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HomeMy WebLinkAbout12981 (11) CITY OF DIAIVIOND BAI� /� �----��" DEPARTMENT OF COMMUrTITY&DEVELOPMENT SERVICES ` � �,� 21660E.Copley Drive Suite 190 PRESS (909)860-3195 Fae(909)861-3117 •�;:' BUII.DING PERMIT APPLICATION __. FIRMLY � JOB5ITE I ��� ,J i I��d" ��'e VI� APPLICATION�y`4.�. ,�..G�� NUMBIER I�`"'R�1 #/C ¢ APNRESS LOT DATE o � ISSUE �, TYPE OCC °-° �� TRACT �^ ��` DATE�- CONST. GROUP � OWNER G't f i C: O p ADDRES C . I1 Ut4'°" ING SETBACKS Z CITY � �ei.ZIP � T6L.�. -� 16 'ZON FFiONT RW ❑ APPUCAFiT TEL. REAR _ � � SIQE/SIQE STREET RW q a � CONTRACTOR 5 G � E'+'�`) �e�-C-� SIDE ❑�� Q C TY ESS z OSED USE _ Q IP��y TEL� ��; Q � p PROP w' ARCHlENG/ z' ADDRESS � � � UNITS STORIES BEDRO W DESIGNER i - NO.DWEL. NO. NO. �, -� OMS � ZiP? � TEL. F ADJ.AREANA4UATION. � Clll° I � DESCRIPTION SQ.FT. FACTOR PS � w'� ...ceNseuwBr�aini�E�aww�R'ensryori�(sEc�osAseus�RATION.. .. � . .:. '�.. SFfVADD/REM . . . ... .. ��. '�� NER-BUILDERDE _ ., r i un ExEMar FaoM n�E conrtancToas u Garaga/Carport INESSANDPROFESSIONSCODEANYqiYOR .,(� 4.�� CIXINTVNMICMREIXIIRESAPER�IITTOCONSTflUCT,ALTERIMPROVE,DEMOLISHORREPAIRANYSTRUC- _,_W. .�y11D/DBCI( � - ������ ���TURE,�PRIOR TO YTS ISSUANCE,'PL50"RE�l11RE5 THE APPIICANT FOR SUCH PERMIT TO FlCE A SI�NED � . �; STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI- �, ..GENSE LAW(CHAPTER 9(GOMMENCMG.WITH SECTION 7000)OF DIVISION 3 OP THE BUSfNESS AN�PRO- ' LL POOVSpB � � FESSl9NSCODE)OiiTHATHEOF�SHEISEXEAIPTTHEREFROMANUTNEBA515FORxHEALLEGEDEXEMP- v: TION.ANYVIOLATIONOFSECT 7031.SBYANVAPPLICAMFORAPERIAIYSUBlECTSTHEAPPLICpNTTO �'Z Re-Root �, ' ACIVILPENALTYOFNOTMORE�HANFIVEHUNDFiED�OLUAS(5500J:j: d� ❑I,ASOINNEROF7HEPH0 ERTY,ORMY'eMPLOYEESWITHWAGESA9TNEIRSOLECOMPENSAiION, � ��� Commercial � - ..,Zi,. ,N7LL.pD THE.WORK,AND 7HE STAUCTURE IS NOT INTEN�ED OH oFFERE�FOF SALE(SEC.7a44,BU51- J , �,�. NES5 AND PROFESSIONS CODE:ITHE CONTRACTORS LICENSE LAW DOES NOTAPPLY YO IW OWNER DF�� ,, � P4iOPERTVWHOeU1L�SDR¢dP OVES7HEREON,ANDWHODOESSUCHWORKHIMSELFORHEASELFOR; .['C'�, '.THROUGHHISDR-HEROWNEM OVEESp�VIDEDTHA7SUCHIMPROVEMFIJTSARENOTINTENDE�OH'- � ' ' � OFFER6DFOR&ALEIFHOWEVE 'tHEBUILDWGORIMPROVEIAENTI5501DWITHINONEVEAROFCOMPLE- ' ' � '�-0� �'�TION,7MEOWNER-BUILDER WI FIAVE THE BURDEN 6F PROVING hIAT HE OR 6HE�ID NOT BUILD OR� . -- . �� ���� WIPROVEFORTHEPUflPO5EOF5AlE]. � ��- � � � ,� �. ❑I,ASOWNEROFTHEPR PEF.TY.AMEXCLUSIVELYCANTRqCTINGWITHLiGENSEDCONTRACiORS � . �.�� .TO CONSTRUCT THE PR0.IECT(EC.70<4,BUSINESS�AND PROPESSIIXJS CODE:THE CONTRACTORS LI- ' V2IUBS10� ADJ.AREA ��IW. CENSELAWOOESNOTAPPLYT ANOWNEROFAPROPERTYWHOBUILOSORIMPROVESTHEREON,AND'. . ���'+�..�WHO�CONTRACTSFORSUCHPH ECTSWRkACONTRACTOHiS)LICENSEDPURSUANTTOTHECO4TRAG� QUANTITY DESCRIPTiON , ' FEE �, TORS LICENSE LAW.). ,a� ,. .. .J . . . . .. ❑IAM EXF1lAPT UNUEfl S�.� B.&P.C.fOR THIS flEASON � U '� � .. , , . � . . �I LL' DATE � OWNEW � ��U �. � LICE $ED CONTRACTORS DECLARATION -� ' �, W ,I HEFEBYAFFIRM UNDER PEN OFPERJUP.Y THAT IAM LICENSED UN�ER PROVISIONS OFCHAPTEfl , '��� ��B�COMMENqNf'qWITHSEC710N OOo)OFDIYISION30FTHEBUSINESSANDPROFESSIONSCODE,AND Z �'�-� � � '� X ��MY LICENS�IS IN FULI FORCE �EFFECT. m �,, .. � � ��,LICENSECLASS LIC.NO.- . �..F�+�����.� �� . , , J . � ��.]9A7E � CONTHRCTOR - . .. . � fl- � � W """�11 ' � � , WOR�RS'COMPENSAI'ION DECLARATION a � � . �� IHERE6YAFFIRMIIN�ERPEN OFPERIURYONEOFTHEFOUAWINGDECLARATIIXJS: � � �, � CA' �_I HAVE M1D WILLh9AElJTI�IN R CERTIFICATE OF CONSENTTO SEIF-INSURE FOR WOFKERS' _ � �� ���� � COMPENSATION,ASPRVI�EDBVSEC710N37ooOFTHEtABORCDDE,FORTHEPERFORR9ANCE W OF THE WOFK FOR WHI�H THI�PERMIY IS ISSU'c0. � L6�6 I . . . . . .. ' �1 HAVEAN�WILL MAINTAIN 6VOR(ERS'COMPENSATION INSURANCE,AS REQl11RED BY SECTION 6 - 37000F THE LABOR W E,FORTHE PERFOf1MANCe Or�THE WORK FOR WHICH THIS PERMITIS �' ISSUED.MYWOR%ERS' �NSATIONINSUFi�CECARPIERAN�POLICVNUMBERARE: CONSTRUCTIQN .?':,.. CARRIER �� ���1� � � PL6.N REVIEW � . ' �'; POLICYNUM9ER . � ELECTRiC , Q � � (IH�SECTIL�VNEEDAqT ECCAWRETEOOFiIiEPERMITISf-0RONEHIA�OREODJLIAASfS700)ORLE55). PLUMBING $'� f� Z�' I CERTIFY TFiAT IN THE�,"ERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I MECHANICAI. �,���1 (f', SHALLNOTEMPLOYANrPER50NINANYMANNEFSOASTOBECOMESUBJECiTOTHE ' ��,; WORKERS'COMPENSAYION IAWS OF CALIfORNIA,AND AGREE TNAT IF I SHOULO BECOME INSPECTION FEE � Sl7&IECTTOTH6WORf�ERS'COA4PENSATIONPROV1510NSOFSECTI�N97ooOFTFiELABOR � � � CADE,ISHALLFORHWITHCOMPLVWITH�SEPR�`oNs.���� ISSUANCE — � � SMIP � onre: ` " ,nPrwcnNr. --------- ��. ENERGY P/C - - �� WARNiNG:fAILUFETOSECUR WORKERS'COMPENSATIONCOVERAGEISUNLAWFUL,ANDSHALLBE . . yT�� SUBJECTANEMPLOYER70CR INALPENAL7IESAND�CIVILFINESl1PTOONEHUNOREDTHOUSAND. ENERGYPERMIT ', ODLLAAS(5700,000),INADDITI TOTFiECOSTOFCOMPENSATIDN,DAMAGESASPROVIDE�FORIN '�,. SECTION37080PTHELABOR DE,INTEREST,ANDATTORNENSFEES. ' FIETENTIONFEE: � �x ' � , ����;, C �NSTRUCTIONLEN�iNGAGEfJCY PR6ALTFEE: <? �.� IHEPEBYAFFIPMUNDERPENA�/O�PERJURYTHATTHEREI6ACONSTRUCTIONLEN�INGAGENCV �' FOR THE PEflFORMANCE OFT E WORK FOR WHICH THIS PERMITIS ISSUED(SEC.309�,ClV.C.�. ' ��,,���' ' . . . '. ' . �I LENOER'S NAME � � ��W. LEN�ER'SA�DRESS II � . � . �` �` �� ICERTIF1'THATIHpVEREADT�$APPLICAiIONANDS7ATETHATTHEABOYEINFORAIATIONISCORRECT. TOTAL FEES , � ti�� � .��� IAGFEE TQ CAMPLY W1TH ALL ITYAN�COUNTY ORDINANCES AND 3TATE LAWS RELATING TO BVILOINCi � � � CIXJS7AUCTION,AND HEREBV UTHORIZE REPAESENTATIVES OFTHIS COUNTYTO ENTER UPON THE ' ���. ABOVE-MENTIONEO PPOPERTI�FOR INSPECrION YURPO�5gE/5�. /p��p� COMMENTS -- � :��� . O o.!�^'0 f�B 9 � .. ' , . m'' PERMITTEE NAME(P ' � .¢'�� ... . . '� . ', ' CPj'j �Gjy� 91QNATldREOFPE I ' DATE ' - . . �;, p RECPT.NO. �� PAID BY �' � �,VALIDATION �� � WHITE—DepartmenE Copy,YELLOW—Finance Copy,PINK Assessor Copy,GOLDEHROD—File Copy,GflEEN—Applicant s Copy � � � ��`�"� � �� � � ��� :' � � � ��� ��� � ��� ���� ��� �Y; � � � :� � � � d � � , . _� , � �: . • , ���`��� �� � i � � �=L����C�I`�,,; , �. � � �-�"�•;�1=��`�'������`-��� � � F��,F����t'�"� . , _�° �'.�..���,�`tE�:�;�:���..��'�u .. ._���� . . , . .. � 1.����i�.t�� i�.,t���`.�T;ka"d✓a . � . .. : ._.,.,_..._.d. ,� I .__ � �__� t ��__��__ �--�=_ ----� �� 4.:'��F�y:iCs�r�.' 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