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HomeMy WebLinkAbout17455 (26) crrY oF D�orm BaR � -----��°"--- DEPARI`MENT OF COMIv1UN1"I'Y�DEVELOPMENT SERVICES I I � 21825 E.Copley Drive ' (909}860-3195 FaY(909)861-3117 PRESS '�'-•v�r��' �UILDINGPERMITAPPLICATION FIRMLY � JOBSITE �^�� �� � �r APPLICATION PERMIT P/C � ADDRESS "�4 ,� �'��o° ��� DATE �i�-�S�°--�/ NUMBER� # � ISSUE TYPE OCC .- APN LOT TRACT DATE CONST. GROUP p OWNER /�'� . ��j"� �` ADDRESS �-� ^ ZONING SETBACKS Z CITY /°�'°.�."�a^a�c�C�t�P T L�i�q�ii —�� J FRONT RW O o APPLICANT TEL. SIDE/SIQE STREET RW ❑ z Q CONTRACTOR � e� yy SIDE O O ADDRESS _ PROPOSED USE r� ' f.�a�..� d,c�°' �` " CITY ZIP L. �- o, ARCH/ENG! �� r . � � z DESIGNER w NO.DWEL. NO. NO. � ADDRESS UNITS STORIES !'� BEDROOMS � CITY ZIP TEL. � cn DESCRIPTION SQ.FL FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER DECLARATION SFR/ADD/REM O p I HEREBY AFFIRM UNDER PEN�TV OF PEPJURY TNAT 1 AM EXEMPi FROM THE CONTRACTORS LI- G8f8JQ/C8fP0!! 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F DATE OWNER �� Z � �, LICEN5ED CONTPACTOFiS DECLARATION W ��'� �IHEREBYAFFIRMUN�ERP,ENALTV,OfPERJURYTHATIAMUCENSEDUNDERPROVISIONSOFCHAPTEP � ��. '„e(GOMMENCING WITH 5'cGTION 7000)OF�IVISION 3 OF THE 9USINE55 AND PROFESSIONS CO�E,AND Z LX. MY UCENSE IS IN FUCL FOqC�AND EFfECi.� m �' LICENSE CLASS��.I� _LIC.Nd._ ��� � � j���, DATE� "`"✓���"� � CONTRAGTOR � � h a W �� � WORKE�FtS'COMPENSATION DECLARATION Q �, 1 HEREBY AFFIRM I1N�EA PENALTV OF PERJURV ONE OFTHE FOLLOWING DECLARATIONS� Z Z�, _IHAVEANDWILLMAINTAINAGERTIFICATEOFCONSENTTOSELF-INSUREFORWORKERS' ¢ ' 2 Q COMPEtISATION;ASPfiOVI0ED6Y5ECTION3700'OFTHElA60RCODE,FORThEPERFOPMANCE 'U OFTHE WORK FOR V�,HICH THIS PERMIT IS ISSUED. p � W _I HAVE AND WILLMqINTAIN�WORKEFS'COMPENSATION INSURANCE,A3 RE�UIRED BY SECTION � 37ooOFTHEL4BOftCODE,FOR'iHEPcRFORMANCEOFTHEWORKFORWHICHTHISPERMITIS �� ISSUED.MYWORKER$'COMPENSAiIONINSURANCECARRIERANDPOLICYNUMBERARE: CONSTRUCTION I��R ¢ '���'�' —�/��-- �, CARRIEH � � � PLAN REVIEW Z. POLICYNUM6ER ELECTRIC Q 0� �THISSECTIONNEmNQ78E'�OJM1IPLE7'E�OFIHEPERMIi1SWRONEHUNDRE�DJlLARS($100jORLE55). PLUMBING Z. ICEFTIFVTHATINTHEPERfORMANC€OFTHEWORKFORWHICHTHISPERMITISISSUED,1- MECHANICAL - --�--� - - � SHAILNOTEMPLOYANYRER50NINANVMANNERSOASTOBECOMESIJBJECTTOTHE � � $ �,�.,,.`� ```-���m � WORKEftS'COMPENSATION'I.AWSOFbALIFORNI:S,A�DAOREETHATIFISHOULDBECOME INSPECTIONFEE � - F SU&IECTTOTHEWORKEf�S'COMPENSATIONPROVISIONSOFSECTION37000FTHELABOR ; �`~ �T �� E� �° � C�OOE,ISHALLFOFTHWITH,COMPLYWITH�THOSEPROVISIONS. 9 ISSUANCE � ��J'_ _�� O DATE:( Z✓' .—�APPLICANT:_�Y�� Y � /r) L_ SMIP ; ��''� ^- �� � � w. � " '� ENERGY P/C �__� J�� WAHNING FpILL'RE TO SECUFE WOAKEP.'�iCOMPENSAT:ON COVERAGE I5 UNLAWFUL,AND SHALL BE �� SUBJECTANEMPLOYEFi�TOGRIMINALPENALTIES�ANDCIVILFINESUPTOONEHUNOFEOTHOUSAN� ENERGYPERMIT �t-=<�.T.� }'" DOLLARS(5100.00D.MAObIT10N OTHECOSiO�, ENSA710N,�AMAGESASPROVIDEDFORIN �� y�. F COM ORNEY'S FEES. 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