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HomeMy WebLinkAbout16930 f— —��--- CITI'fJF T�3AMOIVI)BAR � o DEPART.'�NT OF COMMUNTI'Y&DEVELOPMENT SERVICES �,_� 21825 E.CopleyArive (909�860-3195 Fax(909)861-3117 PRESS ''-v���` BUILDING F'ERMIT APPLICATION FIR Y � J08SITE ,�g i APPLICATIO �� �f PERMIT P/C / o ADDRESS�� ��kC.�e��k����.�$��_� DATE ! NUMBER���fkL -- � ISSUE TYPE OCC APN LOT 7RACT DATE � � CONST. GROUP p OWNER o ADDRESS"' / ' 7a -" � ZONING SETBACKS Z CITY ��LJP�_ TEL. FRONT RW ❑ o APPLICA T . �� TEL.� � � SIDE SIDE STREET RW ❑ Z SIDE ❑ Q CONTRACTOR �— .a p� ADDRES � ` � � � ` PROPOSED USE - !J �C . ��l � CITY ZIF TEL. � '� .�'��� p w ARCH/ENG/ , �, z DESIGNER ' w N0.DWEL. NO. �� � oNO. � ADDRESS UNITS STORIES � BEDROOMS � CITY ZIP TEL. � cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION. p� OWNER-BUIL'�ER DECLARATION SFR/AD�/REM O I HEflEBV AFFIRM UNDER P�ENALTV OF PERJURY 7HAT I AM EXEMPT FFIOM THE CONTRACTORS LI� G8f8�0/C3fpOf� � W CEN5EWWFORTHEFOLLOWINGIREASON(SEC.7o31.5BU51NES5NN�PROFE55iONSCODE:ANYqTYOF (n - U' COUNTYWHICHREQUIRESAPER�hITiOWNSTRUCT,ALfEft,IMPROVE,DEMOLISN,ORREPAIRANYSTRUG W • Z TURE,PflIOR TO ITS ISSUANCE,ALSO RE(]UIRES 7HE APPLICANT FOfi SUCH PERMITTO FILE A SIGNED Petio/DeCk � W STATEMENT THAT HE OR SHE IS LICENSE�PURSUANT TO THE PROVISIONS OF iHE CONTFACTORS LI� W � CENSE LAW(CHAPTER 9�COMMENCING WITH SECTION 7000)OF DIYISION 30F THE BUSINESS AND PRO- �' POOI/Sp'd O 'FESSIONSCODE)ORTHATHEOR$HEISE%EMPTTHEREFROMANDTHEBfe51SFORTHEALLEGE�EXEMP- (� �. �� �TION,ANYVIOLAiIONOFSECTION7�37:5BYANYAPPLICANTFOflAPERMITSUBJECTSTHEAPPUCANTiO z Re-Roof � � ' ACIVIL PENALN OF NOT MORE THAN F�VE HUNDRED DOLLAflS(b500J.): '., � ❑I,ASON?JEROFTHEPROPiERTY,ORMYEMPLOYEESWITHSNAG'c5A5THEIR50LECOMPENSATION, � COffIfI10fC12I - �, z WILL DO THE WORK,AND iHE SifiUCTURE IS NOT IN7ENDED OR OFFERED FOR SALE(SEQ 7044,BU51- J � � NESSAND PRO'rES510N5 CODE:THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN ONlKEA OF � � , PROPERTYWHOBIJILDSORIMFFOVESTHEREON,ANOWHOD�E5Sl1CHWORKHIMSELFOqHERSELFOR ' � � THROUGH HIS OR HER OWN EMPI'rOVEES,PROVIDED THAT SUCH IMPROVEMENTS ARE N071NTEN�ED OR m . W OFFEREDFOqSALEIF,HOWEVER'THEBUILDINGORIMPflOVEMENTISSOLDWITHiNONEYEAPOFCOMPLE- ', Z ,TION,THE OWNEF-BUILDEfl WILLy HAVE THE 9UFDEN OF PROVING THAT HE OR SHE DID NOT BUILD OP . � IMPROVE FOR THE PURPOSEOF SALE). � ❑I,AS OWNER OFTHE PROPERTY,AM EXCLUSIVELYCONTRACTING WITH LICENSED CONTRACTORS � � �TO CANSTRUCT THE PROJECT(SEC.7044,2USINESS AND PROFESSIONS CODE:THE CONTRACiORS LI- Valuafion '"' ADJ.AREA 1,�� �CENSELAWDOESNOTAPPLYTOANOWNEROFAPROPERiYWHOBUILDSORIMPROVESTHEREON,AND � WHOCANTRACTSFORSUCHPROJECTSWITHACONTRACTOR�S�LICENSEDPURSUANTTOTHECONTFAG QUANTITY DESCRIPTION . FEE - .� TORS LICENSE LAW.). I � � �I AM EXEMPT UNDER SEC� B.&P.4 FOflTH15 REASON a ?y U � � DATE oWNER U Z � LICEN$ED CONTRACTORS DECLARATION W � ¢ � 1 HEREBYAFFIflM UNDEfi PENALTN Of PEftJUFiV h1AT I AM LICENSED UNDER PflDVI510N5 OF CHAPTER � � p_ 9(COMMENCING WfTH SECTION 7�100)dF DIVI510N 3 OFTHE BUSINFSS ANU PFOFESSI�NS COOE,AND Z X MY LICENSE IS!N FULL FORCE At�EFFECT. �q, � LIGENSE CLASS�LIC.NO. � ����eEr � U� �ATE CONTRAGTOR 3 a W � WORK�RS'COMPENSATION DECLARATION ¢ � I HERE6YAFFIRM UNDER PENALT'OF PERJURV ONE OFTHE FOLLOWING DECLARATIONS: Z L] _IHAVEANDWILLMAINTqIJN'ACEiiTIFICAiEOFCONSENTTOSELF-INSUftEFORWORKERS' � "'"' ¢ -COMPENSATION.ASPROyIDED�BYSECTION37000FTHELABORCO�E,FORTHEPERFORMANCE U ��1 Q OFTHE WORK FOR WHICFi THIS PERMIT IS ISSUED. � � ��-=�+'� -, I . -:- � W d�� _I HAVE AN�WILL MAINTqIN WOFKERS'COMPENSATION INSURANCE,AS REQUIfiED BY SECTION g ' [� , i.�,� � 370oOFTHELABORCODE,FORTHEPEfiFORMANCEOFTHEWORKFORWHICHTHISPERMITIS $ ��9F` � f��R ���� � �'"1'„�.v ISSLIE�.MY WORKFAS'C MPENSATION IN NCE CARR7ER AND POLICY NUMBEFiARE: CONSTAUQTION p l`d � �.! 4 � CARRIER 1���� �AI�• PLAN REVIEW �9 � O (fH�sSENCTIONNE�Noie' I� �� �� ELECTRIC �r-, . : � EOJMPLEfEDOFTNE?EFMRISFOIiONEHUNDREDDq1AR5(5100)ORLESS). PLUMBING'�6--�---�-•--"`^`�""'�""--��� � F � �� Z ICERTIFVTHATINTHEPERFOqMANCEOFTH'cWORKFORWHICHTHISPERMIiI51S5UED,l MECHANICAL ' � ('3 SHALL NOT EMPLDY ANY pERSON IN ANV MANNER SOAS TO BECAME SUBJECT TO THE y WOAKERS'COMPENSATIbNLAW50FCPLIFDRNIA,AN�AGREETHATIFISHOULDBECOME INSPECTIONFEE � SUBJECT70THEWORNE�iS'COMPENSATIONPROVISIONSOFSECT N37ooOFTHELIBOR � CODE.I ALL F iHWITH COMPLY WITH THOGE PROVI510N5. . ISSUANCE 0 �,,�p � p DATE: � fJ �l�IPPLICANT: �i'/ ( SMIP d J�. WARNING:FALURETOSECUflE ORKERS'COMPENSATIONCOVERAGEISUNL4WFUL,ANDSHALLBE ENERGYP/C � SUBJECTAN EMPLOYER TO CRIM NAL BENALTIESAN�qVIL FINES UP TO ONE HUN�FE�THOUSAN� ENERGY PEflMIT r. �OLLARS(S100,000),IN A��ITION�OTHE COST OF COMPENSATION,DAMAGES AS PROVIDE�FOR IN --�Y'.��°/� � SECTION 3�oe OF THE LABOR COQE,INTEFEST,AND ATTOFNEV'S FEES. RETENTION FEE: ��V � CO�,NSTbUCTION LENDING AGENCY PRE-ALT FEE: � IHEREBVAFFIRMUNDEFiPENALfi'DFPERJURYTHATTHEREISACONSTRUCTIONLENDINGAGENCY �- fORiHEPERFORMANCEOFTHEIWORI(FORWHICHTHISPERMITISISSUE�(SEC.3091,CIV.C.). Z W. � LENDER'SNAME 1— LEN�ER'SAODRESS �/y � ICERTIFYTNATIHAVEREADTHISAPPLICATIONAN�57ATETHA7THEABOVEINFORMAiIONISCORRLCL TOTAL FEES . B�` � S / � IAGREETOCOMPIVWITHALLCI7YANDCOUNTYORDINANCESANOSTATEIAWSRELA71N0TOBUILDING � �✓"�� \.� � CONSTRUCTION,ANOHEREBYAUTHOPoZ�REPRESENTATIVESOFTHISCOUNTYTOENTERUPONTHE . Z, ABOVE�MEN710NED PROPERTY FOfl INSPECTION PURPOSES. COMMENTS - � � a J - m . a PER E(PfilNn � r • � N SIGN •UREOFPERMITTEE DATE ' = RECPT.NO. - PAID BY� VALIDATION ~ - WHITE—De artment Co YELLOW—Finance Co PINK—Assessor Co GOLDENROD—File Co GREEN—A IicanYs Co ' � P PY� PY. PY� PY� PP PY� ,:,.: .:.- _ __ , ,. .. . .. � � ., . ,,.. 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