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HomeMy WebLinkAbout17074 (23) „,�w•�-----�� CITY oF dd�IANiOND�r�R ,�---� -----��'--- DBpARTME�I'I'pF`COA��v1iJNTTY&DEi,ELOPMENT SERVICES S M { � � 21825 E.Co�ley�rive ^� (909)860-3195 Fa�:(904)$6d-3117 RESS � "'%��'�' BUILDING PE131�HI'T AFPLICATION FIRMLY ' � JOBSITE 1 APPLICATION � �� NUMBER � �� #`C � � o ADDRESS���%O '�'I/�LCU� V(� DATE' �o ISSUE TYPE OCC APN �OT ?RACT DATE CONST. GROUP p OWNER .�,RCK 1/U o ADDRESS / ZONWG SETBACKS z CITY ZIP / TEL FRrJNT RW ❑ , p aPPLICANT TEL 5 DE SIDE STREET RW ❑ z ¢ CONTRACTaR t. SIDE ❑ � ADDRE S • = � CITY � 21P 'TEL 1 .��07 PROPOSED USE �� � 'ARCHI G/ W ',DESIGNER NO.DWEL. NO. � ADDRESS UNIT5 STORtES BEDROOMS � CIIY ZIP TEL. cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION �� � '�,�.q� OWNER-BUILDER DECLARATION SFWADDlfiEM O I HEREBY AFFlRAA UNDER PENALTV OF PERJl1RV THAi I AM EXEPA?T FROM THE CONTRACTOFS li- G8f8ge(C8fp01t � ��.W CENSELAWFORTHFFOLLOWMGREASON(SEC.7o31.68U51NE'aSAN�PROFESSIONSCODE:ANYCITVOR (n �U � COUNTVWHICHREQUIRESAPERMITTOCONSTAUCT,AITcR,IMPROVE,�EMOLISH.ORREPAIRANVSTRUC- �J.J pdt10/DQCk �'.Z� 7UF1E,PRIOR To ITS ISSUANCE,AL50 qE�UIPES THE APPLICANT FOq SUCH PEFMIT TO FILE A SIGNED ' 'w 'STATEMENR TH0.T HE OR SHE IS LICENSEO P�RSl1ANT TD THE PROVISIONS CF THE CON7RACTORS LI. w � CENSE lAW(CHAPIER 9�COMMENCING WITH SECTION]000)OF�IVISION 3 OF THE BUSINE55 AN�PRO� � PooVSpa 0 FESSIONSCODE)ORTHATHEORSHEISE%EM?TTHEflEFflOMAN�THE6A515FOflTHEALLEGEDEXEMP- (� '� .V TION.ANYVIOLpT10NOFSECTION7031,5BYANYAPPLICANTFORAPEPMITSUBJECTSTHEAPPLICANTTO Z fle-Root A CIVIL PENALTY OF NOT MORETHAN FIVE Hl1NDRED DOLIAflS(S5o0;.7: � � ❑I,ASOWNEROFTHEPROPERN,ORMYEMPIOYEESWITHINAGESpSTHEiR50LECOMPENSATION, 0 CORiRIBfC1d1 - . �,”;WILL DO THE WORK,AN�THE STRUCTURE IS�OT INTEN�ED OR OFFERED FOR SALE(SEC.7044,6USi� J I ,�' NESS AND PROFESSIONS CODE:THE CONTRACTCqS�ICENSF LAW DOES NOT APPLY TO AN OWNER OF ? O�/ � �PqOPERTVWH00UILDSORIMPROVESTHEREON,AN�WHODOESSUCHWORKHIMSELFORHEFSELFOR IJGr -[C� THROlJGH1iI50RHEROWNEMPLOVEES,PROVIDEDZFiATSUCHIMPROVEMENTSARENOTINTENDEDOH m ' �"��''� QW� pFFERE�FORvpLEIF,HOWEVER,THEBU1401NGOI2IMPROVEMENi1550IDWITHINONEYE0.ROFCOMPLE- f O �,.,, Z.I TION,THE OWNER�BIIIL�ER WILL HAVE THE BIIR�EN OF PPOVWG THAT HE OR SHE OIO N07 eUll�OR W�,,, IMPROVEFOPTHEPURPOSEOFSALE). �� C I,A3 OWNER OF THE PFOPERTY,AM EXGLGSIVELY CONTR,ICTING WITH LICEflSED COIJTRAC70R5 �.� i.'", ['L; 'TO CONSTRUCT hiE PROJECT(SEC.7044,Bl/SINESS AND PROFFSSIONS CODE THE CONTRACTORS Li, VBIUflt10f1 ADJ.AREA � '','. W" CENSELAWDOESNOTAPPLYTOANOWNEROFAPROPERTYWHOBUI[➢SORIMPpOVESTHEHEON,AND � 'i �'','. �,WHOCONTRACTSFOR6UCHPROJECTSWITHACANTRACTOF{S�L{CENSEDPURSUANTTOTHECONTRAG QUANTI7Y DESCRIPT�ON FEE ,� ¢, TOqS UCENSE LAW.). - - Q � ' CI 1 AM EXEMPT 11N�ER SEG &8 P.C.FOR THIS REASON � � U' DATE OWNEfl H ���. � �r � �1 W ��, �, LICENSED CON7RACTORS DECLARATION W ¢ ', � t HEREBYAFFIPAI UNDER PENALTY CF PERJURV THAT I AM LICENSE�UNDER PflOVI510N5 OF CHAPTFA � , / ` �jn � a;� 9�COMMENCING WITH SECTION 7oao)OF DIVISION 3 OFTHE BUSINESS AND CAOFESSIONS CODE,AN0 Z '� Y V X MV LICENSE IS IN FULL FORC6 ANO EFFECT. �� � ;, � LICENSE CLASS_����LJG.NO. 2 � � F- .-� J 1 DATE COYTRAC O � w �3 fl �.- 7 R a�i WORKERS'COMPENSATION DECLARATION -� ,il ' ' � I HEREBV AFFIRM 11�DER PENALTY OF PERJURY ONE OFTHE FOLLOWINO DECLAFA:ION3: Z ' . � � _IHAVEANDWILLMAINTAINACERTIFlCATEOFCONSENTTOSELF�INSUREFOPWORKERS' _ ¢ COMPENSATION,AS PROVIDED BY SECTION 370o OF THE IABOR CODE.FOq THE PEftFORMANCE U �� Q OFTHEWOFKFORWHICHTHISPEAMITISISSUED. � QQI HAVE AN�WILL MAINTAIN WORKERS'COMPENSATION INSLIRANCE,AS RE�UIRED 2Y SECrION �y y o �� 3��OOFTHELA90RCO�E,F�RTHEPERFORMANCEOFTHEWORKFORWHICHTHISPERMITIS ����- ISSl1E�.MYWORKERS'COMPENSATIONINSURANCECARPoERANDPOLICYNUMBERARE'. CONSTRUCTION ���o J j cnFlqieR_._ PLANREVIEW �� . Z POLICV Nl1MBER ELECTRIC �� ¢ r'" �' p (iHISSECTIONNEmNOTBE00lA%.ETEDOFhiEPEflMITISFORO�EHUNDREDDd.lARS(b100)ORLESS). PLUM8ING � W I CER'fIFVTHAT IN THE PERFORMANCE OF 7NE WORK FOR WHICHTHI RM171S 1554E�.1 MECHANICAL � � Z ' („3' SNALL NOT EMPLOY ANY PERSON M ANY MANNEH SO AS TO BECO BJECT TO THE ' �� � � WORKEqS'COMPENSATION LAWS OF CALIFORNIA,AN�AGREE �SHOULD�ECOME INS�ECTION FEE O . '= 5 BJECTTO?HEWORKERS'CAMPENSAiIONP 'ONSO ION37000FiHELA R — — E,ISHALLFORTHWITHCOFAPLVWITHT EPR IS ISSUANCE �q o SMIP . --��\y ,p DATE: APPLICANT: .1 , ,:J WA� NG:FAILURETOSECUREWDflKERS'COMP SATIONCOVERAREISUNLAWFUL,ANDSHALIBE ENERGYP/C . "��LL SUAIECTANEMPLOY'eR70CRIMINALpENALTIESANOCiVILFMESLIPTOONEHUtJDREDTHOUSAND ENERGYPERMIT DOLLARS(Sto0,000�,IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDE�FOR IN ' �� SECTION 37080FTHE LABOR CO�E,MiEREST.AND ATTORNEV'S FEES. RETENTIOM FEE: _ _ _ �� � ��„O CONSTRUCTION LENDING AGENCY PRE-A�T FEE: __ • 0. I HEpLBV AFFlRM UN�ER PENAL�Y OF PERIUFV THAT THERE IS A CO�STRUCTION LENDIIJG hGENCY FOR THE PERFORMANCE OFTHE WORK FOR WHICH THIS PERMIT IS ISSUED(6EC.909],CIV.C.). - Z W i � '.,� LENDER'SNAME � ' . 1-� IEN�ER'SPD�RESS � P� ` --� �!��� �, w ICERTIFYTHFTIHAVEflEADiHISAPPIIGAiIONANDSTATeTNATTHEABOVEINF�RMATIONISCDRRECT. TOTAL FEES � ) � � � I AG9EE TO COMPLY WI1H-qLLGITY AND COUNTY ORDINANCES AND STATE LAWS RELATING i0&IIL�ING `! ' ; � CONSTRUC710N,ANDHEFjEBYAUTMOR2EREPF'-.SENTATNESOFTHISGOUNTVTOENiERUPONiHE � � � z A90VE-MENTIONEDPROPERNFOFiINSPECTIONPURPO5E5. 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