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Home My WebLink About16679 (80)CITY OF WOND BAR DEPART,. �NT OF COMMUNITY & DEVELOPMENT SER,* . -ES l- 21825 E. Copley Drive (909) 860-3195 Fax (909) 861-3117 -:� BUILDING PERMIT APPLICATION JOBSITE ADDRESS `' �S �� APN LOT TRACT OWNER 4LEY _ ADDRESS : ► 0 CITY DIPr-xn4 r, 13gg ZIP r/7Llr TEL. APPLICANTC-'%Jl2VS TEL. L CONTRACTOR , xoLj $('( L� \J . ADDRESS 1 LjLI �_ -Y CITY Mi, L_57Y/i A/A ZIP ! �7�! ARCWENG/ DESIGNER ADDRESS CITY ZIP TEL. OWNER -BUILDER DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI. CENSE LAW FOR THE FOLLOWING REASON (SEG 70715 BUSINESS AND PROFESSIONS COOE:ANYCITY OR COUNTY WHICH REQUIRES A PERMITTOCONSTRUCT. ALTER IMPROVE, DEMOLISH, OR REI ANY STRUC- TURE. PRIOR TO ITS ISSUANCE, ALSO REOUIRES THE APPLICANT FOR SUCH PERMIT TO PLC A SIGNED STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS U. CENSE UW (CNA PTER9 (COMMENCING WITH SECTION TOM0) OF DIVISION 70F THE RUSIN ESS AND PRO. FESSIONS CODE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP- TION. ANYVIOLATION OF SECTION 7031.5 BY ANY APPLICANT FOR A PEPIU17 SUBJEC, S THE APPLICANT TO ACML PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (SSW)) O LAS OWNER OPTHE PROPERTY OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION. WILL DO THE WORK. AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 7044. 81,131 - NE SS UST.NESS AND PROFESSIONS CODE. THE CONTRACTORS LICENSE UW DOES NOT APPLY TO AN OWNER OF PROPERTY VI BUILDS OR IMPROVES THEREON. AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR THROUGH HIS OR HER OWN EMPLOYEES. PROVIDED THAT SUCH IMPROVEMENTS ARE NOT MENDED OR OFFERED FOR SALE IF. HOWEVER THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF COUPLE. TON, THE OWNER BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE 010 NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALE). C LAS OWNER OF THE PROPERTY. AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (SEC. 7044. BUSINESS AND PROFESSIONS COCE: THE CONTRACTORS LI- CENSE LAW DOES NOTAPPLY TO AN OWNER OFA PROPERTY WHO BUILDS OR IMPROVES THEREON, AND WHO CONTRACTS FOR SUCH PROJECTS WITH AOONTRACTOR(S) LICENSED PURSUANT TO THE CONTRAG. TORS LICENSE LAW 1 ❑ I AM EXEMPT UNDER SEC. B. a P.C. FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT IAM LICENSED UNDER PROVISIONS OF CHAPTER e (COMMENCING WITH SECTION 7000) OF DIVISION 70F THE BUSINESS AND PROFESSIONS CODE. AND MY LICENSE 15 IN FULL FORCE AND EFFECT LICENSE CLASS / DATE �. . Y (7 . CONTRACTOR r a. IPL7oF(AF o WORKERS' COMPENSATION DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS: 1 HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT 10 SELF -INSURE FOR WORKERS' COMPENSATION. AS PROVIDED BY SECTION 7700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORN FOR WHICH THIS PERMIT IS ISSUED I HAVE AND WILL MAINTAIN WORKERSCOMPENSATION INSURANCE, AS REQUIRED BY SECTION 77M OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. MY WORKERS' COMPENSATION INSURANCE CARRER AND POLICY NUMBER ARE CARRIER POLICY NUMBER (MLS SECTION NEEDNOTBE Q7.4PiETEDOF TIE PERU, IS FOR ONE EA.ICAMC JLLARS (SIM) OR LESS) I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS 70 BECOME SUBJECT TO THE WORKERS' COMPENSATION LAWS Or CALIFORNIA. AND AGREE THAT IF I SHOULD BECOME SUBJECT TO THE WORKERS' COMPENSATION PROVISIONS OF SECTON 3700 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 CML F W ES UP TO ONE HUNDRED THOUSAND DOLLARS (7100.000). IN ADDITION 70 THE COST CF COMPENSATION. DAMAGES AS PROVIDED FOR IN SECTION 070a OF THE LABOR CODE, INTEREST AND ATTORNEY'S FEES. CONSTRUCTION LENDING AGENCY I NEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE ISA CONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC. 7017• CIV C.). LENDERS NAME LENDER'S ADDRESS N CERTIFY THAT I HAVE READ THIS APPLICATION ANO STATE THAT THE ABOVE INFORMATION IS CORRECT 1 AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING 70 BUILDING CONSTRUCTION, AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES lZ C405 42&I!5z4' V PERMITTEE NAME (PRINn 02 1 TUREOFPERMITTEE DATE PRESS FIRMLY APPLICATION J D PERMIT P/C DATE J NUMBER x ISSUE TYPE OCC DATE _10CONST. GROUP ZONING SETBACKS FRONT RW REAR SIDE/SIDESTREET RWLj — SIDE r PROPOSED USE��FOFF Vrcx7c)S)IAK�-= ( !' NO. DWEL NO. NO. UNITS STORIES BEDROOMS DESCRIPTION SO. FT FACTOR PSF ADJ.AREA/VALUATION SFR/ADD/REM ' Tn Garapa/Carport W PatiD/Deck LJ- POOVSPa _ ZRe -Roof S 0 Commercial m aluation O ADJ.AREA QUANTITY DESCRIPTION FEE U D: H U w ELI 0 Z DID CL U_ QZ S U w g D CONSTRUCTION PLAN REVIEW ELECTRIC PLUMBING MECHANICIL-�_ INSPECTION FEE J N1 �J ?Qi ISSUANCE SMIP I ENERGY P/P: ' i 1,_' ENERGY PliflIFITT-' -- RETENTION FEE: PRE -ALT FEE: TOTAL FEES ( • DV. COMMENTS RECPT NO.`� 11�PAID BY VALIDATION WHITE—Department Copy, YELLOW—Finance Copy, PINK—Assessor Copy. GOLDENROD—File Copy. GREEN—Applicant's Copy