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HomeMy WebLinkAbout17271 .--�-_.�-_---��- � CITY OF I3I�MOND BAR ���� � t' ---�`' --- DEPf�RrMEWT OF COMMNNITY&DEVELOPMENT SERVICES ' I � • _ 21825 E.Copley Ihive I ,, -�:w (909)860-3195 Fax(909)861-3117 PRE$$ I '''%v��'`' BUYLDING PERMI'�APPLICATION . , FIRMLY � JOBSITE �€.� APPLICATION�����,�^ PERMIT P/C `, ��� o AUDRESS��-����������°"' /�--�-� DATE NUMBER� # �� V`7 `� APN LOT T CT �SSUE TYPE OCC o OW��R � �� � Rf�� ,�����,���� DATE CONST. GROUP A o ADDRES LL �"��'����� ��f���""`�'�� ZONING SETBACKS z CITY�/.�.�`.r"�C%r�1"�`��j—ZIP�d7�.� TEL.� G��✓^s !'z"`�'i`� FRONT RW ❑ a APPLICANT_� � ,�'��'1 TEL. �'�°^:�::L`.�.� SDE/SIDE �""°^� u Z ., _,.,.. .. —.._�,�"°.••� � __._,.,s. II Q CONTRACTOR _ SI ADDRE�S ���;:� _� � �"�-�,. � � CITYa�i���� ZIP ��'��' TEL.��.�°�-°.��� PROP ED USE o ARCH/ENG% z DESIGNER d ADDRESS NO.D NO. � , �' CITY ZIP TEL. UNITS BEDROOMS c� � cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION '�, �� � � OWNER•BUILDER DECLARATIQN � p SFR/ADDlREM ., p I HEREBY AFFIRM UN�ER PENALTY OF PEflJURY THAT i AM EXEMPT FROM THE CONTRACTORS LI� Gdf290IC2f(JOIf �, 4J"�CENSEUIWFOR7HEFOLLOWINGREASON(SEC.7o31.5BUSINESSAN�PROFESSIONSCO�E:ANYCITYOR (n I U'..COUNTYWNICHREDUIRESAPERMITT�CONSTRUC7,ALTEA,IMPROVE,DEMOLISH,ORREPAIRANYSTRUP - w, ��TURE,.PBfOR TO ITS ISSUANCE,ALSO REQUIRES THE APPLICANT FOR SUCH PERMITTO FILE A SIGNEO W Pailo/DeCk ��j�` � �' ''STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI� ', �CENSE LAW(CHAPTER 9(COMMENCMG VlITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO- LL POOVS�J3 O�'' .�FESSIONSCODE)ORTHATHEORSHEISEXEMPTTHEREFROMANDTHEBASISFORTHEALLEGE�IXEMP- � V, ''�TION.ANYVIOLATIONOfSECTION7031.5BYANYAPPLICANTFOFiAPERMITSUBJECTSTHEAPPLICANTTO Z Re-RooF � � ACIVIL PENALTY OF NO'f MORETHAN FIVE HUNDFED DOLLARS(5500).�: '' � ❑I,ASOWNEROFTHEPROPEflTY,ORMYEMPLDYEESWITHWAGE5A5iHEIR50LECOMPENSATION, Q �� Z� ,�.WILL W THE WORK,AN�THE STRUCTl1flE IS NOT INPENDE�OR OFFERE�FDii SALE(SEQ 7044.EU51� J Comm0fCi81 - , �'."NESS AND PROFESSIONS CO�E:THE CONTRACTOPS LICENSE LAW�OES NOT APPLY TO AN OWNER OF '�PROPEHTYWHOBUIL�SORIMPROVESTHERF.ON,ANDWHODOESSUCHWORKHIMSELFORHERSELFOR � � � � � 'i'iTHROUGNFYI50RHEROWNEMPLOVEES,PROVIDEDTHA75UCHIMPROVEMENTSARENOTINT'cNDEDOR m .��;'OFFEREOFbFSALE.IF,HOWEVER,THEBUILDINGORIMPROVEMENTISSOL�WITHINONEYEAROFGOMPLE- TION,THE OWNER,BUIL�ER WILL HAVE THE BURDEN OF PP�vwr rwnr H,E OR SHE�ID NOT BUILD OR �.lMPROV�E FOR THE PURPOSE OF SALE ' � _� � QXir.QSaWNEROFTHEPROPE�,A LUSNELYCONTRACTINGWITHLICENSEDCON S � ����,.TO CONSiRUCT THE PROJECT(SEC.7�kS�eUSMESS AND PROPESSIONS CO�E:THE CONTRACTOPS L� V21Uation ADJ.AREA W', CENSE AP�T�UANOWNEROFAPROPERTYWHOBUIL�SOPIMPROVESTHEHEON,AN� - _�' NTPAC75FORSUCHPROJECTSWITHACOMRACTOR�S)UCENSEDPURSUANTTOTHECONTRAC- � I �' oqsuceNSEuw.). '�q- UAN7ITY �ESCRIPTION FEE � Q ❑IA�rjIXEMP RSEE*' _B.SP,C.FORTHISREASON Q ' �, `� ' �_, U �'=' '� T . .. ' OWNER H Z r: U 'F,,,,;'� LICENSED CONTRACTORS DECLARATION W ,,¢,, �. � , � . �'�.1 HEREBYAFFIFM UNDER PENALTY OF PERJ HAT I AM LICENSED UNOER PPOVISIONS OF CHAPTER � �'I ��,�.'�j9�COMMENCMGW�THSECTION70W)OFDIVISION30FTHEBUSINESSANDPflOFESSIONSCODE,AND 2 , `X, ,MY UC�N5E IS M FULL FOPCE AND EFFECL m . 'I ��, LICENSECLASS� LIC.NO. - � ,i ,W,'�, �DATE � - CONTRACTOR __ d �, � � WORKEFS'COMPENSATION DECLARATION a � � I HEREBV AFFIRM UNDER PENALTY OF PERJURV ON'c OF THE FOLl.OWING DECIAqATIONS: z . , '' � ' _IHAVEANpWILLMAINTAINACERTIFICAiEOFCONSENTTOSELF-INSUREFORWORKERS' _ Q COMPENSATION,AS PROVI�ED BY SECTION 37oa OFTHE LABOR CODE,FOR THE PERFORMANCE U ., Q� OFTHEWORKFOPWHICHTHISPERMITISISSUE�, � �'� _I HAVE ANO WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,q5 REQl11RED BY SECTION ��` �g ,%y <C� 37o00FTHELABORCODE,FORTHEPERFORMANCEOrTHEWORKFGRWHICHTHISPERMITIS ��� � ISSOE�.MY WORKERS'COMPENSATION INSURANCE CARRIER AN�POLICY NUlABER ARE, CONSTRUCTION a�w J j� caRRiER � PLAN REVIEW � d �° ZPOUCYNUMBER ELECTRIC Q ' � (IHISSECfICIJNEmNOTBECDMFtEfE�OFi}iEPERMfTISPJRON�HUNDf�DDOUARS($tOC)ORLESS). PLUMBING W Z. ICERTIFYTHATINTHEPERFORMANCEOFTHEWORKFOflWHICHTHISPERMiTI5155UED,1 MECHANICAL �', C,�}� SHALLNOTEMPLOYANYPERSONI(VANYMANNERSOASTOBECOMESUBJECTTOTHE 4 '^;, �� p �� � WORKERSICOMPENSATION LAWS OF CALIFOFNIA,ANO AGREE THAT IF i SHOULO BECOME lNSPECTION FEE �''� �� � " ,m/�''. = SUBJECTTOTHEWORKERS'COMPENSATIO�PROVISIONSOFSECTION37000FTHELABOR -' �. CODE.I SHALL FOflTHWITH COMPLV WITH THOSE PROVISIDNS. ISSUANCE P1 O � � V p� DA7E: APPLICANT: SMIP � �.! e W a J WARNING FAILURE TO SECUFE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL.AND SHALL BE ENERGY P/C ' �y SUBJECT�ANEMPLOYERTOC,4IMINALPENALTIESANDCIVILFWESL1Pi00NEHl1NDflEDTHDUSAND ENERGYPERMIT f,'.-"'R'�.T,. ODLLARS(E10a.oCo),IN ADDITION i0 THE C�STOF COMPENSATION,DAMAGES AS PROVIDED FOR IN � � SECTION3]OeOFTHELA90RCODE,IN7EREST,ANDATTORNEY'SFGeS. RETENTIONFEE: �. " .-- -..-:..= J����f d � CONSTRUCTION LENDING AGENCY PRE-ALT FEE: � IHEREBYAFFIRMUNDERPENALTYOFPERJURYTHATTHEREISACONSTRUCTIONLEN�INGAGENCY FOR THE PERFORMANCE OF iHE WORK FOR WHIC1i THIS PERMIT IS ISSUEO(SEC.34A�,CIV.C.�. Z W __ ', ? LENDER'S�AME � I'— IENDcR'SAD S � ��^�� TOTAL FEES �Q =�"� �+� (J ICERiIFVTHATIHAVEREADTHISAPPLICATIONANDSTATETHATTHEABOVEINFORMATIO CORflECT. � � I AGREE TO COMPIV WITH A 'kND CDUNTY ORDINANCES AND STATE LAWS RELAiING TO LDING ' � CONSTRUCTION,A' BYAUTH IZE�,,,� NTATIVESOFTHIS VVTOENTERUPON� � A90VE-MEN � PROPERTYF �WS�ECTION POS f�A p �. COMMENTS �4'�� � � � �� J � � m PERMITTEENAME�PRINT) � � � SIGNATURE �q �� oC VALIDATION '�' RECPT.NO. PAID BY � .. WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLOENROD--File Copy,GREEN—ApplicanYs Copy . ,- �� �.,' ,,� � . .��..A � .x . , - � �. 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