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HomeMy WebLinkAbout16996 (44) ----�,�•_--- CITY OF I)IAP�10Ni1 BAR I� � DEPART[vYENT OF COMMUNITY&DEVELOPMENT SEItVICES � 2fl825 E.Copley Drive � (909�860-3195 Faac(909)861-3117 PRESS �:,.��'�' BUra.,,�r�ac r��iT arrLicaTioN — FIRMLY � JOBSITE �a"f P"j Q/ I��`j�/�"'7f�'� ��1 APPLICATION i 7 PERMIT �� /C ' ' o ADDRESS � I� l.�✓ �� DATE � �1 �t NUMBER # � , ISSUE TYPE OCC APN LOT TRAC DATE CONST. GROUP p OWNER �L '' LL ADDRESS ` ' ZONING SETBACKS w FRONT RW ❑ z CITY ZIP�_��S�TEL. o APPLIGANT l. EL. � � SIDE/SIDE STREET RW ❑ m' CONTRACTOR � a SIDE ❑ � CITl' S �`� ' Zlp � TEL. � PROPOSEDUSE ; '/�1��� . �� o (a"7�',i 33 n �.� pi o ARCH/ENG/ ' �`r, - z DESIGNER NO.DWEL NO. N . d ADDRESS UNITS � STORIES BEDROOMS � CITY ZiP TEL. �` DESCRlPTION SQ.FT. FACTOR PSF ADJ.AREANALUATIDN p� , OWNER-BUILDER QECLARATION 5FR/ADDlREM � O' �I HEREBY AFFIiiAA 11NDEFi PENALT,V OF PEf7.R1RY THAT 1 AM EXEMPT FFlOM THE CONTRP.CTOAS Lb Cidf7]O/CafP01j ' W",' 'CENSELAWFORTHEFOLLOWIN�IREASON(SEC.7031.5BUSINESSANOPROFESSIONSCODE:ANYqNOR (,/) _ Z�' ,CIXINTYWMCHRE�l11RE5APBiMITTOGONSTRUCT,ALTER,IMPROVE,�EMOLISH,ORREPAiRANVSTRIJC� W pytl0/DBCk .TURE,PflIOR 70 ITS�SSl/ANCE„4L50 fiEQUIIiES THE APPLiCANT FOR SUCN PERMIT TO FILE A SIGNE� 'w' STATEMEM THAT HE OF SHE IS�.ICEN$E�PURSUANT TO'THE PROVISIONS OF THE CONTRACTORS LI� W ��'� 'CENSE LAW(CHAPTER 9(COMMENCING WITH SECTION 70�0)OF DIVISIDN 3 0F THE 6USINESS ANU PRO� u' POOUSP2 FESSqNSCODE)ORiHATHEOR5HE1$EXEMPTTHEREFROM19ANDTHEBASISFORTHEALLEGEDE%EMP- (� .V, TION.ANYVIOLATIONOFSECTION7037.¢BYANYAPPLICANTFORAPERMITSUBJECiSTHEAPPUCANTTO 2-R001 �ACIVILPENALTYOFNOTMORETHANFINEHUNDEiEDDOLLARS(550a).): . Q ❑I,ASOWNFAOFTHEPROP�RTY,�]flMVEMPLOVEESWITH:WAGE5A5THEIRSOLECOMPENSAiiON, COff1R12fCIBI '- Z WILL PO THE WORK.AND iHE 57(lUCTURE IS NOT INTENDED Ofl OFFERED FOR SALE(SEC.7044,BU51� J - 'NESSAND PROFESSIONS CODE:THE CONTRACTORS LICENSE LAW�OES NOTAPPLV TO AN OWNER OF '� '�;PqOPERTYWHOBUILD50RIMPflQVESTFiEREOPI,ANDWHODOESSUCHWORKHIMSELFORHERSELKOR � '� '.THROUGHHISORHEROWNEMPI,OYEES.PROVI�EOiHATSUCHIMPROVEMENiSARENOTINiENDE00R m � Q�'� '�OPFEREDFORSALE.IFHOWEYER,ITHEBUILDINGORIMPROVEMENTISSOLDWITHINONEYEAROFCOMPLE- ;Z,;,�,TION;THE OWNER-9UILDEfl WILL'�,HAVE''��,THE BUR�EN OF PROVING THAT HE OR SHE DID NOT BUIID OR �IMPROVE FOR THE PUqPOSEOF SqIE).�' ;�,�', '., ❑I,A60WNER�FTHEPRORERTY,�AMEXCLUSNELYCONTRhCTINGWI7HLICENSEDCONTRACiORS '�[['.�''�,'TO CONS7RUCT THE PROJECT(S�C.7ajf4.6USINE55 ANO PqOFES51ON5 CO�E:TNE CONTRACiOpS LI� V81l1fl�1011 ADJ.AREA �W', �CENSEL4WDOESNOTAPPLYTO NONMEROFAPROPERTYWhiOBUI'�_DSORIMPFOVESiHEflEON,ANU Y � ;''�,WHOCONTRACTSFORSUCHPRO.IECTSIWITHACONTRACTOR(5)LICENSE�PUFSl1qNTTOTHECONTRAP I 4UAN71TY DESCRIPTION FEE x 'TORSLICENSELAW). ' ', � ❑IAM EXEMPT UN�Eft SEC.� ' B.&P.C.FOR 7HIS REASON � �' � W. �ATE ' OWNER_ _ � �. W �' LfCEN$ED CONTRACTORS DECLARATION �j ¢ ' � i HERE9YAFFIRM UNDER PENAL7'f OF PERJURV THAT I AM LICENSE�11N�EF7 PR�VISIONS OF Ct.PPiER � �' 9(COMMENCIN6 WITH SECTION 7ECo)OF DIVISION 3 0F iHE BU5WES5AND PROF'cSS10N5 CO�E,A��D z X MY LICENSE IS IN FULL FO CEAND EFFECT p �� LIGENSE CL4 S� Lw✓"�, LIC.NO. �W���✓ ✓� � }� �y—�.� � ~ DATE CONTRACTOPI/��I 1 F �- U�.0 i� WORKERS'GOMPENSATION DECLARATION � � p Q R/� ' V �. I HEREBV AFFIRM UN�ER PENALTY DF PERJURY ONE OF THE FOLLOWING DECLARATIONS: z �'� _IHAVEANDWILLMAINTAINACERTIFICATEOFCONSEKfTOSELF-INSUREFORWORKcRS' _ - CAMPENSATION,ASPROViI�EOBYSECTION3]ooOFTHELABOflCODE,FORTHEPERFORMANCE U � Q fpF THE WORK FOR WHICF�iHIS PERMIT IS ISSUED. � � ''.�IHAVEANDWILLMAINTAI�JWOFKERS'GOMPENSATIONINSURANCE,ASREDUIREDOYSECTION ,•� f�,� ^� 37000FTHELABORCODE4FORTHEPERFORMANCEOFTHEWORKFORWHICHTHISPERMITIS. G..�J �—J ISSUEO.MY[w,rp�RS�'COyMPEN$ATIOpN�INSURANCECARRIER�AN�POLIJqr NUMeERARE: CONSTRUCTION � � CARflIER v �F"i.7��Il"L C'"/ 7 __ PLAN REVIEW ZpoucrNUMeEn ��""��,�� ELECTFIC ¢ (IHISSECTqNNEmNOiBE�COMPI,EfEDOFTHEPERMITISFORCN=HUN�RED�OLLAFS($10�)ORLESS). PLLIMBING C] ' W I CERTIFV THAT IN THE PERFORk�IANCE OF THE WORK FOR WHICH THIS PERMIT I5 15SUED,1 MECHANICAL ---��-- �J' SHAILNOTEMPLOVANYPER50NINANYMANNER50A5TOBECOMES'JBJECTTOTHE ��qq / �d I �. WOflKERS'COMPENSATIOIJLAY!$OFCALIFORNIA,ANDAOftEETHATIFISHOUL�BECOME INSPECTIONFEE _J f� F` a �8 SUBJECTTOTH=WORKEAS'COMPENSATIONPflOVISION$OFSECTION3taDOFTHELABOR d //1 ��� COOE,ISHh4LFORTHWITHCOMPLYWITH7NO5EPROVI510N5. ISSUANCE 9 �v� a �� a 5 p ..DATE: APPLICANT SM�P 9 rg � J' �, WARNING:FAILUFE TO SECUftE W�RKERS'COMPENSATION COVERAGE IS UNU�WFUL,AND SHALL BE cNERGY P/C " 4 4y .Sl10JECTANEMPLOVERTOCflIMIryALPENALTIESANOCIVILFINESUPTOONEHUNOREDTHOUSAN� ENERGYPERMIT � � 'DOLLARS(51oa,o0o),INAODIiIONTIOTH6CO5TOFCOMPENSATION,DAMAGESASPftOVIDEDFORIN � ,SECTIDN3�080FTHELABORCODE,INTEREST,ANDATTORN�"SFEES. ' RETENTIONFEE: ______ ___ , �. , CONSTRUCTION LENDINGAGENCY PRE-ALT FEE: C �'. '�,,I HERE9YAFFIRM UNOEfl PENALTYIOF PF�RJUftY THATTH=HE ISACONSTRUCTION LENDING AGENCY �FOflTHEPERFORMANCEOFTHEWORK�ORWHICHTHISPERM1715155UE0(SEC.3091,GV.C.). �; LLI �, LENDER'S NAME 1_'„ LENDER'SADOFE55 '� 6� ' e � TOTAL FEES �'� �' ICERTIFVTHATIHAVEPEADTHISAPPLIdATIONANDSTA7ETHATTHEA80VEINFORIUATIONISCORRECT p�; I AGflEE TO COMPLY YATH ALL CITY AND COUNTY OROINANCES AND STATE LAWS PELATING TO BUILDING � � '�,��CONSiRUCTION,AN�HEREBYAUTHOflIZEREPRESENTATIVESOFTHISCOUN'VTOENTEqUGONTFiE �'. ,( ,�A60VE-MENTIONE�PROPERTY FOR INSPECTION PURPOSES. COMMENTS - �; ��Q.,��i_ 7�'� '�-�.�1/�rrC�l�3- — m� P MI E N ME NT) �/y�p j �'p i ��� �'�.'.' 1 40 �0 V 1 f'� A E 1 , �/j�' �51 ATU EOFPEFMITT ' D E [.� I � � � RECPT.NO. PAID BY ' VALIDATION ~� WHITE—Cepartment Copy,YELLDW—Pinance Copy,PMK—Assessor Copy,GOLDENROD—File Copy,GREEN—ApplicanYs Copy . w;.4. ;,� �. .�,�,�n 3 � x i ... . . . 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