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HomeMy WebLinkAboutROOF-19-1128 T;o T abed 6TOZ'VT aunr aleO :Ag pa MI 610Z 'VT eunl „ .4...}r- r fro,_273/5/// iQ 7v/v{_ 4 2-L9-L sAep anpnoasuoo 0NT ;o po!iad e ao;aoloadsu!8u!p!!nq elpe3JV ;o Alp e Aq pal!aan uaaq sal J!aoM an!ssaa oid ou;!10 sAep angnoasuoo / ��4 J d5t1 081 104 pauopueqe Jo papuadsns s!l!waad s!ll Aq paz!aoylne slaoM Aue 4!pp ��� 1�APvJ pue!mu sawooaq pue saa!dxa mond s!ll'IeU!wgns ueld;o alep all w a; tto /.col, 3dsJq doge/-3,4dID�- /-L sAep 021 u11)11M paulelgo IOU s!1!waad all;!JO aouenss!;o alep all wail sAep 0g1 u!gl!M paouawwoo IOU s!nwaad all Aq pazuoylne)poM all;!p!oA pue onu sawooaq pue uope8wg awµAq saaldxa Ma!naa ue!d/1!waad sly1 Sy .Q7e Lr'or9 _i9 -s,1 %' .�- 0,4, Nv,1�3/ t .d'3 � 4,2-4-1., •papaau s!way!uoµoadsui leym pue aWeJ;awµ'ssaappe Din 8uµsanb it9 Yo4 yam' —Vs w a8essae aneal 'OSVS-VLS-9Z9 le auoldalal Aq uogoadsu!ao;;sanb � >� SNOIlD3dSNI 1Od S11VD r�_t3YISI, "�•-' 2 w-ta-a 0313idadooi t i 1_ aa•1oP/5s17 - /tel b7-...Q-7 15'899$ :lelol 00'0$ :an0 lunowy SZ'9$ aai wawa2eueW aiseM P1105 15'899$ 61-OSSTO-33U#ld!aoaU/lsej sZ'ST9$ saai woad 8u!pl!ng 151199$ saa3 lelol TO'Lb$ aaj 8u!nss!8u!ppng pled lunowy sluawAed lunowy saad -'-'r q ueld II t!oal0 ue!d 00'0 :lead bs!awl (OA) OS 86'311±1VN191U011tl15N13U '1N3WAVlU30Nfl lueual 00'000'SE $ :uopen!eA M3N 11V1SNI 0 N OONOJ lV 31119NI1SIX3 al L06E£6 ZES9-LO£(Z9S) £b£T6 VD'39001121ON'3AV 1113d 09t'6 3AV M31AUIVd E59 ao13e4uo0 *JNI 3JIAU3S 9NIJ00U.153M N301O9 aauMO N3HS 3fls • sloeluoJ LTOZ008LLS VD'e!pealy 3AV Ma!nl!ed E59 lagwnN!soled d!Z'awls'Am ;!u0 xl;ns lawn aweN sawn xyaad J!0 'ON IPPV :uoL1eJ(dx3 I'6LOZ/n/90:aleo`anssµ : - �IIQY32IF/ pansy( sn;oJSJrwlad )i.."4-1“::: :t �a - 'a - 91V5-VLs(9z9) 1 epua !sa oaa uouni issn ao'� r is l^ �' TZ09-990T6 VO'e!pemV I P a a y /7 M ; 1 S G {f{{ TZ009 xCS aogiO lsod'anu0 uok2upunH 1saM ObZ )OOa:adAlsl!u!uad. • Lt .�c al a,P 1�„„�.� (� luawlaedaO sa�!naaS luawdolana0 szi 6i 3ooa ONJlwlad VD `e(peaJV 40 QIP , if 'R 4. i it PERMIT/PLAN REVIEW APPLICATION le ii. gi� tarr Development Services Department,240 West Huntington Drive, Post Office Box 60021 ` Arcadia, CA 91066-6021, (626) 574-5416, Fax(626)447-9173 City of Arcadia LICENSED CONTRACTOR'S DECLARATION WORKERS'COMPENSATION DECLARATION 0 1 hereby affirm under penalty of perjury that I am licensed under provisions of I hereby affirm under penalty of perjury one of the following: Chapter 9(commencing with Section 7000,of Division 3 of the Business and Professions Code,and my license is in full force anddeffect. ❑ I have and will maintain a certificate of consent to self-insure for workers' License Class c-3 el L�icen No. "IWO O7 Exp. Date9r / 2 O Signature of Contractor _ compensation, as provided for by Section 3700 of the Labor Code, for the G/i performance of the work for which this permit is issued. OWNER-BUILDER DECLARATION 0 I have and will maintain workers'compensation insurance,as required by Section 0 I hereby affirm under penalty of perjury that I am exempt from the Contractors 3700 of the Labor Code,for the performance of the work for which this permit License Law for the following mason(Section 7031.5,Business and Professions is issued.My workers'compensation insurance carrier and policy numbers are: Code.Any city or county which requires a permit to construct,alter,improve, Carrier g7 ( o/P/ demolish,or repair any structure,prior to its issuance,also required the applicant Policy Number 1 0 5 e2-6 6 I for such permit to file a signed statement that he or she is licensed pursuant to the provisions of the Contractors License Law(Chapter 9(commencing with Section (This section need not be completed if the permit is for one hundred dollars or less) 7000)of Division 3 of the Business and Professions Code)or that he or she is exempt there from and the basis for the alleged exemption. Any violation of 0 I certify that in the performance of the work for which this permit is issued,I shall Section 7031.5 by any applicant for a permit subjects the applicant to a civil not employ any person in any manner so as to become subject to the workers' penalty of not more than five hundred dollars($500)): compensation Laws of California,and agree that if I should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,I shall ❑I, as owner of the property, forthwith comply with those provisions. or my employees with wages as their sole compensation,will do the work,and the structure is not intended or offered for çDate �� SL// gnature Sisale(Section 7044,Business and Professions Code:The Contractors License . _T Law does not apply to an owner of property who builds or improves thereon, or who does such work himself or herself or through his or her own employees,provided that such improvements are not intended or offered for WARNING: Failure to secure Workers'Compensation coverage is unlawful, sale.If,however,the building or improvement is sold within one(1)year of and shall subject an employer to criminal penalties and civil fines up to one completion,the owner-builder will have the burden of proving that he or she hundred thousand dollars($100,000),in addition to the cost of compensation, did not build or improve for the purpose of sale). damages as provided for in Section 3706 of the Labor Code, interest, and; attorney's fees. , ❑I, as owner of the property, am exclusively contracting with licensed — - contractors to construct the project(Section 7044, Business and Professions Code:The Contractors License Law does not apply to an owner of property CONSTRUCTION LENDING AGENCY who builds or improves thereon,and who contracts for such projects with a I hereby affirm under penalty of perjury that there is a construction lending agency contractor(s)licensed pursuant to the Contractors License Law). for the performance of the work for which this permit is issued (Section 3097, Civil Code). ❑ I am exempt under Section 7044,Business and Professions Code,for this reason: Lender's Name Date Signature Lender's Address IMPORTANT: APPLICATION IS HEREBY MADE TO THE BUILDING OFFICIAL FOR A PERMIT SUBJECT TO THE CONDITIONS AND RESTRICTIONS SET FORTH ON THIS APPLICATION AND THE FOLLOWING: 1. The City's approved plans and permit inspection card must remain on the job site for use by City inspection personnel. 2. Final inspection of the work authorized by this permit is required.A Certificate of Occupancy must be obtained prior to use and occupancy of new buildings and structures. 3. Per South Coast Air Quality Management District(AQMD)regulations,renovation and remodeling work that results in the removal,stripping,or altering of asbestos containing materials requires an asbestos survey and removal prior to disturbing the asbestos. Please contact AQMD at(909)396-2000 for further information. ��-/7 f t are Mj e."v� / NjNAME (7 rile P12- 5(06/V 7 / PRINT NAME I‘certify that I have read this application and state that the above information is correct and that I am the owner or duly authorized agent of the owner. I agree to comply with all City ordinances and State Laws relating to building construction. I hereby authorize representatives of the City of Arcadia to enter upon the above-mentioned property for inspection purposes. \Date61/" / / 7 nature _ _