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HomeMy WebLinkAbout17454 (26) crrY o�D�orm�� .<��-����'� i ----� I�EPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES � � 21825 E.Copley Drive � �`" � �`� (909)860-3195 Fax(909)861-3117 �„/ t'RESS '"'%v�y���' BULLDINGPERMITAPPLICATION FIRMLY � JOBSITE �������i'""��� �� APPLICATION ° ` PERMIT e� P/C �0 ADDRESS� ���J / DATE !� � C� _ NUMBER !� � # o ISSUE TYPE OCC � APN �OT TRACT DATE CONST. GROUP p OWNER �°�-��. �'�C "����_�- LL ADDRESS "�-"-�"� ZONING SETBACKS � � ZIP TEL. FRONT RW ❑ zo CITY �� APPLICANT _��+fl��"' TEL. REAR ❑ � SIDE/SIDE STREET RW ❑ z � CONTRACTOR SIDE ❑ � ADDRESS PROPOSED USE ^� � � CITY ZIP TEL. oARCHIENG/ z DESIGNER NO.DWEL. NO. NO. � ADDRESS UNITS STORIES � BEDROOMS � CITY ZIP TEL. v' DESCRIPTION SQ.FT. FACTOR PS� ADJ.AREANALUATION � Q ONlNER-BUILDER DECLARATION SFR/ADDlREM O p 1 HERE9Y AFFIRM UN�ER PENALTY OF PERJURY THAT i AM EXEMPi FROM THE CONTRACTORS LI- Gfl�fl92/Cd�Olt � �W CENSELAWFORTHEFOLLOWINGREASON�SEC.7031.58USINESSANDPROFESSIONSCODE:ANYCITYOR (� _ U COl1NTYWHICHRE�UIHESAPEpMITTOCONSTRUCT,ALTER.IMPROVE.DEMOLiSH,ORREPAiRANYSTRUC- W P8fi0/�eCk Z . TURE.PRIOR TO ITS ISSUANCE,AI'4S0 REQUIRES THE APPLICANT FOP SUCH PEfiMIT TO FILE A SIGNE� - W STATEMENT THAT HE OR SHE IS LICENSED PURSUAN7 TO THE PROVISIONS OF THE CONTRACTORS ll- W � CENSE LAW(CHAPTER 9(COMMENCINO WRH SECTION 7000)OF DIVISION 3 Of THE OUSINESS AND PRO- � POOVSPfl � FESSIONSCOOE)ORTHATHEORSHEISEXEMPTTHEREFROMANDTHEBASISFORTY.EALLEGEDEXEMP- � TION.ANYVIOLATIONOFSECTION7031.bBYANYFPPLICANTFORAPEPMITSUBJECTSTHEAPPL�CANTTO Z Re-Roof A CIVII.PENALN OF NOT MORE THAN FIVE HUNDRED DOLL4R5(SSoO�.): �0 ❑I,ASOWNEROFTHEPROPERTY,ORMYEMPLOYEESWITHYJAGESASTHEIRSOLECOMPENSA710N, 0 CommefCiAl � Z, WILL�O THE WORK,AND THE STRUCTURE IS NOT INTEN�E�OR OFFERE�FOR SALE(SEG 7044,B1151- J �' � NE55 MID PROFESSIONS CODE:TNE CONTRACTORS LICENSE LAW DOES NOTAPPLV TO AN OWNER OF ? PROPERTYNhiO8U1LOSORIMPRQVESTHEREON,AN�WHODOES6UCHWORKHIMSELFORHERSELFOR m CL THROUGHHISORHEROWNEMPLOYEES,PROYIDEDTHATSUCHIMPROVEMENTSAFENOTINTENDEDOR Q �OFFERE�FORSALE.IF,HOWEVER,THEBUILOPIGOFIMPROVEMENTISSOL�WITNINONEYEAROFCOMPLE- � 'TION,THE OWNER-BUILDER WILL HAVE THE BUR�EN OF PROVING TFIAT HE Ofi SHE OID NOT BUILD OR = IMPR_OV�FORTHEPURPOSEOFSALE). ��r AS OWNER�F THE PPOPERTV,AM EXCLl151VELY CONTRACTING WITH LICENSED CONTRACiORS � ,I TO G�bA57FiUCTTHE PROJECT(SEC.7044,BUSINESS AN�PROPESSIONS CODE�THE CONTRACTORS LI- VeI0flfI0D �� AQI.AREA W CENSELAWDOESNOTAPPLYTOANOWNEROFAPROPEFtTYWHOBUILDSORMPROVESTHEREON,AND � ,'�,WHOCONTRACTSFORSUCHPROJECTSWITHACONTRACTOR(SjLICENSEDPURSUANTTOTHECONTRAC- QUANTITY DESCRIPTION FEE � Y 'TORS LICENSE LAW.J. � ❑IAlA E%EMP7 UNDER SEC.� B.&P.Q FORTHIS REASON � ' � U � � oarE �� owNea V Z W � � LICENSED CONTRACTORS DECLAFATION W ¢ ��.� I HEREBY AFfIFiM UNDER PENALTII OF PERJURY THAT I AM LICENSED UNDER PHOVISIONS OF CHAPTER � .� 9(COMMENCING WITH SECTION 1000)OF DNISION 3 DF THE BUSINESS AN�PROFESSIONS COOE,AND Z �X MY LICENSE IS IN FUIL FORCEANtl EFFECT. m � LICENSE CLASS _ LIC.N0. � V �ATE � CONTRACTOR a W � WORKEAS'COMPENSATION DECLARATION a � U � IHEREBYAFFIfiMUNOERPENALNOFPERJUPYONEOFTHEFOLLOWINGDECLARATIONS: Z � _IHAVE/WDWILLMAINTAINACERTIFICATEOFCONSEN7705ELP-INSUREPofiWORKERS' S � " COMPENSATION,ASPROV'DEDBVSECTION37ooOFTHELABOFCODE,FORTHEPERFORMANCE U � OFTHEWORKFOHWHICHTHISPERMIT13155UE�. � , d W __IHAVEANDWILLMAINTAIf�WORKERS'COMPENSATIONINSURANCE,ASREQUIREDBYSEC710N �j.` Q 37ooOFTHEL4BORCOD�FOR7HEPERFORMANCEOFTHEWORKFORWHICHTHISPERMITIS � ISSUED.MYWORKERS'C,MPENSATIONINSURANCECARRIERANDPOLICYNUMBERARE: CONSTRUCTION J � CARRIER PLAN REVIEW Z POLICYNUMBER ELECTRIC ¢ '.(iHISSEClIONNEmNOiB�COMPLEfEDOFiHEPERMITISFOFONEHUI�RED00l1AR5(StDO�ORLESS). PLUMBING � � - -.- __ ,._ '_' � Z ICERTIFYTHATINTHEPEMFORMANCEOFTHEWOFKFORN'HICHTHISPERMITISISSUED,I MECHANICAL �� �r . ' ��'0 (} SHALLNOiEMPLOYANYPERSONI�ANYMANNER50A5TOBECOME5U6JECTTOTHE �`-"" � ' "' '- - �---� trj VJOHKERS'COMPENSATIqN LAWSOFCALIFORNIA,ANDAGFEETHATIFISHOULOBECOME INSPECTIONFEE , �' Sl1BJECTTOTHE'NORKERS'COMPENSATIONPPOVISIONSOFSECTION37000%THELABOfl , (� �'°" !� .g - � CODE,I SHALI FORTHWITH COMPLY WI7HTHOSE PROVISIONS. ISSUANCE ' R��p� �/p.� /F��1 - p� DATE: APPLICANT: SMIP k Y3' o.I � � �� J WARNINGFAILURETOSECUREW,ORKERS'COMPENSATIONCOVERAGEISl1NLAWFl1L,AN�SHALLBE ENERGYP/C ���xr ; �y� SUBJECTANEMPLOVERTOCFIMINALPENALTIESANDCIVILFINESUPTOONcHUNDflEDTHOUSAND ENERGYPERMIT ��^�---..�.�..-':�."'W-�•�-�-••-�---;_-...___.__.,_.._-� DOLLARS(E1 W,OOo),IN A�OITION j0 THE COST OF COMPENSATIDN,DAMAGES AS PROVIDED FOft IN - - �- - J SECTION3]OBOFTHELABORCO�E,INTEFEST,ANDATTORNEY'SFEcS. RETENTIONFEE: � � � CONSTRUCTION LENDING AGENCY PRE-ALT FEE: O � IHEREBVAFFIRMUNDERPENALTYOFPERJURVTHATTHEREISACONSTflUCTIONLENDINGAGENCY - � FOR THE PERFORMANCE DF THE WOflK FOR WHICH THIS PEFMIT IS ISSUE�(SEG.309],CIV.C.j. . � Z W � LENDEfl'S NAME F'- �ENDEF'SAD�RE55 I y w ICERTIFYTHATIHAVERE4D7HISAPPLIGA710NANOSTATETHATTHEABOVEINFORMATIONISGOPREGT. TOTA�FEES / �N4 �� � I AGREE TO COMPLY WITH AlL CIYY ANO COUNTY ORDINANCES ANO 5?ATE LAWS RELATING TO BUILOING ��� � � CONSTRUCTION,ANDHEREBYAUTHORIZEREPRESENTATNESOFTHISCOUNTVTOENiERUPONTHE , � ABOVE-MENTIONED PROPERTYFOF INSPECTION PUFPOSE � COMMENTS - — - � � m' PERMITTE //p �ry f!� / Y/ �y �p �fj SIGNF RE OFPERMITfEE onT RECPT.NO. � � PAID BY L% � ,G, . 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