AND PqOFESSIONS CODE:THE CONTRACTORS LI- VdlUdli011 I ti'�""� qDJ.AREA W CENSELAWDOE9NOTAPPLYTOANOWNEROFAPROPERNWHOBU:LOSOHIMPROVESTHEREON,AND Z YAIOCONTMCTSFOFSUCHPq0.1ECTSWYRdACONTRACTOR(S�LI�NSEUPURSUANTTOTHECONTRAG QUANTiTY DESCRIPTION FEE Y 70R5 UCENSE UVY.�. � ❑1 AM E7fEMPT UN�ER SEC. B.&P.C.FOP THIS REASON Q � U — � � DATE OWNER V W F�—, LICENSED CONTRACTORS DECLARATION W � I HEREBY AFFIRM UNDER PENALTV OF GE0.IURV THAT I AAR IICENSED L'NDEH PROVISIONS OF CHAPTER � � 9�COMMENCINOWYfH5ECTKKJ7000)OFDIVISION30FTNEBUSINESSANOPROFESSIONSCODE,AN� Z �� MY IICENSE IS IN FULI FORCE ANU EFFECT. M1 m �• 0 LICENSE C 5 ' - �'7'`�- LIC.NO. � � � � � � � e J V DATE Y � CONTRACTOR itl���F`� �i'/�,��I�L a. .:.. r W � ����al,��� � WORKERS'COMPENSATION pECLARATION. . �, Q . .. � �. �., .. : � � , .. . . .. .., .,.. �- ..✓. : ..� V ... .. �. . � ..� ... . . . � IHEREBVAFFIRMUNDERPENALTYOFPEA;IUNVONEDF7NEFOLLAWING'DECLARRTIO�S;. .$ . � � ��� � � _IHAYEANDWILLQ�AINTAINACERTIFICATEOFCANSENTTOSELF-INSUREFOFWORKERS' _ ' COMPENSMION,AS PHOVIDED BY SEC710N 970o OF 7S1E LPBOR LaDE,FOR THE PERFORMANCE U � y OFTHE WORK FOR WHICH TFBS PF.RMIT IS ISSUED. � . . W /� I HAVE AND WILL MAINTAIN WOAKERS'COMPENSATION INSURANCE,AS REUUIRED BYSECTION 7-''' /7 Q 37000PTHE LABOR CODE,FORTHE PERFORMANCE OF THE WOAK FOfl WHICHTHIS PEHMIT IS . f�-�� // GSSUED.MY WORKER�S'-CrO�M.PENSATION INSURANCE CAAHIER ANO POLICV NUMBER AftE: CONSTRUCTION .�/ � � CARRIER��\.G'�7� \�\ �Vl 1T�� PLAN REVIEW _� i � ,� Z POLICV NUMBEp V"'�5 K: '�C`) Cf�t • ���� +L ELECTRIC _ e � (IFIISSECIKJNNE�NOTBECOl�LE7EDOF7lfPERMRtSFOHIXaEHUPORED00LWL5(ElaO)ORLE55�. PLUMBING ___ Z ICERTIFV7HATINTHEPERFORr.1ANCEOFTHEWORKFORWHICHTHISPEHMITI515SUED,I MECHANICAL _ (J SHALLNOTEM7LOYANVPERSONINANVMANNERSOASTOBECOMESUBJECTTOiHE Uj WORKERS'COFAPENSATpNLAW50FCAUf-0RNIA,AN�AGREeTHAT,IFISHOULDBECOME INSPECTIONFEE ._,_ � SU&IECT TO THE WORKERS'COMPEN9ATION PROVISION OF SE bN 3700�,F TNE LABOR � COOE,ISFi FORTMWITHCOMPLYWITHT OSFfP�,OVI50N5. • ISSUANCE _ � � ` , s �_ SMIP p DATE: � � �4�':aAPPLICANT: �. � . � ENERGY P/C �'P'�'�_(���T�M�NU WARNINQ iAILURE TO SECURE WORKERS'COMPENSAT10Y CAVEfiAGE IS UNLAW FUL,AND 3HALL BE � � SU&IECTANEMVLOYERTOCRIMMRLPENALTIESANOCNILFINESUPTO�NEHUNDREDTHOUSAND ENERGYPERMIT T�T4Fi Y1T a'�3�?�$AFETY DOLIARS(5700,000J,IN ADDII7IXJT0 THE COSTOF CAMPENSATION,DAMAGES AS FROVI�ED FOR IN --- P � SECTION 9'loe OF THE LAeOR CO�E,IkTEREST,AND ATTORNEY'S FEES. RETENTION FEE: . _ � d CONSTRUCTION LENDING AGENCY PRE- T FEE: CC IHEREBYAFFIRMUNDERPENAL7YOFPERJURYTHAi7HEREISACONS7RUCTIONLENDINGAGEfiCY G � FOP THE PEFiFORMANCE OFTHE WORN FOR WHICH TWS PERMIT IS ISSUED(SEG 3097,CIV.C.1. Z W � LENDER'SNAME_ ' 1_ LENDER'S ADOHE55 D � ICEFTIFYTIATIHAVEREADTHISAPPLICATIONANDSTATETHATTHEABOVEINFORMATIONISCARRECT. TOTAL FEES " 5�� W IAGFEETOCOMPLYW1THAlLCITYlWDCWNTVORDINANCESANDSTATEUIWSHELATINGTOBUILDING /'� � CANSTRUCTION,AND HEREBYAUTHORIZE REPRESENTATNES OF THIS COUNTV TO ENTER UPON THE ' 1'�0 0 � � ABOVE�AIENTIONED PFiOPERTY FOH INSPECTION PUflPOSES. ��� � Z COMMENTS �/t � /S _- — _ ���.I`. ` �1t�1�.1�y�'_.l� L.- `..1� �. '4 l � �' m PERMI7T N (PRINn � � _ '�" � .. C.J(1 Vj SIONAN 'OFPERMITTEE �TE � RECPT.NO. 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