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Home My WebLink About12320 (13) ..-.., �__.�,, .. ..,_ .... . : : �� _ CITY OF DI. .�ND BAI� • - DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES 2]660 E.Cnp}�y Brive Suite 190 .' -� ,,.,._....•. (909)860-319S,Fax(9(f9)861-3117 � PRESS � BUII.DING�'ERMIT APPLICATION ,,,. _. ,: FIRMLY <.. ,., . , , .. ..... .. . .....,:. � JOBSITE /_ �] L[��]��.J�� ' APPLICATION�� (yPERMIT '�� .a�. � P/C � o ADDRESS I�J 1 •r� / v DATE �a NUMBER� # c� ,� ;ry ISSUE Q�,^2 D�� "�PE OCC APN LOT TRACT_7/`7 DATE__1 � o CONST. GROUP p OWNER o ADDRESS . - «,± ZONING SEl'BACKS Z CITY��,�.�ZIP��TECL37��,�.� REART RW � g APPLICANT TEL. SIDEJSIDESTRE�T RW 1 � CONTRACTO J/E'. �� .��-'-; CH'w SIDE _ � ADDRESS �' /�:� � CITY Ir. _ ZIP dt°�=' �ZZ�•'��j.� PROPOSED USE-- pARCH/ENG/ _ � DESIGNER ------- NO.DWEL. NO. NO. p_ ADDRESS UNITS STORIES BEDROOMS � CiTY ZIP TEL._ — � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � O � OWNER-BUILDEH D�CLARATION SFR/ADDlREM 0 I HEREBY AFFIRM UNDER PENALN OF PESLIUPV THAT I AM F%EMPT FHOM TH'c CONTRACTORS LI- �gf999/CefpOfl W ' CENSEIAWFOiiIHEFOILOWINGREASON(SEC.7037.SBUSINF.SSANOPROFESSIONSCODE:ANVGTYOR (n U COUNiYWMICHREWNRESAPERMRTOCL'NSTRUCT.ALTER,IM7ROVE,DEMOLISH,ORREPA�RANVSTRIIC- 1! patiolDeCk w7URE,PRIDR TO RS ISSUANCE,ALSO REWIRES THE RPPLICAM FOR SUCH PERMIT TO FILE A SIGNED w � STAIEMENT 7HAT HE OR SHE IS IICENSEO PURSUANT TO THE PqWISIONS OF THE CONTRACTORS LI- � CENSE LAW(CHAPTER B(COMMENCING WITH SECTION 7DOOj OF DIVISION 9 0F l}IE BUSINESS AND PRO- V' POOJSpd FESSqNS CODE)OR THAT HE OR SHE IS EXEMPTTHEREFROM AND THE BA515 FOR THE ALIFOE�F%EMP- � TqN.MlYVIOLATIONOFSECTION7031.SBYANYAPPLIGANfFORAPERMITSU&IECTSTHEAPPLICANTTO Z RB-ROOI � ACML PEN�LTY OF NOT MORE THAN FNE HUNORED DOLLARS(SsoO�.): � GI,ASONMEfiOFTHEPROPERTY,ORMVEMPLOYEE5YVI7HWRGE5R5THEIR50LECAMPENSATION. � ;;Omm6rCial ' WILL DO THE WORK.M1D THE STRUCTUflE IS NOT INTEN�ED OR OFFEREO FOR SALE(SEC.lOd4.BU51- .J NESS AND PLqFESS10NS OODE:THE CGN7RACTORS LICENSE LAW OOES NOT APPLY TO AN OWNER OF � PROPEHTVNMOBUILDSORIAiPROVEStHEREON,ANDWHODOE55UCHWORKHIARSELFORNERSELFOR � � THqOUGHHISORHEROWNEMPLOYEES,PROVIDE�THATSUCHIMPROVF_MEMS'APF.NOTINTENDEOOR � QOFFEREDFORSALEIF,HOWEVF.R7MEBUIIDINGORIMPROVEMEN?ISSOIDWRHINONEYFAROFCOMPLE� _ Z TIDN,TNE OWNER-BUILDER WILL NAVE THE BURDEI4 OF PROVMG hiAT HE OR SHE DID NOT�UILD OR = IMPROVEFOH7HEPUFWOSEOF5ALE). � � ❑I,AS OWNER OF7HE PROPERTV.AM E7(CLUSIVELY:AN7qAC?ING WITH LICEYSED CC4'TRACTOflS � 70 CANSTRUCT THE PROJECT(SEC.1044,B1151NESS AND PROFESSIONS COOE:�FIF COYTqAC?ORS LI� Valuatlon _ ____ ____ADJ.AFEA_,_ LU CENSEUWDOESNO7APPLVTOANOWNEROFAPROPERTYWHOBUILDSOP,IMPROVESTNF.REON,ANO � WHOCONTRACTSf-0RSUCHPROJECTSWITHA(bNTRAC?OR(5)LICEUSEDPIJRSUANTTOTHF.CO4TRAG QUANTITY DESCRIPTION FEE � TORS LICENSE UW.). _ r o ❑1 AA9 E%EMPT UNDER SEG.___________B.n A.C.FOR'HIS REASON ` Q�_� Ci U"�e'f��(�CS i f ' OO � _ - � �I A _ �r T 00 DATE _'_ OWNFR____'_— ---- U� I .�" � ' . ' � ' D(/ � LICENSED CONTW>CTORS DECLARATIGN � �i I�j ^ �r � W .:a _ �R �f �C�l S � o � O 1 HEREBV AFFIRM UNOER PENALN OF PERJURY THAi IAM L!CEYSEO UNDER PROVU'IONS OF CHNTER 3 / f�. /► � � e(LOMMENCING ri1TH SECTION 7000)OF OMSION 3 0F THE 6UStNESS NND PROFESSIOYS CADF..AND � .�_ r �/��'.W E�,�!� {°ti Sd X MY LICENSE IS IN FULL FORCE M7�EFFECT. i /J' �, : m _��fi. r=�,� ^ i� .� t� o LICENSE CLASS_ ____. LIC.NO._ � �J �� i re�fuc�. C_C:�.3 32 [� ~ DATE GONTRACTOR_"___._"_ � d — � '___"__ � �isz�---�'" � WORKERS'CQMPENSATIO�!DECLARATION _ ��? � -:�r� 2 60 �O � IHEREBVAFFIRMUNDERPENALTYOFPERIl1pYONEOFTHEFOL!OWING�F.CLARA?IONS: 7I t!J ¢ � IHAVEANDWILLMAINTAINAGER7IFICATEOFCONSENTTOSELF-iNSUREFORWOR{�RS' _�— � COMPENSATION.ASPHOVIDEOBYSFCTION37000FTM.E:ABORCODE,FORTHF.P�RF'ORMA4CE W� .__— OFTHE WOPoC FOR WHICH7HIS PF.RMI715155UE0. �i � _IHAVEANDWIILMAItiTAINWORKEHS'CAM7ENSAT!OVINSURANCE,ASREOUIP.EDF,YSECT!ON � Q 37000F THE LAPAR COOE,FOH THE PERFORMANGE OF THE WORX FOR WHICH THIS PEPMIT�S ISSUED.MYSVORKER�'�MPENSATIONIiJSUMMCECARR:ERAN7POlICYNUMeEFAR`c I CONSTRUCTION ___.___._._ ____.__ _______ __.__.______ J j cnaaiEa___ PLANREVIEW ._____ ____ Z POLICYNUMBER _ __...____ ._.____.._--_ ELECTRIC _________ _ 6 (fHISSEGRJPINE�NOTBEWMR.EfWOF'PF!EPEMARISFo�CNEHUhA:REDIX%.UNS(StOGl��55�. � PLUPv7BING �o � '— _ � 1 CERTIFV THAT IN7HE PERFORMANCE OFTHE WDRK FOR WHICHTHIS PERMI?IS ISSUE�.� MECHANICAL __��_ D � _"__"'__—___' (�J SHALL NOT iMPLOYANY PE0.50N IN RNV MANNER SOAS TO BEfAUF.SU9JECT TO'HF � WORKERS'COMPENSATION LAY1S OF CALIFORNIA,RND AGREE TH0.T IF I SHOl1LD PF_COt�1E i � I��SPECTION FEE ____ _ SUBJECTTOTHFWORKERS'�MPENSATIONPROVISIONSOFSECTION3'1n00F7HclA30P ' i — D OD oCOOE,I SHALLFORTHWITH COMPLY WVTHTHOSE PROVISIONS. ISSUANCE ____ _ � p DATE: APPLICANT: _ _.__._______ SMIP __ ____ W ENERGY P!C J WARNING.FAIIURE TO SECURE WORKERS'COMPENSATION COVf:RAGE IS UNLAWFUL,ANC SHALL BE — J � SUBJEGTpNEMPLOYERTOCRIMINALPENALTIESANDCIVILFIYESUPTOONEHUtiDREDTHOUSANO ENEHGYPERMIT DOLLARS 1310D.000).�N AO�ITION TO THF.COST OF COMPENSATION.DkM0.GE5 AS?AOV!DEO FOR IN — — � SECTION370BOFTHELABORCODE,INTLREST,ANDATTORNEV'S�EEs. RETENTIONFEE: _______—__.___.— — a CONSTRUCTION LENDING AGENCV pHE-ALT FEE: ___ ___ _ O � ISiEREBYAFFIflMUNDERPENALTYOFP[flJURYTHATTH[REISJ�CO45TRUCTIONLEN71N6A(3F.NCY � FORTHEPERFOR�IANCEOFTHEWORKFORWFnCH'HISPERN.ITISISSUEO(SEC.3om,CIVC.) ---��-- Z W � LENOER'SNAME_,._ -- _ _ ' � lENOER'SADDRESS___.______.____ . � ICERTIFYTHAiIHAVEFEADTHISAPPL{CATIONANDSTA:ETHATTHEABOVEINiORNNTKNJISCORREGT. TOTALFEES � � (Ji �D W IAGREETOCAMPLYVATNALLCIT/ANDCOIINTYOR�INANCE5AND5TaTELAWSRELATINGTOOUILDING � ! � CONS7RUCTIOY.AND HEREBY AUTHORIZE REPRESENTA7IYES OF THIS COUNN TO ENTER UPON TME C:3 A80VE-MFNT ED PROPERT'FOR INSP'eCT'AN PURPOSES. � Q � �� _ COMMENTS�. '� ' � � • Q PERMITTE (PRINT) [°� f i c� � C�� ---� .: � SIGNA HE I DA7E �� pECPT.NC. �� ;,__ PAID BY _�� -. 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