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HomeMy WebLinkAbout17269 C�TY�F BIAIvi�ND BAR ---�`--- DEPAJ�TNRENT OF COMMUNTI"Y&DEVEi.OFMENT SERVICES � � 21825 E.Copley Drive (909}8603195 Fa�(909)&61�3117 PRESS '"-v��' ' BITILDINGFERMITAPPLICATION FIRMLY � JOBSITE APPLICATI, N PERMIT + P!C o ADDRESS� � DATE � � �' NUMBER �^� # o ISSUE TYPE OCC =-° APN OT TRACT DATE CONST. GROUP p OWNER " ADDRES � ZONING SETBACKS oCITY ZIP TEL. �' L FRONT RW ❑ p APPLICANT J TEL. S DE/SI�E STREET RW ❑ � CONTRACT SIDE . ❑ � ADDRE S ` 3 ��piED�USE L � CI ZIP TEL. � ( o ARCH/ENG/ D W DESIGNER NO.DWEL. NO. O. d ADDRESS UNI7S STORIES BEDROOMS �, 'CITY ZIP TEL. �, DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p�� OWNER-BUILDER DECLAAATION SFWADD/REM O p I HEREBY AFFIRM UNOER P�NALTY OF PERJURY THAT 1 AM EXEMPT FROM THE CONTRACTORS LI- � Garage/Carpor[ W CENSELAWFORTHEFOLLOWINGPEASON(SEC.7o31.58U51NES5ANDPROFESSIONSCODE:A�YqTYOR ZCOUNNWHICHREQUIRESAPERMITTOCONSTRUCT,AL7ER,IMPROVE,OEMOLISH,OFREPAIRANYSiRUC- W P8tI0/DeCk ' W TURE.PRIOR TO ITS ISSUANCE,ALSO REQUIRES THE APPLICANT fOR SUCH PEAM!T TO FILE A SIGNED w � STATEMENT THAT HE OR SHE IS UCENSm P11R5�JANT TO THE PROVISIONS OF THE CONTRACTORS LI- � CENSELAW(CHAPTER9(COMMENCINGWITHSECTION7aDa)OF�NfSiON30FTHEBUSWESSANDPRO- V' POOUSPB FESSIONS CO�E)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BA515 FOFi THE ALLEGED EXEMP- �� TIDN.ANYVIOLATIONOFSECTION'7031.5BYANYAPPLICANTFORAPERMITSUBJECTSTHEAPPLICANTTO z P,g-R00� ' ' ��� AqVIL PENALTY OF NOT MORE TI{AN FIVE F:UNDRED DOLLARS(5500).): ❑I,ASOWNEROFTHEPROPERTY,ORMYEMPtAYEESWiTH�WAGESASTHEIR50LECOMPENSATION, ❑ COfnRIBfC18I Z�� .WILL UO THE WORK.AND THE ST�iUCiURE IS NOT INTEN�E�dFi OFFERED FOR SALE(SEC.7044,BUSI- .J � � NESS ANO PROFESSIONS COOE:THE CONTflACTORS LICENSE LAW DOES NOT APPLY TO AN OWNEP OF � '7ROPERTVWHOBUILOSORIMPROVESTHEPEON,AN�WHO�OESSUCHWORNHIMSELFORHEASELFOR m CL �7HROl1GH HIS OR HER OWN EMPI,�VEES,PROVIOEO THATSUCH IMPROVEMENTS ARE NOT INTENDED OR �' OFFEflEDFORSALE.IFHOWEVEfl„THEBUILDINGORIMPflOVEMENTi550LDWITHINONEYEAROFCOMPLE Z ,TION,THE OWNEF-BIJILDEA WILL'��HAVE THE BURDEN OF PfiOVING THAT HE OR SHE DID NOT BUIL�OR = IMPflOVE FOR THE PURPOSE OF$ALEJ. , OI,ASOWNEROFTHEPFiOFLERTV,AMEXCLUSIVEIYCONTRACTINGWI7HLICENSEDCONTRFCTORS � TO CONSTRUCT THE PR0.JECT;SpC,7a44,BUSWESS AND PROFES510N5 CODE:7HE CONTRACiOFiS�l- -�V21u2ti0� ADJ.AREA W� CENSEI.AWDOESNOiAPPLVTOANOWNEflOFAPROPERTVWH00L1!LDSORIMPROVESTHEREDN,AN� � WHOCONTRACTSFORSUCHPR011ECTSWITHACONTRAC?OR�S�LICENSEDPURSUANTTOTHECONTRAC- �QUANTITY DESCRIPTION FEE Y TORSLICENSELAWJ. � ❑i AM EXEMPT UNDER SEC.. B.8 P.C.FOR hf15 REASON � � � LJ._ � DAiE OWNER U W � ¢ LICEN$ED CONTRACTORS DECLARATION W � IHEREBYAFFIRMUNOERPENALTYOFPEAJURYTHATIAMLICENSEDUNDERPROVISIONSOFCHAPTER � ,� 9(COMMENCINGWI7HSECTION7pW)OFDIVISION30FTHEBUSINESSANOr'FiOFE5SI0N5CODE,ANO Z LLL MY,LICENSE IS IN FULL FOFCE ANR!D�E/FF�ECT. � /f m � UCENSE CLA55___�� LIC.NO. ��Z/�v j . V OATE� �� �"�' ��CONTqACTO������w � W a� WORKERS'COMPENSATION DECLARATION Q = U � IHEREBYAFFIqMUNDEFPENALTYOFPERJURVONEOFTHEFOLLOWINGDECLARATIONS: C� Q � �HAVEANDWILLMAINTAINACEflTIFICAiEOFCONSENTTOSElFINSUftEFORWOPKEPS' _ CAMPENSATION,ASPROVIDEDBVSECTION37000FTHELP.BORCODE.FORTHEPERFORMANCE U a OFTHE WORK FOR WHICH THIS PERMIT IS IeSUED. � � � _I HAVE AND WILL MAINTAIN WOflKERS'COMPENSATION INSURANCE,AS REdL11RE�BY SECTION r'I`� Q 37000FTHELABORCODE.FORTHEPERFORMANCEOFTHEWORKFORWHICHTHISPERMITIS f 7 0 ISSUEO.MYWORKE S'COMPENSATIONINS CECARRIERANDPOLICYNUMBERARE: CONSTRUCTIQN /� Q ] CARRIER � PLAN REVIEW Z POUCYNUM6ER � �� � ���7--� ELECTRIC Q p (tHI55ECT10NNEE6�WTBECUMPLEfE00F7HEPERMRISFOfiONEHUNDREDDGIARS(5100)ORLESS). PLUMBING _ z ICERTIFYTHATINTHEPERFORMANCEOFTHEWORKFORWHICHTH�SPERMITISISSUED,I MECHANICAL ('3 SHALL NOT EMPLOYANY PERSON IN ANY MANNER 50 AS TO eECOME SUBJECT i0 TNE � WORKERS'COMPENSATIONLAWSOFCALIFORNIA,AN�AGREETHATIFISHO�L�BECOME INSPECTIONFEE � SUBJECTTOTHEWORKERS'COMPENSATIONPROVISIONSOFSECTION37ooOFTHEIABOR 4 = CODE,ISHALLFORTHWITHCOMPLYWITHTHOSEPROVISIONS. ISSUANCE Ca � SMIP �� �aJ p DATE: APPLICANT: � WARNING FAILURETD SECIAfiE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL BE ENERGY P/C �—y SUBJEC7ANEMPLOVERTOCRIMINALPENALTIESANDqVILPINESUPTOONEHUNOREDhIOUSAND ENERGYPERMIT r DOLLARS(S10o.o00),INADDITIONTOTFiECOSTOFCOMPENSATION,�AMAGESASPROVIDE�FORIN �, J SECTION3�OBOFTHELABOPCO�E,INTEFiEST,ANDATTORNEY'SFEES, RETENTIONFEE: �.. � � CONSTRUCTION LENDING AGENCY pRE-ALT FEE: O � IHEREBVAFkIRMUNDERPENALTYOFPERJL1qV'HATTHEREISACONSTRUCTIONLENOINGAGENCY FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PEflM1T IS ISSUE�(SEC.30'Jl,CIV.CJ. . Z W � LEN�ER'S NAME I'= LENDEA'S ADDRESS / � ICERTIFYTHATIHAVEAEADTHISAPPLICATIONANDSTATETHATTHEABOVEINFORMATIONISCORRECT. TOTAL FEES l��Z e�� � IAGflEE TO COMPLV WITH ALL CITY AN�COUNTY ORD7NANCES AND STATE LAWS RELATING TO�VIL�ING CONSTFUGTIQN,AND HEREBV AUTHOfllZE REPRESENTATIVES OF1HI5 COUNTY TO ENTER UPON THE � A60VE-MENTIONEO P1POP T FOR INSPECTION PUF�SE,/%!9�-i�� � ^/�' �.� COMMENTS - J V � / � � m PERMITTEE NAME�PRINT) � � � t� -��-�1 � SIGNAiUREOFPER E DATE �— � � RECPT.RO. � PAID 8Y� VALIDATION WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENFiOD—File Copy,GREEN—App�icanYs Copy : ::, _ ,. , . ,,,, . , _ ._ . _ _ 5..,. ... � , _ - _ , _ . .:�,: .F ... , _ �. , ,. � _. , �i� �,.� ���r� (.,� ��.����. , : � ,,.. . �.�� . , ,�,P,�" �a ya c.a� ���5.B � y�.�, a � � ` .� . ti' �� �. � � �'� a� o- ^ s � k�' i t �".�` x „;� o- � ".k � a y "} ¢ .�...F, x c a�, ° k � �e%:"�'� r �° �3 �': � � ��s� °e��� � r c:'" .^c ^m� � ; "i x � ,a j i c ..� t i ,���,� � '� �'�. ; � '..r,��` n a �s ��„�a ' `� a�:;$�.e.�.�,�� ,.�...�•4%���s.����.;� � ,� �:... � _.�;'� .s � "� n`:k�y. �"�.i°r� „� �a ., a a.,�.:x .e ; x,� � n ��� ,.�� _.^y �' � �� � � � �_ . �,�- a _ ^k ¢:.�,'�': .�,..����.,..� s ..�.�s:,wu���.��,,. :�3 � ..;�: . . :.._d.. ,,.�d. . � _ t . 7 � ..__._.,.....__,... ............_ ...._....._...._. ._.__.,_ .....:...._............... ...........___...,...,...-...._.. i ......._ ._ . . ,_.._.�«-. . ... �.,�u-r"a, ....._._.__..._ _ ,.,_.,...._..__.._...._ ........ _____._ _..�_..___ � � .,, ,� , � :'�.a .€r:`# :, �_ : �� . p --:.�-a �. � , 0 �p ........ _..........»....... .._........... ._._......._. . .........._........._.._.......,,,..__ _ .._.__. _ _.._......._.__._.__ ........_.,......_.._�..�...._..._......_.._....._....__.. ..L.w. 9 I�1� .�,., �e ' S 1 tt __.._._ ...... _ ....:...... _._....._........ __._........,.. __..._..............._..................... _...r.. ..._ ....... ...,.. ____ ......._.._...._.. _. _.............�__.......__....._..._r.,.. <,�. ...r .,� .. . .. ..... � .m.....w.��. � v�'��^,L ..� p� �dfi��E . 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