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HomeMy WebLinkAbout13310 (14) _��_ CITY OF DIAIVIOND BA� � DEPARTMENT OF COMMLINITY dt DEVELOPMENT SERVICES � 21660 E.Copley IDrive Suite 190 ( ) �� _, �. (._..� .,..�.. , � .,.,,. �,. r f - .�„ PR S .r���' ,',�,. . w, :.. .. ,� ��N.. ES �ri�G��R�t`IBArri�iCA�'tOt�t FIRIiALY N JO�SITE [� Q- / APPLICATION,,,,���._ PERMIT �{�� � P/C � ADDRESS �T Z o I • ���`S�C��� pATE NUMBE��°'�" # � ISSUE TYPE OCC APN LOT� TRACT DATE GONST. GROUP p OWNER LL�RS> b,�17�"LCk1 fj(��Gd, vt�gbr✓T � ADDRESS�� �_ O � � ZONING SETBACKS Z CITY ['A���j ''rf� ZIP�� TEL.� FRONT RW ❑ g APPLICANT TEL: REAR ❑ � SIDE/SIDE STREET RW p � CGINTRAC70 K -� - ' .G � SIDE � Q ADDRESS { t.�; �/�-J�(q� t7.44 �y,/,�.,rl CiM !�/L#�1��2.Q,_('�rZIP�(�.�� TEI��'�,,..I��-� PROPOSED USE � ARCWENG/ �: i � DESIGNER - NO.DWEL. NO. NO. AODRESS UNITS STORIES BEDROOMS � CIW ZIP TEL. � cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANAWATION p� OWNER-BUILDER DECLARATiON SFR/ADO/REAA O p I HER�Y AFFlRM UNDER PENALTY OF PERJURY 7HAT�AM EXEMPT FR041 THE CONTRAC70FS LI- Gaf8y0/C0Ip012 LP,I CENSELAWWRTHEFIX.LOWINGREA.SON(SEC.7031.66USINE$SANDPROFESSIONSCODE:ANYCI7VOii (n GJ CIX/N7YWH;CHRE�UIRESAPERMtTTOCONSTRUCT.ALTER,IMPROVE,OEAdOLISH,ORq�'PAIRANVSTRUC- Z NRE,PRIOR-TO ITS ISSUANCE,ALSb REUUIRES THE APPLICANt FqR SUCH�PERAI(T TO'FILE A SI(iNED W �ati0/DOCk LL� STATEMENT THAT HE OR 6HE IS IICENSE�PURSUANT TO THE PHOVISIONS OF THE CONTRAC70RS G- w �•����.-���� ��� � CENSE UW(CHAPTER B(COMMENCINO WITH SECTION 7000)'OF D�VIuION 3 OFTNE BUSINESS P.ND�PRO- � Pool/Spa � FESSpNSCDDE�OHTHATHEOR5HEI5EXEMPTTHEREFROMANDTHEBR515FORTHEALLEGEUEXFMP- (� TIOIV.ANVVIOl.AT1ONOFSEG710N7ai1.60YpNYAPPLICANTFORAPERMiiSU&lECiSTHEAPPUCANTTO � RE-R00} � ACIVIL PENALTY OF NOT MORE THAN FIVE HUNDHEp DOLLAiiS(S60o).): � � � - - . � ❑I,ASOWNEROFTHEPROPERTV,ORMYElAPLOVEESW17H1n7AGE5ASTHEiR$OLECOMPENSATION, L� COromBfCial . �- WILL 00 THE WOpK;AN�THE STRUCTURF lS NOT INTEN�ED OR`OFFF.RED FOR SA1 F(SEC.10u,BUSI- � � NESS AND PROFESSIONS CODE THE CONTRACTORS IICENSE CAW DOES NOTAPPLY T4 AN OWNER OF � PROPERTV WIIO BUILOS OR IMPROVES THEREON,AND ViHO tlOES SUCH WORK HI/ASEIF OP HEfiSELF OR CC THFYOVQHHtSORHEROWNEMPLOYEES,PROVIDEDTHAT3UCHIM7ROVEft1ENTSARENOTINTENDEDOR � Q .OFFEREDFORSALEIF,HOWEVERTMf8UIl01NGORIMPpOVEMENTI550LD1VITMINCNEI'EAROFCOMPI,E- � 'TIOIV,THE OWNER-BNLOER WILL HAVE THE dUROEN OF PRbNING'HAT HE OR�SHE�ID NOY 9U�ID OR � IMPROVE FORTHE PURPOSE OF SALE). . . �,!.+;�'. . .. . W ❑t,ASOWNEROFTHEPAOPER'fY,AMERIX.U5IVELYIX7NTRACTINGYdITHLiCENSEDCANTRACTOFS — � TO CONS'tRUCT'•HE PpOJECT�SEC.7044,OUSIMESS AND?pOPESS10N5 CODE�THf C[JNTRACTORS LI- ValUafiort ADJ.AREA W CENSEUWDOESNOTAPPLYTOAN9WNEROFAPROPERTV,NMQ8UI4DSORIMPFlQVESTFlE4EOM,A�D . � WFIOCONTRACTSFOFlSUCHPRQIECTSWITHACONTRAC'OR(S)UCSNSC-0PllPSUhNTTC�TF?ECQNTRAG QUANTITY DESCRIPTION FEE Y TORS UCENSE L4W.). � /J � ❑I AM E%EMPT UNDER S�G_ _ _B,R P.C.FOP THIS REASON U � �r C/(\ iti• � �D � � �.W � � DATE ONMER ._ U �_ � LICENSED CONTF;ACTORS DECLARATION w �+.a�:,,�^"' � � "". I I HEREBYAFFIRM UNDEfl PENAITY OF PERJUHY TMAT 1 AM LICE�dSED UNOER PROVISIONS OF CHAPTER � B(CDMMENCINCi WITH SECTION 700Dj OF DIVISION 3 OF THE BU5INESS ANO PPOFESSIONS GODE,AND ' ?G MY CICENSE IS IN FULL FORCE AND EFfEC7. �� t3J � I �� r o LICENSE CLA �� � _ LIC.NO._�j � U DA7E CONTRACTOR_.1J�����6� "" •� � � W L �,���/��7�� � WORKERS'COMPENSATION DEGIARATfO�i�lk�^�^^""'� -� �� — t � IHEqEBYRFFlHMUNDERPENALTVOFVEPJURVONEOFT,NEFOLLOWINGDECLARATIONS: � � _IHAYEAMDWiLLMAINTAINACEWTIflCA7EOFCOPISEN7TU5ELF�INSUREFOfiWORKERS' COMPENSATION,AS PROVI�ED BY S[CTION 37000F THE LABOA CODE,FOR 7HE PERFORPAANCE OFTHE WORN FDA WNICH THIS PERA9IT IS ISSUF.D. � �I HAVE AND YNIL MA�NTAW WORKER8'COMPEPJSATION IM1'9URANCE,RS REQUTAED 8Y SECTION Q 37ooOFTHELABORCODE,FOqTHEPERFOFMANCEOFTNEWORKI�ORWHICH7HI5PERMITIS ISSUED.MY WORKERS'COM�P.E�NS�A,TION INSURANCE CARFIER AND Pq�ICY NUMBER AP,E: CONSTRU.r,TION "� _�'�.q1 y_�{f/ra P VIEW � CARRIEH � � POLICYNUMBER T � � �� .� � M '^;f; n;",.,_.+y �iHssEcr�avrlE�rdoTBFwnsv�ttEnoFir+.EP£FMTISr�iCNlEfrxs�RED�I.Wi�ryio�IORLESS�. PLUM�ING -�- "°P W T} --�..:'".,ls.',' �,' 1 CERTIfYTHAT IN THE PERFOpMANCE OF THE 1NORk FOR W41CH THIS P-RAAIT IS ISSt;ED,1 MECHANICAL �° SNAtL u07 EMPLOV ANY PER^uON IN ANY MANn'ER 5o as To 9ECOME SUB.'�ECT To THF � WORKERS'COMPENSATiON UlWS OF GLIFOFNIA,AND AGREE THA?II"I SHOULD 9ECOME lNSPECTION FEE SU&IECT TO THE N'ORNERS'COMP_NSATION PROVISIONS DK SECTIPN 3100 OF THE 1A80R �G a! �j GOOE,I SHALL FOFiTMWITH COMPLY WI7H TNOSE PROYI5fON5./f ISSUANCE ����`y � � '+'� t V n DATE:�I��� APPLICANT: ._____��f//M�^��__ SMIP �rv,+� ?. YT-`�'� �.-- — � ENERGY P/C ��.$ �1' -:.. �. .„ . `""+,-�^� J WARNING.FAILURE TO SECURE WORKEFiS'COMPENSATION GOYERAGE IS UNLAWFUL,AND SHALL 9E ,�;;.,,,-��. ;:,�..�.,,,. �..,-�. � SU&IECTqNEMPLOYERTOCRIMINlLLPENAL7IESAN�CIVILFINESUPTOONEMUNDFiEDTHOUSAND ENERGYPERMtT �'�%'�ay�� OOLLARS(5700.000).IN AODITIONTO THE COSTOF COMPENSATION,DAMAGES AS PP.OVIDED FOR IN � SECTION37080FTHELABORCOOE,INTEREST,ANDATTORNEY'SFEES. RETENTIOIVFEE: a CONSTRUCTION LENDING AGENCY PRE-AlT FEE; O � I HEREBYAFFlRM UNDER PENALN OF PERJURY�HAT TNcRE IS A CONSTRUCTION l'cNDMG AGENCY FOR THE PERFORMANCE OFTHE WORK FOR WHICH THIS VERMIT IS ISSUED(SEC.909],CIV.C.). W � LENOER'S NAME h IENDER'SAO�RESS__, — � I CERTIFYTHAT 1 HAVE READ iH15 APPLICATIOh'AND STATE THATTHFABOVE INFORMATION IS CAFRECT. TOTAL FE ES � � r � I AGREE TO CAMPLY WITH ALL CITYAND COUNTYORDINANCES AND STA7E LAWS R'cLATING TO BUILDING � CONSTRUCTION.AND HEREBYAUTHORIZE REPFESEN7ATIVES OF THIS COUNTY TC ENYER UPONTHE Z AAOVE-MENTIONEO PROPERTY fOR INSPECTION PURPOSES. COMMENTS � ('.fid-�v�v�' r�0, l m PERMITTEE NA0./E(PRINT) ' Q / — � �.�(yI � SIGNATUflEOFPE 1 (�/'�C��— ' - - � AECFT.NO, __ ___. ___ PA�D BY - 'VALIDATION WNITE—Department Copy,YELLOW—Financ�Copy,PINK—Assessor Copy, Ol.t)ENRO ile Copy.GREEN—Applicant's Copy . . ... �� r. ..... .. _._.. ..-_.. ........ .�...,-� ' r..r.l:.w., �� .. 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