HomeMy WebLinkAbout19030 (39) . /^.r� --�-- ....: C/C lluw�v.w�.....-. _. /
DEPARTMENT OF COIVIIviUN[IY 8t DEVELOPMENT SERVICES Jy'
21625 E.Copley Drive
(909)860-3195 Fax(909)861-3117 PRESS
� ^"'"'� SUILDINGPERMITAFPLICATION " FIRMLY
'n JOBSITE APPUCATION ; - PERMIT p/p
o ADDRESS �'J'' DATE NUMBER A
� ISSUE , 7YPE pCC
APN—(-�—�LOT--{— TRACT DA7E CONST. GROUP
p OWNER 1""L(✓�✓1 'lTAS , .
u" ADDRESS � '� ZONING SETBACKS
0
� CITY � ' ZIP;-" TEL ' FRONT RW ❑
APPLICANT ' ,T��• SIDFJSIDESTREET RW ❑
� CONTRACTOR' •' ` SIDE ❑
� ADDRESS ' '
p . PROPOSED USE
CITY • ZIP -TEL.
o ARCWENG/ ' � ..._
� DESIGNER
ADDRESS N�.OWEL. _ ' NO. NO.
� CfTY ZIP TEL UNITS STORIES BEDAOOMS
�
cn DESCRIPTION S�.FT. FACTOR PSF ADJ.AREANALUATION
p� OWNEH•BUIIDER DECLARATION SFR/A00/REM
O
1 NERE9Y AFFMiM UN�ER 7ENALtY OF OERA1Rv i1/AT 1 AY FXEMDT FROA1 TNE CONTRACTORS LL O8i8p6/CB�pOfI
� CEHSEUWFOf1THEFOLLO`MNOREASON(9EC.7alt.6&15NE59AHDiROFE5510N9CO0EANVGTYOR (n
LOUNTYW/IIQ/REQURESAVEAMRTOLONSTRUCT,ALTERMPROVE,DEMOLISN,OIiHEFAIRAN'/STRl16 W PatldDeck
7URE,PPoOR M RS ISSl1ANCE,ALSO REOUIRES THE MPLiCANT FGl SUCH PERMIT TO FILE A SIGNED W
SU7EMENT TNAi ME OH SME IS LICENSEO RJRSUANT i0 7NE PROVi5lON4 OF TY1E OONTPACTOR6 L4
� � CENSfUW�PTER�(OpJMENCYq1MfTNSEGTION)000�OFOINSIONiOFTHEBUSINESSIWOPqO- V" PooUSpa
FESS�ONS COOE)OR TNAT ME OR SME IS El(EMPT iMEREFROM ANO TME BASIS FOR T/1E ALLE�EO E%EMP•
TqN.ANVV10lAT10NOG5ECT10NTW1.50VANVAPpLICANTFORAPERMITSUBJECT4THEAPVIICMITN Z Re-Rool
F, ACMLPEIULTYOFMOTMORETIW1iIVEM1NOREDDOttARSliSao).):
� �4�OWNEHOFTIIEVROPERTY,dIWEMDIOVEESWITMWAGESASTMEIqSOIEOpMPENSATM)N. O Canmerclal � �
WM1L DO TNE WORK AND THE STRl1CTURE tS NOT It/TEnDFA OR OFFERED fOR S�LE(3EC.701a,BU31• J
� NE54 A!q iNOFE5510N5 COOE TME COffTMLTOR3lICENSE lAW DOES NOTADOLY TO AI:OVMEROG j
OROPERTY M11D BUM1.OS OR MPROVES TIEREON.MA MfHO DOES Sudl VAHK HIMSEIF Oq HERSEIF OR �
K TMROUQHMSORMERONTIEMVLOYEES,VROVDEOTMAiSUQ11MPROYEMENTSAPENOTINTEIAE�IXi CL�
�1 OFFFREO FOR 8ALE K.F10WEVER iME BURANO OH MPROVFMEIYI6 SOID WRHM p7F YFAR OFCOYpIE.
z TION.TNE 01VNER�UIL�ER WILL MAVE TME BUNOQI OF VHOVYXi TFNT NE OR SME DID NOT BUIL.D Oq
YiROVE FOq THE OURFOSE OL 4ALE}
O 1,A4 OWNER OF hIE iROVEi1TY,AM EXCLUSIVELY CONTRACTNO WfTH LILENSED COMMCTORS
(= 7D CONSTRUCT TNE PROJECT�SEG)Ou.BUSINE33 M1D VROiE5510N5 CODE TME CONTRACTORS U� VlIU8SI011 � ADJ.AF7EA
W CEHSEUWDOE9NOTMFIYTOIWONMERDFAPR07ERTYWHOBU0.D30RWPROYESiNERE011,AND
T� WNOCONTRACi3FOR5Uf]IiRO.1EMSM7THACOMiMCTOfi�5�l10EN5EDM1RSl1ANTTOTHE00NTRA6 QVANTITY DESCF�IPTION �E
� TORSLICENSEUW.4
O 1 MA EXEMPT U1AER SEG B.�P.G fOH TMIS REASON Q
3 �'
� �
OATE OWNER V
�Z �
LICENSED CONTRACTORS DECLAAATION W �
� IMEHEBYAFFlRMUNDERPENAITYOFVEFWRYTMATIMILIGEN5E0UNDERPf10V1510N90FCHAPTER Vr
p_ •(CpMAENCIN6NnTNSECTION7000)OfDMSqN�OfTHEBU5MES5�NOPROFE55qN5CODE,NA Z
� W UCENSE 6 N ML FORCE MU EiFECT. m
� LICENSECLASS 11C.N0. - ,. .. �
VpATE � CONTMCTOR � �
W � `
� WORKERS'COMPENSATION DECLARATION �"""`••`�� - �
NINEREBYAFFtIM1UNDERCR1AlTVOFiERIUHYONEOFTNEiOILON'INa�ECUqAT10N5: Z
� _I/1AVEANOWiLLMAINTAtNACERTIFlCATEOFCONSEMTp$ELFJNSUREFORWCAKERS' 41'
COMPENSnTqN.ASPROViDEUBYSECT�OH77000FiHEU1BORCOOE.FORTHEPEHFOiWANCE W
OFTFIEYVOPoCFORWHICNTH19pENd�TISi55UED. � �
�
Q �I HAVE ANO NnLL 4AwTAW WORKEIIS'COM7EN5l�TqN INSURANCE,A3 PEOUIRED BY SECT�ON /� �v)�
� itao OF TME IABOR COOE,FORTNE OfRFpRMANCE OF iHE MIORK FOR WMCH THt4 VEIUAR 15 I /,�. �J.V
� ISSUED.4YYqPo(ENS'COMPEqSATpNWSURANCECMfilERM10POLICYHUMBERME: CONSTRUCTION � !/V
� urrrueq PLAN REVIEW
� va�cr wueen y ELECTRIC
� (M163ECrcNrEIDwTBERY.FIEimOFi)EPFlMfisFCaaElU�D17Ep00t1N1S(floqOntE55} PLUMBING
Z ICERTiYTMATMiMEPERfOiWANCEOFiMEWOi1KFOqWHiCHTF114PERMIT6iSSUE0.1 MECFIANICAL
(} SHALLNOTEYPLOVANYPERSONW/�NYYANNERSDASTOBECONE9UBJECTTOTME
N YqRKERS'COMVEN9ATqNlAW50GCIlif-0RNIA,ANO�ppEEiHAT614/KKILDBECOME INSPECTIONFEE
S SUaIECT i0 TNE WORNERS LOMPENSATION YROYISIONS OF SECTION]7000FTHE LA60R �.
OODE,I SHALL i011i1NnTH CpAPLY NA7H THOSE PiqVIS�ONS. ISSUANCE �
O . �� �`�..:-� .,� SMIP
p OATE: '� �APPLICANf: .
� WAANiNGFA1LURETOSEWREM�RNERSCOMPFJi5AT1ONGOVERAGEI3UNUWFUL,IINDSMKLBE ENERGYPPC
� SUBJECTINEM7lOVERTOCRYAULVENALTIE4lWOCMLiWESU�TOONEHUNDRED7MQ1SAN0 ENERGYPERM�T
DOLUR9 p t00.000).W ADDITION TO THE COST OF�pMPEN5AT10N,DAMAOES RS PROVIOED FOR IN
¢ SECiqNl7osOFTMEUBORCODE.INTEi7E5T,AN0ITiOM'EY3FEEi RETENTIONFEE: �
a CONSTRUCTION LENDING AGENCY PRE•ALT fEE:
O
� � IHEREB`/AFFliWUNOERPENKTVOFFERNRYTNATiNEREISACONSTRUCTION�ENDwQAOENCY
Z FOP iNE GER W RMANCE Oi TNE M'ORN fON MMKH TMIS PEiwiT IS�SSUEG(SEC.NY7,pY.G�.
W
� LENDER'S NM1E
C lEN0ER5ADORE55
� ICERTIFYTHATINMEREAOTIII4ADPLICAt10NANOSTATETUiTXEABOVENFONNATIONISfDRREC2 TOTAL FEES ' � ' �
� IAGRFE70CdAPLYYATMALLCffYNACOUNTYONDWANCE5ANO3iA7EUWSRELATNOTpBULDINd ' �' '
� QDNSiRUCT10N.ANOHEAEBYW7Fqfi1ZEREPRESENTATIVE50iTHI5001A'/TYTOENiERUPONTHE
��E�MEN710NE0 PROPERTY FCR INSPECTqN PVRVOSES. COMMENTS
�
J , .
�
m PEPAIIREENAtAE(PWM�
Q �_._
flJ
� 8�CNATURE OF VEAMITTEE DATE , {•,
� RECPT.NO.� ' � P/UD BY ' ` VALIDATION
WHITE-0epartment Copy,YELLOW—Finante Copy,PINK—Asseisor Copy,GOLDENROD—Fil�Capy.GREEN—Appl�canCs Copy
� ���-��
!. -. ��� �
�' �
. . . . � .�
- �����
�1
�� �-