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HomeMy WebLinkAbout17351 (23) � ��y���� __ . __,_ � ��`� C��OF Dt�vtorm B� -----���``�--- I7EPARTPv�ENT OF COMMUNITY�&DEVEiAPMENT SERVICES � 21825 E.Copley Drive (909)860-3195 Fax(4fl9)861-3117 PRESS ''=%��'' BiJII,DING PERMIT APPLICATION FIRMLY Q ADDR'ESS�� �� T`o✓G'� /7�L�.O�J DATE'CATION �� NUMB R � �� � #/C��'�'��� � ISSUE � �� ONST. GROUP APN LOT TRACT DATE p OWNER ��Da,r„ 'S AG o ADDRESS ?� F� f DI.�A ZONING SETBACKS z CITY 4�M�MON P TEL. +Z FRONT RW ❑ � APPLICANT �y-T��, REAR ❑ � SIDE/SIDE STREET RW ❑ ¢ CONTRACTOR�r�O-SS L_��.CJ3�T�de1I�Ti Q�1 SIDE ❑ ADDRESS�S� �OCV,�T—�y � *. e� � CITY I��A G TO ZIP �`l3?�TEL�, ��� PROPOSED USE � � ° w ARCH/ENG/ z DESIGNER I�J�T�/SJ�N�$'S"O�'- NO.DWEL NO. NO. � a ADDRESS �a�'—� UNITS STORIES BEDROOMS � CITY T ��C ZIP��76!" TEL. O �ii�6 � DESQRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION OOWNER-BUILDER DECLARATION SFWADD/REM ,p I HEREBY AFFIRM UNDEfl PENALTY OF PERJURY THAT 1 AM EXEMPT FROM THE CONTRAC70R5 LI- � GafBge/C81pOfI W CENSELAWFORTHEFOLLAWMGFEASON(SEC.7031.5BUSINESSAN�PROFESSIDNSCODE:ANYCITYOR ZCOUNTVWHICHREOl11qE5A7ERMITTOCONSTRIJCT,A�TER,IMPROVE,DEMOLI5H,0AR_PAIRANVSTRUG W patio/Deck TUqE,PRIOF TO ITS ISSUANCE,ALSO REQUIRES THE APPUCANT FOR SUCH PERM{T TO FILE A SIGNED W STATEMEN?THAT HE OR SHE IS LICENS[D PURSUANT TO iHE PROVISIONS OF THE CONTRACTORS LI- �' CENSE LAW(CHAPTEF 9(COMMENCING WI'fH SECTIDN toaa)OF DIVISION 3 OF THE BUSINESS AN�PRO- � POOUSPB FESSIONSCADE)ORTHATHEORSHEISE%EMPTTHEREFftOMHN�THEBA515FOFiTHEALLEGEDEXEMP- � �^ � TION.ANYVIOLATIONOFSECTION7031.SBYANYAPPLICANTFORAPEPMITSU6JECTSTHEAPPLICANTTO Z Re-Roof M � A CIYII PENALTY OF NOT MORE THAN FIVE FRINDRED DOLLARS(ESoO).): . 0 ❑I,ASOWNEROPTHEPROPER7V,ORMVEMPLOYEESWITHWAGESASTHEIRSOLECOMPENSATION, ❑ Cof11m2fCial -� - Z WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDE�OR OFFERED FOR SALE(SEC.7D44,BUSI- J NESS AN�PROFESSIONS CODE:THE CONTRACi ORS LICENSE LAW�OES NOT APPLV TO AN OWNER OF � PROPERTYWHOBUILDSORIMPROVESTHEREON,ANDWHO'�OESSUCHWORKHIMSELFORHERSELFGR � �' TFIROUGHHISORHEROWNEMPLOYEES,PROVIDE�THATSUCHIMPROVEMENTSARENOTINTENDE�OR m � OF�ERmFORSALE.IF,HOWEVER,THE0UIL01NG�RIMPROVEMENTI550LDWITHINONEYEAROFCOMPLE- .Z .TION,THE OWNER-BW4DER WILL.HAVE THE BURDEN OP PROVING TIiAT HE OR SHE DID NOT BUILD OR = IMPROVEFORTHEPLIRPOSEOFSALE). ❑I,AS OWNER OF iHE PLiOPERTV,AM EXCW SNELY CONiRACTING WITH LICENSE�CONTRACTORS � TO CONSTFUCT THE PPOJECT(SEC.7040.BUSINESS AN�PROFESSIONS CO�E:THE CONTRACTORS LI- VaIU2tIOf7 ADJ.AAEA ' W CENSELAWDOESNOTAPPLYTOANOWNEROFAPflOPERTYWHOBUILDSORIMPROVESTHEREON,AND � WHOCONTRACTSFORSUCHPROJECTSWITHACONTPACTOR(SJLICENSE�PURSUANTTOTH'cCONiRAG QUANTITY DESCRIPTION FEE Y TORS LICENSE LAW.). '� ❑I AM EXEMP'f UNDER SEQ B.&P.C.FOR THIS REASON � - �i' LL � DATE oWNER V W � � LICENSED CONTRACTORS DECLARATION i j ¢ '.� I HEREBYAFFIRM UN�ER PENAITY OF PERJUHY THAT I AM LICENSED UNDEF PROVISIONS OF CHAPTER � �.d 9(COMMENCINGWITHSECTION7000)OFDIVISION30FTHEB�SINESSANDPROFESS�ONSCDOE,AN� z '.�X MY LICENSE IS IN FULL FORCE AND EFFECT. m ',� LICENSECLASS L_ � / LIC.NO. �S��Q� � // � �V DATE f(�'Z'r Q / CONTRACTOR QdSS G�1�N,�.� d W � WORKERS'COMPENSATION DECLARATION � ¢ � IHEFiEBYAFFIRMUN�ERPENALTYOFPEftJURYCNEOFTHEFOLLOWINGDECLARATIONS: U � Z '� IHAVEANDWILLMAINTAINACERTIFICATEOFCONSENTTOSELF-INSUREFORWORKERS' _ MPENSATION,AS PROVIDE��Y SECTION 3]0o Of THE LA30R CODE,FOflTHE PERFORMANCE U ¢ OF THE WORK FOR WNICH THIS PERMIT IS ISSUED. � � W I HAVEAN�WILLMAINTpIN W09KER5'COMRENSATION INSURANCE,AS RE�UIRED BYSECTION $ ` ,Q 370o OF THE LA90R CADE,FORTHE PERFORMANCE OF THE WORK FOR WHICH iHIS PERMIT IS �Q�y t�� ISSUED.MYWORKERS'COM.rPE�NSA+TION�/{N�SURANCECAwRfiIEFANDPOLICYNUMBERARE CONSTFUCTION h �"1 j CARFIER �A I � T'�J`IV.�Y PLAN REVIEW � � � PDLICYNUMBER _ ���/� ELECTRIC a (fl-IISSECTIONNE�NOT6ECOMPLE(EDOFTYE?ERMITISWRONEHUNDREDDOLLARS($700)ORLESS). PLUMBING � Z ICEflTIFYTHATINTHEPERFORMANCEOFTHeWORKFORWHICHTHISPERMIiI5155UE�,l MECHANICAL � � CJ SHALLNOTEMPLDYANYPERSONINANYMANNERSOAST06ECOMESUBJECTTO7HE y WORKERS'COMPENSA?IONLAWSOFCALIFORNIA,AN�AGREE7HATIFISHOUIDBECOME INSPECTIONFEE �? SUBJECTTOTHEWORKERS'CON�PENSATIONPROVISIONSOFSECTIDN37aaOFTHELA60R � CODE,1 SHALL FORTHWITH COMPLY WITH TtiOSE PROVISIONS. �SSUANCE O r SMIP �� p DATE: � APPLICANT. . J WARNING;FAILURETOSECUREWORKERS'COMPENSATIONCAVERAGEISUNL4WFUL,ANDSHALLeE ENERGYP/C LL SUBJECTANEMPLOYERTOCRIMINALPENALTIESANDCIVILFlNESUPTOONEHUNDREDTHOlJSAND ENERGYPERMIT DOLLARS(§too,000�,IN ADDITIONTO THE COSTOF COMPENSATION,DAMAGES AS PROVIDED FQR IN � SECTION370BOFTHELABORCO�E,INTEREST,ANOATTOfiNEY'SFEES. RETENTIONFEE: �.��� d CONSTRUCTION LENDING AGENCY PRE-ALT FEE: O � IHEftEBYAFFIRMUNOERPENALTYOFPERJURYTHATTHEREISACONSTflUCTIONLENDiNGAGENCY ' � FORTHEPtRFORMANCEOFTHEWORkFOFWHICHTHISPEFMRI5155UE0(SEC.30W,CIV.C.). Z r'� W y j LENDER'S NAME F � � F_ LENOER'SAODRESS � ICERTIFYTHATIHAVEREADTHISAPPLICA-IONANOSTAiETHATTHEABOYEINFORMATIONISCORRECT. TOTAL FEES H �� W I AGFEE TO COMPLY WITH ALL qTY AND COUNTY ORDINANCES ANO STATE LA'JJS RELATING iO BUILDING � CONSTRUCTION.ANDHEREBYAUTHOBIZEFiEPRESENTATIVESOF7HI5COUNiYTOENTERUPONTHE � AE30VE-MENTIONED PROPERTY FOR INSPECTION PURPOSES. � Z COMMENTS o �..� , � �,�� m PERMITiEENAME�PRIN7J - � �/"'2 � � EOPPERMITTEE ' OA7E " ;✓� = RECPT.NO. 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