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HomeMy WebLinkAbout17181 CITY OF DTAMOND BAR � -----�'�---, 37EPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES I I 21825 E.Copley Drive (909)860-3195 Fax(909)861-3 L 17 PRE$$ '''-�r�' ' BUII.DING 1'ERMIT APPLICATION FI LY � JOBSiTE APPLICATION PERMIT `"'� � PIC o ADDRESS�,.Z� '�'^' 4 l 1 C� DATE �'O� NUMBER # � ISSUE� ^ TYPE �OCC APN LOT TRA DATE CONST. GROUP °C OWNER O �'` ADDRESS���2� ZONING SETBACKS z CITY IP TEL. FRONT RW ❑ o APPLICANT TEL. SIDElSIDE STREET RW � z ¢ CONTRACTOR ' � � ,�JG� SIDE ❑ o C�RESS� ZIP � Y TEL. PROPOSED USE��,� �a�"�.�.:�5"'��� � o ARCH/ENG/ �� �A���� � _ � w DESIGNER NCJ.DWEL. NO. NO.� � ADDRESS � CITY ZIP TEL. UNITS STORIES BEDROOMS � cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER DECLARATION SFR/ADD/REM � O p I HEREBY AFFlRM UNDEP P�NALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTPACTORS LI- GHfBJB/CefPOlf W �.CENSELAWFORTHEFOLIOWINGREA50N(SEG7031.SBUSINESSANDPROFESSIONSCDDE:ANYqTYOR (n U COUNTYWf11CHREOUIRESAPEflMITTOCCN5TRLICT,ALTER,IMPROVE,�EMOLISH,ORFEPAIRANYSTRUC- W p$(10/DBCIC w�� �.TURE,PRIOR TO ITS ISSUANCE,AL50 REDUIRES THE APPLICANT FOR SUCH PERMIT TO PILE A SIGNED W ��,STATEMENT THAT HE OR SHE IS CICENSED PURSUAN7 TO THE PAOVISIONS OF THE CONTRACTORs LI- �' ;CENSE LAW(CHAPTER 9(CCMMENCING WITH SECTION 70D0)OF OIVISION 3 OF THE BUSINESSANO PRO- � PooUSpa � � Q �'�FESSIONSCODEJOFlTHATHEOflSHEISEXEMPTTHEREFROMANDTHEBASISFORTHEALLEGEDEXEMP- (� . , V "�TION.ANYVIOLATIONOFSECTION�7o31,56YANYAPPLICANTFOFAPEflMITSUBJECTSTHEAPPLICAiJTTO Z Re-Root � �' A qVIL PENALiY OF NOT MORE THAN FIVE HUNDRED DOLUlFS(S5oe).): ❑4 AS OWNEROFTHE PROP�RTY,Ofl MV EMPLOYEES WITHINAGESAS THEIR SOLE COMPENSATION, Z �,WILL UO THE WORK,AN�THE STRl1CTl1pE 15 NOT INTENDED OR OFFEREO FOR SALE(SEC,7044,BU51- � ComRlefCifll - � I��NESS AN�PflOFES510NS CODE:7HE COMRACTOfiS LICENSE LAW DOES NO7 APPLY TO AN OWNER OF j .PflOP�RTYWFiOBl11LDSORIMPROVESTHEREON,ANDVJFI000ESSl1CHWORKHIMSELFORHEiiSELFOR CC�� �„THROUGHHISORHEROWNEMPLOYEES,PROVIDE�THATSUCHIMPROVEAAEfJPSARENOTINTENDEDOR m � �';��.OFFERWFORSALE.IF,HOWEVER,�THEBUIL�INGOftIMPPOVEMENTIS50tDWITHNONEVEAROFCOMPIE- Z,";',TION,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVINa THAT HE OF SHE DID NOT BUIlO OR � IMPROVE FO(i THE PURPOSE OF SALEj. G7 I,AS OWNER OF THE PROF{EflTY,A!A EXCWSNELY CONTFACTING WITH IICENSED CONTRACTORS ��'�,��,TO CONSTRUCT THE PROJECT(SEC.7oa4,BUSINESS ANO FROFESSIONS CODE:THE CONTRAC70RS LI� ValuatiQn ADJ.AREA � W' 'I CENSE L4W DOES NOTAPPIYTO AN OWNER OFA PROPERTY WHO BUILOS OA IMPROVES THEREON,AND � I�WHOCONTRACTSFORSUCHPROJECTSWITHACONTRACTOR(5)LICENSEOPl1p5UANTTOTHECONiRAC- QUANTITY DESCRIPTION � FEE Y 'TORS LICENSE LAW J. , � �, ❑I AM EXEMPT UNDEF SEG B.&P.C.FOR THIS REASON Q � � U �, � �DATE OWNER U , � W � � UCENSED CONTRACTOFS DECLARATION W ¢ CC � IHEREBYAFFIRMUNOEftPENALTYOFPEAJURYTHATIAMLICENSE�UN�ERPROVISIONSOFCHAPTEF � . .q4'�,9(COMMENCINGWITHSECTION70W)OF�IVISION30FTHEeUSiNESSAN�PFOFE5510NSCODE,AND z �'X��'MY LICENSE IS IN FULL FOFCE ANb EFFECT. m � a�� � 0� IICENSE CLASS��LIC.NO. � (,~j�'�A7E CONTRACTOR � . W �� WORKERS'COMPENSATION DECLARATION Q � IHEREBYAFFIRMUNDEFPENALTYOFPERJURVONEOFTHEFOLLOWINGDECLARATIONS: Z � �I HAVE AN�WILLMAINTAIIi A CERTIFlCATE OF CONSEfr'TTO SELf-INSURE FOF WORKERS' ¢ ¢. CAMPENSATION,ASPROVI�E�BYSECTION37ooOFTHELABORCDOE.FORTHEPERFORMANCE U Q OFTHEWORKFORWHICNTHISPERMITISISSUEO. � W' _IHAVEANDWILLMAINTAINWORKERS'C0IAPENSATIONINSURANCE,ASREQUIRE�BYSECTION gg Q� 37000FTHELA80RCODE,FORTHEPERFORMANCEOPTHEWORHFORWHICHTHISPERMITIS � g �{ C_� ISSUED.MY WORKERS'COMPENSATION INSURANCE CARRIEFAN�PO�JCV NUMBER ARE: CONSTRIJCTION b g r � ¢ CAFFIER �'"�.�-��t^ PLAN REVIEW > �, coucvNUMeEa����4� C ELECTRIC �A "0 (iHIS5EC710NNEmNOTBE PLETEDOFhIEPERMITISf-0RONEHIAJDREDDOLLARS�S70�ORLESS). PLUMBING Z 1 CERTIFYTHAT INTHE PEPFORMANCE OFTHE WOPo(�OR WHICH THIS PERMIT IS ISSUED,I MECHANICAL (,'}'� SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SOAS TO BECOME SUBJECT TO THE (fj WORNEliS'COMPENSPTIONLAWSOFCALIFORNIA,ANDAGReETHATIFISHOULOBECOME INSPECTION FEE � SU&IECT TO THE WORI(ERS'COM2ENSATION PROVISIONS OF SECTION 37o00F THE LA60fl �.. JpODE„I HALLFOR7HWITHCOMPLYWITHTHOSE?ROVISIONS. �SSUANCE e��p �' 1 SMIP p.�� p DATE:� A4'PLICANT:��� P J WARNIN¢F LURE TO SECURE WOfiKERS'COMPENSATION COVEFAGE IS UNLAWFUL,AN�SHALL 0E ENERGY P/C - � SUBJECTANEMPLOYERTOC�RIMINALPENALTIESANDCIVILFMESU7i00NEHUNDREDTHOUSAND ENERGYPERMIT �OLLARS(E10o,[1C[f),IN ADnITION i0 THE COSTOF COMPENSATION.DAMAGES AS PROVIOED FOR IN � SECTION37080FTHELABORCODE,INTEREST,ANDATTORNEY'SFEES. � p� RETENTION FEE: � �� � CONSTRUCTION LENDING AGENCY PREALT FEE: �, IHEREBVAfFIRMUNDERPENALTYOFPERJURVTHATTHEREISACONSTRUCTIONLENDINGAGENCV FORTHE PERFORMANCE OF THE WORK FOR WHICHTHIS PEFMIT IS ISSVED(SEC.3091,CIV.C.J. Z, Lu � LENDER'S NAME � FI-T LENDER'SADOflESS � ICERTIFYTHATIHAVEREA�THISAPPLICATIONANDSTATETHATTHEABOVEWF00.MATIONISCORR[CT. TOTAL FEES ' ��l '-j� �� I AGREE TO COMPLV WITH ALL CI7N ANU COUNTY ORDINANCES AND STAiE L4WS RELATINO TO BUILDING �.� �y��� ;Z', CDNSTRUCTION,ANDHEREBYAUTHORIZEREPRESENTATIVESOFTHISCOUNTY70ENTERUPONTHE �� � tls ��/ ABOVE-MENTIONEDPROPERTYFORINSPECTIONPURPOSES. V �� ��. , COMMENTS� � �, � --- m PERMITTEENA (FIM) d � -�°1 � f e � SIGNATUREOFPERMITTEE DATE m r' \�a� = RECPL NO. �-� PAID BY VALIDA710N / ~ WHITE—Depadment Copy,YELLOW—Finance Copy,PWK—Assessor Copy,GOLDENR06—File Copy,GREEN—Appllcant'S Copy � ,.. ,... ._ __ _. ..,... ,���.� -�- . ,��� --. ,.�r:,.�r �.� _7: .. .. .:..... ., _. ._ ,., s _,.. .,._ ..,-. _ . __ � . tt . .. 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