HomeMy WebLinkAbout16792 �. �� ----�'�---- CTTY OF l3IAMOND BAR �.,.. , � " � DEFART'YIENT OF COMMUNITY&DEVELOPMENT SERVICES ��*—°°�'""���F''e� �u-;,�. ., 21825 E.Copley Drive � ,� m�„ � (909}860-3195 Fax(9Q9)861-3117 �F� �,�.�'' PRESS "%v���� BUILDBNGPERMITAPPLICATION FIRMLY a DDRESS_ � 4 � ���� �� APPLICATION 1 2 n� PERMIT ��/C o DATE �.J NUMBER °�° APN L T T CT ISSUE 2 TYPE OCC DATE G� � CONST. GROWP p OWNER � o ADDR SS � ��'' ZONING SETBACKS Z CITY� ,.t�i ��ZIP TEL: FRONT Ryy ❑ o APPLICANT TEL. REAR ❑ Z SIDElSIDE STREET RW ❑ Q CONTRACTO � SIDE ❑ ADD SS � CITY ZIP TEL. PROPOSED USE � ARCH/ENG! � I a ADD ESS d! NO.DWEL. NO. NO. � � UNITS STORIES BEDFOOMS � CITY ZIP TEL. cn DESCRIPTION SQ.FT. FACTOFi PSF ADJ.AREANALUATION' � p� � OWNER-BUILDER DECLAP.ATION SFR/ADD/REM � " �'�' OI , p'. 1 HEREBY AFFIRM UNOER PENALN OF PERJURY THAT I AM EXEMPT PROM iHE CON7RACTORS u- Gdl'dge/Ceryart � . 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PftOPERTY iWHO BUILbS OR IMPRO!/ES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR �'.', THROl1GHHISORHEROWNEMPLOYEES,PROVIDEDTHATSUCHIMPROVEMENTSARENOiINTENDE�Ofl m 0'���,I OFFEAE�FORS/�E.IF,HOWEVER,THEBUILOMGOFiIMPfiOVEldENiISSOLDW1iHINONEYEAROFCOMPLE- , ;Z�,..i TION.THE OWNBR�BUILDER WILL HAVE THE BUROEN OF PROVING THAT HE OH SHE�ID NOT eWLD oR . , ;���,'.;'�IAApRpVEFORTHEPURPOSEOFSALE). 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WORKE�RS'COMPENSATION DE�N �D�t 1�� U � IHEREBYAFFIfiMLND�flPENALNIOFPERJLIRYONEOFTHEFOLLDWI D CLAfiATION: �I� r z _IHAVEANpWILL'MAINTAIN��CERTIFICATEDFCONSE4TTOSELF-INSUREFORWORKERS' _ ¢ COMPENSATION,ASPROVIbEO.BVSECilON3�ooOFTHELABOflCODE,FORTHEPERFORMANCE U OFTHE WOgK,FOR WHICH��'HIS PERMIT IS ISSUED. W 0 QW '. IHAVEANpWILt,�MAINTAiNM/ORKERS'COMPENSATIONINSURANCE,ASREOt11RED8YSECTIDN ' � ' 370aOFTHELABORCODE,FORTHEPERFORMANCEOFTHEWORKFORWHICHTHISPERM1T15 ��, ISSUE�.MYWOIiKEP&'C�E AilON�SURANCECARRIERANDPOLICYNUMBERARE: CONSTRUCTION —' nri j CARRI�R �: r.�-� PLANREVIEW v � POLICYNUA�9ER ELECTRIC � (fYISS�GTI01VNEmNOTBE IqW�APLEfEDOFiHEPEHMfrS UND ED�R (SU)O�iIESS). PLUMBING V Z ICERTIPYTHAY�INTHEPE�FORMANCEOPTHEWORKFOR HI HT �iMl�is sueo MECHANICAL - . ` (,'3 SFIFiLL�NOT EMPLOY ANY P RSON IN'�,ANY MANNEft SO AS TO BECOME SUBJECTTO THE ��.<.�--..�.-, , (n WORK�RS'CO,MPENSAiIOW LAW$OF CALIFORNIA,ANDAGREETHA7IF I SHOUG�BECOME INSPECTION FEE _..�^:.' 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