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HomeMy WebLinkAbout11335 ----�--'�---. crrY oF Diah�oNn BAR ���►g�,�� � C01�IMUNITY DEVELOPMENT DEPART;vIENT �( , - 21660 r.Copley Drive Suite 190- (909)860-319�Fax(909)R61-3117 R�!�if '� Fl �(��(� PRESS ':�`', BU NGP R IT.4p L AT �^ � J FIRMLY N JOBSITE ��/ � � �, ' APPLICATION PERMIT ] � P/C o ADDRESS f� - DATE NUMBER I���� # � � ISSUE � TYPE OCC APN LOpT ' TRACT __ DATE CONST. GROUP p OWNEFi �C-� o ADDRESS � � ZONING SETBACKS OCITY �% !�" Jivl� ZIP�"��TEL.----- I REART _ RW C7 o APPLICANT TEL._ � SIDFJSIDE STREET RW ❑ Q CONTRACTpR � A✓f ✓a' ��. � SIDE _ ❑ r � � ADDRE � 't° ��' �� PROPOSED USE � cirr ziP 5�.( T��.— o ARCH/ENG/ z DESIGNER NO.DWEL. f NO. NO. a ADDRESS UNITS 6 STORIES Z BEDROOMS�_ � CITY _ ZIP TEL. cn � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION Q OWNER-BI;ILDER DECLARATION SFP/ADD/REM p I hEREBY AFFlRM U\DER 7EtiALTY OF PERJLRY THAT I AM E%EMPT FRO`A THE CO\TRACTOAS L:� G8fdJ6/C8lpOfL W CENSELAWFORTHEFOILOY/MGREASON(SEC.703�.58USINESSANDPROFESSqNSCODE:AtiYCITYOR (n C� COUNTVWHICHRc'OUIRESAP'cRMITTOO�NSTRUCT,ALTeR,I!AiROVEDc'410L'SH,OPREPAIRAM'S.'HUC� patio/DeGk � NRE,PRIOR TO ITS ISSUANCE.ALSO REDUIRES?HEA�P_ICANT FOR SUCN?ERIA�TTO FIL=A SIG4E0 W� � STATEMEN�'.HAT Hc OP.SHE IS LICENSEO PURSUANT TO'HE PROVIS+CNS OF TNE COYTRACTOFiS LI� � CENSE LAW(CHAPTER 9(COMMENC!NG W:TH SECTION�o•�a)OF DIV'�,StON 3 O:THE BUSINESS AND PRO� V'� POOI/SP8 � �ESSIONSCO�E)ORiHATHEORSHEISEXEM�T*.HEREFRO�AAkDT�EBASI5=0RTNEA�LEGEDE%EMP� (�� V TIO4.ANYVIOLATIOYOFSECTION�C9+,59YA4YAPPLICA�TFORAPERMITSUG.:ECTSTHEAPPLICANTTO Z Re-Roof A C:VIL PENALTY O:NOT MORE THAN FlVE HUNDRED DOL:ARS�55:01): � CI,ASOWNEROFTHEPROPER'.Y,OR1dYEldPLOVEE5W:7�WAGcSAS.-HEIRSOLECCMPENSATION, � Cort1111BfCiel Z WILL 00 THE WORK,AND THE STRUCT:,RE IS\OT;NTEN�ED OR OFFEaED FCF SAL'c;SEC.7�44,9U51� J � NESS AND PROFESSIONS CODE:'HE CON7RAC70R5 LICENSc UW DOES KOT APPLV TO AN OWNER OF j 7ROPERTV WHO BUILDS OR IMPROVES TNEFEON,AND WHO DOES SUCH WORK HIMSEL�OR HERSELF OR [[ THROUGHHISORHE�OWNEMPLOVEES,PROVIDEOTHATSUCkRJ.aROVEMENTSARE�OTINT.ENOEDOR m QOFFEREDFORSALEtF.HOWcY'cR'H-BUItDINGOaIMPROVEMENT1550�DWITHINONEYEARO:COMPLE� Z TIOh,THE OWNER-BUILDER'MLL HAVE THE BURDcY OF PFOVI\G T:;AT NE OR SHE DID NOT DUILD OR � :MPROVEFORTHEPURPOSEOFSALE). w CI,ASOWNEFOFTHEPRO°ERTY,AMEXGLUSIVeLYCONTRAC'INGWIiIiL:CENSEDCOtiTRpCTORS Q TO CANS?RUCT THE PR0.IECT(SEC 70a4,9USINESS AN�PROFESSANS CO'JE:?HE CON7RACT0�5 LI� V81u81i0f1 ADJ.AREA W CENSELAW�OESNOTAPPLY?OANOWNEROFAPROPEP.TYWHOBt11LDSORI!d?ROVES�HEREON,ANO � WHOCONTRACTSFORSUCHGR0.IECTSWITHAC�lTRACTOP(S)LICENSEDPl1RSUANTTOTHECOMRAC� QUANTITY DESCRIPTION FEE Y TORS LIC'cNSE LAW j. � L:I AN'c%EMPT UNDER SEC. 9.B P.C.fOR'HiS REASON � __'_ � '"__ ____'"_"_ � JATE OWVEa__„_ Z � LICENSED CONTRACTORS DECLARATION � � IHEREBYAFFIRMUNOcflPENALTYOfPERJJRYTYATIAU:ICEISEDUNDERP�OVISIONSOFCHAPTE9 � 9(COMMENC1NGWfTHS'cCT:ON�coo)OFDIVIS'�ON30FTHEBUSINESSAN�PROFE55!045C0'JE,AND _ X MV UCENSE IS IM1 FULL FOflCE AND EFF_CT. � UCENSE CLA S C"[y�� LIC.40._/D' ��6°L�'t� U DATE � a�_6,� CONTFACT °fa•��— � WORKEFiS'COMPENSATION D CLARATION U ,'. Cy f�- 2�dy�-.�y �di � I HERE FFIaM UNOER GENALiY OF Pc'RJURY ONEOFTHE FOLLOWING DECLARATIONS: z � C. i�"'��a�C, i �c�ri+ , �� � I HAVE AND WILLMAINTAIY ACEFlTIF!CA-E OF CONSeNT TO SELFdYSI:RE FOfi WORKERS' _� Z CCM.PENSA'ION,ASPROVIDEDBVSEC?IOY370oOFTHELABOaCODE,FORiHEPER�ORNANCE U Q OF TN'c WORK FOR WHICH THIS PER�AIT:S ISSl1ED. � �JAy '�r,�� P'� 4� „y-r �(' .�� �+b' �M°� 1 �+7 M. J w _I HAVE AND WILL MAINT.AIN WORKE�S'COh'PENSATION IM1SURA\CE,AS RE�UIRE�9Y SECTION Q 37000F7HELA90RC07E,FORTHEPERFOFMANCEOF7HEWORH�ORWHICHiHISPERMITIS ISSJED.MV WOR�RS�',,D/r�pENSATIDN INSURA4C'c CARRIER AND POLICY NUMBER APE: CONSTRUCTION � CARRIER--�I��;¢��T � � �J PLAN AEVIEW -- — ZPOLICV NUM9ER_�_ _ �(_"� ELECTRIC ______ Q � (iFdSSEC'qNNE�NOTB=OJN?LEfEDOFTrtePcRMfTISFO�ONEHUN�REJWl1AR5ib100!ORLE55!. PLUMBING __ W yy� z I CER71��T4AT IN THE�ERFORUAKCE OF'HE'h'ORK FOR W41CH THIS PcR47�T I5155LED, MECHANICAL _ I�I. �j' SHALL M1OT EM?LOY ANV PERSON IN ANY MANNER SO AS TO BECOME SUB�ECT TO THE � WORKEFS'COMPEhSA7iOHLAW50FCALIFORNIA,ANOAGREcTNATIFISHOUL��ECOUE I INSPECTIONFEE ___,_ SUBJECT TO THE WORKERS'COMPcYSAT�ON PP.GVISIOKS OF SEC.'ION 37o00F'HE LABOR � CODE�IS�WITHCAMPLYWI SEPROVISION I ISSUANCE _ I� a� � � SMIP p DA7E: � APPLICANT. -�✓&��' --._'__— � ENERGY P/C _ _____ J WAPNING:FAILURETOSECUREWORK'cR5'COMPENSATIONCOVERAGEISUNLAWFUL,ANDSHFLLBE � SU&IECTANEMPLOYER?OCRIMNAIPENAL7!ESANDCIVILFINESUPTOONEHUNDR'cDTHOL'SAN7 ENEFGYPERMIT DOLLARS(St00,Oc0),IRADDITIONTOTHECOSTOFCOMPENSA,ION,DA4UIGESASPROVIDEDFORIN —�------ - � � SECTION37080FTHELABORCODE,IN?ERESTANDA'TORVEY'SFEES. RETENTIONFEE: ___�� ��� � CONSTRUCTION LENDING AGENCY a " PRE-ALTFEE: __________ � � IHERE3VAF�IRNUNDeRPENALTYOFPERJURYTHA'THEReiSACONS'FUCTIONLcNDItiGAGCKCY � FOR THE PERFOaMANCEOF'HE WOFK FOR WHICH THIS PERM!T IS ISSU'c��SEC.3�9'J,CIV C�_ �-- �� �h W — • ? LENDERS4PIJ.E' __'_' --__'__'_ '� — + � __ _"_"'_'_'_� ' F_- LENDER'SA7DRE55___________ � I CERTIFY ThAT i NAV'e READ THIS APPLICATIO.4 AND STA-E'NATTH[A90VE IN'rOaNAT�OY,s��RRE�T. TOTAL FE ES ,�'� � � � IAGREE?OCOMPLVWITrIALLCI7VANDCOUhTVOflDINAM1C'cSANDSTATE:AWSReLA'IM1'GTO6UILDING � CONSTrIUGTfON,AN'JHERE3YAU7HORIZER_?RESENTAi!V'c50FTH'�CO'JN:YTCEVTERUPOV7Hc' � ABOVE�MENT;ONcD PROPEFlTY FOR IKSPECTION PVR?OSES. COMMENTS_„__ _________ �� y.��� p � . " iV r�____'"'__"_ _'- '_'_"'_'__ __ � 7ER N E(PRINT) /� ____"—'_ —"_"_'_'__... � " —� __��� __ __ � SIGN �U OFPE � �tiE .I �1� = RECPT.NO. �1 � � PAID BY _� � VALIDATION _I�� ~ WHITE—De ariment Co YELLOW—Financa Co PINK—Assessor Co GOLDENROD—File Co GFiEEN—A IicanPs Co P PX DY. 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