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Home My WebLink About17301 's� �._— C1TY OF I�IEIMOND BAR � � DEPARTIv�ENT OF COIvIMUNITY&DEVELOPMENT SERVICES � Q- ,w . 21825 E.Copley Lhive � (909)860-3195 Fax(909j 8613117 PRESS �'%•y�� B�I.DING PERMiT APPLICATION """`�` FIR LY o AOD RIESS °�� .t�� ' _ DATECATION � ��36 �'y� PERMIT A' Q �/� '� ej� NUMBER o�o ISSUE /'► TYPE OCC APN LOT TFiACT DATE C.� CONST. GROUP p OWNER ` � � � � ADDRESS � '� ' ZONING SETBACKS 0 OCITY��s�P�'li'c�!'��i�ZIP�' T �TEL�� FRONT RW ❑ APPLIC N�''�r�� t"�i�,o�c�� TEL. REAR ❑ � � �Y�� SIDE/SIDESTREET RW ❑ z ¢ CONTRACTOR SIDE � ADDRESS ' � C�TY ZIP TEL. PROPOSED USE g � I w ARCH/ENG/ �� z DESIGNER � ADDRESS N0.DWEL. NO. NO. cn UNITS STORIES BE�ROOMS � CITY ZIP_ TEL, � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION ' OWNtR-BUILDEF DECLARATION p� SFR/ADD/REM � p I HEREBY AFFIflM UNDEFi PENALN OF PERJURY THAT I AM E%EMPT FqoM 7HE CONTRACTORS LI� G8l8CJ0/C3fpOf[ W CENSELAWFORTHEFOLLOWMGREASON(SEC.7031.SBUSMESSANDPROFESSIONSCO�E:ANYCITYOfl (� �� WU' CDUNTVWHICHRE�UIPESAPERMITTOCONSiRUCT,AITER,IMPROVE,DEMOUSH,ORFEPAIRANYSTRUC- W patio/Deck �,TURE,PPoOR TO ITS ISSUANCE,ALSO RE�UIflES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED � STATEMENT THAT HE OR SHE IS LICENSEO PURSUANT TO iHE PAOVISIONS OF THE CONTRACTORS!1� �� '�� CENSELAW.(CHAPTEfl9(COMMENCINGWITHSECTION�WO)OF�IVISION30FTHEBUSINESSANOPRD� u' POOI/Sp2 �, �"' FESSIONSCODEJDRTHATHEOf15HEI5EXEMP7THEREFROMANDTH'c8A51SFORTHEALLEGEDEXEMP- (� i U TION.ANYVIOLATIONOFSECTION7037.58YANYAPPLICANTFORAPERMITSUBJECTSTHEAPPLICANiTO Z R2-ROOf � ACIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED�oLLARs IE5uo).)c � II 0'. ❑I,ASOWNEROFTHEPROPERTV,ORMVEMPLOVEESWIiHYJAGESASTHEIRSOLECOMPENSATION, O COffIRI0fC18I .Z',', WILL DO THE WDAK,AND THE STRUCTURE IS NOT INTENDED OR OFFEfiED FOR SALE(SEC.7044,BU51� J I ��', NESSAND PPOFESSIONS CODE:THE CONTRACiORS LICENSE LHW DOES NOTAPPLY TO AN OWNEFi OF � .' PflOPERTYWHOBUII.D50RIMPROVESTMEREON,AfJ�WHODOE55UCHWORKHIMSELFORHERSELFOR I ��.�' THROUGHHISORHEqOWNEMPLOYEES,PROVIDE�THATSUCHIMPROVEME�TSApEYOTINTENDEDOR m �, Q�,.OFFEflE�FORSAIE.IF,HOWEVER,THEBUPDINGORIMPROVEMENTISSOLDWITHINONEYEAROFCOMPI& Z�.TION,THE QWNER-BUIIDER WILL HAVE THE 9URDEN OF PROVING THAT HE OR SHF.DID NOT BUILO OR .�'I IMPROVE POR hIE PU(iPOSE OF SALE). fl I,AS ONMER OF THE PROPERTV,AAA EXCLUSIVELY COMRACTING WITH LICENSEO CONTRACTORS �'�' TO CONSTRUCT THE PRQIECT(SEC.7044,BUSMEES AND PROFESSIONS CODE,THE COMRACTOflS LI- V8IU8IIOfl ADJ.AREA _" CENSE LAW DOES NOiAPPLVTOAN OWNER OFAPROPERTY WHO BUILDS OR IMPROVES THEREON,RND -- ,�'�I WHOCOMRACTSFORSUCHPFOJECTSWIhiACONTRACTOR(5)LICtNSE�PURSUANTTOTHECONTRAC- Q�JQNTIN DESCRIPTION FEE Y �TORS LICENSE LAW.). � ❑I AM EXEMPT UNDEF SEC. B.&P.C.FORTHI� EASON Q �. yy - ;-....,.., U . �'�' DATE L ` � *�-��OWNER � ` � F- ` ,� .o'•^'.. �r i . _ _..__. _ .Z__._.___ ._..___. ___.._,. . ,,.+� - ,. _. U � LICENSED CON;LRACTORS DECLARATION � W � IHEREBYAFFIRMUN�ERPENALTYOFPEAJURYTHATIAMLICENSEDUNOERPROVISiONSOFCHAP7EP � � 9�COMMENCWGWIiH5ECT10N700o)OFDIVISIDN30FTHEBUSINESSANDPRO'rESSIONSCODE,AND Z �� MV LICENSE IS IN FULL FORCE AND EFFECT. m � LICENSE CLASS_ LIC.NO. _ V DATE CONTPACTOR d W � WORKERS'COMPENSAIION DECLAPATION a � IHEREBYAFFIflMl1NDERPENhLTYOFPEflJURYONEOFTHEFOLLOWINGDECLARATIONS: U � z Z �HAVEAIJOWILIMAINTAINACERTIFICATEOFCONSEMiOSELF-INSUREFORWORKERS' a 2 ¢ CAMPENSATION,ASPROVIDEDBYSECTION3�OOOFTHELABOR�CODE,FORiHEPERFORMANCE U OF THE WORK FOR WHICH iH15 PERMIT IS ISSUE�. w 0 � � _IHAVEANDWILLMAINiAINWORKERS'COMPEN9ATIONINSURANCE,ASREDUIREDBVSECTION 'Q 37000FTHELABORCODE,FORTHEPERFORMANCEOFiHEWORNFORWHICHTHISPERM1T18 `��_ ` Q� J, ISSUFD.MVWORKERS'COMPENSATIONIN3URANCECARRIEFANDPDUCYNUMBERARE: CONSTRUCTION �r�� (-� L � CARRIER PLAN REVIEW Z POLICYNUMBER ELECTRIC ¢ � (i}iIS5EC'fIONNEmNOiBE�,1PLEfEDOF7HEPERMfTISFORONEHUN�RE�WLLAf1S($10DjORL63). PLUMBING W Z I CERTIFYTHAT IN THE PERFORMANCE OFTHE WORK FOR WHICH THIS PEqM1T IS ISSUED,I MECHANICAL CJ SHALLNOTEMPLDYANYPERSONINANYMANNERSDASTOBECOMESUBJECTTOTHE (/) WOflKEflS'COMPENSATIOVLAWSOFCAUFOflNIA,ANDAGREETHATIFISHO�LOeECOME INSPECTIONFEE � ? SUBJECTTOTHEWORKERS'COMPENSATIONPFOVISIONSO�SECTION37a00FTHELPBOR � • CO�E,�SHALL FORTHWITH COMPLV WITH THOSE PROVISIOhS. ISSUANCE � �p� DA7E�. APPLIGANT; SMIF A W __ 'J WARNING:FAIWRETOSECIJREWORKER5COMPEN5ATIONCOVERAGEISUNLAWFUL,ANDSHALLBE ENERGYP/C �' SUBIECTANEM?LOVERTOCflIMINALPENALTIESANOqVILFINESIIPTOONEHUN�RE�iHOUSAND ENERGYPERMIT DOLLARS{5700.000),IN ADDIiION TOTHE COST OF COMPENSATION,DAMAOES AS PftOVIDED FOR IN J SECTION 37oeOFTHELABOR CODE,INTEREST,ANDATTORNEY'S FEES, W RETENTION FEE: � O CONSTRUCTION LENDING AGENCY PRE-ALT FEE: �� IHEREBYAFFIRMUNDERPENALiVOFPEftJUqVTHAiiHEREISACONSTRUCTIONLENDINGAGENCY � � FORTHEPERFORMANCEOFTHEWORKFOflWHICHTHISPE�MITI5155UED(SEC.309�,QV.C.), Z' W � LENDER'SNAME Ir� LENDEFi'SAD�RESS __, � �. �� ICEflTIFYTHATIHAVEREADTHISAPPLIGAiIONANDSTATETHA7THEA90VEMFOFMATIONISCDRRECT. TOTAL FEES �� . ` ��y, IAGfiEETOCOMPLYWITHALLC(TYAN�WUNTYOFDINANCESANDSTATELAWSRELATINGTOBUILDING �p�( � ,�y� CONSTRUCiION,AN�HEREBYAUTHORRE REPflESENTATIVES OF7HIS COUMV TO EN7ER UPON THE �{! \.! Z A80VE-MENTIONED PROPERTY FOR INSPECTION PURPOSES. COMMENTS �' � �'�� 1 � m -PERMITTEE N E(P � �� ,.,.. —__ SIGNA , O � DATE - � RECPT NO. PAID BY VAUDATION � WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDEN OD—File Copy,GREEN—ApplicanPs Copy ,.:: , �. ., ,.�.,. . .x,:- , . ,;r,o +,,,. ; a,.�t�,.�w.�,,�- ,�;-u. . . ,. ,...,,,�, x .., , ,, .. ..,,.... . � . � w ' ,. . . ��""�an r:��.:. a ruW��. �` .�."'.� s-� � � s t; , s � �� , 7 � a �+ ' � r,� a § � .�^� �. ��,�' �. g x r`� ; �.�^�. � 7 �,�"s I 3 �'r ° �. �^m � x s � • '�..�. $a�,� ^ � � C � � s'�,g � P ��i� � �',v �� a d � ';� k '�a �'�"�'� �� n�,�r��f ?'�,.�.. :�.�� :�'a� ��` �:.;,�.°' . ��... � �` ... ,:�x...�:�.. �.�.,."�.'� �n#. �� :' , . ..� __ �. «� ��:. ;a!a .�. �: .4.. s. '�� _ .e r+..E'�':� "..�i a�`-..�s�."��;r t?..�� i ..._ '� ..�, � � ,,. 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