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HomeMy WebLinkAbout16699 (39) -��-- CIT'I'OF'�I�IO��� _-��-�.; -� ' � � D�Pf1IZ�1VT��C� � Th'&IDEV�LO�MENT SEI2VICES �`�� 21�25 E.�opDey I?r'sve �� � ,,� " (909)360-3195 F�a(909)�61-3 i i e ��. � P R ESS :_,,y�y.:., �iri�.�uv��E �P�,�c�Tio�r FI Y � JOBSITE /� � / �/ �y � APPLICATION PERMIT P/C o ADDRESS�V ��5� J T��G J /rJQ� � ��. A pATE � � �� NUMBER � � # g ISSUE � � � TYPE OCC APN LOT, RACT DATE CONST. GROUP � OWNER 6U/ .,/JS� ��' OO o ADDRESS ZONING SETBACKS Z CITY ZfP TEL. FRONT RW � p APPLICANT TEI. g pE/SIQE STREET RW ❑ z ¢ CONTRACTOR / /2 SIDE C ADDRESS I l L C. v , �.�,� ��� e� ��� a CITY I ZIP /7 TE ' d PROPOSED USE o ARCH/ENG/ , ' w DESIGNER � NO.DWEL. NO. NO. � ADDRESS � � CITY � ZIP TEL. UNITS STORlES BEDROOMS � cn DESCRIPTION SQ.Ft FACTOR PSF ADJ.AREANALUATION � O�NER-6UIL�ER DECLARATION SFR/AaD/REM � O 0 I HEflEBY AFFIRM UNDER P PIALTY OF PERJURY THAi I AM EXEMPT FriOM THE CONTRACiORS��- GaragelCarport W CENSEL4WFOFlTHEFOLLOWING EASON(SEC,7o31.50USINESSANDPROFESSIONSCODE:ANYCITYOR (n U COUNTYWHICHR`eQUIRESAPER ITTOCONSTRUCT,ALTER,IMPROVE,DEMOLISH,ORREPAIRANYSTRUG � W TURE,PRIOR TO ITS ISSUANCE, LSO flE�UIRES THE APPLICANT FOR 5UCH PERMITTO FILEA SIGNE6 � Pdt10/DeCk � STATEMENT THhT HE OA SHE IS ICENSED PURSl1ANT TO THE PqOVISiONS OF THE CONTRACTORS LI- � � CENSE LAW(CHAPTER 9(COMME CING WITH 5'cCTiON�aoo)OF DIVISION 3 OF THE BU9NESSAND PRO- POOVSp2 Q FESSbNSCADE)ORTHATHEOR HEISD(FMP7THEflEFROMANOTHEBASISPoflTHEALLEGEDE%EMP- (� V TION.ANYVIOLATIONOFSECTIO 7031.5BYA3dYAPPLiCAR'TFORAPEflMITSUBJECTSTHEAPPLICANTTO Z Re-Reof A CIVIL PENAITY OF NOT MORE T AN FNE HUNDRED�OLL4fl5�5500).): o ❑I,ASOWNEROFTHEPROP RTY,ORMYEMPLOYEESWITHWAGESASTHEIRSOLECONiPENSATION, � �,pmm0fC13I - � WILL DO THE WORK,AND THE ST�UCTURE IS NOT IN7ENPED OR OFPERED FOR SALE(SE0.7044,BUSI- _i � NE55 AND PFIOFESSIONS CODE: HE CONTRACiORS LICENSE LAW�OES NOT APPLY To AN oWNEfl oF � ' PROPERNWHD9UILUSORIMPR VESTHEREON,AN�WHODOESSUCHW09KHIMSELFORHERSELFOR - � TNflOUGHHISORHEROWNEMP YEES,PROVIDE�THETSUCHIMPAOVEMENTSARENOTINTCNDGDOF m Q OFFEREDFORSALE.IFHOWEVER,THEBUILOINGORIMPROVEMENTiSSOL�WiTHINONEYEAROFCOMPLE- Z TION,THE OWNER-BUILDER WILL HAVE THE BURDEN OF?ROVWG iHAT HE OR SHE DID NOT BUIL�OR � IMPFOVE FOR 7HE PURPOSE OF A.EJ. W LJI,ASOWNEROFTHEPFio ERTV,AMEXCLUSIVELYCONTRACTINGWITHLICENSEDCONTRACTORS � TO CONSTRUCT THE PR0.7ECT(S C.7044,BUSINESS AND PROFESSIONS CODE:THE CONTRACiORS LI- ValUation ADJ.AREA W CENSE LAW DOES NOiAPPLYTO N OWMER OFAPPOPERTV WH0 8111LDS OR IMPROVES THEREDN,AN� _ ' WHOCAMPACTSFORSUCHPRO.�ECTSWI7HACONiRACTOP�S)LICENSEDPURSUANTTOTHECOMRAC- � TORSLICENSELAW.). QUA.NTITY DESCRIPTION � FEE - � I g ❑I AM EXEMPT UNDER SF_C.�'i, B.&P.C.FOR THIS flEA50N J U �' ¢ OATE OWNER F o � W � LICEN�ED CONTRACTOFiS DECLARATION W � Q CG I HEREBYAFFIRM UNDER PENALTj'OF PERJURY THAT I AM LICENSED UNDER PROVi510N5 OF CHFPTER (/� � 9(COMMENCINGWITHSECTION�¢oo)OFDIVISION30FTHE0USINESSANDPROFESSIONSCODE,AND z �� C ✓✓�L�• 7< MY UCENSE IS IN FULL FORCE ANf1 EFFECT. �,�/ / o LICENSECLASS �� LIG.NO. f �ZG%�O/ � � � U DATE � GONTRACTOR���I�S. a UJ I � WORK�RS'COiv7PENSATION DECLARATION Q . � � I HEREBYAFFIRM UNDER PENALT�'OF PERJURV ONE OF THE FOLLOWING�EqARATIONS; � � . _IHAVEAN6WILLMAINTAI ACERTIFICATEOFCONSENTTOSELF-MSUREFORWORKERS' a ¢ CAMPENSATION,ASPiiO�IDED9YSECTiON37aDOFTHELABORCODE,FORTHEPERFORMANCE U Q OF iHE VdORK FOR'NHIC THIS PEP.MIT IS ISSUE�. � QW _IHAVEANDWILLMAINTAINIWORKERS'COMPENSAiIONINSURANCE,ASFiE�UIRED6Y5ECTION 37o00FTHELABORCO�,fOflTHEPERFORMANCEOFTHEWOFKFORWHICHTHISP�RMIT15 _ ISSUED.MY WORKFAS'C�MPENSAT�IO/N INSUR��jN CE CARRIERAN�P�O'-''1jCV NUAABEaAPE: CONSTRUCTION � C.4RRIER d �/G �vV%, PLAN REVIEW ................... --� �� „�.,...... ... �t Z POLICYNUMBER�_i�=3��,. II�JI� �Z-/..�• ELECTRIC �_,�_��._����,, ¢ � � � .� ,. � (iHIS5EC71Q�'NEmNOTB�O�MFLETEDCFlH"ePERMITISWRIXJEHUNDREDCOLLAR5�51�ORLESS). PLUMBING -*� �l � V� ,, • Z ICERTIfYTHATINTHEPE�iFORMANCEOFTHEWOFiKFORWHICHTHISPEftM1T15lSSUE�,I MECHANICAL '"' -� '� SHALLNOTEMPLOYAh'YIPERSONiNANYMANNERSOASTOBECOMESIIBJECTTOTHE (J� WORKERS'GOMPENSATI�NLAWSOFCALIFORNIA,ANDAGRcETHATiFISHOULOBECOME INS�ECTIONFEE i � SUBJECT 70 THE WORKE 5'COM?ENSATION PROVISIONS CF SECTIOIV 37000F iHE LABOR � CODE,ISHALLFOPTHWIT�COMPLYWITHTHOS'c?pOVISIONS. ISSUANCE o s � DATE: A�PLICANT: SMIP J WAPNINGFAILURETOSECUREWORKERS'COMPE�SATIONCOVERAGEISU�NLAWFUL,AN�SHALLBE ENERGYP/C � SUBJECTANEMPLOYERTOCqIMI�lALPENAL7IESANDCIVILFMESUPTOONEHUNDREDTHDUSAND ENERGYPERMIT DOLLARS(Si 00,D00),IN MOITION TD THE COSi OF COMPENSATION,DAMAGES AS PROVI�ED FOR IN J SECTI0+13]OBOFTHELABORCOdE,iNTEREST,ANDATTOR�EY'SFEES. rr RETENTION FEE: QCO STRUCTION LENDING AGENCY PRE-ALT FEE: � 1 HEREBV AFFIRM UNDER PENALT�'OF PERJURV THAT THERE IS A CONSTRUCTION LENDING AGENCV Z FOF THE PERFORMANCE OF THE WORK FOR 6VHICH THIS PEPMIT IS ISSUE�(SEC.303],CIV.C.�. W _ � LEN�EWSNAME � F— LENDER'5 ADDFiE55 ,� TOTAL�EES �� , � � I CER7IFV THAT 1 HAVE READ THIS�APPLICATION AND SiATE THAT THE ABOVE INFORMA;ION IS CORRECi �� I AGREE TO COMPIV WITH ALL CI AND CDUNTV ORDINANCES AND STATE LAWS RELATING TO BUILDIN6 � CONSTRl1CTiON,ANDHEREBYAU HORIZEFEPRESENTATIVESOFTHISCOUNTV70ENTERUPONTHE Z ABOVE-MENTIONEDPROPERTY AINSPECTIONPUFPOS s. 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