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Home My WebLink About17141 (10) CITY OF D►"�'OND BAR ,,�— - ��`` 1 DEPARTI�i� OF COIvAdUNTI'Y&DEVELOPMENT SERVII } � 21825 E.Copley Drive (909)860-3195 Fax(909)8 I-3117 PRESS �� BUILDIJaIG PERMIT PLICATION FIRMLY � JOBSITE �' �,�6 APPLICATION �i� �1 ` PERMIT � P/C� � • -, o A�DRESS ��z � Dl�j"n'�G�+�/J �Y 1/\ i'� DATE � 4 �� r NUMBER I # � lf � � �'" � ISSUE TYPE OCC APN LOT TRACT DATE CONST. GROUP p OWNER �/�� r j� " J I o AODRESS `A. " t 6 � 20NING SETBACKS z CITY C6 '. � ZIP�� TEL. • '� FRONT RW ❑_ p APPLICANT �h-FH-N ��L � TEL' �' - REAR � Z SIDE/SIDE STREET RW ❑ - a CONTRACTOR_ SIDE C � A�DRESS PROPOSED USE . i� • �,;` " ' � CITY ZIP TEL. o ARCMYENG7- z DESIGNER K/-�-f�/�r L N,�� NO.DWEL. N0. NO. a ADDRESS�S_S ��',f�cA-1C.�?GY f�L. � � UNITS STORIES BEDROOMS � CITY GCt/Z�f-CIt=S ZIP��C�! TEL.�il.�T/�'_C' + cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION Q OWNER-BUILDEADECLARATION SF ADDYREM ��,�/ O � I MEREBV qFFIRM UNOEN GENALTV OF PERIURY THAT I�M EXEMPT FROM THE CONiRACTORS ll- Gdf8J8�C2IPOft W CENSELAWfORTHeFOLLOWINGHEA50N(SEC.]071.SBVSINESSMIDPROFESSIONSCAUEANYCITYOR (n ZCAUNTYNM1IICMREOUIRESAPERMITTOCONSTRUCT,ALTER.IMPROVE,DEMOLISH,ORREPi11RANYSTRUG W pg�j0/DeCk w TURE.GRIOR TO ITS iSSUANCE.AL50 REOUIHES THE APPUCANT FOii SUCH PERMIT TQ FILE A SIGNE� W STATEMEHT THAT HE OR SHE IS LICENSEO PURSIIANT TO THE PROVISIONS OF THE CANTRACTORS LL � CENSE LAW(CMAPTER 9�COMMENCING WITH SECTION 1000)OF DIVISION 3 O'r THE BUSINESS AN�GPO� LL POOUSpB FESSIONSCODE)OR7HATMEORSHEISE%EIAPTTHEREFROMANDTHEBASISFOPTHEAILEGEDE%EAIP- � � 710N.ANV VIOUTION OF SECI'ION]091.5 B�ANY APPLICANT FOR�PERMIT SU&lECTS THE APPLICANT TO Z Re-Roof ACIVIL PEN�ILTY OF fvOT MOPETHAN FIVE HUNDRED DOLURS(S500j.�: ❑I,AS ONMEii OF THE PROPERTV,OR Mv EMPLOVEES WITH WAGES AS TNEIR SOLE CAMVENSATION, O � Commercial Z WILL 00 TNE WORN,�NO THE.STRUCTURE IS NOT INTENDE�OR OFFERE�FOR SALE(SEC.]aN,BU51� J � NESS AND PROFESSIONS COUE:THE CONTRACTORS LICENSE UW OOES NOT AFPLV TO AN OWNER OF � PROPEflN NMO BUILDS OR IMPROVES THEFEON,ANO WNO DOES SUCH WORN HIMSELF OF HEHSELF Oq Q THiiWCH HIS OF NENOWN EMPLOVEES.PROVI�EO THAT SUCH IMPqOVEMENTSARE NOT INTEN�EDOR m OOFFERE�FORSALEIF,HOWEVER,THEBUILDMGORIMPROVEMENTISSOLDWITHINONEYEAROFCAMPLE� Z TION,THE OWNER-BVILOER WILL HAVE THE BURDEN OF PqOVMG THAT NE OR SHE�IO NOT BUILO OR � IAIPROVE FOR THE PURPOSE OF SALE). /• w ❑I,ASOWNEROFTHEPROPERTV,AMEXCIUSIYELVCONTRACTINGWITHLICENSEDCANTRACTOiiS � TO CqNSTRUCT THE GflOJECT(SEC.]Oa�.BUSINESS AND PqOFE5510NS CO�E�.TME CONTfUCTOHS LI� Vd1118110f1 � �J -/ ADJ.AREA W CENSE UW�OES NOT APPLV TO RN OYMEP OF A PROPERTY WHO Bl11LD5 OR IMVROVES TMEREON.ANO � WHOCONTMGTSFORSUCMPR0.IECTSWITMRCAfYTRACTOR�S)LIC NSEDPURSUANTTOTHECANTRAC- QUANTITV DESCRIPTION FEE TOHS LICENSE l/�W). ^ Ql�l AM E%EMPT L1N�Efi EEC. B.8 P.C.FOR iM15 RERSON Q v ��I, `� (��r[�� ZDRTE � � OWNER U / ��C�' �� O w � LICENSED CONTRACTORS DECLAFATION w Q Q IHEREBVAFFIRMUNOERPENALNOFPERJURvTHATIAMLICENSEDUN�ERPROVI510N50FCNAPTER V. � ��(.,y„� �rAj d 9(COMMENCING WITH SECiION 7000)OG DIVISiON 30F THE BU51NES5 ANO PROFESSIONS COOE,AND Z � /V `X A1V LICENSf IS W FUI�FOFC(=AN�EFFECT m � ! f=�f�� .`_�r/1/l� � LICENSE CLASS LIC.NO. � �• ) ` � DATE CON7RACTOR a J W a� WOFiKERS'GOMPENSATION DECLARATION � /1 � a �J �r� i G C � I HFREBY AfFIPAI UNDER PENALTV OF GERIURV ONE OF THE FOLLOWING DECLAHATIONS: Z , � I HAVE AND WILI MAIMTRIN P CERiIFICATE OF GONSENTTO SELF-INSUPE FOR WORKERS' a Z Q CAM7ENSATION.AS PROVIDED BY SECTION Po00F ThE UBOR CO�E.FOR THE PEFFORAIMICE `U Q OF THE WOqK FOR WNICH THIS PERMIT IS ISSUED. � w I HAVE AND WILL MAIMTAIN WORKERS'COMPENSATION INSURANCE,AS REOUIRED BY SECTION Q 3�00 OF THE LABOR CODE,FOR THE vERFORMIINGE OF TME WORN FOR WHIGM THIS PERMIT IS �� C�J ISSUEO.MY WORKER:�CAMPENSATiON INSURANCE CARRIER AND POLICV NUMBER ARE: CONSTRUCTION �I / J j cnaaiEa PLAN REVIEW _ � _ ' Z POLICY NUMBER_ ELECTRIC � � (7}1155ECilONNE�NbTBEQ."MPLEIEDOFh1EPEPMTISWRONEFNhDfiEDDOL1PAi(5t0o)ORlESS). PLUMB�NG ��.,� � W Z I CEPTIFv THAT IN THF_PEi7FOFMANCE OF THE WORK FOR WHICH TH'S PERMIT IS ISSUEO,I MECHANIGA� (�J SHALL NOT EMPI.OV ANV 7ERSON IN ANV MANNE9 SO A$TO BECOME SUBJECT TO THE Uj WORKERS'COMPENSATION UWS OF CALIFORNIA.ANDAGREE THAT IF I SHOULD 9ECOME INSPECTION FEE = SUBJECTTO THE WOtiKERS'C0IAPENSATION GROVISIONS OF$ECTION 3)0o OF THE UBOR �,`�j� ` CODE.I SHALL FORiHWITH COMP�V WITH THOSE PROVISIONS. �SSUANCE vV � SMIP ��' r) + !i,I IT� y � � DATE' . APPLIGANT: - � J WARNWG�.FAIIURETOSECVREWORKERS'COMVENSATIONGOVERAGEISUNLAWFUL,ANDSHALLBE ENERGYPlC � SVBJECTpN EMPLOYER TO CRIMINAL PENA�itES PND CIVIL FINES UF TOONE HUNDRED THOUSANO ENERGY PERMIT / OOLLARS(ft00,000),IN ADDITIONTO THE COSTOF COMPENSATION.DAMAGES AS PROVIDE�FOR IN �'1 J SECTION�IOB OF THE 1A80R CO�E.INTEREST,AND ATTOFNEYS FEES. RETENTION FEE: . r �-V O � d CONSTRUCTION LENDING AGENCY PRE-ALT FEE: O � I HEREBV AFFiRM UNDER PENALTV OF PERlURV THAT THERE IS ACONSTRUCTION LENDING<GENCV FOR THE PERfORIJANGE OF fHE WORK FOR WHICH THIS PERAIIT IS ISSUED(SEC.309),CIV C.y. W y LEN�ER'S NAME � F- IEN�ER'SACDRE55 ¢ I CERTiFY TNAT I HAVE READ THIS APPL�CATION AND aT4'ETHATTHE A30VE INFORMRTION IS CORRECT. TOTAL FE ES �� '""-`� �� W I AGREE i0 COMP�V WITN AL,.CITY AND COUNtV ORDINANCES AND STRTE LAWS RELATING TO BUILDING 2 CONSTRUCTION,AND HEREB V AUTHORIZE REPRESEN'Ai1VE5 OF THIS COUNTV TO ENTEH UPON THE L � ABOVE�MENTIONED PROFERfY FOF INSPEC'ION PURPOSES. ) / / � ^ ^ •7' � Z A �( COMMENTS V �1 (� V�+� o �l f��7/�/ �. �1�� ' / � - J � � Cr m GEFMIiTEE NqME�PRINT� ^V 9 �1 � � � � ��1�� ' �T' ! '- �� -- �� SIGNATURE OF PE � �AT� = RECPT.NO. PAID BV VAUDATION ~ WHITE-Depanment Copy.YELLOW-Finance Copy.PINK-Assessor Copy.GOLDENROD-File Copy,GREEN-Applica 's Copy � �`'" �, � � G`�►`t�� 1 //;��-�� ..��,.� �� - �(nl�`l�� `�� J/��1-�� ______._..__ r"° �p��,��' �Z ��"`7 ( �,,��L.- �. � JOBSITE ADDRESS 112 7 i i 'I APN LOT TRACT OWNER Lj1Yk1C'PLI f ADDRESS .t 6 CITY bat'.45C41 ZIP�f 1 TEL L APPLICANT HA-N�3 L%I TEL.- �' CONTRACTOR_ ADDRESS CITY ZIP TEL. DESIGGNER�Kr*ArAJ/,S/J ADDRESS CITY Gf AOyf�L S ZIP� TEL. OWNER-BUILDER DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI- CENSE LAW FOR THE FOLLOWING REASON (SEC 7031.5 BUSINESS AND PROFESSIONS CODE:ANY CITY OR COUNTY WHICH REQUIRES A PERMIT TO CONSTRUCT.ALTER. IMPROVE,DEMOLISH.OR REPAIR ANY STRUC- TURE. PRIOR TO ITS ISSUANCE.ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LL CENSE LAW(CHAPTER 9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO. FESSIONS CODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP- TION.ANY VIOLATION OF SECTION 7031.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS($500),): ^ I.AS OWNER OF THE PROPERTY,OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION. WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC. 7044,BUSI. NESS AND PROFESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF PROPERTY WHO BUILDS OR IMPROVES THEREON.AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR OFFERED FOR SALE. IF. HOWEVER THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF COMPLE- TION,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALE). ^ I,AS OWNER OF THE PROPERTY,AM EXCLUSIVELY CONTRACTlNG WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT(SEC. 7044. BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI. CENSE LAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON.AND WHO CONTRACTS FOR SUCH PROJECTS WITH ACONTRACTORIS)LIC NSED PURSUANT TO THE CONTRAC- TORS LICENSE LAW) )lI AM EXEMPT UNDER SEC B. &PC. FOR THIS REASON 1, DATE C OWNER LICENSED CONTRACTORS DECLARATION (HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER 9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE.AND MY LICENSE IS IN FULL FORCE AND EFFECT LICENSE CLASS LIC. N0. DATE CONTRACTOR WORKERS'COMPENSATION DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS. I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS' COMPENSATION.AS PROVIDED BY SECTlON 3700 OF THE LABOR CODE. FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE.AS REQUIRED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. MY WORKERS COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE. CARRIER POLICY NUMBER_ (THIS SECTION NEED NOT BE COMPLETED OF THE PERMIT IS FOR ONE HUNDRED DOLLARS(5100)OR LESS). I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE WORKERS'COMPENSATION LAWS OF CALIFORNIA.AND AGREE THAT IF I SHOULD BECOME SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR CODE.I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS. DATE' .APPLICANT. WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL BE SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS($100.000),IN ADDITION TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE. INTEREST,AND ATTORNEYS FEES. CONSTRUCTlON LENDING AGENCY I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS ACONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC. 3097. CIV C). LENDER'S NAME LENDER'S ADDRESS CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. AGREE TO COMPLY WITH AL-CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING CONSTRUCTION.AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ABOVE MENTIONED PROPERTY FOR INSPECTION PURPOSES. A r1AA1 ts. RL-'I PERMITTEE NAME(PRINT) iV�?�j/� SIGNATURE OF PERIOTTEE DATE 0 0 LA 17 W 0 z 2 0 0 W U Z W 0 U 0 Z 0 2 a X W 0 I- E- U W cn N Z 0 W 10 W LO I--- 0 W J J uJ W 0- 0 Q d W F- W d m CI) CI) CITY OF D1 '-KOND BAR DEPARTNU OF COMMUNITY&DEVELOPMENT SERVII 21825 E.Copley Drive (909)860-3195 Fax(909)8 1-3117 BUILDING PERMIT.APPLICATION PRESS FIRMLY APPLICATION-7 PERMIT P/C t I-, It R DATE NUMBE # ! if ISSUE TYPE OCC DATE CONST GROUP ZONING SETBACKS FRONT RW^ REAR^ SIDE/SIDE STREET RW^ SIDE C PROPOSED USE N0. DWEL. N0. N0. UNITS STORIES BEDROOMS DESCRIPTION SQ. FT. FACTOR PSF ADJ.AREA/VALUATION SF AD9/REM U) Garage/Carport W Patio/Deck LL Pool/Spa Z Re-Roof Commercial co Valuation �T(j-i ADJ.AREA QUANTITY DESCRIPTION FEE 7;?-&V OV L-:=T U W J W Z NK J CL J Q C.C, U Z W �� II/ CONSTRUCTlON �r f PLAN REVIEW ELECTRIC PLUMBING MECHANICAL INSPECTION FEE Tf ISSUANCE S,�V SMIP SEF t'a 'I lITj ENERGY P/C ENERGY PERMIT 0 RETENTION FEE: 3-170 PRE-ALT FEE: TOTAL FEES V7 1 � 1 Jam. COMMENTS Y .-•V;- �c�cam:.. Z-4 C RECPT. N0. PAID BY VALIDATION 2 WHITE-Department Copy,YELLOW-Finance Copy, PINK-Assessor Copy. GOLDENROD-File Copy,GREEN-Applicarh's Copy