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HomeMy WebLinkAbout15287 (19) � � ,.� � �, �` �vTOND BA8 f `�� ��I�NT OF COMMUNITX&DEVELOPMENT SERVICES 'y� e '`E� ..Copley Drive Suite 190 � ,�,,,,;,, �v�)860.3195 Fax(909)861-3117 PRESS ��'� BUII.DING PERMIT APPLICATION FIRM�Y o ADDR'ESS I�� C�C►1C I6L.t/�A, 1� DATEICATION �, U" NUMB R�"✓� p/C � " . � g' ISSUE TYPE OCC APN LOT TRACT DATE CONST. GROUP p OWNER AV( 1.t) p ADDQ€�S ZONING SETBACKS � cirrLl.�� IP TE � REART RW O APPLICANT TEL. SIDEJSIDE STREET RW ❑ � CONTRACTOR S � SIDE ❑ � ADDRESS PROPOSED USE 1t.�70+,� S 'T � • Cri.'�� - � CITY ZIP TEL. - t��+ ARCHlENG/ � DESIGNER ��-- ' ADDRESS UNITS E` �G� IE �` OOMS - � CiTY ZIP TEL. G y — u� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREA/t/ALUATION � Q� -�� OWNER-BUILDER DECLAf1ATION SPR/ADD/REM O � 1 NEREBY AFFlNM UN�ER PENALN OF PERJIlRV THAT I AM E%EMPT FROM THE CONTMCTORS U- G8f8g8/C2fPOf[ CEHSEUWFORTMEFOIIOWMGRFASON(SEG70.91.SBUSINESSANDPROFESSIONSCODE:ANYCITYOF (n OOUNTYWHICHPEOUIRESAPERMITTOCONSTRl1C7,AL7ER,iMPFiOVE,OEAIOLISH,ORRER4IRANY3TAt1P W P8t10(DBCk � TUNE.PPIOR TO ITS ISSUANCE,ALSO REQUIRES THE APPLICANT FOR SUCH PERMI7 To FILE A SfpNEO W � STATEMENT THAT HE OR SHE IS LICENSFA PUflSUAN'T TO THE PROVISIONS OF hIE CONTRACTORS LI- LL CEN3ELAW I�PTER 9(COMMENCINa WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS ANO PAO- POOUSp2 � FESSIONSCOOE)OHTHATHEORSHEISEXEMPTiHEREFROMANDTHEeASISFOR7HEALlEGEDEXEMP� (� g�y - TION.ANYVKKATIONOFSECTION7031.68YANYAPPLICANTFORAPERMITSU&IECT57HEAPPLICANTTO Z Re-Roof L�vv r AqY1LPENALTY OF NOT MORE THAN FIVE HUNDREU UOLLAR5(5500)J: ❑I,ASOWNEROFTNEPROPERTY,ORMYEMPLOYEESWITHWAGESASTHEIRSOLECOMPENSA710N, � CORI�IIB(CI81 � N7LL DO THE WOPK,AND THE 3TRUCtURE IS NOT INTENDEO OR OFFEfiEO FOR SAIE(SEQ 7044,BUSI•. _1 � NF55 AND PROFESSIONS COOE:THE CONTMCTORS LICENSE lAW DOES NOT APPLY TO AN OWNER OF j . , � PROPERTYNRIDBURDSORMIPROVESTHEPEON,ANDVAiODOESSUCHWORKFIIMSELFORHERSELFOq � THlpU�liHiSOpHEROWNEMPLOYEES,PROVIDEDTHATSUCHIMPROYEMENTSARENOTINTENDE�OR m � � .OFFEREDFORSAIE.IF,HOWEVER,TNE8UILDINGOflIMPROVEMENTiS50LAWITHINONEYFAftOFCAMPLE- �._ 'TION,THE OWNEH�BUILDER WILL HAVE THE BUHOEN OF PROVING THAY HE OR SHE DIO NOT BUILD OR IMPROVE FOR TNE PURPOSE OF SAL�. '�. W ❑I,It50WNEROFTHEPAOPEHf'/,AMEXGLUSIVELYC6MRACTTIQWRt1UCEN5EDCONTRACTOR5 - �'. TO CONSTRUCT7HE PRQIECT(3EC.7oM,Bt13WES8 AND PPOFESSIDNS CODE:THE CONTRACTORS LI- V81UfltlOn � 6�� ADJ.AREA } - W CENSELAWDOESNOTAPPIYTOANOWNEROFAPROPER7YNM1ioBUIlD50RINPROVESTHEREOM,AN� k f WHOCONTRACTSFORSUCHPR0.IECTSWITiAGONPRACTOR(S}LICENSEDPURSUAN7TOTNECONTRAG QUANTITY DESCRIPTION FEE �. TORSt10ENSEL0.WJ. ) � ❑1 AM E7(EMPT UNDERSEC. B.8 P.C.FORTHIS HEA50N Q � 3 � " LL OATE � Z-� V OWNER V W � UCENSED CONTRACTORS D LAiiA710N � OC IHEflEBYA�iRMUNDERPENALTYOFPERIl1RYTNATIAMUCENSEDUNDEFlPPOVISIONSOFCNAPTEfi � , d 0(COMMENCIN(3WITHSECTION7000iOFDIVIS10N30FTHE8UbMES6ANDPROFESSIONSCqOE,AND Z �L� MYIICENSEiSiNFU.IFOftCEANDEFFECT. m . 0���LICENSE CLASS UC.N0. _______.__ . �.. � J V -DATE GONTFIACTOR d W � WORKERS'COMPENSATION DECLARATION Q . � U � I HEREBYAFFlRM UNDER FENAITY OF VERJURY ONE oF 7HE FOLLOWING�ECLARATIONS: Z � ,_IHAVEANDWILLMAINTAINACERTIFICATEOFGONSENTTOSELF-IN3UftEFORWORKEfl3' $ COMPEN5A7roN,AS PROViDE�BY SECTION a7oo OF THE LABOH CODE,FOR THE PERFORMANCE U � OF THE WORK FOR NM1iICH THIS PENMIT IS ISSUEO. � � �i HAVERND WILL MNNTNN WORKEflS'COMPENSATION INSURANCE,AS RE�UIRED BV SECTION �/�� 1 p''f Q 37000FiHElF90RCWE,FORTHEPERWRMANCEOF7HEWORKFOflWHiGHTHISPERM1T15 � �+ / �/ ISSUED.MY WORKERS'COMPENSATION INSURANCE CARRIER AND POLICYNUMBER ARE: CONSTRUCTION �,,,_. � �`�"' Zf � / � � jcaaaiEn PLAN REVIEW . z voucrNuuaEn _ ELECTRIC _,_ - ¢ � (I}tlSSECIIONNEHIhUTBEf1kM.EfEDOFTF�PERAqTtSFOHONEHtNi7fiEDDOIIARS(510�ORLESS� PLUMBING C/ __, W I CERTIFY THAT INTHE PERFORMANCE OF 7HE WORK FOA WHICH THIS PERMIT IS ISSUED.I MECHANICAL Z �' SHAL4NOTEMPLOYANYPERSONINANYMANNERSOASTOBECDMESUBJECTTOTHE � WORKEflS'COMPEN50.TIONLAWSOFCALIFORNI0.�'DA6flEETHATIFISHOULDBECOME INSPECTIONFEE F SUBJECT707HEWORKERS'COMPENSPTIONPHOVISIONSOFSECTION37aoOFTHELABOF � CADE,1 SHPL.FORTIiWITH COMPLY WITH THOSE PROVISIONS. ISSUANCE � SMIP p, DATE: APPUCANT. — 6 e �� J; WARNING�FA�Ll1FETO5ECUREN'ORKERS'COMPENSATIONCOVERAGEISUNLAWFUL,FN�SHALLBE ENERGYP/C ,_,,,_ � SU&1ECTANEMPLOYERTOCRIMINALPENALTIESANDCIVIIFMESUPTOONEHUNDPEDTHOUSAND ENERGYPERMIT � 'i� ' � ' DOLLAflS(510D.000),INADDITIONTOTHECOSTOFCOMPENSATION.DAMAOESASPROYIDEDFOflIN �p',J��j��'�y / �(.�df �- SECtioN37neOFTHELA80F1CODE.MTERESLANDATTORNEY'SFEES. RETENTIONFEE: ����1Vd'V+v�+d]a / ' _ OCONSTRUCTION LENDING AGENCY PRE-ALT FEE: ���il�A.'F'T�.� _ � IHEflEBYAFFIRMUNOERPENALIYOFPENUflYTHATTHEREISACONSTqUCTIONLENDINGAGENCY - n- FORTHE PFRFOPMANCE OK iHE WORK FOR WHICH THIS PERMI715155UE0ISEC.3oB7.CIV.C.). � � . � - -. � Z W � f � LENOER'3 NAME � ' � F- LENDER'SADDRESS � ��� � � � ICERTIiYTHATINAVEREADTHiSAPPLICATIONANOSTATETHATTHEABOVEWFORMATIONISCARRECT. TOTAL F ES����� -- �� �- +. � � W IAGREETOCAMPLYWITHALLCITYANDCOUNiYOFDINANCE5AND5TATELAWSREIATINGTOBUILDING � � ' � CONSTRUCTION,ANDHEREBYAUTHORI2EREPRESENTAiIVE50FTHISCOUNTYTOENTERUPONTHE . . - - z ABOVE-MENTIOkED PROPERTV FOR MSPEC710N PUFIPOSES. COMM T � �� - - � � - � � P�ERMITT NAM�Pfl ��r ��J�l��� � �� d : �, v,:; � SIGNAT qEOFP ITT �DATE � � = RECPT.NO. PAID BY VALIDATION ~ WHITE—Department Copy,YELLOW--Finance Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—Applicanfs Copy i � , --� __ ___.. , �. __ _ _�� ..�_ _ ._._i__ �.� � j � ...:P � � i � 3 i �� �E I j i ; � .. I I.� € � , E �. i � (� I � j � I i i � � z � � � � ( � :� � � d � I . � 4 � � ' i - E � � � � k I €' � � ( �� � i � � 3 1 �'� I ! � ` 1 � � AI � �{ � � � . 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