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HomeMy WebLinkAbout17207 (23) CITY OF I3I�MOND BAR ---- �"'�`'� DEPARTl�1ENT OF COMMUNTI'Y�c DEVELOPMENT SERVICES I 21$25 E.Copley Drive (909)8603195 Fax(909)861-3117 PRESS ''='-�ri�'" BUILDING PEgiMIT APPLICATION FIRMLY � JOBSITE APPLICATION �y PERMIT P/C o ADDRESS ���� S� G IZ19J�I� ���- ����IDA/D B� DATE � � � •� �/I NUMBER ��� #��� � ISSUE TYPE OCC -- APN LOT TRACT DATE CONST. GROUP p OWNER��E �F/�G ��'�9�,E [s�P6[��' ADDRESSz�a S• J�I/� �/ , ZONING SETBACKS Z CITY� c ZI �'D TEL7�51,������ FRONT RW ❑ o APPLICANT �r�- ' 6 t�'�/ TEL.7/S�lilJ9_L/li/y SIDE/SIDE STREET RW ❑ z 1,,�� ¢ CONTRACTOR J�' r • '�++'�S"ti r�r�,��yyl SIDE ❑ o CDDRESS V� g� ZIP� TEL.�S '�$j^ q$�,Y PROPOSED USE � �p �� "sO� �� o ARCH/ENG/ � � � w DESIGNER NO.DWEL. NO. NO. a ADDRESS � CITY ZIF TEL UNITS STORIES BEDROOMS � u� DESCRIPTION SQ.PT. FACTOR PSF ADJ.AREANALUATION p� � OWNER-BUILDER DECLARATION SFR/ADD/REM O p� I HEPEBY AFFIRM UNDER PHJALT`7 OF PEflJURY THAT 1 AM EXEMPT FROM THE CONTRACTORS LI- G8f8gE/CBfPOII � - W CENSELAWFOHTHEWLLAWINGREASON(SEC.7031.5BUSINESSANDPRCFESSIONSCODE:ANYGTYOR (n �U COUNTYWHICHRE�UIRESAPERMITTOCONSTRUCT,ALTER,IMPROVE,�EMOLISH,OflflEPAIRRNYSTRUC- I W 'TURE,PRIOR TO ITS ISSUANCE,ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED w Patio/Deck �STATEMENT THAT HE OR SHE IS 610EN$ED PURSUANT TO THE PROVISIONS OF THE CONiRACiORS LI- � CENSE LAW(CHAPTEfl 9(COMMEryCING WfTH SECTION 7000)OF�IVISION 3 OF THE BUSINESS AN�PRO- V' Pool/Spa . 'FESSIONSC�OE)ORTHATHEOR$HEISE%EMPTTHEREFROMAN�THEBASISPoFTHEALLEGEDEXEMP- (� , � TIDN.ANYVIOLATIONOFSECTIONi7031.5BVANVAPPLICANTPoRAPERMITSUBJECT57HEAPPLICANTTO z Re-Roof ACIVIL PENALTY OF NOT A40RE TNAN FIVE HUNDRED DOLLARS(5500).): Z � ❑I,ASOINNEROFTHEPftOP€RN,OF.MYEMPLOYEESWITH.WAGESASTHEIFSOLECOMPENSATION, 0 COrtIf11BfC13I - WILL DO iHE WORK,AN�THE STRUCil1RE iS NOT WTENDm OR OFFERED FOR SALE(SEC.7D44,BU51- J � �NESS AND PROFESSIONS CODE�,THE CONTRACTORS LICENSE LAW DOES NOT APPLV TO AN OWNER OF j "PROPERTY WHO BUI��S OR IMPPqVES THEREON,AN�WHO�OES Sl1CH WORK HIMSELF OR HERSELF OR �� [r� THROUGHHISORHEROWNEMPLOVEE$,PROVIDEDTHATSUCHIMPROVEMENTSARENOTINTENDE�OR m ' Q �OFFEREDFORSALE.IF,HOWEVEH,THEBUILDINGORIMPROVEMENTISSOLDIMTHINONEVEAROFCOMPLE- �Z �T�ON,.THE OWNER-BUILDER WILL HAVE'THE BUR�EN Of PROVINO THAT HE OR SHE DID NOT BUILD OR �� '�IMPROVEFORTHEPURPOSEOFSpLE).� w ❑I,ASOWNEFIOFTHEPROP�RTV,'AMEXCLUSIVELYCONTRACTINGWITHLICENSEDCONTRACTORS �� ?O CANSTRUCT THE PROJECT(SEC.70A4,BUSINE55 AND PROFESSIONS CO�E:THE CONTRACTORS LI• ValUaYion ��� ADJ.AREA � � W� '��.CENSELAWDOESNOTAPPLYTOqNOWNEROFAPROPERTYWHOBUILD50RIMPROVESTHEREON.AN� �. T� ,WHOCONTRACTSFORSUCHPRQIECTS'.WITHACONTRACTOR(5)LICENSEOPURSUANTTOTHECONTRAC- ' �" roasudENse�nw.�. QUANTITY DESCRIPTION FEE � � ❑I AM EXEMPT UNDER SEC. B.S P.C.FOR THIS REASON Q � U � � DATE OWNER U � Z � -ip��� - � - --- - - --.. � � LICENSED CONTRACTOFS DECLARATION W � ¢ � I HEPEBY AFFIRM UNDER PENALTY OF PERJURYTHAT I AM LICENSED UNDER PROVISIONS OF CHAPTER � � [� 9(COMMENCINGWITHSECTION7aooJOFDIVI510N30FTHEBU51NE55ANDPROFE5510NSCODE,AND Z X MY LICENSE IS M FULL FORCE ANO EFFECT. � �� ��. LICENSECLASS ���� LIC.NO. ������ � � ��-t��-� J U, DATE � ' CONTRACTOFi a W ' � WORKERS'COMPENSATION DECLARATION Q - ', �' I HEi3EBV AFFIRIA UNOER PENALTY OF PERJURV ONE OFTHE FOILOWING DECLARA710N5: Z 0 _I HAVE AND WILL MAINTAIN A CERTIFlCATE OF CONSENTTO SELF-INSURE FOR WORKERS' _ . '¢ CAMPENSATION,AS PROVIDE�BY SECTION 370o OFTHE LA00R CODE,FOR THE PERFORMANCE �U Q OFTHEV✓ORKFDfiWHICHTHIS,PERMITI515511ED. � QW I HAVE AND WIIL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS AEOUIRED BY SECTION 8� . 3700 OFTHE LABOR CD�E,FOR���iHE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS � �}� '� �., ISSUE�.MY WORN,FApS'C,OdNPENSA/I�IO��N INSURANCE CARRIERAN�POLICV NUMBERARE: CONSTRUCTION i�A o � �j�, cnqaiEa �'l�!6p-h '� !'E'�.�.��,y���4.C. AN REVI C g+ ° � � POLICYNUMBER �A,1����'��/�"��.✓t�.?� ELECTRIC °t a Q � 0 (tHI55ECTIONNEmNOTBE07MREfEDOFIHEPERMI7ISWRONEHUJDREDCOLLARS�81W)ORLESS). PLUMBING _ ' �., I CERTIFVTHAT INTHE PERFORMANCE OFTHE WORK FOR WHICHTHIS PERMIT IS ISSUED,i MECHANICAL , (� .SHALL NOT EMPLOY ANY PERSGN IN ANY MANNER SOAS TO BECOME SUOJECT TO THE � - , � WORKERS'COMPENSATIONLAW,SOFCALIFORNIA,ANDAGR=ETHATIFISHOULOBECOME INSP€CTION'FEE' "'""J^��� -,`"`�"� '� SUBJECT TO THE WORKERS'COM2EN5ATIUN PROVISIONS CTION 370o OF THE LABOR ' 1'y-� �! �ry yy' �', �, CADE,ISHALLFORTHWITNCOM1IPLYWITHTHO EPROVI� ISSUANCE - f�° - ___y ✓�✓lJ " � y� ; 6� , Q, DATE: �"�1e� APPLICANT. SMIp ! b R! ��� � �� ENEFGY P/C P'���� �I °1 I� 4 ��. � WARNING FAILURE TO SECUpE WOqK�RS'COMPEN C V FAG IS UN WFl1L,AND SHALL BE v , � SUBJECTAN EMPLOYER TO CRIMINAL P�ENALTIES AND qVILFINES UP T UNDRE�THOUSAN� ENERGY PEFMIT �OLL(RS(51aa.oCo),IN A��ITION t0 THE COSiOF COMPENSATION,�AMAGES AS PPOVIDED FOR IN � �' SECTION3]080FTHELABORCODE,INTEREST,RNDATTORNEY'SFEFS. RETENTIONFEE: �\`� �- 1 •„.�� (YJ' , , -_ ' ...,.,,.,._'__ �..r.:,.=.�-m� , O CONSTRUCTIONLEN�INGAGENCY PRE-ALTFEE� � ��� � IHEREBVAFFIRMUNDERPENALTVOFRERJURYTHATTHEREISACONSTRUCTIONLENDMGAGENCV FOR THE PERFORMANCE OF THE WORI{FOR WHICH THIS PEAMIT IS ISSUED(SEC.309J,CIV.C.f. Z L1J j LENDER'S NAME y F'- LENOEfl'SADORE55 ��,� ICER7IFYTHATIHAVEiiE4D7HiSAPPLICATIONANOSTATETHATTHEABOVEINFORMAiIONlSCORRECT. TOTAL FEES �,�� .� �^��o�� 'w 1 AGREE TO COMPLV WIiH ALL CIN ANO COl1NTV ORDINANCES AND STATE L4WS FELATING 70 BUIL�ING �' 4 �-- 0.� CONSTRUCiION,ANDHEREBYAUiHORIZEREPRESENTATIVE50FTHISCOUNTVTOEM'EflUPONTHE �i .z�� ABOVE�MENTIONEO PIiOPERTYFOR INSPECTION PURPOSES. �y �y Q . � COMMENTS: � ���C!�'� �'t�,'�, ���� J ,�� ,��,s �� � �. Q��'�, PERMITT�F�, (PRINT) ' � ��r �� ���� � SIG � �E OF PERMITfEE �A F ' �_� � RECPT.NO. 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