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HomeMy WebLinkAbout17249 (26) CIT4'OF I3IAM�ND Bt1R � � -�°`' - DEPART`M�',NT OF COIrffVIUTTI7'Y&DEVELOPMENT SERVICES ----- � 21825 E.Copley Drive (909)860-3195 Fax(909)861-311'7 f�RE$S "'%v��'� BUILDING PERMIT APPLICATION FIRMLY � JOBSITE � � ,=p �f���y%y_.�J/�•� � APPLICATION ; � � �� �,`,PERMIT 1 F`r ' � P/C o AD�RESS L ""�C%�''/W� DAFE ��' "�-^' NUMBER�� # � ISSUE TYPE OCC APN LOT TRACT DATE CONST. GROUP p OWNER �111�il��`i. �' �_ /Z.� AD�RESS ° C� D ��r '��T� ZONING SETBACKS Z CITY _J . ZIPC�i��� TEL.�'��4Ic�Uv�i9'`� FRONT RW ❑ o APPLICANT ��� TEL. S DERSIDE STREET RW ❑ z ¢ CONTRACTOR�°����� G�/L.��2' SIDE p � ADDRESS ' � .-� • � � � GITY ZkP TEL. PROPOSED IJSE 1� ��.. � `t'-"�� p ��,�i°* `;"i� �" ,-� _w , w ARCH/ENG! ` 3 0 7`" "�;�J�""�- iz DESIGNER NO.DWEL. NO:�� NO. a, ADDRESS � CITY ZIP TEL. UNITS STORIES BEDROOMS cn cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER pECLARATION SFR/ADDlREM O I � 1 HEREBY AFFIRM UNOER CENALTY DF PERJURY THAT i MA EXEMP?FROM THE CONTRACTORS LI- G8fHJ0/C2fPOf[ � W CENSELAWFOq7HEFOLLOWINGREA50N(SEC.7oa1.58U5ME5SFN�PROFE55iON5CODE:ANYGIT'!OR (JJ U COl1NTYWHICHREOl11RE5APERMIT70:ANSTFtUCT,ALTFA,IMPROVE,OEMOLISH,ORREPAIRANYSTRUC- � W TUqE,PRiOfl TO ITS ISSUANCE,AL50 REOUIRES THE APPLICANT FOR SUCH PEflM1T'TO FILE A SIGNED - � W Patiol�eck STATEMENT THAT HE OR SHE IS LIGENSED PURSUNNT TO THE PROVISIONS OF 1"HE CONTFIACTOflS LI- '� CENSE LAW[CHAPTER 9(COMMENCING WITH SECTION 7oJo)OF DIVISION 3 OF THE BUSINESS AND PRO- V" PooVSpa �� FESSIDNSCADE)ORTHATHEORSHEISEXEMPTTHEREFflOMANDTHE8p5i5FOflTHEALLEGEDEXEMR (� - ' �' � _ TION.ANYVIOLATIONOFSECTION7o31.58VANVAPPUCAN7FOPAPERMIiSU&lECTSiHEAPPLiCANTTO Z Re-Roaf ���'_ ��5'•W ' A CIVIL PENAL7Y OF NOT MORE THAN FIVE HUNDflED DOLLAPS(5500).�: � ❑I,ASOVYNEFOFTHEPROPEHIY,OrhMYEMPIOYEESWITHWA�E5A5THEIR50LECOMPENSATION, � Commercial Z WILL DO THE WORK,AND THE STRUCTULiE IS NOT INTENDEC OR OFFEFE�FOR SALE(SEC.7o4a,BUS4 J � NESS AND PftOFE551IXJS CDDE:THE COI,�TPACTORS LIGENSE LAW JOES NOT APPLY TO AN O'NNER OF � PROPERSYWHOBUIL�SORIMOPOVESTHEF7EON,ANDWHOOOESSIJCHWORKHIAASELFORHERSELFOR m [L THR04GHHISOflHEROWNEMPLOYEES;PPOVIDeOTHATSUCHIMPROVEMENTSARENOTINTENDEDOq QOFFEREOFORSlLLE.IF,HOWEVER.'HE�IYLDINGORIMPROVEMENTI5501�WITHINONEYEAROFCOMPIE- Z TION,THE OWNER-BUILDER WILL HAVE THE BURDEM�F PR�VING TtiAT HE Oq SHE�ID�OT 9UIL�Op � IMPpOVEFORTHEPURPOSEOFSALE). � W ❑I,ASONlNEROFTHEPROPERTV,AME%CLUSIVELYCDN7RAC'ING'uVITHL�CENSE�CCNTRACTORS - ' [[ 'O CONSTRUCT THE PRO�ECT(SEC.7C4ji,BUSMESS AND PROFGSSIONS CO�E:THE CONTRACTORS LI- VflIU8lI0f1 `P"'�=. ��',� ''�' _ADJ.AFEA 1�:lJ CENSEIAWD�ESNOTAPPLYTOANOWN OFAP PEfliYWH06UItD5�RIMPROVESTHEREON.ANO =��� � WNOCONTRACTSFORStJCNPR0.1ECT5 ITH O RCTOR( '_ £NSEDPURSUANTTOTHECONI'RAG QUANTITY DESCRIPTION FEE Y TORS LICENSE LAW.). �� ❑I AM E%EMPT UNDER SEC� '� � 9.8 P.C.FOP THIS REASON Q U � �ATE� "I �!✓ � � OWNER U Z W � LICENSED CONTAACTORS DECLARATION - W � I HEPEBY AFFIFlM UNDEP PENALTY OF PERJURY THAT IAM IICENSED UNDER PROVISpNS DF CHAPTER � d 9�COMMENCING WITH SECTION 7Ca�)Od OIVISION 3 OF?HE fiU51NES5 AN�PROFE9510N5 CO�E,AND Z �X MY LICENSE IS IN FULL FOFlCE AND EFFE;CT. m o LIGENSE CLA55_ � LIG.NO. j V DATE � CON?RACTOR a W � WORKERS'G'��OMPENSATION DECLARATION Q � INEREBYAFFIRMUNDEfiPENALTYOFPERJURYONEOFTHEFOI.IOWING�ECLARATIONS: Z Z `I HAV6 AND WILL MAIN7AIN A CEFiTIFICA�E OF CONSEN7T0 SELF-INSURE FOR WOFNERS' ¢ � 2 Q COMFENSATION,ASPflOVI0ED0Y5ECTiON37000FTHEL400FiCO0E.FORTHEPERFORMANCE U OF THE WORK FOq WHICH THIS pERMIT IS iSSUEO. � O �i � _IHAVEANOWILLMAINTAINWORKERSCOMPENSATIONINSURANCE,,ASREdUIREOBYSECTION ,��j i � 3700 OF THE LABOR COOE,FOR 14HE PERFOP.MANCE OF THE WORK FGP WHICH TNIS PERMiT IS F h� ISSUED.IAY WORKEPS'COMPENSATICN INSI1flANCE CARFIER AND POLICY NUMBERARE: CONSTRUCTION 3 k,`' '���''� J j cnaaiEa � PLAN REVIEW � POLICYNUMBER_ ' ELECTRIC � Z i Q I :� (iHiSSECT%N�1NEmN0T6EO�MPItEI'EDOFTHEFERMITISFORONEHtNJDREDDOtIARS(Stta)ORLe55). PLUMBING Z I CERTIFV THAT IN THE PERFORMANCE OF THE WORK FDR YIHICH 7HIS PEPMIT IS ISSUED.1 MECHANICAL -(,}'' SHALLNOTEAlPLOYANYPERS¢NINANYMA.VNERSOASTOBECOM&SUBJECTTOTHE � WORI(ERS'GOMPENSATION tA4 5 Of GALIfCRN:A,AND AGREE THAT IF�SHOULO BECOME INSPECTION FEE „�:, � �. SUflIECTTOTHE WORKERS'C�MPEN3ATION PqOViSIONSOF SECTION 3]0o OF THE L4BOfl ' �':� � CODE,ISHALIFORTHWITHCOl�PLYWITHTHOSEPROVISIONS. ISSUANCE `��^��" � SMIP °���:J . �-�` p DATE: APPLIGANT: . - J WARNING.FAILUftE TO SEGURE WORKF�RS'COMPE�SATION COVERAGE IS UNLAWF�JL.AND'aHALL9E ENERGY P/C YSUBJECTANEMFLOVERTOCfiiMINALPENALTIESAN�CIVILFINESUPTOONEHUNDREDTHOUSAN'� ENERGYPEflMIT bOLLARS�510o,00a),IN ADOITION TO TH�CCST 0=COMPENSA'ION,DAMAGES AS PROVIDED FOP.IN J� SECTION37080FTHELABOFCOOE.MERES'.ANDAiTORNEY'SFEES. f1ETENTIONFEE: ___ d CONST�UCTION LENDING AGENCY PRE-ALT FEE: O � I HERE9Y AFFIRM UNOER PENALT\'OF PERJURY THAT iHEftE IS A CONSTFiUCTION LENDING AGENCY � FORTHE GEqFORMANCE OFTHE WOfiI�FOR WHICH THIS PERMIT IS I55UED(ScC.309�.CIV.C.). Z W � IEN�EA'SNAME_ '_ �,,'_'___ ___"_' "_—.._-'—'_—_ __"_ H LEN�ER'SAD6RES5 _�i_._-__—__—.__.__ ___.-_—___._� � TOTAL FEES � , ,,, � ICERTIFVTHpTINAVEAEA�THISAPPtIICA'IONA!JDSTATETHATTHcABOVEINFORMATIONISCORRECT �•� ��` W IAGREETOC'JM?IYWITHALLGTVAN CAUNTYOR�INANCESANDSTATEIAWSRELATIN6TOBUILDING O_ CONSTRUCTION,AN�HEqE6YAUTHOl�IZEPC-PFESENiATNESOFTHiSC�UIJTYTOENTERUPONTHE } 'i '-. zABOYE�MENTIONEDPROPERTYFOIiINiSPECTI�NPURPOSES. ��� ,J�y �� ' n .�,..�-�- COMMENTS J � m PER ME(PFINT� ' cn :�'� Y l�yl' .., � _____ .,, (/� 5 N UR OFPERMITYEE �ATE '°t� _ ���, , _ '�� pECPT.kQ. � PAID BV ' �-. VALIDATION_� ~ ' WHITE—De artment Co YELLOW—Finance Co PINK—Assessor Co GOLDENROD—File Co GREEN—A IicanYs Co P PY. PY. PY� PY. PP PY 5������ �t J�3��� �� � � � � �������c� �z-6��� a CG�s����� ���ll-�i ; ..._ ,