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HomeMy WebLinkAbout16879 (44) �-- --- _. _ ----- . _ -��`-- CIT Y OF ID�AMOND BAR DEPAR.T1vfENT'OF COMM[JNITY&DEVELOPMENT SERVICES ---- �,��,; 21825 E.Copley Dtive (909)860-3195 Fa�c(909)861-3117 PRESS '`'-.�^�� BIJILDING PERMIT APPLICATION FIRMLY QJOBSITE � T-----.�s � APPLICATION PERMIT r 2 P/C�I`1 , � a ADDRES5�.�..�� ��al�f�S�'a2 iF "l ����.° DATE � NUMBER ��� # tJ� '' m ISSUE TYPE OCC APN LOT TRACT DATE � CONST. GROUP p OWNER �^. � �° ' � � " ADDR SS " "e' ' ZONING SETBACKS � CITY - ZIP TEL. `�� �.. FRONT RW ❑ p APPLICANT �� �fi� TEL. ,�,�� REAR ❑ � �� SIDE/SIDE STREET RW ❑ a CONTRACTOR SIDE ❑ o' ADDRESS PROPOSED USE'����,.Q�C�1� �$�'P B$3 ko���� o CITY ZIP TEL. ��____..---- o ARCH/ENG/ W DESIGNER NO.DWEL. NO. NO, a ADDRESS i UNITS STORIES BEDROOMS = CITY ��_ ZIP TEL, � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNE�-BUILDER DECLARATION SPRlADD/fiEM � O p I HERE9V AFFIRM UNDER PF,NALT OF PERJURY THAi I AM EXEMPT FROM THE CONTqACTONS LI- G8189E/Cef(10R ' W CENSELAWFOflTHEFOLLOWING�IREAS N(SEC.7091.SBUSINESSANDPROFES510NSCODE:ANYCITYOR {n C� COUNTYWHICHRE�UIRESAPERMITTO�ONSTRUCT,ALTERIMPROVE,�EMOLISH,DRREPAIRANYSTFUC- W , ySl Deck � Tl1FiE,PFiIOR TO ITS ISSUANCE,AL50 qEQU1RE5 THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNE❑ W STAIEMENT THAT HE OR SHE IS�ICEN$ED PUftSUANT TO THE P{70VISIONS OF THE CONTRACiORS LI� � CENSE�AW�CHAPiER 9(COMMENCING WITH SECTION 7uo0)OF DIVISION 3 OF THE BUSINESSANO PRD� � POOUSpa . FESSIONS CODE)OR THAT HE OR SHE IS EXEMPi iHEflEFRCM AND THE BASIS FOR THE ALLEGE�E%EMP- � TION.ANVVIOLATIONOFSECTION7a31.50VANYAPPLICANTFORAPERMIiSUBJECTSTHEAPPLICANTTO Z Re-Roof A CIVIL PENALTY OF NOT MORE TFiAN FIVE HUNDREO DOLLAflS($500�.): O ❑I,ASOWNEROFTHEPROP�RTY,bRMVEMPLOYEESWITHYJAGESASTHEIR50LECOMPENSAiION, ❑ COrt1RIBfCIdI " � Z 'WILL DO THE WORK,AND THE STRUCT4RE IS NOT INTENDED OR OFFERED FOR SFLE(SEG 7049,BU51- J NESS AN�PROFESSIONS CO�E:THE C�NTRACTOFS LICENSE LAW DOES NOT APPLV TO AN OWNER OF �' PflOPERTYWHOBUILDSORIMPflDVES�HEflEON,AN�WHO0DE55UGHWOflKHIMSELFORHERSELFOR � CC' ,THROUGHHISORHEROWNEMP�OVEE$,PPOVIOEDTHATSUCHIMPROVEMEMSAPENOTINiENDEDOR m �., 'OFFERE�FORSALE.IF,HOWEVER!7HEBuIL�INGORIMPROVEMENTISSDL�WITHINONEYEAflOFCOMPLE� ,TION.THE'OWNER�BUIL�ER WILL',HAVEITHE BURDEN OF PROVING THAT HE OP SHE�ID NOT BUIID OR . �� ��IMPROVE FORTHE PURPOSE OF SALE).i ❑I,AS OWNER OFTHE PROPEflTY,iAM EXCLUSIVELV CONTRACTINa W ITH LICENSED CONTRAC70ftS a 'TD CONSTRUC7 THE PROJECT�SEC.7op6,Bt151NES5 AN�PROFESSIONS CODE:THE CONTRACTORS LI- VeIU8210t1 � ADJ.AREA Wi '.CENSELAWDOESNOTAPPLVTOANOW�NEROFAPFOPERTYWHOBUIL�30alA1PflOVESTHEflEON,AND � WHOCONTR4CTSFORSUCHPROJECTSIW�iHACONTRACTOR(S)LICENSEDPURSUANTTOTHECONTRAP QUANTITY DESCRIPTION FEE � TORS LICENSE LAW.j. , I, , � ' I AM EXEMPT UNDER SEG.� B.&P.C.FOR THIS REASON � � y � y � LL' �AiE � OWNER ..i 1� U Z a W � � LICENSED �ONTRACTORS DECLARATION W ¢ � � IHEHEBVAFFIRMLIN�ERPENALTYOFP�RJURYTHA7iAMLICENSE�UNOEFlPFWISIONSOFCHAP7ER � , p; ,9(COMMENCINOWITHSECTION7000)OFDIVISION30FTH'c6USINESSAN�PROfES510N5CO0E,AND Z . �X MY LICENSE IS IN FULL FORCE AND EFF�CT � � LICENSE CLA55 � I LIC.NO. _ _ j � J U DATE I GONTRACTOR a W � WORKERS' I�OMPENSATION DECLARATION —� � < � U � I HEitEBV AFFIRM UNOER PENALTV OF P RJURY ONE OFTHE FOLLOWING DECL4RATIONS; Z 0 �IH4VEANDNALLMAINTAINACE TIFICATEOFCONSENTTOSELFINSUREFORWORKERS' _ CAlAPENSATION.ASPROVIOED�VSECTION37GaOFTHELAeORCODE,FORTHEPERFORMANCE U Q DFTHEWORKFORWHICH7HISPERMITISISSUEO. � W __I HAVEAND WILL MAINTAIN WORI ERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION Q 37000FTHELABORCODE�FOF�HEPERFORMANCEOFTHEWORKFORWHICHTHISPERMITIS ��9�� ISSUE�.MYWORKERS'COMPEN ATIONINSURANCECARRtERANDPOLICYNUMBERARE: CONSTRUCTION !J � CARRIER PLAN REVIEW � � � � . Z POLICYNUMBER ELECTRIC Q . � (iHISSECTIONNEmNOTBEOJM EfEDOFi}1EPERMRISFORONEHUNDREDDOLL4R5(5100)ORLE55). PLUMBING z I CERTIFV iHAT M THE PEBFOR 7A'NCE OFTHE WORK FOR WHICH THIS PEPMIT IS ISSl1E�,I MECHANICAL �' SHALLNOiEMPLOYANYPERSO�INANYMANNER50ASTOBECOMESUBJECT70THE � � WOqKERS'COMPENSAiIONLAW OFCALIFORNIA,ANDAGREETHATIFISHOULDBECOME INSPECTIONFEE � SUBJECT70THEWORKER,S'CO PENSFTIONPpOVI510N50F5ECTION37a00FhIELABOfl � CODE,I SHAIL FORTHWIiH COM LY WITH THOSE PROVISIONS. ISSUANCE r t � SMIP C p DA7E: APPLICAINT: J � � ENERGY P/C -�.��a;�� � �WARNINGFAIWAETOSECUREWQflKE 5'COMPENSATIOY�VERAGEISUN�WFUL,ANDSHALLBE �� ,J.-��„v.,� � � � SUBJECTANEMPIOYERTOCRIMIWALP NALTIESANOCIVILFlNESUPTOON[HUNDREOTHOUSANP ENERGYPER � r D�LLARS(Eiaa.a0o),INAD�ITIONTOTH COSTOFCOMPENSATION,�AMAGESASPROVIDE�FORIN � J� SEGTION37o80FTHELABORCO�E,RJiREST,ANDATTOPNE�"SFEES. RETENTIONFEE: ^` pw.. CONSTR,uCTION LENDING AGENCY PRE-ALT FEE$ � �- d �� � IHEflEBVAFFlRMUNDERPENALNOF?�RJURYTHATTHEREISACONSTFUCTIONLEN�INGAGENCY t ' FOR iHE PERFORMANCE OF THE WORK i OR WHICH THIS PERMIT IS ISSUED(SEG.309�,dK C.). °�F 3'�Te ' � . �4`-P, 6 . , W� ' ''--.a�.......��..__....___. -_a� �. .�- � LENOER'S NPME I— LENOER'SPDDRE55 g c.� W ICERTIFYTHATIHAVEREADTHISA2PLI ATIONA�OSTATETHATTHEABOVEINFORMATIONISCORRECT. TOTAL FEES �y� 4 � L ���1 �� � IAGREETOCOMPLVWITHALLCITYAND OUNTYDR�INANCESANDSTATELAWSRELATINGT09UILDING Y i �. :' CONSTRUGiION,ANDHEREBVqUiHOfli EflEPRESENTATIVE50FiHISCAUNiYTOEN7EflUPONTHE - z A80VE-MENTIONED PROPERTV FO{i INS ECTION PURPOSES. C MENTS o �,.r f�4 ���� � .' m '�'� E MITTEENAME(P Ni) � h'A� � � � . � , ����`�� �. �'�;,, � ATUREO P 'EE ' DATE _� ��� RECPT.N0. PAID BY �' VALIDATION ~ �yVHITE—De artment Co YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENROD--File Co GREEN—A licanfs Co � P PY� PY. PP PY ' ifli.�. !'� _�� 4 C rt :. � w; ���. Y "g",'. 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