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HomeMy WebLinkAbout13445 (27) „��� r ��� ,r CITY OF DIAIVIOND BAI� �!�'�► � �---�"� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES � _ w , 21660 E.Copley Drive Suite 190 ,,,,,,,�. (909)860-3195 Fax(909)861-3117 �, PRES$ �,y�';. BUII.DING PERIVIIT APPLI�ATTON --- FIRMLY ¢ D RIESS '' � �1 �' ' ' APPLICATION PERMIT rPlC p ��' DATE NUMBER 0 ��S #. APIV LOY IS$UE / TYPE OCC � � `�° � �ACT ^ DATE �I/ '—�'9 CONST. GROUP p OWNE e,__ L p ADD S � ZONWG SETBACKS w APPLICANT i : 'TEL. FRONT RW ❑ 6 REAR ❑ z CITY ZI T ¢ E � � SIDE/SIDE STREET ` RW p � ��MRACT R -. ” SIDE , � ADDR , � �, OSED USE �. � CITY ZI���._r_"^TEL. PROP, w ARGWEN I � AD$IGNER NO.DWEL. NO.,RIES B DR, ` � CI , �z DE � fDRESS II ZIP TEL. UNITS STO, OdMS � '� p 1 HEREBY AFFIRM UNDER f�NALTYROF PELfiIURY T�AT�REXEOMPT FROM THE CONTRACTDRS LI- SFRJADD/REM ,,,, . . REANAL,UAT�ON rn DESCRIPTION SQ.Fl: FAC _ TOR PSF A�J.A � W. CENSEL4WFORTHEFOLLOWIN REASON(SEC.7031.58L151NESSANOPFOFESSIONSCOUE:ANYCITYOq � G81898/CB�oit � �� CS , COUNTYWHICHRE�UIRESAPER ITTOCONSTRIICT,qLTER;IMPROVE,UEMOLI5H2ORREPAIRANYSTRUC- ' ' ' W '��Tl1RE;-PRIOR i0�iT5ISSUANCE, .REQL11RE5 THE APPLICANT FOR SUCH PERMIT TO FIIE A SIGNED �W Patiol�eck � � . STATEMENi THAT HE OR SHE I IJCENSEU PURSUANT i0 THE PROVISIONS OF THE CANTflACTORS LI• -" • � � CENSELAW(CHAPTER9(COMM NCINOWITHSECTION7oo0)OF�NISION30FTHEBUSlNESSANbPRO- � � POOUSP3 ' � ' � � �' , �� �FE3310N3CODE�ORTHATHEOF{SryE15EXEMPTTHEREfROMANDTHEBA5ISFORTHEALLE6EDEXEMP- .(� � � ,' �' , ,, � , TION.ANYYIOLA710NOFSECTIO��IZo37.56YANYAPPLICANYFORAPERMITSUBJECTSTHEAPP6ICANTTO . ��z�� Re-Roof F ( ... . .. � .' ' I ��ACMLPENAL7YOFNOTMOREIIFiANFiVEHUNDREDDOLLARS$5001.):� ❑I,ASOV/NEROFhIEPROPERTY.ORMYEMPLOVEESWITHWAGESASTHEIR50LECOMPEN§AiION, 0 Cqmmeroidl ....Z '�. WILL 00 THE WORK,ANO.TME S7RIJCTURE IS NOT.IN7ENOE0 OH OFFERED FORSALE(SEC.7044,;BU51- J � �NE55 AND PqOFES51IXJ5 CODE:I7HE CONTRACTORS LICENSE LAW DOES NOTAPPLY YO AN OWWEq OF � ; ' ''. PPOPERTYVhp8U1LOSORIMPF�OVESTHEREON,ANDWHODOESSUCHWOftKFiIMSELFORHER9�LFOR� ' � �OC i��THROUQFIHiSORHEHOWN`cMPFOYEES,PRDYIDEDTHATSUCHIMPROVEMENTSARENOTINTENDE00R m� �, � ' �. � . Q ���OFFEHEDFORSALEIF,HOWEVEF',TiEBU1LDMGORIMPFOV�MEPRI55oL�W�THINONEYEAFOFCOMRE �;�710N,THE OWNER�BUIL�ER WIµHAVE THEeURDEN OF PPOVING THAT HE OR SHE�i�NOT BUIID OR _ ���MPROVEFOfiTHEPUflPOSEOFISALEI. . ' ..� � . . . � ' W , ❑I.AS OWNEflOFTHE PROPEHfY,AM EXCLLISIVELV CANTRACTING WRH LICENSE�CONTRACTORS � ;70 CONSTRUCT THE PR0.IECT(SEC.7oq4,BUSfNESS AN�PROFESSIONS CODE:THE CONTRAC70R5 LI-� VdIUa{IOf1 � ADJ.AR�A - . W �.CENSEL1WD06NOTAPPLYTQ�ANOWNEROFAPROPERTVWHOBUIL�SORIMPROVESTHEREON,AND -----�+- � '� ��"WHOCONTMCTSFORSUCHPRAIECTSWITY.ACONTRACTOR(9)LICENSEDPUR3UANYTOTHEGONTRAG Q ANTITY DESCRIPTION � � FEE � '. 70R9LICENSELqW.). I, . , �� ❑IAMEXEMPTUNOERSEC. 6,8PCFORTHIS�REASON Q �I� - � ...�.. .. I . .. �. �� � � � , iJ��., W � � �'a' DATE . .. OWNER � F � � �" z W ; � � � � LiCE SED CONTRACTORS DECLARATION. �� '� , � ,.. - OC �IHER�YAFFIBMUNDEflPENP17Y�OF?ERJURYTHATIAMLICENSEDUNDERPROVISIONSOFCHAPiER I�r � .�9{COMMENCINGWITHSECTION�OOa)OFDIVISION30FTHEBUSINESSANDPROFESSIONSCODE,AN� Z I X� �MY L:CENSE IS IN FULL F E O;EFFECT. � LLI j ,,��/rr �.� LICENS LASS " �*. . LIC.N0. �'�� F�-�4 �:'. ' . � � . � V,'.`�DdTE '�� � CONTRACTO ` '� d� � W � WORK RS'COMPENSATIONDECLO\RATION H �� IHEfl�YAFFlANUfdDERPENPI ��OFPERJURYONEOFTHEfOLLOWINGOEClARATIONS: � � 0 IHAVEANDWILLMAINTAWACEPiPIFICATEOFCAN5ENT705ELF-INSUREFORWORKERS' ¢ - . ��;� � �CAMPENSATION,AS'PR�� IDE08VSECTION37aoOFiHELABDRCODE,FORTHEPERFOflPAANCE ' C.7 Q �/` OFTHE WOqK FOR YdHI HTHI9 PEFMIT IS ISSUED. g FW„� ' �IHAVEANDWILLMAINTAM�'dORHERS'COMPENSATIONINSUAANCE,ASFiEQUIREDeVSECTION � . „, a37aoOF THE LABOp C0� ;FORTHE PERFORMAN�OF THE WORK FOR WHICHTHIS PERMIT IS J I55UED.MY WORK �MPENSATION INSURANC IER AN6�icv NUMe:R r�e: CONSTRUCTION �� CARRIER � p ..Eyy � POLICY NUMBER � � !��.:.='.;- -� Z��� ''LLL ELEQTRI t;+ .� ""+"A q . ' , ., .� , .�.;� � (fFiSSECTIONNE�NOT�COMR.EfEDOF1HEPEFUMISFOpONEHUPAREDWLIMS(EtCo)DRL[SS} MBING � 1 CEflTIFY THqT IN T➢1E P RFORMANCE OF THE{NORK FOR WHICH 11i15 PERMIT IS ISSUED,I �MECHANICAL =n3 e CS� SHALLNOi EMPLOY ANy PEHSON W ANY MANNEF SO AS TO BECOME SUBJECT TO THE y �s � WORKERS'CDMPENSAT�N LAWS OF CALIFORNIA,ANDAGREE THAi IF I SHOULD BECOME INSPECTION FEE �� �. r'c� � '�`i� ��, � SU&IECTTOTHE WORK R5't�MPENSATION PROVISIONS OF SECTION 37ao OFTHE LABOR �+�5""3�� t ,�, �. CAOE,ISHRt1FORTHW�WCOMPLVW EPROVISIOISS. ISSUANCE �.� � ��^�' �� -, � .. ����� � - ' ���~� � ��n� ��� p, DATE� ���I�.� �PPUGAYVT: �'w. o- �� � ENERGY P/C °'' �'^����°',f+v J�. WARNING:FAILURETOSECURE�� pqKgRS'CDMPENSATIONCOVEPAGEISUNLAWFUL,AN�SHALLBE -- -�y�,' SUBJECTANENPLOYERTOCR� IIUp4PENALTIESPN�CIVIL-FINESUPTOONEHUNDREDTHOUSAND ENERGYPERMIT DOLLARS(C7oo,000),INAD�IT� ,YOTHECOSTOFCOMPENSATIOPl,�AMA(iESA3PROVIDEDFORIN � S'cCTION37080FTH'cLp90R � E,INTEREST,ANDATTORNEI"SFEES. RETENTIONFEE: � O�, C�STRUCTION LENDIYJG AGENCY PRE-ALT FEE: i ��.� 1 HER�YAFFIflM UNDER PENAL OF PERJURYTHATTH�RE IS A CONSTRUCTION LENDING AGENCY - ' ��'� FOR THE PERFORMANGE OF7H WORK FOR WHIGH 7HI5 PERMIT IS ISSUED(SEC.3oW,CIV.CJ. - � Z' W' ���, -LENDER'S NAME ..�I . 1-. LENDE}l'SADDRE55 - �'�. ICEflTIFYTHA7IHAVEREADTHI APPLICATIONANDSTATETHATTHEABOVEINFORMATIONISCAqqECT. TOTALF�ES � :�,� �d/" �. a;, IAGFEE?O COMPLY WITH ALL q V AND COUNTY OF�INANCESAND STATE iAWS RELATING TO BUILDIN� - . ���, CONSTFUCTION,ANDHEFiEBYAUTH�RIZEHEPRESENTATIVESOFTHISCDUNTYTOENTERUPON7HE . � - , �- ., . Z�� A90VE-MENTIO ED PROPERTY R INSPECTION PURPOSES. COMMENTS -- - � 0'', J'�', , . ` ' .. . . . . m. PER NAhAE � . . , � . . [d ;r � ��. �� � GNATURE flMITf DATE �., � - RECPT.NO. 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