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HomeMy WebLinkAbout16866 (25) ---�`�--- CITY OF IAIAMOND BAR � � DEPARTIvIENT OF CONINIUNITY c�DEVELOPMENT SERVICES - 21825 E.Copley Drive (909)860-3195 Fax(909)861-3117 PFiESS `"%.ya��'��' BIJILDING PERMIT APPLICATION IRMLY JOBSITE , APPLICATION `LI.� � PERMIT P/C o ADDRESS �I�� �Af r"�� d�� �� OATE � � NUMBER ''��� CO APN LOT TRACT ISSUE y py TYPE OCC DATE � �•9 CONSt GROUP p OWNER C�( �I �� o ADDRESS �,1�Y� �3ar'�'� ��� � ZONING SETBACKS z CITY T�ICt1v��sA�o'" ZIP TEL. FRONT RW ❑ � APPLICANT TEL. REAR ❑ o SIDE/SIQE STREET RW ❑ � CONTRACTOR r� r .ri�� SIpE ❑ � ADDRESS ' PROPOSED USE dr' � o CITY tt.��x; '�/aP ZIP TEL. � � w ARCH/ENG/ � � �z DESIGNER ���� NO.DWEL. NO. NO. a ADDFESS UNITS STORIES BEDROOMS � Cff`! ZIP TEL. � � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � � OWNER-BUILDER DECLARATION SFR/ADDlREM O I HEREBY AFFIRM UNDER PENALTY OK PEFJUqV THAT I AM EXEMPT FROM THE CONTPACTORS LI� G8BJ2/C8fp01i W CENSELAWFORTHEFOLIOWINdREASON(SEC.7a31.58115MESSANDPAOFESSIONSCADE:ANVpTYOR (n . U �pUNTVWHICHREQUIFIESAPERMiTTOCONSTRUCT,ALTER,IMPFIOVE.�EMOLISH.ORREPAIRANVSTRUC� W pyt10/DBCk W TURE,PRIOR TO RS ISSUANCE,ALSO REO�IRES THE APPLICAtvT FOR SUCH PERMIr TO FILE A SIGNEO w � � STAiEMENT THAT HE Ofi SHE IS LICENSE�PUF75UANT TO THE PqOVI51ON5 OF THE COY7RACTOR5 LI� � � CENSE LAW(CHAPTER 9(COMMENCING WI7H SECTION 7oao)OF�IVISION 9 OF THE 6U31NESS AND PRO- � POOUS{18 FESSIONSCO��ORTHATHEORSHEISEXEMPTTHEREFROMANDTHEBASISFORTHEALLEGE�EXEMP- (' � � TIpN.ANYVIOLATIONOFSECT10N7031.58YANYAPPLICANTFORAPERMITSUBJECTSTHEAPPLICAN7T0 z RB-ROOT � ACIVILPENALTVOFN�TMORETHANFIVEHUNDRE�COLLARS(8500).)� � �� CI,ASOWNEROFTHEPROPERTY.ORMYEMPLOYEESWITHINAGE5q5THEIR50LECOMPENSATION, � C0111fI10fC131 - � z WILL DO THE WORK,AND THE STRVCTURE IS N0T INTENDED OR OFFEflED FOP SALE(SEG�044,6U51- J � � NESS AND PROFESSIONS CODE:THE CONiRACiORS LICENSE LAW�OES NOT APPLV TO AN OWNER OF � PAOPERN WHO BUILDS Oq IMPROVES THEqEON,AND WHO DOES SVCH WORK HIMSELF OR HERSELF OR . � 'THROl1GH HIS OR HER OWN EMPLOVEES,PHOVIOEO THATSUCH IMPqoVEMENTSAqE NOT INTEN�Eo OP m ' �, OFFEREDPoRSALE.IFHOWEVER.THEBUILDINGORIMPROVEMENTISSOLOWITHINONEYEAROFCOMPLE- ' � ��..TION,.THE DWNER-BUILDER WILL HAVE THE BURDEN OF PROVINO THAT HE Ofl SHE DID NOi BUILD Oft � IMPROVEf-0RTHEPURPOSLOFSALE�. w � ❑I.ASONMEROFTHEPROPERTV,AMEXCWSIVELYCONTRACTWGWITHUCENSE�CONTRAC70RS (,r TO CONSTRUCT THE PpOJECT(SEG 7046,B1151NE55 ANO PROFESSIONS CODE:THE CONTFACTORS LI- V81Ud110f1 ADJ.AREA W'.CENSEIAW�OESNOTAPPLYTOANOWNEROFAPROPERNWHOBUILDSORIAAPROVESTHEREON,ANC ��.,WHOCONTRACTSFOqSUCHPROJECYSWITHACONTRACTOR(S)LICENSEDPURSUANTTOTHECONTRAP QUANTITY DESCRIPTION FEE x TORSLICENSELAW.�. O�. ❑I AM EXEMPT L1N�ER SEC. 9.&P.C.FOR THIS REASON Q � � � � OATE OWNEq U Z W �� LICENSED CONTRACTORS DECLARATION �j � I HEPEBV AFfIRM UNDER PENAL7Y OF PEAJURY iHAT I AM LICENSED UNDER PROVISIONS OFCHAPTER � � 9(COMMENCING WITH SECTION 7000)OF DIVISION 3 0F THE 9USMESSAN�PROFESSIONS CO�E.AN[1 z �X MY LICENSE IS IN FULL FORCE AND EfFECT. - � � UCENSECLASS� «7� FP�� LIC.NO. � g���° � / p� � U DATE CON7RAC70�.�.ltcl8'Q/�r5(�&'�/`� a L11 � � WORKERS'COMPENSATION DECLARATION Q � IHEREBYAFfIRMUNDERPENALTYOFPERJURYONEOFTHEFOLLOWINGDECLApAT70NS: U � Z �' ��HAVEANDWILLMAINTAINACERTIFICAiEOFCONSENiTOSELF-INSUREFORWORKERS' _ COMPENSATION,ASPROVI�EDBVSECTION3]ooOFTHELA60ACODE,FORiHEPERFOqMANCE U Q OFTHE WORK FOR WHICH THIS PERMIT IS ISSUED. � W � �IHAVEANDWILIMAINTAINWORKERS'COMPENSATIONI,�'5l1RPNCE,ASREQUIRE�eVSECTION Q 3]OOOFTHE LABOR CO�E.FOR THE PERFOflMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUE�.MV WOPKERS'COMPEfJSAiION INS�RANCE CAqpIER AN�FOLICV Nl1MB aaE: CONSTRUCTION a GARRIER S"�2,�'�. G :°� �h3�L�t'z'�<-2 �[� PLANREVIEW > �y� � POLICYNUMBEH ����R � '�Il ��✓S�@ C�Zo�Q��� ELECTRIC_ P� � (IHISSECTIONNEFDNOTBECOM,�LEfE�OFTHEPERMfI'ISFORONEHUNDREDDOLLMS($1W)OflLESS). PLUMBING v��.-/ � W Z',� ICEPTIFYTHATINiHEPEflFORA9ANCEOFTHEWORKFORWHICHTHISPERMITISI5SUE0,l MECHANICAL � SHALLNOTEMPLOYANYPERSONINANYMANNERSOASTOBECOMESUBJECTTO7HE ��. LVORKERS'COMPENSATIONLAWSOFCALIFORNIA,ANDAGREETHATIFISHOUlD6ECOME INSPECTIONFEE �, � SU6JECTTOiHEWORKER5'.COMPENSA�IONP�OVISIONSOFSECTION3]QOOFTHELABOR ISSUANCE � CODE,I SHALL FORTHWITH COMPLY WITH TNOSE PROVISIONS, � p p SMIP p� DATE: APPLICANT; -'� WARNINGFAILURETOSECURENlOF7KERS'COM�ENSATIDNCOVERAOEISUNLAWFUL,ANDSHALL6E ENERGYP/C ,� - --�^^4^"'""""'" J SUBJECTAN EMPLOYEflTO CRI{AINAL PENAL7IES AND CIVIL FlNES UP TO ON6 HUNDRED THOUSAN� �j��_„� ,r''�ti� f� °�i�::':�,.' �' DOLLARS(S10o,o00).IN Ap�ITIDN70 THE COSTOF COMPENSATION.DAMAGES AS PROVI�ED FOR IN ENERGY PER�tlIT - J' SECTION3lOeDFTHELABORCO�E.INTEREST,ANOATTORNEY'SFEES. RETENTIONF�: O� � CONSTRUCTIONLEN�INGAGENCY PRE-ALTFEE: �,�� � � IHER�OVAFFIRMl1N0ERPENAITVOFPEfiJURVTFATTHEFEISAGONSiFUCTIONLENDINGAGENCY � FORTHE PERFORMANCE OFTHE WORK FOR WHICHTHIS PERMIT IS ISSVE�(SEC,309�,CIV.C.). � w i _._--i=, S� LENDER'SNAME �.� —-- e -- F- LENOER'SA�DRE55 '`y ��. ICEFiTIFYTHATIHAVEflEADTHISAPPLICAiIONANO5TA7ETHAiTNEABOVEINFOpMATIONISCORflECT, TOTAL FEES � a �V � �. IAGREETOCOM�VWITHALLCITYANDCOl1NTYOP�INANCESqNDSTATELAWSRELATiNGT09111L�ING � ' (\7NSTRLICTION,AN�HEREBYAUTHORIZEREPRESENTAiIVE50FTHISGOVNTYTOENTERUPONTHE � ' ABOVE-MENipNEO PROPERTYFOR INSPECTION PURPOSES. COMMENTS . � � j���e�--� e�. [t,e��7���s m ¢ PERMITTEE NAME i; } � _ (JJ �✓ � SIGNATURE PERMITT'cE DATE � RECPT NO. PAID BY VALIDATION ~ WHITE—Departmenl Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—Applicani's Copy :. � ,�,,� �¥o � "_ ! > . . '� _ . .. .. .� „ t � k � �:. � < >,i��' � . ., 'i .��_ x. "z Ia�r,"'�� a�x, a� i ��, � a �' � �� !��, ��.�. 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