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Home My WebLink About16679 (77)CITY OF WOND BAR DEPAR'I,._.NT OF CONLMUN17Y & DEVELOPMENT SER,* . -ES IXC. C 21625 E. Copley Drive (909) 860-3195 Fax (909) 861-3117 BUILDING PERMIT APPLICATION JOBSITE ADDRESS i l,d� [��lJ C►, �{PJG APN LOT TRACT OWNER _JEY ADDRESS cITY D►ArJn feRE ZIP �17L� TEL. APPLICANTe-MIRK Q!r&e f,",Oi7 TEL CONTRACTOR_ `c; -_ X31 15 (A L rna 112 ADDRESS AI c -,c1 r:_ o_i.A� :JAY - CITY {rl. (&24 AIA ZIP i7"- / TELY7`i'�Chi S Fs$� ARCFVENG/ DESIGNER ADDRESS CITY ZIP TEL. OWNER -BUILDER DECLARATION 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LH CENSE LAW FOR THE FOLLOWING REASON (SEC. 703I.S BUSINESSAND PROFESSIONS CODE: ANY CRY OR GOLMTY YY/IIClI REQUIRE S A Df RMIT TO CONS7AUCT, ALTER. IMPROVE. DEMOLISH, 011 REPAIR ANY STRUC• TURF PRIOR TO ITS ISSUANCE. ALSO REOUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS Lb CENSE LAW (CHAPTER (COMMENCING WITH SECTION 7000)OF DIVISION 5 OF THE BUSINESS AND PRO- FESSIONS WOE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP- TION. XEMP.TI N. ANY VIOLATION OF SECTION 7071.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS tIlSOCI 1' ❑ L AS OWNER OF THE PROPERTY. OR MY EMPLOYEE S WITH WAGES AS THEIR SOLE COMPENSATION. WILL DO THE WORK, AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 7044, BUSI. NESS AND PROFESSIONS CODE THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF PROPERTY WHO BULDS OR IMPROVES THEREON. AND WINO DOES SUCH WORK HIMSELF OR HERSELF OR THROUGH HIS OR HER OWN EMPLOYEES. PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR OFFERED MR SALE. IF. HOWEVER THE BUILDING OR IMPROVEMENT ISSOLD WITHIN ONE YEAR OF COMPLE- TION. THE OWNER -BUILDER WILL HAVE THE BURDEN OF PROVING THAT NE OR SHE DID NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALEL C L AS OWNER OF THE PROPERTY. AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (SEC. 70-11. BUSINESS AND PROFESSIONS CODE- THE CONTRACTORS LI. CENSE LAW DOES NOTAPPLY TO AN OWNER OFA PROPERTY WHO BUILDS OR IMPROVES THEREON. AND WHO CONTRACTS FOR SUCH PROJECTS WITHACONTRACTOR(S) LICENSED PURSUANT TO THE CONTRAG TORS LICENSE LAW) u 1 AM EXEMPT UNDER SEC. B. A PC. FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT IAM LICENSED UNDER PROVISIONS OF CHAPTER I (COMMENCING WITH BECTON 7000) OF DIVISION S OF THE BUSINESS AND PROFESSIONS CODE. AND MY LICENSE IS IN FILL FORCE AND EFFECT LICENSE CLASS - l y LIC. NO. 7Sa 31 DATE CONTRACTOR C , f:4,- �dOFIl1}�a WORKERS' COMPENSATION DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE CF THE FOLLOVJNG DECLARATIONS. I HAVE ANO WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF.INSURE FOR WORKERS' ION. AS PROVIDED BY SECTION 7700 COMPENSATION. OF THE LABOR CODE. FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED 1 HAVE AND WILL MAINTAIN WORKERSCOMPENSATON INSURANCE. AS REWIRED BY BECTON 5700 OF THE LABOR CODE. FOR THE PERFORMANCE CF THE WORK FOR WHICH THIS PERMIT IS ISSUED- MY WORKE RS' COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE CARRIER POLICY NUMBER (PULSSECTIONNEEDNDTBEOWtE'rMOFTHCPERM-ISFCACNENIn ODOLIARSDIOC)ORLESS} I CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I SHALL NOT EMPLOY ANY PERSON N ANY MANNER SO AS TO BECOME SUBJECT TO THE WORKERS' COMPENSATION LAWS OF CALIFORNIA AND AGREE THAT IF 1 SHOULD BECOME SUBJECT TO THE WORKERS' COMPENSATION PROVISIONS OF SECTION 7700 OF THE LABOR CODE. i SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS DATE: APPLICANT WARNING' FAILURE TO SECURE WORKERS" COMPENSATION COVERAGE IS UNLAWFUL. AND SHALL BE SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FNES UP TO ONE HUNDRED THOUSAND DOLLARS (5100.0001. N ADDITION TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR IN SECTION 0700 OF THE LABOR CODE. INTEREST, AND ATTORNEYS FEES. CONSTRUCTION LENDING AGENCY I HEREBY AFFIRM CINDER PENALTY OF PERJURY THAT THERE 5 A CONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC. 30I7• GV. C.). LENDERS NAME LENDERSADORESS 1 CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT 1 AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING CONSTRUCTION. AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES �'Nk7 /�%LKL��YYIAN PERMI111IJAME(PRIM) - TORE OF PERMITTEE DATE OF PRESS FIRMLY APPLICATION J O PERMIT P/C DATE J NUMBER N ISSUE TYPE OCC DATE CONST. GROUP ZONING SETBACKS FRONT RW REAR _ SIDE/SIDE STREET RWLl - SIDE PROPOSED USE _ CFF V rLL>O OS AA K E NO. DWEL NO. NO. UNITS STORIES BEDROOMS DESCRIPTION SO. FT. FACTOR PSF ADJ.AREAA/ALUATION SFR/ADD/REM ' fn Garape/Carporl W Patio/Deck LL PocUSpa - ZRe•Flcd Sr Commercial m aluation OO C. ADJ.AREA ou-AWITY DESCRIPTION FEE J a U Q H U w J LAI CD Z m a U Z a 2 U W CONSTRUCTION -D PLAN REVIEW ELECTRIC PLUMBING MECHANIC JL :�_ _ INSPECTION FEE J UN 1 ISSUANCE .i Z�ym o SMIP ENERGY P/C;_3 y+. ENERGYkliroR�"--•-•-- RETENTION FEE: PRE -ALT FEE: TOTAL FEES 1 AN • D V, COMMENTS fa A Oct RECPT. NO. _ - PAID BY VALIDATION WHITE—Department Copy. YELLOW—Finance Copy. PINK—Assessor Copy, GOLDENROD—File Copy. GREEN—Applicant's Copy 1 lvr"!y -j a? loh-b