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HomeMy WebLinkAbout13456 (25) �� CITY OF DIAIVIONI7 BAR ' �. DEPARTMENT OF COMMUNITY�DEVELOPMENT SERVICES ! _ w 2�66oE.coP�eyvrivesuit��90 PRESS .. � ,, (909)860-3195 Fax(909)861-3117 ' 9�' BUII.DINGFERMITAPPLICATION _— ; FIRMLY, . ¢ ADDRESS ���a3 '�/��Ylsa LL1/'!� � DATEC �� , ? � Y ; � JOBSITE ATIO�� ��/� NUMB R� a�..-C.Y #/C 7 � iSSUE /''� TYPE OCC .- APN LOT TRA ���- � DATE ��Z"��"1�_CONST. GROUP � OWNER " ' O � ADDR 5S i . IL�,�"` 10 r; ZONING SETBACKS �W APPLICANT ZIP z�z��TEL. 9 � FRONT RW ❑ ' TEl. REAR, ❑ CITY �' z . S�DEISIDE STREET , RW � � 1 a PROPOSED USE C// ❑ CONTRACTOR I /1`� � CITY SS ZI?� 0 TEL. " �' � :,.�. �,�,. o ARCWENG! W DESIGNER �P NOJDWEL. NO. NO. d ,ApDRESS j_ UNIfiS STORIES BEDROOMS � CITY ZIP TEL. DESCRIPTION SQ.FL FACTOR PSF qDJ.AREAYVALUA y TION O , , , (.�1NNER-BUILDER DECLARATION � . SFR/ADD/REM � � � - ��� � � � � Q I HEREBY AFFIFlM UNDEF P,ENPLN dF PERJURY THAT I AM IXEMPT FROM THE CONTR0.CTOA5 LI- � „G2�d9B/CdfPOfl .. � ' W.� CENSEIAWFORTHEFOLLOWIN6REASON(SEC.703/.68USINESSPNDPfiOFES510NSCADE:PNYCITYOR � - �- C.1 COIINTYMMICHRE0UIRESAPERMITTOCONSTRUCT,ALTER.IMPROVE,DEMOLISH,ORREPAIRANYSTfiUG �J.J Patio/�eck � ��W','� TURE,PRIOR TO ITS ISSUANGE,�'AL50 REQUIRES THE APPLICANT FOR SUCH PERMIT TO FlLE A SIGNEU W - , �: STR7EMENT THAT HE OR SHE IS�LICENSEO PURSUANT TO TNE PROVISIONS OF THE CON7RPC70R5 LI• . .�� �CENSE lAW(CHAPTER e(COAIM�NCING WITH SECTION 7000)OP DIVISION 3 OFTHE BUSINESSAN�PN0. � PooUSpa FESSqNS CODE)OR THAT HE OR ShIE iS EXEMPTTHEREFROM AN�THE BASIS FOR THE AILEGED EXEMP• TION.ANYYbLATIONOFSEC710N7031.58YANYAPPLICANTFORAPERMRSUBJECTSTHEAPPLICANTTO - Z Ae-R001 � ' �' V'' ACINLPENALiVOFNOTMORETHANFIVEHUNCRED00LL4Rs(SSoo�.): . ~ ❑I,ASOWNEROF7HEPROPERTV,ORMVEMPLOVEESWITHWAGESASTHEIRSOLECAMPENSATION, Q ' � ��' .WILL DO THE WOHIC,M1U THE57RUCTUqE IS NOT INTENOE�OR OFFERED FOR SALE SSEC.7044,BU51- J CortllTtefCidl � " (,i ��� �'�; NESS ANO PRDFESSIONS C�E:THE CONTRAGTORS LICEhSE LAW DOES NOT APPLY TO AN OWNER OF j '� � � C � .PROPERTYYMOBUIIDSORIF9PqOVESTHEREON,ANDNMDOOESSUCHWORKHIMSELFOflHERSELFOq � � ��' 'THROUGHHISDRHEROWNEMPLOVEES.PROVIDEDTHATSUCHIMPHOVEMENTSAAENOTINTEN�EDOR , "� �, �- � ,OFFEREDWRSALEJF,HOWEVER,'fHEBWLDINGOHIMPROVEMENTISSOIDWRHINONEYEAROFCAMPLE- � `�TION,THE OWNER-BUILDEFi WILL HAVE THE BUHDEN OF PROVING THAT HE OR SHE OID NOT BUIL�OR- = IMPROVEFORSHEPUNPOSEOFI,SALE). ' � ,,,��� ❑I,AS OVMER OF THE PROPERTY.AM EXCLUSIYELY CANTMCTING WITH LICENSED CANTRACTORS , �, � ' i '.([. '��TO CONSTRUCT THE PR0.IEGT(SEC,7044,BUSINESS I1ND PROFE3310P13 CODE:THE CONTRACTOflS LI-- V8IU8IIOfl � ADJ.AREA ���W CENSEtAWDOESNOTAPPLYTdANOWNEROFAPROPERTYWHOBUILDSORIMPROVESTHEREON,ANO . �^��+�:��'WHOCONTMCTSFORSllCHPRGIECTSWITHACANTRACTOfl(5)LICENSEDPUFSUANTTOTHECONTFAG -QLJANTITY DESCRIPTION �� - . � ' � FEE � ��, TORS LICENSE LAW.). ., . .. , , , � , 8.&P.C.FOR THIS REASON Q� ' ' �� � , .....^ ❑IAMEXQAPTUN�ERSE6 � . . U .. , �' I i S� ... i ��. F . , ... .. .. u' DATE OWNEfi � � � � �, '� _ W �t��—,y, LICENSED CONTRACTORS DECLARATION _ - �j ��, � CC I HEREBYAFFIRM UNDER PENAL�TV'OF PERIURV THAT IAM LICENSED Ut3�ER PROVISIONS OFCHAPTEH - ��� B�COMMENCINGWiTHSECT{ON�)000)OFDIViSION30FTF�BUSME6SANDPROFE5510NSCODE,AND z I' '� ���'� �;��' �'' � MY IICENSE IS IN FULL FORCE A�1D EFFECT. m �(� �tl '� . /� p' �. �j O, LICENSE CUl S LIC.NO. -.�"l✓� T�" " . ... /ry�� `2 r•�j�j � . ".U:' DATE ���- � CCNTRACTOR 'C� �j d � � A '�y�g': .. W. �` [��° (W �'' WORt�ERS'COMPENSATION DECLARATION a ' , ��/T � U .. . � . . � 1 HEREBV AFFIAM 11N0ER PENAIffYOF OERIl1RV ONE OFTHE FOLLAWING DECLARATIONS: z � _IHAVEANDWILLMAINT�INACEFttIFIChTEOFCANSENTTOSELFINSUREFORWORKERS' _ �Z' COMPENSATION,ASPflOVIOE�J9YSECilON37000FTHElABORCODE,FORTHEPERFOHMANCE V �� OF 7FE WORK FOR WHI�FI THIS PERMIT IS ISSUED. � d '� _IHAVEANDWILLMAIM/�INWORKERS'COMPENSATIONINSURANCE,ASflEOUIRED8Y6ECTION ' �� � 37000FTHELABORCOpppE,FOR7HEPERFORMANCEOFTHEWORKFORWHICHTHISPERMITIS ISSUED.MYWOR S�MPENSATIONINSURANCECARRIERANDPOLICYNUMBERARE: CONSTRUCTION y CARRIER y PLAN REVIEW _ ,Z aoucvNu�aeEa �� ' � � _ ELECTRIC 0 (MLSSECIIONNE�NOT�EWMPLEfEDOFTNEPEt�RI.5FOf1aNEHUN9REDDOIJ.ARS�Etao)OFLESS� PLUMBING ��`� � �Z 1 CEHTIFYTHAT IN THE PERFOti61ANCE OF THE WORK FOR WHICH THIS PERMIT IS iSSUEU,I MECHANICAL " -�-'J' ' �� SHAI.L NOT EMPLOY AN�'PER50N iN ANY AAANNER 50 AS TO BECOME SUBJECT TO THE � z.- WORKERS'COMPENSA�TfION UWS OF CALIFORNIA,AND AGPEE THAT IF I SHOULD BECOME INSPECTION FEE �' SU&IECTTOTHEWOR�fERS'COMPENSATIONPflOV1310hSOFSECTION37000FTHELA60R � p�, � CADE,I SHALL FORTNWI TH COMPLY WI1H THOSE PROVl510NS. ISSUANCE ���� .�'°0�;'^� q �y�"'a* �' DATE: - IAPPLICANT: - -SMIP �^ _.,_� `� d 1 .'.�,y�. . � WAR(dlNGFAILUFETOSECUREIWORKERS'CAMPENSATIONCOVERAGEISUNIAWFUL,ANDSHALLBE ENERGYP/C � y "'���'� �'�' SUBJECTANEMPLOYERTO'CRIMINALPENALTIESANOCIVILFINESUPTOONEHUNDRE�THOUSAN� �„� �.'�"'"a� v "�� � ENERGYPERMIT „-�.+"��d }, OOLLARS(5700.0001.INADDITIOr1T07HECOSTOFCOMPENSATION,DAMAGESASPROVIDEDFORIN �r ,._j J�. SECTION37oNOFTHELABOHC �E,INTEREST,AN�ATTDRNEY'StEES. a�. P , RETENTION FEE: �""x "p�.,� � C�JNSTRUCTIONLENDINGAGENCY '���N � PRE-ALT FEE: ..Q, IHEREBVAFFIPMUNDERPENALTYOFPERJURYTHATTHEflEISACONSTRUCTIONLENDINGAGENCY ' ' FOa THE PERFORMANCE OF TF�E 1NORK FOR WHICH THIS PERMIT IS ISSUED(SEC.3097.CIV.C.). _ � i ,..,�.. ' . � . . �. . � LENDER'S NAME 'y LENDEfl'SADDRE55 J��j' a . K'(✓ . . . . ., �"�,W ICERTIFYTHATIHAVEREADTf{ISAPPLICATIONANOSTATE7HATTHEA00VEINFORMAYlONISCORRECL TOTAL FEES ���° � � � �,� IAGREETOCOMPLYWITHALLCITYANDCAUNTYOROINANCESANOSTA7ELAWSREIATINGiOBUIL�ING � � . �,�; �CONSTRUCTION,ANO HEAEBYAUTHOF2E AEPRESENTATIVES OFTHIS COUNTVTO ENTER UPON THE . . , . ', . .. . � , ',I�' ABOYE-MENTIONED PflOPERTYi FOfl fNSPECTION PU9POSES. COMMENTS - � �'�� I d' /6s91.�'i+i WV Vw4+�r G� te'✓a� . �m PE ' E NAM (P NTI - . ,� . . �'. d` m�n^_". ' . � '�' SIGNATURE Of PE E� � DAT ' �� ' - ' �_ � RECPT.NO. PAIDBV ��'�,VALIDATION. ' ��� ' ' � WHITE—D artment Co YELLOW—Finance Co PINK—Assessor Co GOLDENRdD—File Co GREEN— licanCs Co � eP PY� PY� PY� PY. 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