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HomeMy WebLinkAbout17238 (26) ——_�' �ITY OF➢IALIrIOND HAR � � � DE�ARTMENT OF COr�MMtJNI'I'Y&DEVELOPMENT SERVICE5 21.825 E.Copiey Drive � (409)860-3i95 Pax(909)861-3117 PRESS '`'`�v»y'�"' BUdLDING PERMIT AY'PLICA'1'I'ION FI R LY � JaBSITE ! APPLICATION PERMIT P/C o ADDRESS �% �1.J�i 1 DATE �� '� � NUMBER � # oro ISSU� ��p TYPE OCC APN 1�_ LOT �`RACT DATE__�"/T_g���I CONS7. GROUP p OWNER u" ADDRESS ��t.1dd I2�.�,���� ZONING SETBACKS o CITY �t":ta..��e� 1'��Z!P EL. � -� --� FRONT RW ❑ a•• REAR ❑ p APPLICANT �_ TEL. — SIDE/SIDE STREET RW ❑ ' a CI�NTRACTOR SIDE ❑ I p� ADDRESS i" � �� � i o CITY �d e��.,�,��.d '�S��ZIP � ��EL. 4[„L .- �� �, PROt?O�D USE � '� ' � � W ARCWENG/ M1 �_l ��'' �'�` i/��� ' �Z DESIGNER NO.DWEL. NO. � NO. N AD�RESS UNITS STORIES BEDROOMS CITY ZIP TEL. I = � DESCRIPTION SQ.FL FAC70R PSF ADJ.AREANALUATION cn � OWNER-BUILDER DECLARATION SFR/ADD/REM 'j.�'e,q� O � I HERE6V AFFIHM UNDEH PENALTV OF PERJURV THA?I AM EXEMPT FROM THE CONTRACTORS:i- � Garage/CarpoR � � � W CENSELAWFORTHEFOLLOWINC�FIEASON(SEC.7031.5BUSINESSANDPROFESSION3CODE:ANYCITYOfl ZCIXINTYNMICHREOl11RE5APERMIT7000NSTRt�JCT,ALTERJtdPROVE.OEMOLISH,ORREPNRANYSTRUC- W Pgtio(DBCk TURE,PRIOR TO ITS ISSUANCE,ALSO REQUIRES THE APPLICANT FOR SUCH PEHMIT TO FILE A SIGNED �. 57ATEMENT THAT HE OR SHE IS i,LICENSE�PURSUpNT TO THE PflOY1510N5 OF THE CONTRACTORS U- W C6NSE LAW(CNAPTER 9(COMMENCING WITH SEC710N 7a0o)OF�IVISION 3 0F THE Bl15WE55 AN�PR0- V' PDOVSpe QFESSIONSCOOE�ORTHAiHEORI5HEI5EXEMPTTHEREFROMAND7HEBASISFORTHEAlLEOEDEXEMP� � . , V TION.ANYVIOLATIONOfSECT101�7031.5BYANYAFPLICANTFORAPeRMITSUHJECTSTHEAPPUCANTTO z RB-R00} � ACIVII PENALTY OF NOT MORE THAN FIVE HUNDpE�DOLLARS(SSoo).): Z ❑I,ASOWNEFOFTHEPFOPERTY;ORMYE�yIPLOYEESWITHYIP.GESASTHEIRSOLECOMPENSATION, �� COfnrt10fd21 ' � W�LL DO THE WORK,AN�THE 57!qUCTl�1RE IS NOT INTENDED Oa OFFEflED FOR SALE(SEC.7064.BU51- J 'NESS AND PftOFESSIONS CODE:THE CONTRACY,ORS UCENSE LAW�OES NOT APPLY TO AN OWNER OF � PR�PEFTYWHOBIlILOSORIMPROVESSHEREON,ANDWHODOE55l1CHWORKHiMSEIFORFiEPSELFOR �' � � THROUGHHISORHEROWNEMPLOYEE5,PROVIDEDTHATSl1CHIMPROVEMENTSANENOTINTEN�EDOq m' i, Q. OFFEREDFOfl5ALE.IF,HOWEVER';hicBUILDWGORIMPROVEMENTISSOLDWiTHINONEYEAROFCOMPLE , Z TION,iHE OWNER-BUILDER WILI���HAVE iHE BUROEN OF PROVING THAT HE OR SHE�IO NOT BUILD OH . � IMPROVEFORTHEPURPOSEOFSALE):, �,. �yy, DI,ASOWNEROF7HEPROPERTY,'.AMEXCL,USIVEIYCONiRACTINGWITHLICENSEOCONTRACTOR3 '�, �, TO CANSTRUCT THE PROJECT(SEC.7tid0.sUSINE55 AND PROFESSIONS CODE:iHE CONTRACTOR'e LI- VaIUBtion I ADJ.AREA '�, W� 'CENSE LAW DOES NOTAPPLYTObN OWNER OFA PflOPEfl7Y WHO BUILDS OF IMPROVES THEREON,AND �� WHOCONTRACTSFORSUCHPRdJECTSWITHACONiRACTOfi(5)LIGENSEDPURSUAM'TOTHECONTRAG QUANTITY �ESCRIPTION FEE Y TORSLICENSELAW.). �� ❑I AM EXEMPT UNDER S�C. B.&P.C.FOR 7HIS REASON � � l.L � �, ' DATE OWNER U � Z W '�, � LICENSED CONTR'�ACTORS DECLARATION �y � � IHEREBYAFFIqMUNDERPENALTYOFPEPJURYTHATIAMLICENSEDUNDERPPOVI510N50FCHAPTER � � 9(COMMENCINGWITHSECTION70o0)OFDIVISION30FTHEBUSINESSANDPROFESSIONSCOOE,AND Z �, W MY LICENSE IS IN FULL FORCE ANO EFFECT. ¢� �1 m � LICENSE GLA55 y� �LIC.ND. �J m��"�� � U DATE �� C ,J R CONTRACTOR �t�2. ^ y�� W O� � WORKERS'COMPENSATION DECLARATION a � U � 1 HEflEBV AFFIRlA IJN�ER DENALTV OF PFflJUPV ONE OF THE FOLLONlING DECLARATIONS: Z Q Z _IHAVEANDWILLMAINTAIYACERTIFICATEOFCONSENTTOSELF-MSUREFORWORKERS' 2 COMPENSATION,A9 PROVIDED BY SECTION 3�OOOFTHE LABOR CODE,PoR iHE PERFOflMANCE C) ¢ OFTHEWORKFORWHICHTHISPERMI7151SSUED. � � W I H0.VE AN�WILLMAINTAIN WORK5RS'COMPENSATION INSURANCE,AS REQUIRE�BYSECiION �/� Q ^37uoOFTHELA90RCODE,FORTHEPERFORMANCEOFTHEWORKFORWHICHiHISPEftM1T15 ��a S / ISSUED.MY WORKEA'COMPENSATION INSURANCE CARRIE AND POLICV NUMBER ARE; CONSTRUCTION t� 'LO ¢ ��-���� �, CARpIER '�-"'�F� PLAN REVIEW Z POLICYNUMBER`..�—_X�,���- ELECTRIC q (�HISSEC110NNEmNOTBECOMPLEfEDOFhiEPERMITISFORONEHUNDRED�OLIARS(5100�ORLESS). PLUMBING � � ICERTIFVTHATINTNEPERFORMANCEOFTHcWORKFORWHICHTHISPERMITISI55UE�,l MECHANICAL �,J' SHALL NOT EMPLOY ANY PERSON IN ANY MANNEFi SOAS TO BECOME SUBJECT TO iHE � WORKERS'COMPENSATIONLAV/SOFCALIFOflNIA,ANDAGftEETHATIFISHOUL�BECOME INSPECTIONFEE � SUBJECTTOTHEWORKERS'COMPENSATIONPPOVISIONSOFSECTION370oOFTHELABOR � CODE,I SHALLFORTHWI7H COAiPLY WITHT:-IOSE PROVI51 NS. ISSUANCE p � O � � SMIP 9''�V p DATE: �J - APPLICANT. ij��.fA , J WPRNING:FAILURETOSECUREWORKERS'COMPENSATIONCOVERAGEISUNLAWFUL,ANDSHALLBE ENERGYP/C �y._ SII6JECTANEMPLOYEATDCRIMINALPENALTIESANDqVILFMESl/PTOONEHUNDRE�THOUSAN� ENERGYPERMIT DOLLARS(51oo,Dao�,IN ADDITIONYO THE COST OF CAMPENSATION,DAMAGES AS PROVIDED FOP IN J SECTION3�o90FTHELABORCODE,INTEflEST,ANOATTORNEY'SFEES. RETENTIONFEE: Q a CONSTRUCTION LENDING AGENCY PRE-ALT FEE: O � IHEREBYAFFlRMUNDERPENALTNOFPERJUFYiHATTNEREISACONSTRUCiIDNLEN�INGAGENCY 0- FOR iHE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUEO(SEC.3097.CIV.C.). � Z W � LENOERB NAME F- LENDERSADDRE55 ¢ IGEflTIFYTHATIHAVEREADTNISAPPLICATIONANDSTATETHATTHEA80VEINFORMATIaJISCORRECT. TOTAL FEES �� '� r�� W I AGREE TO COMPLV WITH AL:GTY AND COUMV DRDINANCES ANO S7ATE LAWS RELATING TO BUILDING 4 CONSTRUCTION,ANDHEREBYAUTHORIZEREPRESENTATNESOFTHISCOUNTYTOENTERUPONTHE z ABOYE-MENiIONED PqpPERTY FOR INSPECTION PURPOSES. COMMENTS I � ��� �� _ m PERMITTEENAb1E(PRI J'.� /` ¢ �1 ,A �� � C!) R � SIGNATUREOFPE ITTE DATE = RECPT.�O. PAID BY VALIDATION ~ �WHITE—Deparlment Copy,YELLOW—Finance Copy,PWK—Assessor Copy.GOLDENROD—FileCopy,GREEN—ApplicanPs Copy ,::.;, .. _.,,,; .,.:..,. ..�...,,,,. ,� . ..:.... . ........ ..•..,,...:,. . :, .- . .�::a•,'.r�> �. � . 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