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HomeMy WebLinkAbout12786 (11) �� CITY OF DIAA�IQND BAR �,? - rt DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES � f� s „ 21660 E.Copley Drive Suita 190 � � (909)860-3195 Fax(909)8b1-3117 �s PRESS � ������°�� BUQ.DING 1�ERMI'�"APPLICATtON ' � FIRMLY � JOBSITE /� ��j � APPLICATION �` PERMIT � P/C o ADDRESS ( 0 0 L��� l/1� � ' DATE_ � "" � . NUMBER ��� � #_ � APN �OT�� TRACT__��� D TEE CONST. GROUP p OWNER D(L� ON D � �,. � � LL ADDRESS �,� � R T� IZf1� '� ��.2 ZONING SETBACKS Z CITY _��j? ZIP Q�� TEL.�G�'2�2�Q R�O�NT RW �,_ g APPLICANT _�_�Q__ TEL�Fj3c��2S�'� SIDE/SIDE STREET RW �I � CONTRACTOR " PACI E=-t CA__.���. S��� � ADDRESS_� -Q-� p C�TY �pr,n,p�A �ZIP�(C�O 7 TE�L �.��� y�L pp PROPOSED USE ���_cf s�[uzo� o ARCWENG/ _ W DESIGNER NO.DWEL. NO. NO. a ADDRESS_ UNITS^_ STORIES BEDROOMS � CITY ZIP 7EL. _ � � DESCRlPTION SQ.FT. FACTOR PSF ADJ.AREAlVALUATION p� OWNER-6UILDER�ECLAP.ATION SFRIADD/FEM O -- Q I HEREBV AFFlRM UNDER PENALTV OF PERIURY THAT I AM EXEMPT FROM 7FIE CON?NACTORS L'- � Garage/Carport [d.! CENSELAWfORTHEFQLLOWINGREASON(SEC.7091.SB1151NESSANOPROFESSION5CO0E:ANVCITVOR . CS C�UNTVHMICNREWIRESAPERMRIDCONSTRl1CT.ALiER,IMPROVE,OEMOLSH,ORREPAIRANVSTRUC- �,jj py����Deck W TURE,PHIOR TO ITS ISSUANCE,ALSD RE�4�IRES THE APPLICANT FOR 6UCH PERMIT TO F!L'c A SIGNED W STATENENT THAT HE OR SHE IS LICENSED PURSUAN7 TO THE PROVISIONS OF THE CANTRACTORS LI- - � CENSE LAW(CHAPTER 9(COMMENCING WITH SECTION 70001 OF DIVIS�ON 3 OF TFIE BUS�NESS AND PRO- LL PooVSpa � FESSIONS��ORTHATHEORSHEISEXFMPTTHEREFROMANDTHEBASISFORTMEALLEGEGEXEMP- (!� '-- ,� TNIN.ANYVKKATiONOFSECTION7091.5BVANVAPPLICANTGORAPERMIi5U8JECTSTHEAPPLICANTTD Z Re-RooP � ACMLPENALTYOFNOTMORETHANFIVEHUNDREDDOLLARS(55o0)): ❑1,AS OWNER OF TH'c PROPERTY,OR MY EAIPLOYEES WITNI4AGES ASTHEIR SOLE COlACENSATIOh, Z � Commercial __ - YVILL DO THE W�RK.AND THE STRUCTURE IS NOT iNTENDED OF OFFERED FOR SALE(SEC.701a,BUS'�.� J NES�A4D PqOFES510NS COOE:THE CAN7RAC70RS LICENSE LAW DOFS NOTAPPLV 70 AN OWNER OF I � P{WPERTYWFIOBUILDSORIMGqOVESTHEREIXJ,ANDWHODOESSUCHWORKHIMSELFORHERSELFOR � (� THRIXIGHNISORHERONMEMPLOVEES.PflOVIDEOTHATSUCHIMPROVEMENTSARENOTINTEN'JEDOR �'� � OFFEREDFORSILLEIF,HOWEVER,THEBUILDINGORIMPROVEMENTISSOLDWITHINONE.VEAROFCOMPLE- i _ � ipN,hiE OWNER$UILDER WILL HAYE THE BURDEN OF PROYING 7HAT ME OR SHE DID NOi 5U:1 D oq � IMPROVE FOR7HE PURPoSE OF SALE). '- qyJ C71.ASOWNEflOFTHEPROPEHTY,AME%CLUS�YELYCONTRACTIMGWRHL'CF.NSE�CON7RM1CTORS �-'--- �[ TO CONSTRUCT THE VROJECT(SEC.704l,BUSINESS AND PROFESS!ONS COOE:THF CONTRACTORS LI� I V81U8�1Of1 ADJ.AREA_ 71J CENSEIAWDOESNOTAPPLYTOANOWNEROFAPROPERTVWHbBUILD50HIMPROVF.5T11EFEON,AND ---- - = WIKICANTMCTSFORSUCHPROJECTSWITHACONTRACTOq(S)LICENSEDPURSU�YTTOTHECANTRAC- � QUANTITY DESCRIPTION FEE YTOFi9 UCENSE UW.) �_ � _"' �� - []I AM E%EMP7 UNDEti SEC. B.6 P.r„FOR 7Hi5 aEASOh U i _ � � r - , ' - � DATE __ OWNFR_'___-_'_-_-'_'_'-_"""_ �� / � � U I W; �Q LICENSED CONTRACTORS DECLRApTION W i CL I HEREBV AFFIRM UNDEFl PENALTY OF PERAIRV THA71 AM LICENSED UNOEfi PROV!SIONS OF CI'AP?[R �! � 9(COMMENCINO WITH SECTION 7000)OF DIVISION 30F THE Bl15WESS ANO PRDFESS'ONS COOL.A40 Z i , � MY LICENSE IS IN FULL FORCE ANO EFFECT � mi o LICENSE CIASS � LIC.NO._��_��,��._` I �r- V DATE_�����_ CONTRACTOR__���,�._.�S(J� d� W � WOP�KEFIS'COMPENSATION DECLARATION �� � N U r-- � 1 HEREBV AFFIRM UNDER 7ENAL7V OF PERIURY CNE OF THE FOLI.OWING DFCLAF0.TION5: I z� I Q` Q .�IHAVEANDWILLMAINTAINACERTIFlCATEOFCONSENTTOS'eLf-I.NSL'RFFORWORKERS �; � COMPENSATION.ASPROYmFDBYSECTION3)OOOFTHe'IABORCOOf_,FORTHEPEaFORMANCE ' ��.__ � I OFTHEWORKFORWHICMTHIGPFRMITISISSUED. : � O ` � _IHAVEANDWILLMAINTAINWORKERS'COMPEkSATIONINSVRANCE,ASRE(]V.RF.DBYSEGTION f Q � 370o OF THE LABOR CODE,FORTHE PC-RFORMAwCE OF T4E WCRK(OR WHiCH THIS PER�A;T IS 0 � ISSUE�.h9Y YJOFNERS'COMPENSATION INSURANCE GARFlIER AN�POUCY NUM9ER ARE CONSTRUCTION _____ ___ Q y , cnaaieA__. ___ .. PLAN FiEVIEW . � 70LICY NUMBER_ �_____'_'"'_'_..._. _. @LEIi~TN � '_'_ ___��� r Q Q (fHISSECiIONNE�NOiBECONPLEfEDOFTHEPERMITISPoRONFFiJk�iIEDDCLIARS�S70CjORLESS� `PLUM6ING ---- ��-- - � I CERTIFY THAT INhIF PERFORMANCE OFTHE WOHK FOr^,WHIGH THIS PERASITIS ISSUFD.I g MECHANICAL _____,_,_ ! (J SHPLL NOT EMPLOY ANV PERSON IN ANY tAANNER SOAS�O BFCAME SUL'.iECTTO THE ���/� (q WORKEFS'COMPENSq710NLAW$OFCALIFORNIA,ANDACREETHATIFISI:OJLDBLCOME � INSPECTIONFEE _ .�y� _o�'� � SU&IECTTOhIE1NORNERS'COMPENSA'IONPROYISION�OFS'cCTI0Y17700F'H`clA90R � ��� �JoJ{i � � CADE,iSHALLFORTHW17HCOMPLYWITHTNOSEPROVIS!ONS � iSSUANCE __,_, L=�L � Y1 SMIP 2 R A 17.�AAT f_y���y p DATE:���L�B APPLICANT: __� i�Py�_�•+'1'- --�-- � Yl v J WAflNING:FAILURETOSECUREWORIfERS'COMPENSATIO�f,OVEFlAGEIS�NLAWFJL,AN'�SHM1I.:.BE ENEflG.P/C �}$�-��F(e, AA�71��T.�,.'�,+��_ � SUBJECTAIVEMPLDYERTOCRIMINALPENALTIESANOCIV!LFINE£UPTOONEHUNJREDTHOLJSANJ � AJ6.Jf.1.+=�11�V r'��t'� � ODLLARS(SiOa.Goa),IYA.�D:TIONTOTHECOS?OFCOM?FNSATION,C7AMAGESASPAOVIDEDFOFIN � ENERGYPERMIT ___.,___ _! J SECTION 37oe OF�1-IE LABOR CODE,INTEREST,ANDO.TTOPNEV'S�EES. RETENTION FEE: � _-_-'_ OCONSTfiUCTION LFNDING 6.GENCY � PRE-AL?FEE: __ _ _ __ � IHEREBYAFFIRMUNDER?ENALTYOfPCR:URYTIIATTHr�C10ACOHETFlVCTIONLCNDINCACCNCV � d- FORTHE PEflFOflMANCE OFTHE WORK FOR WH!CHTFiIS PERMIT:S ISSUEO(SEC.3.^4!,G�V.C.�. ----- . Z � W _"_ � LENDEH'SNAME__'__`_"_'_ _"'___ ____ I'- LC-NDER'SADDRE55____ ...___ ____ �/') � ICERTIfYTNqTIHAVEREA�THISAPPLICATIONANOSTATETHATTHER90VEINFORMATIONISCORRECT. TOT/'SL�EES ✓ ` � IA6REETDCOMPLVWITHRLLCIiYANDCOUNTVOflDINANCESANDSTATELAWSRELATINGTOBUIL�ING � � C-0YSTRUCTION.AN�HEREBYAUTHORiZEREPRESENTAi1V�5aFTH�$COUnTVTOENT�RUPON'HE • Z ABOLE-MENTIONED PROPEFTY FOR INSPECTION PURPOSES. COMMENTS j � /� ��(( ( � J l 1 1 n � .�l_�_!-�1�/____- _________-�- ] m PE{iMITTEE NAME(PPoNT � Q __' -_ `� "° ��-------��=10-`��.-- --- - � Uy SIGNATUiIE OF PEPMITT DATE � = RECPT.NO. _-�._�PAID BY V��� ~ WHITE—Department Copy.YELLON/—Finance Copy,FINK—Assessor Copy,GOL�ENRO�Fiie Copy,GREEN—ApplicanYs Copy �`�' . iR'S. -' 'fi.a �k "t g' E_ � . � .. ..,'�s=�s�:� s:r�:�::«i �'���'i''. ., €'a�'�:. . ... .. r'�A'S�� ,"t�"y ..Y��t�� - .-.:�: a...:.x�:'.;.t x ., 't '.::'L i'-•,.:.,.�.. ' " ��':z :l"� " - T'£': i F:"'Y'ttY"'w ' •i:'.•<fiY?!'-':c4rKs;XSYMc^^"ZF'e-:.'+Y6;, � �., , F 6••;..: - . ._., . �.....;:,'.. :§, °v„' :-�z"rt�. .j,'''c � :�;�.':� Zf:::�...�.'»: �rr+�a%.:' a: . -, " Y• � -..�' ,..' i: �`° �x �t,�. '" .�$�.iE7�s��7'�� � �V` �}' ,�� =';i r,. � �.. �. ��w; `}•;� ' ',F#I,.., . 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