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HomeMy WebLinkAbout12906 (13) \\ � ... ...�_.. ..:::�.. . \e+" _�F.� CITY OF DIA1vIUND BAR � DEPARTMENT UF COMMUNITY&DEVELOPMENT SERVICES _ � 2t660 E.CopleyDrive Suite T9i) ` . • , (909)660-3195 Fax(909}861-3117 PRESS _.• BUrI.D�l�'G�'��t1C'ITT'APP�:,IG�A�`b�° .,,,; ' .__ . FIRML�f , � . �iAtf� .,.... � ...,.,,.,'a ...,w w.�, � .i��. ., . ,.... . -- , .. y . .. .. , rv�v'r .. r -.�.',v . ..w ..:,..:�...:...i. � JOHSITE re � h , s� � ;�µ a�:, , APPLICATION /; PERMIT P/C o ADDRESS �������'�����` � '�� DATE l �� NUMBER •-<'�� # � RPN^„_, LO � TRACT � � �� � DATEE ONST. GROUP p OWNER '' " ADDRESS ` ' ZONIt3G SETBACKS � CITY _ ZIP TEL ` '��L FRONT RW L� � APPL{CAN'f _ TEL REAR ❑ SIOE/SICE STREET RW U � CONTRACT R � � i _ g ' SIDE ❑ � ADDRE S `0 j� PROPOSED USE '� ClTY ZIP T . o ARCH/ Gi , 9 � DE5IGNER NO,DWEL. NO. NO. � ADDR �' UNI7S STORIES BEDROOMS � CITY IP '}TEL . � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � � OWNER-BUIL�ER DECLARATION S�RlAD61REM O (, I HEREBY AFFIRM UNDEP PENALT/OF PERJURY TFiAT I AM EXEAdPT FROM THE CONTFACiORS tA� GyfA96/CB�Ort W CENSEUWfORTHEFOILO�NtN�RFl�50N(SECJo31.58USINE55ANDPROFESSIONSCOOE:NJVCI7YOR (n � cOUN7VWHICHflEWIRESAPERMITTOCONSTRUCT,ALTEA,IMPROVE,DEMOLISH,ORREPAIRANYSiRUG W pati0/DeCk w TURE,Pfl(OR TO ITS ISSUANCE,ALSO REOUIRES THE APPLICANT FOR SUCH PERMIT TO FP_E A SIGNEp � � STATEMENT Ti9AT HE OR SHE 6 IICENSED PURSUANT To THE PpOVI51tlN5 OF THE CONTRAGTORS LI� � CENSE LAW(CNAPTER B(COMMENCINQ WITM SECT�ON 100U)OF DIVISION 3 OFTHE BUSINESSAND�PRO� ' u' POOUSPB FESSpNS CODE�ORTHA7 HE OR SHE IS IXEMGT7HEREFROM AND TNE BASIS FOq THEALLEGEO EXEMP� TWN.ANYVWLATIOPIOFSECTION703/.SBVANYAPPLICAN7FORAPERMITSUBJECYSTHEAFPLICANTTO � Re-Roof r A CIViI PENALtt OF NOT MORE THAN FlVE HUNDRED DOLLARS(SSoo).J: - ^ ❑I,ASOWNEROFTHEPq4PERTY,ORMVEAdPLOYEESWITHWpGESASTHEIRSOLECOMPEN5ATI01J, C� GOfI11TIBfC1aI - � YALL00 THE WORK,AN�THE STqUCTUflE 15 NOT INTEN�ED OR OFFEREO FOR SALE(SEC.7D44,BU51� J NESS Ml�PROFESSIONS ODDE:THE CONTRACTORS UCENSE lAW DOE3 NO7APPlY TO AN OWNER OF � PHOPERTYWHOBUILp50RIMPROVESTHEREON,ANONM1i000E5SUCHWORKHIMSELFORHER6ELFOt1 � � 1HROUGHMSORHEFIOWNEMPLOYEES,PROVIDfATNATSUCHIIUPROVEMENiSARF.N071N7ENDEDOR m ' pOFFERFAFORSALEIF,HOWEVfiR,7HE8U1LDINGORIMPROVEMENTISfiOtAWITHINONEVEAPOFCCMPI� �, 'TION,THE OWNER-BUIIDER WILL HAVE THE BUflDEN OF PROVING THAT�HE OR SHc DID NOT BUILD OR � IMPqOVE FORTHE PURPoSE OF SALE). ❑I.A50WNEH OFTHE PROPERTI;AM E%CLUSIVELYCANTRACTING'NI?H LICENSED CONTRACTOHS d 70 CONSTRUCT TiE PROJECT(SEG�oss,BUSINESS AND PROFE5S10NS CODE:7HE CONTRAC7pR5 LI- V81U81i0n ADJ.AREA W CENSELAW�OESNOTAPPLVTOANOWNEROFAPROP'cRTYWHOBUILDSORIA7PqpVESTHEREDN,AND � WVIDCONTRACTSFORSUr%iPRQIECTSW17kACqNTFACTOP(S�LICENSEDPl1pSUANT?OTHECONTRAG (]UANTITY DESCRIPTION FEE Y iORSiJCENSELAW.). � � o ❑IM4E%EMPTUNOERSEC. B.BP,C.FORTHISRElSON Q � U LY LL DATE OWNER � U Qs� LICENSED CONTRACTpRS OECtARATIDN W� OC I NEREB�AFFIRM UNDER PENALNOF PERJURV THAT I AM LICENSED UNDEft PROVISbNS OFCHAPTER�� � / �/f�/� � D(COMMENCINO YVITN SECT70N 70Jo)OF�IVISION 30F THE BUSINESSAND PflOFE5510NS CODE,AND Z �-�+v qY UCENSE�S iN FULL FOPCEAND EFFECT. j� � p UCENSECLAS � LIC_NO. �"�� '"'� '� f' —'��`y . .,.. :i � J V DATE ___ CONTRACTOR_ a a - - d$ WORKERS'COMPENSA710N DECLARATION � _ ¢ � IHEREBYAFFlRMUNOERPENAITIOFPEP.JUflYONEOFTNEFOLL'6VJWG�DECLAAATIONS: �� U � � G1 ,IHAVEANOWII.LMAINTAINACER7IFICATEOFCONSENTTOSELF-INSUREFORWORKERS' � � CAAdPEN$ATION,ASPROVIOEDBYSECTON37MOFTHELABORCOOE,FOqTHEPERFORMANCE� w _ OF THE WORK FOR WNICHTHIS PERMIt IS ISSUED. � � W _I HAVEAND WILL MAINTAIN VJORK£RS'COMPEN50.TION INSURANCE,AS REQt11RE0 BV 5ECTION 4 370oOFTHELABORCODE,FORTHEPEAFORMRNCEOFTHEWORKFORWHICHTNISPERMIiIS Q ISSUEO.MY WORKE S'�C9OMPENSATION INS�RANCE CARRIER A�NDJ POLICV NUMBER ARE: CONSTRUCTION � CARRIER � -l�'���� �� �FLL. PLAN RE41EW . . .. .. . . . � POLIGYNUMBER Z Q �rrss�c:rioivrvemraoreE�e�ooFn�aeanur�swaauEr+unoaeooa.tnas(5�aoloq�essx LUM6ING �r,r+�. � w Z i CERTIFY iHnT IN THE PERFORMANCE OF THE WORK FOF`MHICH THIS PERAd1T IS ISSUED,1 P�.3' SHA��N07EMPLOYANYPERSONIN/WYMANNERSOAST08ECOMESUBJECTTOTH'c �ONFEE � WORKEFS'COMPENSATION LAWS OF CALIFORNIA,ANO REE THAT IF I SHDULD BECOME � SU&lECT70T{E6YORKERS'COMPEN5ATIONPROV SE'�TION37oDOFTHEL480R .����y L COUE, SH f+ORTHWITHCOMPLYWITHhIOSE 'S. � � SSUANCE �A A�����_�y,i,�_ J " � . . � � - 9�AAJ�i DATE: APPUCANT. ' SM�P W a� ENER`$LJ�Y X�IA'1lT fz R1�r'�AhTA�!�$1��, _ J WARNING:FAILURE TO ECURE W�RKERS'CaMPENSATi�N GOVEFAGE i5 UNLAVJFUL.AND SHAL�BE �^ ry�v�,r � SU&IECTANEMPIOYE.RTOCRIM�NRLPENALTIESANDCNIIFINESUFTOONEHUNDREOTHOU3AN� ���RG �����y����p"y�'q g y, OOLLARS(51uo.000).IN AD011'ION TO THE GOSTOF GOMPENSATI04,pAMAOES AS PROVIDED FOR IN � SECTION37080FTHELABOflCODE,iN7ERE5T,ANDATTORNEI^SFE[S. RETENTIONFEE: d . CONSTRUCTION LENDING AGENCY PRE-AL7 FEE: ___�_—__ � I HEREBYAFFIRM UNOE�PENALTV OF PERJURY THATTHERE IS ACONSTRUCTION LEN�ING AGENCV� �- FpR 7HE PERFORIAANCE OFTHE WORK FOR WHICHTHIS PEAMIT IS ISSUED(SEC.3097,CIV.C.). . . Z W � LENDEH'S NAME ' �� F- IENDEN'SAOORES3 . W ICERTIFYTHATIHAVEREADTHISAPPLICATIONANDSTATETHATTHEABWEINFORMATIONISCORRECL �OTAL F�ICS , . � .. . ' .. ..: ..,,. � I AGREE TO COLIPLV WITH N.L C(YY AND COUNTY OROINANCES AND STATE LAWS RELA7ING TO BU�LO�NG . � . CONSTRl1CTION,AND MEREBY AI/THORI2E REPRESENTATIVES OF 7HiS COVNTY TO ENTEq UPON THE � ABOVE�MENi1pNEDPROPERTYFORINSPECT�ONPURPOSES. COMMENTS a � ��f _ � 4 PEFNI7TEE NAME(PRIN'� f ,/ /' ( � / j. �'; " � 3 '. A` i- (/1 �,�P't-�r�*V_J - �T/ \.r V P--I �...�� � �� �pl A��4L�s � � ''} �" )�,�'�^��A,r .A' {n SIGNATUP—EOFPER/ ��' r/'" DATE —�—�� I � z+E'.¢§ ie� ' = FECPT.NO. �PAIO BY _,_i . 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