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HomeMy WebLinkAbout17177 (37) c1�oF��orm��u f�� ----��"'�'`'---� DEPAR'I'MENT OF COMMUNfi'Y&DEVELOPMENT SERVICES � 21825 E.Co�1ey Drive '`� � (909)�60-3195 Fax(909)861-3117 PRESS "`%H«�'' BUILDdNG PERIVYIT APPLICATION FIRMLY o ADDRESS� � I S / S�APP h��.c CJ�1 Q� DATEICATION �� NU B R ( #,C � ��� � �4 � �I ��� � � ISSUE TYPE OCC APN LOT TRACT DATE CONST. GROUP p OWNER '�,�11�I� YS'�� L 4 V�1�:Y� o ADDRESS��.cj,�'� SA,ePI.Jr� C.�r�.�,y�. �1� ZONING SETBACKS z CITY���+9_C ZIP�/7L�TEL.(4��G'tL?f� FRONT RW ❑ � APPLICAN7 I i EL. REAR ❑ � SI�E/SIDE STREET RW ❑ z m CONTRACTOR t ",y� SIDE qb I � ADDRESS v F G'� � i p PROPOSED USE � a�' -.�.- , ��� r`"' �,, . � o CITY �T L�4�. � �� ZIP �1't�frL TEL.�'dV�i3/�37e5/ ., fi 4�- 4',` e Q ARCWENG/ '3a \'+� Y y .�" I�" � ''� '� z DESIGNER NQ.DWEL NO. `-' NO. a ADDRESS UNITS STORIES BEDRO�MS � CITY ZIP TEL � y �� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION O OWNER-6UIL�ER DECLAflATION SFR/ADD/qEM ��p I HEREBY AFFIRM UNDER P�NALTY OF PERJUftY THAT i AM EXEMPT FROM THE CONTRACTORS LI- Gef8J8/C2�Off W CENSELAWFORTHEFpLLOWING EASON�SEC.7031.SBUSW'eSSAN�PROFESSIONSCODE:ANVqTYOR (n C.� COUNTVWHICHREQUIRESAPERA�ITTOCONSTFUGT,ALTER,IMPROVE,OEMOUSH.ORREPAiRANYSTRUG W PdlIO/DEGIC w', TURE,PRIOR TO�TS ISSUANCE,F�LSD HEQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED � ' STATEMENT THAT HE OR SHE IS LICENSED PL1RSl1ANT TO THE PflOVISIONS OF THE CONTRACTORS LI� ,� CEtJSE LAW(CHAPTEfi 9(COMMEIIJGNG WI7H SECTION 7000)OF DIVISION 3 0F THE 6USINESSAND PRD- LL POOVSPB ,FESSIONSCOD�JORTHATHEOR5HEISEXEMPTTH'eREFROMAN�THEBA5ISFOR7HEALLe'GE�EXEMP� �'� 710N.ANYVIOLATIONOFSEC710NI7031.$BYANYAPPLICANTFORAPERMITSU&IECYSTHEAPPLICANTTO Z RB-ROOF � O•, '�ACIVILPENALTYOFNOTMORET�ANFryEHUNbRED�OLlMS(S50o),�: ❑I,ASOYJNERDFTHEPROP RTY.DRMYEMPLOYEE5WITHYJAGESASTHEIRSOLECOMPENSA710N, � COfI1RIBfCIHI Z,,'WILL DO THE WORK,AND THE 5T VCTURE IS NOT INTENDE�OR OFFERED FOR SALC(SEG.7044,6U54 J ,�. NESS M10 PROFESSIONS COOE;fHE CONTRACTORS LICENSE LAW�OES NOTAPPLY TO AN OWNEft OF � -'� �'PROPERTY WHO BVILDS Ofl IMPROVES THEREON,AND WHO DOES SUCH WORKHIMSELF OR HERSELf OR �', �THROUGHHISORHEROWNEMPLOYEES,PROVIDE�THATSUCHIMPpOVEME:ViSARENOTINiENDE�OR m '.Q'�. ',OFFEIiEDFORSAI.E.IF,HOWEUER,�fHEBUILDiNGOHIMPROYEMENTISSOLOWITMINONEYEAROFCOMPLE ' ,�710N',THE OWNER-BUILDEF WIIL�iAVE THE BUROEN OF PROVWG THAT HE OR SHE DID NOT BUIL�OR �'�,, ,;_ 'IMPHOVEFORTHEPUf1POSEOF9�ALE7.'� f . '�i �.� ❑I,ASOWNER.OFTHEPflOPIERTY,AMEXCLUSIVELYCONTRACTMGWITHLICENSEDCONTRACiORS W y�� 4 I ' '�' TO CANSTftIiCTTHE PROJECT�SF'C.7044.BUSME55 AN�PROFEeSIONS GODE:THE CONTRACiOFS LI- Vfll�2[IOf1 � !\.J� °� ADJ.AREA "��CENSELAW'�OESNOTAPPLVTOANOWNEROFAPF70PERTYWHOBUILDSORIMPROVESiHEREON,AND '�. �;".WHOCONiRACTSFORSIJCHPRQ,ECTSWITHACONTFiACTOR(5)LICE45EDPURSUANTTOTHEWNTRAC- QUANTITY �DESCRIPTION FEE �TORS LICENSE LAWJ. � � �� �❑.IAM'EXEMPT UN�ER S�C.�II B.&P,C.FOR THIS REASON Q �o�", .. , .., .. . - U � � LL [YA7E I OWN-R __i__ � �' W '���„ � LICEN ED CONTRACTORS DECLARATION W � I �. 1 HEREBYAFFIRM UNDER PENALTVf OF PEFJURV THAT I AM LICENSED UNDEfl PROVISIONS OF CHAPiER � ' �'� e���COMMENCINGWITHSECTION7[�0o)OF�IVISION30FTHEBUSINESSPNDPROFESSIONSCO�E,AND Z '�. �X., 'MY�ICEN6E IS IN FULL FORCEANDI—EFFECT. - m '�,�, LICENSE*CLASS ��5 I 1 � LIC.NO. � � U DqTE I.�j�t=:Q? I � .. CONTRACTO _ a �� �`.���y.*"��."��WORKERS'COMPENSATIO CLARATION r Q �', IHERE6YAFFIRMUNDERPENALTYIOFPEFJURYONEOFTHEFOLLOWINGDECLARATION3 U Cn I .. Z ��� ,^INAVEANDWI�;LMAINTAI ACERTIFICATEOFCONSENTTOSELF-INSUREFORWORKERS' _ COp,1PEN5ATION,ASPROV��ED8Y5ECTION37DOOFTHELA60RCODE,FOflTHEPERFORMANCE U �Q„ OF'THE WOqK'KOfl WHICHITHIS pERM1i IS I55UED. � � w' _I HAVE'AND WII�.LMAINTAIN WORKERS GOMPENSATION INSUFANCE,AS REOUIRED BY SECiION �y /� a,i`\ Q„ 370uOFTHELABbRCOOE FORTHEPEflFORMANCEOFTHEWORKfORWHICHTHISPERMiTIS �/ ISSUED.MYWORKERS'COMPENSATIONMSUR4NCECARRIERANDPOLICVNUMBERARE: CONSTRUCTION I a�""r / ¢ � caRaiEa � L PIAN REVIEW Z' FoucVNUMaea'� — ELECTRIC Q � (1'HISSECTFJNNEmNOTBE ETEDOFhIEPERMITI3FORONEHUNDREDDOLIAflS�§1P))ORLESS). PLUMBING � � ICEFTIrVTHATMTHEPERFOR�NANCEOFTHEWORKFORWHICF.THISPER�11TI5155UE�.l MECHANICAL ('3 SHALL NOT EMPLOY ANY P RSO�J IN ANY MANNER SO AS TO BECOME SUBJ[CT TO THE � WORKER5'COMPENSATIO LAWSOFCALIFORNIA,AN�AGREE?HATIFISHOl1LDAFCOME INSPECTIONFEE = Sl1BJECTTOTHEWORKE 5 COhi1PEN5ATIONAROVISIONSOFSECTION37oaOFTHELABOp — �` �CO�E,ISHALLFORTHWIT COMP�YWITHT ���� ISSUANCE �� �'� �\ � � �\ �=y"'� p ����U�� �a,--�� �—'�/ SMIP i J , , _ ..�i � CS A PLICANT. � "" '�� ENERGY P/C `� 7 - J WA NI :FAIL�JR OSECURE �S'(SIMPENSATIONCOVERAGEISt1NLAWFUL,AN�SNALL6E '1 r LL SUBJECTAIJEMPLOYERTOCRIMI ALPENALTIESAN�CNILFINESUPTOONEHUN�flEDTHOUSAND ENERGYPERMIT� DOLLARS(E100,o00),IN ADDITION T THE'COST OF COdAPENSATION,DAMAGES AS PROVIOEO FOR N � � SECTION3]090FTHElA60RC0�.INTEFEST,ANDA'iTORNEY'SFEES. RETENTIONFEE:-. o . � CO STRUC710N LENDING AGENCY - PRE-ALT FEE: �=�t��`_ � �, _ _-- �__.�._.___,......--�-� ��'�.IHEFiEBYAFkIRMUN�ERPENALTYDFP�RJUAYTHAiTHEREISACONSTRUCTIONLENDINGAGENCY �FOR THE PEFFORMANCE OF THE V�ORK FOR VJHICH THIS PERMIT IS ISSUE��SEC.30 W.CIV.GJ. Z W ���' LENOERBNPME I I F,_- LEN�ER'SAD�RESS i W ICERTIFVTHATIHAVEREADTHISAPPLICATIONANDSTATETHATTHfABOVEINFORAlAT10NI5CORRECT. TOTAL FEES � � M�,�� � '� IAGREETOCOMPLVWITHALLdT ANDCOUNTYORDINANCESANDS7ATEL4WSRELATINGTOBUILDING � °� CONS7RUCTION,AND HEREBV AUT ORIZE REPRESENTATIVES OF THIS COUNTV TO ENTER UPON 7HE � AB ENTIONE�PROPERN FO INSPECTIDN PURPOSES. COMMENTS - Q �..'.,���� � Q �.PERMITTEEN RINT C!J �' — ' � � c"'� �_i : (/� SIGNA7U �PERAIITTEE , A � RECPT NO. 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