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HomeMy WebLinkAbout17361 (23) �,,.�- � �,.,V ,` �"1 `\ �w crrY oF��o�Ba� f---- - -��' --- DEPART'MENT OF COMMUNTI'Y&DEVELOPMENT SERVICES -�"- I I � _ 21825 E.CopHey Drive (909)860-3195 Fax(909}861-3117 R E$$ '`'-Yry" �UILDIN�PER1�fIT'AgPLICATION FIRMLY � JOBSITE b APPLICATION ` f� /� PERMIT- P/C o ADDRESS .' R� R DATE "� r/ v NUMBER�� # � ISSUE /� TYPE OCC APN LOT TRACT DATE V CONST. GROUP °C OWNER � O p ADDRES S ZONWG SEfBACKS z C� P TE FRONT RW ❑ o APPLICANT TE � SIDFJSIDE STREET RW ❑ z ¢ ,CONTRACTO �f(. � r SIDE ❑ Q ADDRES$ ��sppSED US u � CIT��Iry��_Q� ZI TEL. w, ARQR/ENG/ � 7 � �z DESIGNER NO.DWEL."" O. NO. � ADDRESS � CITY ZIP TEL. UNITS STORIES BEDROOMS �, cn' DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDEF DECLARATION SFR/ADD/REM � O I HEREBY AFFIRM UNDER PENALTV OF PERJURY THP.T I AM EXEMPT FROM 7HE CONT�9ACTORS LI� GflfdC78IC8fP0lI W�' CENSELAWFORTHEFOLLOWING'�REASON(SEC.7031.SBUSINESSANDPFiOFES5ION5CODE:ANYqTYOR (� U �. COUNTYWHICHREQUIFESAPERMITTOCANSTRUCT,ALTER,IMPROVE,DEMOUSH,OFREPAIRANYSTRUG W�'�. TVRE,PRIOR TO ITS ISSUANCE,AL50 RE-0UIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNE� w Patio/Deck '�, STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVI510NS OF THE CONTRACTORS L4 ��'� CENSE LAW(CHAPTER 9(COMMENCING WITH SECTION 7000)OF�IVISION 30F iHE BU5INESS AND PRO- � Pool/Spa �,�i FESSIONSCODE)ORTHATHEORsHEISEXEMPTTHEFEFROMAN�THEBASiSFOflTHEALLEGE�EXEMP- � V�;�,TION.ANYVIOLATONOFSECTION7�37.58YANVAPPLICANTFORAPERMITSU9JECTSTHEAPPLICANTiO Z Re-Roof '�'ACNIL PENALiY OF NOT IAORE THAN FIVE HUNDRED DOLLAqS�E5o0J.): Z�'�., ❑I,ASOWNEAOFTHEPROPiEflN,ORMYEMPLOYEESWITHSMAGE5A5THEIRSOLECOMPENSqTION, 0 Commerciaf -� �, WILL DO TF1E WORK,AND THE SiAUCTURE IS NUT IN7ENDED OR OFFERED FOR SAIE(SEC.7044,BUa"I- J � I,�NESSAN�PROFESSIONS CODE:THE CONTRACTORS UC'eNSE LAW DOES NOT APPLYTO AN OVlNER OF ? I PROPERTYWHOBUILDSORIMPRpVESTHEREON,ANDWHODOESSUCHWORKHIMSELFORHERSELFOR �'�'���THfiOUGH HIS OP HER OWN EMPLOVEES,PFOVIDED THATSUCH IMPROVEMENTS APE N071NTEN�ED OR m Q'�.,��;OFFEAEDFORS/LLEIF,HOWEVER�THEBUILDINGORIMPROVEMENiIS50LDWITHINONEYEAROFCOMPLE Z '�,;TION,THE OWNER-BUILDER WILL,HAVE THE BURDEN OF PROVING ThiAT HE OR SHE DID NOT BUIL�OR _,'�,'IMPflOVE FOR THE PURPOSEOF SALE). � ��� ❑I,ASOWNEROFTHEPROPERN,AMEXGWSIVELYCON7RACTINGWIiHLICEN5ECICONTRqCTORS ��.,'p�TO CONSTRUCT THE PROJECT(SEC.7o44,BUSINESSAND PROFESSIONS CODE:THE CONTRAC70R5 L4 ValUBUon ADJ.AREA W '�� CENSELAWDOESNOiAPPLYTOANOWNEROFAPROPERiYWHOBUILD50RIMPROVESTHEREON,AN� � I���WHOCONTRACTSFORSUCHPROJECTSWITHACONTRACTOR�S�LICENSEDPl1fl5L1ANTTOTHECONTFAG QUANTITY DESCRIPTION FEE � '�.�TORS LCENSE LAW.). ❑I AM EXEMPT UNDER SEC, B.&P.C.FOfl THIS REASON J O V � I' � LL '. �ATE . OWNER U Z,''. W �,. LICEN$E�CONTRACTORS DECLARATION W Q ��..�I HEREBYAFFIRM UNDER PENA�TY OF PERJURY iHAT I AM LICENSED UNDcR PROVISIONS OF CHAPTER � d '„',9(COMMENCMG WITH SEGTION�poo)OF DIVISION 3 OF THE BUSINE55 AND PFOFE5510 5 CODE,AND Z X,��:MY LIGENSE IS IN FULL FOHCEAN�EFFECT. W I LO ��� LICENSE CLASS qqq LIC.NO. _� � �U� OATE "'� �GONTRACT d W � WORKERS'COMPENSATION DECIARATION a � ' I HEREBY AFFIRM UNDER PENALTV OF PERJLIRV ONE OFTHE FOLLOWING DECLARATIONS: Z Z _IHAVEANDWILIMAINTAINACERTIFICAiEOFCONSENTTOSELF-INSUREFORWOflKERS' _ ¢ . CAMPENSATION,ASPROYIDED'BYSECTION37ooOF7HELABORCODE,FORTHEPERFORMANCE U Q, OFTHE WOFK FOR WHICH THIS PEPMIT IS ISSl1EU. � � _IHAVEANDWILLMAINTAI�7WORKERS'COMPENSATIDNWSURANCE,ASREQl11REDBYSECTION � �/� • �� Q 3700 OF THE LABOR CODE,FOR THE PERFORMANCE OF THE WORK FOP WHICH THIS PERMIT IS r] ISSUEO.MY WOPKEAS'CbMPENSATION INSURANCE CARRIER AND POLICY NUMBEfiAftE: CONSTAUCTION v J �. CARRIER ��0� PLAN REVIEW ZPouc�riuMaEa ��j�(���I�'�I' ELECTRIC Q, � (Ri;55ECT10NNE�NOTB€O�MPLEiEDOFTHEPERMITISWRONEHUf�RE�DOLLARS(510D�ORLESS�. PLUMBING Z� ICERTIFVTHATINTHEPERFORMANCEOFTH'<WORKFORWHICHTHISPERMIi15155UED,1 MECHANICA� (� SHALLNOTEMPLOVANYbERSONINANYMANNEF50ASTOBECOMESUBJECTTOTHE (n WORKERS'COMPENSATIQNLAWSOFCALIFORNIA,ANDAGREETHATIFISHOULDBECOME INSPECTIONFEE � SUBJECTTOTHEWOFKERS'COMPENSPTICNPROVISIONSOFSECTION37o00FTHELIBOR �...� CODE,I SHALI FORiHWItH COMPLY WITH 7HOSE PROVISIONS� ISSUANCE � SMIP • � p�� �ATE: APPLICANT. J WARNING:FAIWfiETOSECUREWORKERS'COMPENSATIONCOVERAGEISUNLAWFUL,ANDSHALLBE ENERGYP/C �. SUBJECTANEMPLOYERTOCRIMINALAENALTIESA�d�CIVILFINESUPT006�EHUNDRE�THOUSAk� ENERGYPERMIT OOLLAflS(S100,000�,IN A��ITION;TO THE COST OF COMPENSATION,OAMAGES AS PROVIDE�WP IN J SECTION37060FTHELABORCDDE,INTEREST,ANDATTORNEI"SFEES. p� RETENTION FEE: ._ OCONSTRUCTION LENDWG AGENCY PRE-AL7 FEE �,� IHEFiEBYAFFIRMUNDERPENALTVDFPERJURYTHATTHEREISACONSikUCTIONLENDINGAGENCV FOR iNE PERFORMANCE OF THE�WORK FOii WHICH THIS PEPMIT IS ISSIJED(SEC.309�,CIV.C.). , Z LL] ��. LEN�ER'S NAME 1- LENOER'SA�DRESS ^�y� �" I CERT�YTHAT I HAVE READTHISAPPLICATIONAND STATE iHAiTHEA80VE INFORMATION IS CORRECT. TOTAL FEES �� J I / W 1 AGREE TO COMPLV WITN ALL CITV AND COVNTV ORDINANCES AND STATE IP.WS RELATING i0 BUILDING � d .� CONSTRUCTION,ANOHEREBVAUTH0171Z=REPRESENTATIVESOFTHISCOUNTYTOENTERUPONTHE � ABOVEMENTIONED PwROPERTY FOR INSPECTION PURPOSE3. COMMENTS � � � � I � J !/LrS � � //l I� ¢ PERMITTEEN (PRIN � � `=' _.__�I'_.--�Il �/--Q l��-� � (/� SIGNATURE OF PERMI D�E � RECPT.RO. 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