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HomeMy WebLinkAbout16637 (35) . . .__.—.__—_.. .__ __'____L—.___.._..—.. _ _. . _ . . I _� _ CITY OF I3I�MOND BAR �I I I DEPARTIv1ENT OF COMMUNTfY&DEVELOPMENT SERVICES 2fl825 E.Coptey Drive (909)860-3195 Fax(909)861-3117 PRESS '''%.vr��" BUILDIPIG PERMIT APPLICATION FIRMLY o DDRESS�v�� 1`I�.J�� ��` APPLICATION /"'� � NUMB R� #��F� DATE l.dr� °.° APN�1�G������� LOT,__�e"�___ TRACT �,��y� ISSUE r r .. ,p� TYPE OCC DATE l,� GONST. GROUP p aWNER _� ADDRESS Is• ZONING SETBACKS w � FRONT RW ❑ Z CITY��� ZIR TEL. g ' � APPLICANT Y�11�'�: � ��� TEL , ,� REAR ❑ � SI�E/SIDE STREET RW ❑ m CONTRACTOR P'°` � C�L��' �' ��� SIDE ❑ ¢ II o C�RESS � �� , zIP �fl�� TEL.e ' PROPOSEDUSE w ARCH/ENG/ I �p,�����1 z DESIGNER r �s4� �`0 NO.DWEL NO. NO. a ADDRES UNI7S STORIES BEDROOMS � CITY ZIP � TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANA�UATION � O�NNER-BUILDER DECLARATION SFR/ADD/REM p I I FIER68V AFFIpM UNDEA P€NALTV OF PERJURY THAT I AIA EXEMP7 FROM THE CONTRACTORS LI- G8feg2/CBfpOfl �W CENSELAWFOflTHEFOLLOWING�iRFA50N(SEC.7031.5BUSINESSAN�PFOFESSIONSCODE:ANYCIiYOp (n 'C.� COUNTYWHIqiRC-0UIRESAPERFMITTOCONSTRUGT,'!'L7ER,IMPRWE,�EMOLISN.ORREPAIRANYSTRUC- �,j,j PailO/DBCk ' '��,W TURE,PRIOR Tq ITS ISSUANCE,�LSD qEWIflES T,I1E APPLICANT FOR SUCH PERMIT iD FILE A SIGNED W STATEMENi THAT HE OR SHE IS�LICENSE�PUftSUANT N THE PROVISIONS OF THE CONTRACiORS LI- �p�� '. ��� CENSELAW(CHAPTER9(COMMENCINGWIiHSECTION'7m0)OFDIVISION30F7HEBl151NESSAN'�PR0. u- PooUSpa �-t � � FESSIONSCODE)ORTHATHEOfl'HEISIXEMPTi,fiEREFROMANDTHE&4315FOFTHEALLEGE�EXEMP� (�} � '� ;iION.ANYVIOLATIONOFSECi10�7031.8BYANYAPpLICANTFORAPERMITSU8JEC7STHEAPPUCANTTO Z Re-Roof � � '� � ACIVILPENALTY�OFNOTMORETHIANFIYEHUNDREdDf1LLAfl5(5500).): Q , . ,0 'O7,ASOYHJEROFTHEPROPEflTV,'.DRMVEMPCOYEES WITHYJAGESASTHEIRSOLECOMPENSATION, COffIff7B�C18I '' Z WILL 00 THE WORK,AND iHE�'SibUCTUFE IS NOT INT�NDED OR OFFEFEO FOR SALE�SEC.7044,BUSI- J . ,� i NESS AND PROFESSIONS CODE:THE CONTFt4Ci0'�RS LICENSE UW OOES NOTAPPLV TO AN OWNER OF � � ' �IPR�PEkTVWHtlBUILD50RIMPRQVES7HEAEON,AND'WHODOESSUCHWORKHIMSELFORHERSEIFOR ', �(t �,ITHROUGH HIS OR NER OWN EMPL'�OYEE5,PROVIO�D THATSUGry IMPROVEMENTS ARE NOT INiENDED OR m , ' �,Q !OFFEFEOFORSALE:IF,NOWEVER,RFIEBUILDWGORIMPROVEMEMISSOLDWITHINONEVEAROFCOMPLE � Z ";�'TION;THE OWNEF}BUIL�ER WILL.IHAVE T4E BUfl�EN OF PROVI(tlG THAT HE OR SHE�ID NOT BNlO OR . = IMPROVEFORTNEPLIRPOSEOF6ALE). � , � �i �w ' ..❑I.ASOWNEqOFTHEPROPERTY,AMEXCLU5NELYCONTRACTINGWITHLICENSE�CONTRACTOFS � , �� . , ',, �Q I i�I,70 CONSTflUC7 TNE PROJECT(SE4 7oA4,BUSINF,$S'AN�PFOFESSIONS CODE:THE CONTRACTOflS LI- V21U8SIOtl 'w A�J�AREA � �,�W CENSE�.AWDOESNOTAPPLVTOANOWNEROFAPROPERTVWHOBUIL�SORIMPROVESTHEREON,AND v � IWHOGONTRACTSFORSUCHPRO:IECTSWITHACONTRqCTOR(SJLICENSEDPURSUAN7TOTHECONTRAG QUANTITY SCRIPTION �' ' , FEE - � TORS UCENSE LAW.), . i �,'Q ❑1 AM'EXElAPT UNDER SEC.�, � _B.&P.C.FOR THIS REASON Q �' . �s ,. � U . , . .. � , � � �� �OAiE OWNER U . , I Z ' W �' '� � LICEN$ED CONTRACTORS DECLARATION �j . . � . , . .i,d . � . . �,, . � IHEflEBYAFFIRMl1N0ERPENAIiYOFPERJURYTHATIAMLICENSEDUNDERPROVISION50FCHAPTER � �� 9(COMAAENCINGWITHSECTION1Uoo�OFDIVISION30FTHEBUSINESSANDPROFESSIONSCODE,AtJD Z .,� MY��CENSE IS IN FULI FORCE AND EFFECT. , 'y � �ty� m I 1 �� '� LICENSE C SS � LIC.NO.���y�f�►A�__/�r � � ��U ,DATE . �. �' � CONTRACTOR��/!N.� 7l d(�1 Ys� d . .� W ��' WORKE.,RS'COMPENSATION DECLARATION Q � �� INEflEBYAFFIflMUNDERPENALTI'OFPERJURVONEOFiHEFOLLOWINGDECLARATION3 � ' ' " " � Z Q Z'�.",IHAVEAN�WILLMAINTAINACEFiIFICATEOFCONSENTTOSEIF-MSUREFORWORKERS' _ � . ¢ COMPENSAiION,AS PROVIDED 8Y 5EC7ION 370o OF THE LAeOR CO�E,FOR THE PERFOMIANCE w OF THE WORK FOR WHICH'�,THIS PERMIT IS ISSUED. � � fO, I , dW ',I HAVE ANO l^llLl MAINTA�N�,WORKERS'COMPENSATION INSURANCE,AS HEQUIRE�BY SEGTION �y �' � 3�0o OF THE LABOR CODE;FOR THE PERFORMANCE OF 7HE WOPo(FOR WHICH THIS PEAMIT IS ��, I � ' � �� ISSl1ED.MV,WORKEAaS'GOM?ENSA5iION INSU NQ'CE CARRIER^yAN��POLIC NU ERARE: CONSTRUCTION �� �. CARRIEP �'���o''��\� � 1 ♦ �It.t1 ���� PLAN REVIEW �� POUGY NUMBER_��,��a��^��e ELECTRIC c �' (11115SECTIONNEmNOT6E9JMPLEfE�OFTHEPERMfTISWRONEHUNDRED00LLAR5(5100)ORLESSJ. PLUMBING � A Z ICERTIFVTFiHTINTHEPEFiFORMANGEOFTHEWORKFOflWHICHTHISPERMiTI5155UE0,� MECHANICAL (';� SHALLNOT EMPLOYANY P�RSON IN ANY MANNER SOAS i0 BECOME SUBJECTTO7H'c �'.,' WqRKERS'CDMP�NSATIONLAWSOFCALIFORNIA.ANOAGREETHATIFISHOULDBEC0IAE INSPEC710NFE SIIBJECTTOTHEWORKERlS'COh�PENSAiIONPR9YISl NSOF ECTION3io00FTHELA80R i' �%�'�, ����, � �: COO 15 ALLFORTHWITF{COMPLYWIiHi �,jiR IS �SSUAN(�iE ; . /."='+.`� � 'I I �� � p' �. , I ' Y . � . . . � �,:�_ . p� �DATE � APPLICqNT. �_ SMIP _ �� WARNING FAILUflETOSECUREWORNERS'COMPENSATIONCOVERAGEISUNL9WFUL,ANOSHALLBE ENERGYP/C -O SU�JECT AN EMPLOYER TO CRIMINAL PGNAL71E5 ANO CIVIL FMES UP TO ONE HUNDRE�THOUSANO t���. ENERGV PERMI� � I� � pOLLAR$(E7�l0.OW)..IN ADDIiION TO1HE COST OF COMPENSATION,DAMAGES AS PROVIOED FOR IN J'�A SECTION'37080FTHELABOflCODE.INT6RE5T,ANDATTORNEY'SFEES. RETENTIONFE �!' � �. _..�.n__,.._. -�` O� � COl�STRUCTION LENDING AGENCY PRE-ALT FEE: � � �'�' IHEREBYAFFIftMUNOERPENALTVOFPERJURYTHATTHEREI6ACONSTRUCTIONLENDINGAGENCY P-"��'��� FORTHEPERFORMANCEOFTHEN%OFiKFORWHICHTHISPERMITI5155UED�5EC.3a91,CIV.CJ. ' ' � W'., ��.��, .LEN�EP'SNAME . I'� LENCER'SAODRE55 � � TOTAL FEES ���. � '',.ICEPTIFV7HATIHAVEREADTHISAPPLICATIONANCSTAiETHATTHEA90VEINFOPMATIONISWRRECT. ¢ ,�I AGREE70 COMpLY W17H ALL C171"IANO COUNTY OR�INANCES AN�STATE LAWS RELATING TO BUILDINO ' � .�CONSTRUCTION,AN�HEFiEBYAUTH�RIZEREPRESENTATNESOFTHISCOUNTV70ENTERUPDNTHE ,� �} (�wny,�,�j � �.'ABOVE-MENTIONED PROPERTY FOR INSPECTION PUflPO5E5, COMMENTS �+"� .� ', � ''�, �! � . � � �f U . ---- . — — � '�PEflMI !J��E(P 1 ^ „ . 4 ' C1� � �' V6 � � �j�"�''�SIGNP.V F E MI EE T' ' �� RECPT.NO. PAID BY 4 '. 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