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HomeMy WebLinkAbout16890 (40) CITY OF Il3AMOND�AR �``' --- DEPART'IvIENT OF�OIvIMUNITY&DEVELOPMENT SERVICES 1 1 I`� 21825 E.Copley Drive {409)860-3195 Fax(909}861-3117 PRESS ""%Yny BU�LDING PERMIT AF�Y.ICATION FIRM LY � JOBSITE yy� �,/ � ,,,,y� ' APPLICATION � �� �� PERMIT � J� P/C o ADDRESS����� !!1'GG"CYdf,L,`�.Y'��� C��C.�.�YY�CU�' DATE NUMBER� V # `� APN LOT TRACT ISSUE g� TYPE d� OCC DATE � �� w� CONST. GROUP p OWNE�i'1 Y� o ADDRESS ` l��: ZONING SETBACKS z CITY�LC�4`Y1FsY1(�ei�'�i�ZIP TEL. �R^ GJP"J� FRONT RW � � APPLICANT I TEL. REAR � Z SIDE/SIDE STREET RW � ¢ CONTRACTOF? �.`.�¢ SIDE � p� ADDRE S`6� !� f PROPOSED USE ���+�K�'�' `�'►�'��-�" � CITY c' ZIP TEL. � � . � o ARCH/�NG/ , -"'� z DESIGNER w � NO.DWEL. NO. NO. � ADDRESS p � CITY � ZIF TEL. UNITS ! STORIES _�__BEDROOMS cn cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OYVNER•BUILDER DECLARATION � � � � � � SFR/ADD/REM . I HEREBY AFFIRM UN�ER��P NALTY OF PERJURY THA71 AM E%EMPT FROM THE CON7RACTORS Li� Ga�dJBICB!(JOI[ W CENSELAWFOftTHEFOLLOWINGREASON(SEC.7031.SBUSBJESSANDPROFESSIONSCOOE:ANYCITYOR (n U ��CDUNTYIYHICHFEQUIRESAPEq I77OCONSTRUCT,ALTER,IMPROVE,6EMOLISH,ORREPAIRANYSTfiUG � W� �TU9E,PRIORTOITSISSUANCE; LSORE�UIRESTHEAPPLICANTFOASUCHPERMITTOFILEASIGNE� W PdtiO/DeCk � :STATEMENT THAT HE OR SHE IS ICENSE�PLIRSUANT TO THF.PROVISIONS OF THE CONTRACTORS LI� �, �' CENSE�LAW(CHAPTER9(COMME CINGWITHSECT10N7000)OFOIVISION30FTHEBUSINESSAN�PRO- � POOUSP2 � � Q,.','FESSIQNSCOOE)tlR7HATHEOR HEISEXEMPTTHEREFflOMAND7HEBA515FOR7HEALLEGEDEX[MP- (� . ^ h� , V' ', TION.ANYVIOLATIONOFSECTIO 7037.56YANYAPPLICANTFORAPERMITSUBJECTSTHEAPPLICANTTO Z Re-Roof �" ' � ACIVII.PENALTY O�NOT MOflE�,T AN FIVE HUNDRED DOLLARS�55ao).�: tfrL1 Q� LJI,ASOWNEROFTHEPROP flTY,ORMYEMPLOYEESWITHWAGESASTHEIq50LECOMPENSAT�ON, � Commercial - � Z .WILL DO THE WORK,AN�THE'�ST UCTUFE IS NOT INiEN�ED OR OPFEREO FOR SALE(SEC.7044,BUSb ,J ' ' � NESS hND PROFESS(ONS COtlE: NE CONTRACTORS LICENSE LAW�OES N�T APPLV TO AN OWNER OF � ', � 'PROPEfiTYWNOBUI��SORIMPR VESTHEREON,ANDWHODOESSUCHWORKHIMSELFORHERSELFOfl w' THROUGHNISORHEROWNEMPOYEES,PHOVIDEDTHATSUCHIMPROVEMENTSARENOTINTENDEDOR m ' � �OFFEREDFORSALE,IF,HOWEVERTHE6UILDINOORIMPROVEMENTISSOL�WITHINONEYEAAOFCOMPLE- ,Z TION,THE OWNEq-BUILDER WILL HAVE THE BUR�EN OF PROVING THAT HE OR SHE DID NOT BUILD OR �'���.IMPfiOVE FOR THE PURPOSE OF'SALE). W OI,ASOWNEROFTHEPROf�ERTY,AAAEXCLUSIVELYCONTRACiWGWITHLICENS_DCONTRACTORS CC�. 70 CANS7RUCT iHE�PFiOJECT�.($�C.7044,BUSMESS AND PROFESSIONS CO�E:THE CONTRACTORS LI- Valuetion �� ADJ.AREA W' CENSELAWCOESNOTAPPLYTq'NOWNEROFAPROPERTYWHOBUILOSORIMPROVESTHEflEON,AN� _� WHOCQNTRACTSFORSUCHPROECiSWiTHACONTRACTOR�SJLIC'eNSE�PURSUANTTOTHECONTRAC- ~` TORSLICENSEIAVJ�.). � QUANTITY DESCRIPTION FEE Y ��; �' .❑I AM EXEMPT UN�ER SE,C,�. 8.&P.G FOfl THIS REASON Q �S , U i� � ' DATE OWNER F— �..' W � ��. LICEN�ED CONTRACTORS DECLARATION W ¢' s I �', j IHEflEBYAFFIRMUNDERPENALTYOFPER�RYTHATIANLICENSEDUN�ERPROYISIDNSOFCHAPTER � ', �' '',; 9(COMMENCINGWITHSECTION7�pW)OFDIVISION30FTHEBUSINESSAND?ROFESSIONSCODE,AND z �X'� i,, MY LICENSE IS IN FULL FORCE AN,b EFFECT. m ��'�����.tIGENSE CLASS�,°�„� P�'� LlG.NO. ���-J��� j V �i,��DATE. CONTRACTOR a W. • I � � . WORKERS'COMPENSATION DECLARATION Q � �' �',�IHEREBVAFFIRMUN�ERPENALTYOFpERJURVONEOFTHEFOLLOWWGDECIARATIONS: ZI � '�,, _IHAVcAN�WILLMAINTAIMAC�RTIFlCATEOFCON5EN7TO5ELF-INSUREFORWORKERS' _ ¢. COMPENSATION.ASPRO�IDE�'BYSEC710N37000FTHELABORCODE,FORTHEPERFflRMANCE U Q \ � aFTHE WORK FOF WHICFI THi5 PERMIT�IS ISSUED. � �w �LIHAVEANDWILLMAIN7AINWORKERS'COMPENSATIONINSURANCE,ASRE�UIREDBYSECTION //��Q� � �, �3700 OF THE LABOR CODE�FORTHE PERFORMANCE OF THE WORK FOft WHICH iHiS PERMIT IS �R p)' �o ISSt1ED.MVgW�O(iKERS'COMPENSATION INSUr�RANCE ARRIERAN�/�q{O�LICV�NUU6ERARE: CONSTRUCTION �Y j CARP,IEF�7��1�1�L�.P� 1��C3�"C�C° C'i�l �;d'/!s�� PLAN REVIEW � POLICYNUMBER������ ELECTRIC Q __ � (iHISSECTIONNE�NOTB�COMPLEfE�OFhEPERlMISFORONEHUNDREDDIXLARS(510o)ORLESS). PLUMBING Z ICERTIFYTHATINiHEP6FFORMANCEOFTHEWOP.KFOftVdHICHTFIISPERMITI51SSl:ED,I MECHANICAL ('3 SFIALL NOT EMPLOYANY pER50N IN ANY MANNER SOAS TO BECOME SUBJECT TO THE � WORKERS'COMPENSATIONLAINSOFCALIFORNIA,ANDAGFEETHqTIFISHOULOBECOME INS?ECTIONFEE _ � '� SUBJECTTOTHEWOqKEP5'CpMPENSAT PFOVI�IONSOFSECTYJN37JOOFiHELA80R I ,� ,1�, ' ' '- ,, i'� � � 1C''O��E.I rySHALL FORiHW1iH COMAPLY WI T'OSE PROVI IONS. ISSUANCE �g 1 � � ' /r g�i,d� � 1"��V`�� �.ApPLICANT. �„����i�s SMIP 8 ; . , .. �7��,{ p �ATE: . J WARNING:FAILURETOSECUREN'ORK�RS'COM SAT60NCOVERAGEISUNLAWFUL,AN�SHALLBE ENERGYP/C � JU� � �� ?��9 �y SUBJECTANEMPLOYERTOCRIMINALdENALTI NDCIVILFINESUPi00NEHUNDRED7HOU5AND ! ' OOLLARS(E11N1,o�0),IN AD�ITION�!O THE COST COMPENSATION,DAMAGES AS PROVIDED FOR IN ENERGY PERMIT J' SECTION37080FTHELABORCODE,INTEREST, NOATTORNEV'SFEES. � OC� . � RETENTION FEE: 1-a�;r. � O � NSTRUCTIONLENDINGAGENCY PRE-ALTFEE: �^"-�-���w-------�--"�'���-�-��� �� n_ CO � IHEREBVAFFIpMUNDEFPENQ.�THOFPERJURVTHATTHEREISACONSTPUCTIONLENDINGAGENCV FOR THE PERFORMANCE OF THE�I^/ORK FOR WHICH THIS PERMIT IS ISSUED(SEC.309],CIV.C.�. Z W _ j IENDER'S NAME a F— LENDER'SADDFE55 .+� ¢. ICERTI'YTHATIHAVEREADTHI5APPLICATIONAN�STATE�HATTHEA60VEMFORMATIONISCORR[CT. TOTAL FEES ��f���/ W' I AGREE TO COM°LV WIiH ALL CITV AN�COUNTV ORDINANCES AND STATE LAWS RELATINO TO BVIL�ING � CONSTRVCTION,ANDHEqEBYAIJ�HOR�ZEFEPRESENTATNE50FTMI5COUNTYTOEMEflUPONTHE � ABOVE-MENTIONED PflOPERTYFI]F INSPECTION PURPOSES. Z�� � COMMENTS Q _ -- m' PEFM NA1dE�P NT) ¢ -� � s G-. 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