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HomeMy WebLinkAbout16700 (39) � �i�'��D$l��IOPd'D�� `� ----�'�-- `�..-_:_._,� � � � l Y?��t�R'd'�A1T�F CO 5��DE�IELC3PME3dT SERVICES a��., 2i825 E.�op�ey Driv� '✓ (909)�60-3195 Fax(909}�61-3117 PRE S .'"%��.,., �i3I�.�ir3GP��21l�1I'i't�PPLICA'i'ION F LY � JOBSITE r/ APPLICATION PERMIT P/C Q ADDRESS ��T��� ���� 1�/ • DATE � � NUMBE # o� ISSUE TYPE OCC APN LOT TRACT DATE CONST. GROUP p OWNER ��� 1L�_,���'i �GO� ADDRESS ZONiNG SETBACKS z CITY ZIP TEL. FRONT RW ❑ � APPLICANT TEL. REAR ❑ � S1DE/SIQE STREET RW ❑ Q� / (�/ /� SiDE ❑ CONTRACTOR � ADpRE�SS — 'r L' � pRpPOSED USE Z ��� � � CITY�/ ' ZIP TE .(�u�%���j�' w ARCFI/E / w DESIGNER NO.DWEL. NO. NO. � ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � � OESCRIPTION SQ.FT. 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PROPERTYWHOBUILDSORIMPROVESTHEP,EON,ANDWHODOESSUCHWORKHIMSELFOqHERSELFDR m ' � THROUGH HIS OP HER OWN EMPI�'OVEES.PROVIDED iHAT SUCH IMPROVEMENTS ARE NOT INTc'N�ED OR � QOFFEREDFORSALEIF,HOWEVER.iHEBUI�DINGORIMPRaVEMEN,'ISSOLDWITNINONEYEAROrCOMPLE- Z TION,THE OWNER-BUILDER WILLIHAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUIL�OR �; IMPROVEFORTHEPURPCSEOF$AlE).'� ❑I,AS OWNER OF THE PflOpiERTY,FM EXGLUSIVELY CONTRACTING WITH LICENSED CANTFACTOflS � TO CANSTRUCT THE PflOJECT(S�C.7ad4,BUSINESS AND PROFESSIONS CADE:THE CON7PACTORS LI- VdIUOilOf1 ADJ.AREA LLI CENSELAWDOESNOTAPPLVTOANOWNEROFAPROPEpTYWHOBUILDSOPIMPRGVESTHEREON.AND �' WHOCONTflFCTSKORSUCHPRO.�ECiS�WITHACONTRACTOR(SILICENSEDPUP.SUA4iTOTHECONTRAG QUAPITITV DESCRIPTION FEE Y TORS LICENSE LAW.�. � u I AM EXEMPT UNDER SF_C.���, � B.&P.C,FOR THIS REASON � � ly _— � DATE 'OWNER � LLl � LICEN$ED CONYRACTORS DECLARAT60N W � IHEREBYAFFlflMUNDERPENALTI�OFP[RJUflVTHA7IAMLICENSEDUNDEflPROVI510N50FCHAPTER � � � r� rl'�r1. � 9�COMMENCINGWITHSECTION7doa)O�OIVISION30FTHE0USINESSANDP�OFESSIONSCODE,AN❑ z L � X MY IICENSE IS IN FULL FDRCEANd EFF�Ci. m � LLI Q LICENSE CLASS� ���LIC.ND. Z� j � J V DATE CONTRACTOR A W �i WORKE�iS'GOMPENSATION DECLARATION a = U � IHEqEBYAFFIqMUNDERPENALTI'�OFPERJURVONEOFTHEFOLLOWWGD_CLAPATIONS: Z ' ¢ O IHAVEANDWILLMAINiAIN'ACERTIFICATEOFCONSENTTOSELF-INSUREFOftWORKERS' _ CAMPENSATION,ASPROV�DEDBVSECTION370�OFTHELkBORCDDE,FORTHEPERFORMA�'CE (.� ¢ OF iHE WORK FOR WHlCi1�'�;�HIS PERMIT IS ISSUE�. � � y..�_ _IHqVEANDWILLMAINTAI4IWORKERS'COMPENSATIONII:SURANCE,ASREQUIREDBYSECTION Q 37000FiHELA80RCODE�FOR7HEPEFIFORMANCEOFTHEINORKFORWHICHTHISPERMITIS ISSUED.MYY✓ORKEAS'COMP �A/T�Ig INSL'RA CECAR�N�POLICV NUMBER M1RE: CONSTRUCPION y , cnRRieR_ _�/ � ���✓� /� PLANREVIEW I� 0 POLICY NUMBER_ '� _�(�Ly-- ELECTRIC �� I Q � " '�, � (fHISSECTKKJNEmNOT3EQJMPLETEDOFhiEPERMdTISFORONEHUNDREDWLLARS(5100)ORLESS). PLUMBINGq � I CERiIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH TH:S PERMIT I5ISSUED,l MECHANICAL L'S SHALL NOi EMPl.OV ANY PEHSOM IN ANY MANN'=R S�AS TO BECOME SUBJECiT07HE [/� WOFKERS'COMPENSATIONLAW$OFCALIFOFiNIA,ANDAGREETHAT;FISHWLDBECOME INS?ECTIONFEE � SUBJECT TO 7NE WORKEPB'COM PENSATION PROVI510NS OF SECTION 370o OFTHE LABOP � CODE,ISHALLFORTHWITHCOMPLVWITHTHOSEPROVISIONS. ISSUANCE __ B � � SMIP p OATE: FPPLICANT: J WARNINGFAILURE'NSECUflEW RKERS'COMPENSATIONCOVERAGE:SUNLAWFUL,ANOSHALLOE ENERGYP/C �y SUBJECTANEMPLOYER70CRIMIt�ALPEN.4LTIESAN�CIVILF@JESl1PTOONEHUNDRE�THOUSAND ENERGYPERMIT IXlLLARS�5100.OW�,IN A�OITIDNTO THE GOST OF C�MPENSATION,DAMAGES AS PflOVIDEO FOR IN J SECilON3]OBOFTHELABOflCOO�,INTEftEST,ANDATT4RNEY'SFEES. RETENTIONFEE: � OCON,STRUCTION LEN�ING AGENCY PRE-ALT FEE: � IHEREBYAFFIRMUN�ERPENAL7V'DFPERJUPVTHATTHEREISACONSTRUCTIONLEN�INGAGENCY I FOR 7HE PERFORMPNGE OF THE N�OqK FOR N/HICH THIS PEqMI'IS ISSUED(SEC.309?,CIY.C.). W � LENDEF'SNAME 1_— LENDEH'SADDRESS_.._.____. __ � � ICERTIFYTHATIHAVEREAOTHISAPPLICATIONFND57ATETHATTHEABOYEINFORMATiONISCORRECT. TOTAL FEES W I AGflEE TO COMPLY WIiH ALL CITViAND OOUNTY ORDINANCES AND STATE LAWS RELATiNG TO BUIL�ING + � � CONSTRUCTION,ANO HEREBV AUiI�OR2F�aEPRESENTATIVES OFTHIS C�UNTV TO ENTER UPON THE � ABOVEMENTIONED PROPERT FOR INS?EGTION PURPOSES. GOMMENTS Y d �r _ m PEflM1TT E NA E(P I ) - � ����� • � SIG ,7UP O PE I . � A = AECPT.NO. PAID BY VALIDATION ~ HITE—De artment Co YELLOW—Finance Co PINK—Assessor Co GOLDENROD—Fi e Co P PY. DY, PY. PY,�REEN—ApplicanYs Copy .._ .. ..,, .. , �5 �y . . '.,.. . ,:. ., . . ..,-r.._ . ...,„.. �..,� ,o'. '.,..1d1..5.F�S:,:Y'..;e^ �'"yy�'d^.z}m-e�+`#1�4'�. ,. ..�; ,.. . - t- € a . r . d nz . . t r ''',� X'. 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