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HomeMy WebLinkAbout15720 (9) -.. �,f�„`_ CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES � ' 2156U E.Copley Ihive Suite 19Ci � , ���sbo-3i�s��(go9>s6i-�i i7 PRESS ������ BUILDING PERMIT APPLICATION FIRMLY � JOBSITE ���$' �fq� ?��*� � p APPLICATION , ¢� PERMIT 1� '"')f�, P/C � ADdt�ESS � 1 L} DATE /�f�f' NUMBER�f L� � 15SUE TYPE OCC � APN LOT./� TRAGT �f DATE� ��� __CONST. GROUP p OWNER �,�+�j(�/�,QGY�i�//L?�,– �` ADDRESS / ZON�NG SETBACKS � CITY ZtP�'[��,,�"I"�E�. FRQN7 _.i. RW t:� APPLICANT TEL. �� / REAR ❑ � f SIDE�i�E STFiEET RW ��__._ CqNTRACTCIR .L1r//1� O AdDRESS O -',�G �� CITY �_ ZIP���j TEL�'6 Z PROPOSEQ U5E ^ � � ARCH/ENG/ ^ � DEStGNER� = NO.DWEL. NC?. NO. ADDRESS UNITS f STORIES BEDRdOMS � � CITf ZIP TEL. � ,n dESCRlPTION SQ.FL FACTOR PSF ADJ.AREANALUATtQN � OWNER-BUILDER DECLAFATIpN 5FRtAD01REM �Q I MEflE9v AFFlRM UNDER PENALTY OF PENJURY THAT I NA EkElAP7 FqqAl 7HE CONTRACTORs LI� G2fNgBlCafpolS UJ CENSEUWFORTHEFIX.LQWINGREASON(SEC.]03i.58U51NESSANDPROFESS!ONSCODC;ANYC17YOfl {f) .— � COUtiTYYfFflCNR£IXIIRESAPERk97TOC6N5TRUCT,t1TER,iMPROVE,DEMOLtSH,01'iREPAiRANYSTRVG- W PeIlO/DBCk NRE,PRIOR TO 175 IS5l1ANCE,ALSO RE�UIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNEU W ..� STATEMENT TkiAT ME OR SHE iS UCENSED PUASUANT i0 THE PA4YISIONS 4f TME CONTRAGiC,#i5 lF � CEN3E LAW(CHAPTER 9{COMMENCINO wITN SECI�ON 7oo6j OF OIVISION 3 bf THE BUSINESS AND PRO� � PODUSp3 KESSqNSCODE)bRhIATHEORSHEI3E%EMPTTHEREFROMANDTMEBASISFORTHEALlEGEOEXEMP� (� TIOti.ANY VIOUTIpN Of SEGTiON 749+.5 BY 0.NY ApPI�ANT F4R A PERMIT SUBJECTS THE AFPEICANT 70 Z Re-Raaf � A CIVIL PENALTY OF NOT MORE'f HI1N FIVE HUN�RED DOLLARS(t6D0).�: pI,ASOWNEROFTHEPR9PERTY,ORMVEMPLOYEESWITHWAGESASTHEIRSOLECPMPENSA7lON, � GpmmBtCifi1 'H�l 00 7ME WORK.AFH1 TFIE STRUGNRE IS NOT INTENDE�OR bFFEREo F�A SAI.E{SEC.7o<a,BVSb J � NESS AND PROFESSIONS CWE:7HE CAN7RACTOpS LICENSE 4.AW DpES N4T APPLV TO AN OWNEF tlF � PHOPERTY Wl1D 9URAS f7H 1MpROYES TH£PEd�1.AND WHO170ES SUCH WORK HIMSf.LF OR HERSELF OR (;[ THROU�HHtSORHERtriNMEqPLOVEES,VR4Vi6EDTHATSUqiiMPR4YEMENiSARENOTiNTENpEDpR � �l� OFFEFlED�QRSALEIF,FIOWEVERTME9UILDINGORIMPROVEAIENTISSOLDWITHINONEVEANOFCpMPLE� � FIDN,7ME LWMER�WLLDFA WiLL HAYE THE DURDEN OP PFiOYiNG THRT HE CJR StiE DID NOT BUItD OR � IMPR4VE FORTME PUflPOSf QF S/�LE). W pI,A50WNEROFTHEPqOPERTY.�UIE]CCWSIYELYGONTRACTINGWITHLICENSEDCONTRACTORS � TO CdN57RUGT TNE PflOJEGT{SEC.704F,BUStNE55 AND PflOFESS10N5 CODE THE C�7TRACT�RS U. ValUetiOti ADJ.AREA_,,,,�., LIJ CENSELAWDOESNO7APPLYTQPNOYVNEHQFAPROPEflTVWHOBUILOSOpIMPROVESTNEREON,ANp � WMOCONTFUICTSFORSUCMPf10.1ECT5WRl+ACONTRACTOR{5)IICENSEDP1AR5uAN77oTHFCdNrRqC- QURNTITY � DESCRIPTION FEE y� TORS U�BtSE IAW.}. //y. � C]fAM E%EMpT UMpEA SEC. ,,,,_...__6.8 P.C.iflFi TH15 PEASOY �/+K�TS �� � DATE 6WNER._ _ / D� ^� � � ' UGENSED C{}NTRACTflRS DECLARATION � �� f � S •� U � �NEREBY AFFIRM UNDEP PENALTY OF pERIURY THAT!AM LICENSFD UNDER PROVISIONs oF CHAP7Eq �{��7}j }�.� � $(CQMMENC7NCi WlTH SECTt�Ft TD06}pF ONtS10N 30F TNE BVStNESS AND PR6FESSiONS CODC,4N6 Z ^/�fi � Y j� { I SK MY LICENSE IS IN NLL FORCE AND EtFFECT 'J ���r u�,b � UCEhISE CL4S5 `� �a LIC.NO. / �"�.J—",�....� � �' V►j l!7 ��,�,,�s � 5�. U � •. � o.ara_E�–3Cs –G Z coNrancTOR_y�._,�.—.._—_ � S r4S ...1' •.S e�M�S � '�1i() _ � WQRKERS'GOMPElVSATit?N dECLARATION � � Y„� d\ U � lHEAEBVAFFIRAiUNDERPENAi.TYOFPERIURYONEOfTNEf4lEOWMGDECt4RAT10N5�. � /�,� /.O�Ir1�.����,,, �� Yl_.. 6 JY/V � _INAVEANpWILLMAMTqINACERTIFIGA7EOFCONSENTTOSELF-INSUFEFORWORNERS' — —rt — COMPENSAF�oN,A5 PqqVi6E68Y S6CTIflN 3700 bF FNE tA80Fl CODE,F4ftTHE vFRF�RMAN�F. OF THE WQRK FOR WHICH THI$PERMIT IS I5Sl1ED. � �HAVE ANp WILL MAINTA�N W6RKERS COMPENSA710N INSUqANCE,A$REaIiqED 6V SEC'tON d� �3�0o pF THE LABdR COOE.Fpfl THE PERFGFiMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.MY'NOftKEftS'(.'�7NPENSATIQN INSURANCE CARRtER AN6 PfJtlCY NUA18£RARE� CONSTRUCTION ___ ` jcnaaiea ----- s_ PLAN REviEw � _� � �3 POLICVNVMBER_",. ....--. +EL�1'II}C ...__...,,..._�,p/_c�_������ ^q `i � (o+SSEcnr�NEmwra���uoFn��w.wrara�or�rn�qe�ca.uws�&iaolop�Ess�. LUMBING �.. .,..__.__ � i CEtiTiFYTHAT ita THE FERiOR1IANCE OF TNE WOftK FOR WHICH TMIS PERMIT IS ISSUEO.+ PIECHANICA� , (,�} SMALL NOT EMPLOY ANV PERSON IN ANV MANNER SOAS TO BFCOME SUBJECT'O THE J i � WORKEftS'COMPENSA710N LAWS OF CAL:FORNIA,AN�Af.REE TH0.T IF I SNOULO BECOME �NSPECTION FEE � Sl�&IECTTO THE Xk}RKERS'COM7ENSnTK1N PR6V�5toNfi oF SfcTIQN ato60F 7H[iABOR — -- ClJOE.ISNALLFORI'NWI'1'NC4MPlVWITHTHOSEpAOV1510N5. IS$UANGE i 4 p DATE: _ APPLICANT _ . __. SMIP . ,. � __�. � ENERGY PtC .._ ..... J WARNiNG'FA�URE TO SECURE MXJRKERS'COMAPENSATFOP!COVFRA(3E IS VNLAWFVL,AN�SHALI.i3E LL SU&IECTAN EMPLOVEfl T0 CRIMMAL PENILL.TIES AN�aVli.FINES Uv TO ONE NUNDRED TNqUSAN� ENERGY PERMIT � .r DOtLAAS(Sl W.�}.IN AODITION TO THE COST OF COMPENSATlON,DAMAGESAS PROYtDED FOR tN �����— -���- -- � SECTI(7N3�tl80FTH£LABOFlCbDE,IMERESi,ANpATTOftNEN5FEE5. RETENTIONFEE: ,,, .._ p_ CONSTRUGT�}ONIENDINGAGENCY PRE-ALTFEE: , _.._ . K? CyC 1 HEREBY AFFIRM UNDER PENALTY OF FERJURY TNAT iHEPE IS A CONSTAUCT�oN IENDiNG AGENCY _ 4i' FOR THE PEA�-0RMANCE OF iHF WORK F(ifl WHICiI THiS PERAIIT IS t5&UE6(6EC.3n9�,CN.C.y. Z W � IENDEflSiV0.ME_. _.._....... -.'— � IENDER'SApDRESS� / A� � ICEftTIFY7HA71HAVEREAD7HISAPPLICATIONANDSTATE7HATTHEA80VEiNFORMAT10NI5C4qfl£CT. TQTA�FEER7 41�f! ��� [L I AGREE TO C4MdPlY All CI7Y COUltTY Oi261NANGES AND STATE UWS REI.FTINti TO BU�LDIN6 � CONSTRUC710N.AND E EBV AI,ITHO IZE REPRESENTA7IVES 04 iHIS COUNTV TO ENTER UPON 7HE ABOYE�MEN710kEbP O RTYF9R1 PECTIONPVRPOSES. CQMMENTS _ � '�-' /� �'�- t — � __ _ CERAIITTEE N PRINTJ � . �ilt ... .. V � 51GNATVfiEOFPERMITTE AtE � RECPT.Nd. 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GROUP p OWNER '11�i f'J ..r 1��� ;�.- T � ADDR $S %•�', :';^'""�i �-.' �; r'� ° �>�. �c' ZONING SETBACKS � GITY �" ',,.,✓t,��-'..ZtP-i1� {.::�TEI:����.hc`'( �'t`t� FRON7 RW d APPLICANT TEL. REAR �� � t StdF1SIQE STREET_ RW_. (7 CONTRAC�CIR ���M�-{."'�' '`�..- 1 SIDE ❑ q[ ADdR�S .�-i"�' e ��'" ."-'�.'s ' - � t7 ClTY .h�:V 1�.,_ _ ZfP `�('(_(�='�EL. C � E,, tt�l } PROPC?SEQ USE '=? ' '-•.. a ARCHlENG/ \_Z DESIGNER_�`'1i.�1�4�- �T Y�t��-t�.. ADpRE5S �-:+i-r��y::- NO.DWEL. � NO. � NO. (+1 t1NtTS STORIES BEDROdM5 .� � C1TY ZIP TEL. � rn DE RIPTION SQ.FT. FACTOR PSF ADJ.ARE L ATION � qWNER•BUILDERDECLARATION ADDtREM ��` `.,,�t{"= O [] I MEREBY AFRRM UNDER PENAL7V OF PERJURV TH�T I AM E%EMPT FROM THE CONTRACTORS LI� � W CENSEUWFQRTWEFIX.IOWINGREASAN{SEC.]o3r.5BU5lNESSAHDPROFESSIONSCODE:AHYCITYOfl � GBCage/(:flfp6rt ��� �j j � pOUNTYWNfCtiREQUtRESAOERMtTT4C6NCTRUCT,ALTER,IMPROVE,DEMOi.ISM,ORREPAiRANVSTRUG W P8CI0/DBCk '� �v�� t/_ Q TURE,PHqR TO ITS ISSUANCE,ALSO REp11RES THE APPIICrWT FOR SUCN PERMIT TO FILE A SIGNED � `�'l./��;� � 57ATEMENT THAT HE#4&NE IS IiCENSED PVRSUMtT TO iHE PF�YISIIX3S OF THE C4MTRACTqRS li- "'�„� CENSE LAW(CHRP'!ER 9(COMMENpNf3 WITH SECTK3N 70D0)OF OIVISION 3 QF THE BUSINESS ANO PRO- �' PO01/Sp8 � FESSIONSCX7DE)ORTHATHEORSHEISE%EMPTTHEREFROMANDiHEBASISFORTHEALLEGE�E%EMP- (� S� Tqt{.ANYVK}tATiOMOFSECTtON70.?i.58YANYAPPlN:AN7FORAPERMITSUBJECTSTtiEAPPIICANT70 Z qe�Rooi � A CIYIL FENbI.TY OF NOT MORE THAN FIVE HUNDRED DOLLARS(f5W).)� � ❑I,ASOWNEROFTHEPAOP£RT',ORMYEMpLOYEESWf7HWAGESASTMEIRSOIECOMPEfJSAip�Y, L} �ommBtCiai WN.I DO 7HE WORK,tNd THE 57RUCTt1RE IS NOT iNTENDED OR 6F�ERED FOR SALE(SEC.�OM,BUSb � J � NE55 ANO PROFES510N5 CODE:THE CONTpACTORS LICENSE LAW DOES N4T APPLY TO AN OWNER OK � PHOpERTY Yhf08UfLOSbq IMPROYES THEREON,AND WHp DOES SUCN 4YORK tCM5EtF Ofl HEftSELF OR [� TMR�U(3HHISORHEROWNEMPLOYEES,VROVIDEOTHATSUCHIMPR4vEMENTSARENOTINTENDEDOR m QOFFEPEDF4pSN.E.IF,FIOWEVERTMEBU1lAIN60flINPROVBdEN7I554LOWITHINONEYEAROFCOMPLE� TqN,TME OWNER-&JitfYEA wiU.tiiVE 7HE BUft�N OF PflOVMG TNAT HE 4R StiE OiO NO7 9UItD�i � MPIqVE FQqTHE PURPOSE OF SALEj. '""""'�� w ❑I,ASpWNEHOFTHEPROPEHTY,AME%CIUSNELYCONTMCTINGWI?HLICENSEDCONTpACTORS ` yt 70 CONSTRl7CT7NE AHQIECT jSEC.JWi,&7Si67ES5 AND PROFFSSI(SN5 COOE:THE CONTMCTORS ti� Vall/dtiotl ^AQJ.AREA IJJ CENSEUWOOESNO7APVLVTOANOWNEROFAPROPERTVwFIOBUILpSORMIPfqVES7HEREqN,ANp � 'M1000NTMCT5F�RSUCHPHOJECTSWITHACON7RACTOR(S)UCENSEDPUflSUtNTTOTtiEWYTRAG QUAPITITY DESCR TIOM11 FEE � 70RSUCENSEUW.}. ❑7 AM F.XEl/P7 UNOER SEG p,d P.C.FOR THIS REASON q 3 `—' � � OA75 '___OWNEA_� � U � �ICENSEQ CONTRACTORS DEGIAflAT7G1N W J � I HEREBY AFFIflM UNDER PENALTY OF PERIURY THAT I AM LICENSED UN�EA PAOYISIONS OF GHAPTEft � {,� D(COMAiEt7CM16 WITH SECTiDN 70b6j OF DIViSiON 90F TNE BUS�NESS AND PROFESSiONS GODE,PN� Z �{ MY�ICENSE IS IN GULL F4RCE AND EFFEC7. lLl �.� � � +�� � � 110ENSE C�.ASS ._ LIC.NO. � � J `j OATE 4� �I)1 �.�_CONTRACTa�i '�t�-� �-' d � � WORKEftS'GOMPENSA7lOP1 DECLARATIQN Q � i HERE@YAFFIf4d UNDER PENALTY OF PERIUPY ONE OFtME FOIIOWINCs�ECIARAi�NS: Z � _I HAVE AND WILL MAINTAIN A CERTIFlCATE OK CANSENTTO SEIF-INSURE FOR WORKERS' a 2 �COMPENSATION,AS PfiOY�OEQ 9Y SECTFON 3To�Or THE tA80R C6pE,Ft7R iHE PGRF6RMNVCE U � /OF THE W6RK FOR WHICH THI.S PERMIT IS ISSUEO. � S� i NAVF N1p WiLL MAINTAIN WORKER5'GOMPENSATfON INSURANCE,AS REQUIflED BV SECTION � � � 3�OOOFTHEtAB4qCWE,FORTHEPERFORMANCEOFTHEWORKFORWHiCMTHISPEHM1Ti5 I���� ISSUEQ_MY'DK}RKERS'COM SAT 7 CARF$IEF AN6 PCH.ICY NU616ER ARE-. CONSTRUCT(ON � G� �-� p,.G1' `�.. y CARRIER=� �' � �"' P�,4NREVIEW zvaacv nuMaER��' .S.-. � ��— ELECTFIC . 4 — � (tiass[cnaN+iE�?�+oreEoonsh.ErQ.�oFn1EVFRMr�SwacNEluDDFtEoOaA.nR51y1oolcaLEss4 PLUMBING _._..,..—/—',/y— Z t CERTIFY THAT iN 7tiE PERFQRMANCE OF TNE WQRK FOR WHIC.H 7HIS PER4tT IS ISSUEO,i MECI"IANICAL !, • _^_Lt! S.,'7 SHAI,LNOT EMPLOYANY PERSQN INANY MANNEp SOAS TO BECOME 5UBJECT TOTHE (,() WORKERS'GOMPENSATqNUW50FCAL4FORN10.AN0AGREETHATiF15H9UlDeECOME INSPECTIONFEE _. � SUBIECTTOTHEWORKERS'Cl}IAPENSA7IONPROVISiONSOFSECTiON:f�ooQfTHELABOR .^ coae.i sHnu Foa�NwrrN con+a�v win+rHase aRovisbNs. ISSUANCE O p pATE: _ APPLICANT� SMIP / __....—.. ._ ,— ..—.... .. W ENER6Y PIC �.. � ' � � WARNM(�i.FAItURE TO SECURE W6RKERS'C(SMPENSATION COVERAGE�S UN4AWFUL,AND SHALL BE �— �—�y � � SU&IECTAN EMPLOYER TO CRIMINAL P�NALTIES MIQ CIVII FlNES UP TOONE MUNDRED THOUSANP � �^^ � 0{JUAqS{ft00,00o),lNAOOITIONTOTHECOs'TOffAMPENSATiON.DAMAGE5A5PROYi�Ef}FQfliN ENERGYPERMIT . � #' ��/�,+� � SECiN?M 3]OB OF TNE LABOR CODE,iNTEPEST,AND ATTORNEYS FEES. RETENTION FEE: �. _,,, 'l �/ l! � CON5TRUCTIdN LENDlNG AGENCY PR - T ' � � f�.Jl ..—��� , � 1#iEREBYAFFIPMUNDERPENALTYOFPERlURYTHATTHEAEiSAC�NuTRUCT�ONtENDU1GAGEtiCY `��+ F�fl iHE PERFORMANCE OFTHE WORK fOR WH�CN THIS PERM�T IS tS5VED(SEC.3087,CIV.G.). � + / ""'—"""" --� � /w /y � . � �.�.. �v"�V — � -. IENDER'SNAME___.,._ _ !— lEND6f4'SAODRESS^_� _ --. r � ICERIIFVTNATIHAYEREPDTHISAPPLlCATIGNANp5T4TETkATTHEA84YEMFflRi4ATKKiiSCORRfCT, TOTAL F4�S ��'" �' l((jj� �� � IAGREE TO CQMPLY WITH ALL GtT'YANO COUNTV Op(S�NAMCES ANO STATE LAWS RELATING TO BUiLOING d 1 �C � CONSTRUCTION.ANp HEREBY AU'fHOFIZE REpRESENTATIVES OF 7HIS COUNTY TO ENTER URON THE A80YE•MEM7N7kcR FAOFERTY FOR WSPECTKNI PURPDSES. �. ��\ CdMMENTS�._ � � . , ., --� �i�'�� i► ��'�:.1�� y'xt �Z�,� � _. � PERMITTE M �E PRINn ` '^ } . CfJ � .�.+��..i��. 5 f � '���_ p - . V � SIGNATUFE OF P flMITTEE � � �� DATE "! = RECPT.NO.,t�PAI08V VALIpATI4N � WHITE-Oepartmsnt Capy,YEILQW--Finance Copy,PtNK-Asse,�s opy,GOLEIENROD-Fiie Co�t GREEN--ApplicanYs Copy ' ��� ��fi(�.C�{S _. `r"1� 7. >� ���°`�` �` �� � � �i�� -— �������"��� F���� � e» �; � a {p " " 4i i ' � � c; I �r:�° � � 1 r7 �s� '�"" __ _ __ ___. _ __ .. _ _ _ 5 �___. - - � °'�.�.'F{ ( '�i l P �^,T��-. 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' �-�-.p �"?..� � � .:.3' �, � ` . � .,.. ..__.. .. __... .._.. �._ . _.. __ — `— �— — — = _r,.>. _... w__ .,. _._. . .... . . F;i_,�.�T r� - , " �n . - ��' ' #^.� �=��st3���{"��f.�. �i .... ___. .__ .__ .. . _.. .. _._.. .__. .._.. ... ._ ��.. , ,- ., .._.._.._ .. ...___. . ..,,. . . . ___. �. � �� 1 �; �. ..._,__.._.._ ..._..___.. __... ,. .._. ....... ..,... _.... ._._ _.... _... ..... i ��r a �, _ _ __ _ _ _ _ _ _ __ pv __ _ ___ �. -- ; � ;� ' _ _ .— __ __ i,` -�_ � _ � :' , __..... �____._ _ _ _ _ _ � � _ � . _._ _._ _ �.�_�..�...n.���e.�.�.��...._._..._._�__.._���...�.,��.._�._,��._._��..,.. ._ ___� � ..�_ ._.�.�_ a_ ��. _ � � .._.�.�� _,�.��_.. .. — A�I , ���� � � - _��-- CITY OF I7IAMOND BAht DEPARTMENT OF COMMUNITY&DEVELOPMBN"T SERVICES 2256d E.Coploy llrive Suite 194 (904)8643195 Fax(909)$61-311� PRESS �'�^''y BUII.DIIVG PERMIT APPLICATION FIRMLY JOB5ITE �^y a APPLICATION � ' PERMIT ��PlC �sii ,y, ADDRESS .C–/ _. F7 � � �... y�. �'d':�> i � dATE �'� NUMBER ` # � ISSUE---Y� `l� TYPE C APN LOT TRACT pATE � CONSL GROUP p OWNER _..,{�,.�""�£7 Y? a�t G1��.. � ADDRESS�o 7 ie,'"'"��""+� '-7�"�"a�S 20NING SETHACKS W CiTY flt�-+i`hn'-k +i�s'� 2IP� TEl.il�`��3�t 1 �RaNT RW ❑� � APPIlCAN�-��r%.�—t`�': '>�'i�=A E!TEL.a�I� REAR CJ � SSDE/SIDE STFEET RW ❑ a� CONTRACTOR ��-- M�G1��t�+ y �-� G� lY+�-- SIDE _ O q� ADDRESS �..'�'�' .�k'f�tir��_ Av.2. t� CITY �� F"1 ts+-+ {? ZIP {=d� TEI� ��'�a PRQPQSED USE P� ARCWENG/ z�,, DESIGNER NC1.DWEL. NO. NO. � ADQRE3S — UNITS STOR�ES BEOROOMS = CITY ZIP TEL. tn vs DESCRIPTION S�.FT. FACTOR PS� ADJ.AREANALUATION � OWNER•BUILDEFt DECLARATION �'p/ppp/REM 1 HEFEBV AFFIRM UNDER PENALTV OF PERJUqV THA71 AM EXEMPT FpqM THE CONTRAC7pR5 LI• (`ja�dggfC81pOt2 W CENSEtAWFORTHEFOt.IOWiM6REA;rt7N(SEC.7CTi1,58tJS�NESSANDPR�ES$tDNSCOOE:ANYCiTYOR {f) COIINTYWHICHflE9U1RE3APEflMfTTQCONSTRUCT,ALTER,IMPROVE.DEMOLI5H2OfiREPAIRANVSTRVC- W Patio/Deck TUHE,PRIOR TO ITS ISSUANCE,KSO NEQUIFES THE AppL1CAN7 FOR SUCM PERMIi Ta FIIE q SIGNED w 5TATEMENT TNAT HE 4R SHE IS LICENSEO PUPSUNIT TO THE pROViSIONS QF TNE C6NTMCTpRS 14 � � CENSE UW�CHAPTER Y(COMM6NCIN0 wITN SEC710N]d70)oF DIVISk?N 3 4F THE BUSINESS AND PRO� � PO4VSp2 FESSIONS GODE)Qfl THA7 FlE OR SHE IS EXEMPT TN6REFA06/ANQTNE BASIS iOfi TMEAL7.EGE6 EXEMP• {� TION.AMYVKN.ATK?N6FSEC710N7a3i.68'IANV�VPL�CANTFORAPERMITSUBJECiSTMEAPPUCANTTD Z Re-Roof � A CMt,PENALTV OF NOT MORE TH,W FIVE HUNDREp DOI.UlRS(SSoo�.): �ry GII.ASOYMEfiOfTHEFf�PEftTY,ORMYEMKOYEESW{7HWAG£SASTHEiRSIX.ECQMPENSATP�N, � {,`O(ilmelCldl � �`-�- VALL W THE wORK,AND THE 5TflUc7URE IS NOT IN7ENpED OR OFFERED FOR SALE(SEC.7oe4,9uS�• J . NE59 AND aROFES510NS CODE:THE CONTFiACTORS UCENSE LAW UOES NOTAPPLY TO AN OWNER oF � PROPERTYYh168U�L150ftiM1iAROVESTHEREON,ANDNMO00ESSUCHWOKiKNiAdSF.IFORHER5ElfOFt � CC THROU[3H MIS OR HER OWN EMPLOYEES,PROVIDED THAT SUCH IMPROVEMENTS APE NOT MTEN�ED Op m � OFFERW�ORSN.E.IF;HOWEVEF'lTHE8UILDWGOFIMPROVEIAFN74CSQLOWITNINONEYEAROFCOMPIE � i%JN,Tt{E 4WMEti$UItBEfl NiItL M1iAVE THE flURDEN OF pqOVtMG THAT HE OR SHE LND NOT BUIID OR � IMVRDVE FOR 7ME PURPOSE OF SALE). �yj U1.ASOYMEROFTNEPR6PERlY,MtEXCW5IYELY�MAACTiNGW1TtIliCENSEDtX�NTNAGT6ftS � � TO CpKiSiRUCT THE PRp.1€CT(SEC.7tl41,BUSiNE9S AND PROFESSIONS COUE TH6 CONTR4CTOR5 LI� V81U81i0f1 _ ADJ.AREA__ GENSE UW UOES NOTAPPLV TO AN tlWNER OF A PflOPERTY WMCl BUILpS Ofl IAIPPOVES THEflE4N.ANb � Wl1oOpHiRACTSFORsuOiPRP7ECTSWi7t+ACON'iRAGTOR{s}licENSE0fuA5uAN7TOTHECGNTRAG C}UANTITY DESGFiIPT�ON FEE � T6R54CENSEIAW.). — �i AAt EXEFiFTf UF�ER SEC. 8.E P.C.FOq THIS REhSON � Q �i __._ V ti. � OATE OWNER_, __ � � �ICENSED CONTRACTORS DECLARATION W J � W ! 1 HEflGBYAfFtRM UNDER PEIYtS,TY OF PERIVHY TH,{T iAM LtCENSE4 ilNDEft PROViSIONS OF C#�:AATER � p� Y(COMMENCRIO WRM 5ECT10N 7000)OF DIVISION�OF TI1E BUSINESS AN�PROFFSSIbNS CODE,AND Z }{ MY IICENSE IS IN FULL FOflCE AND EFFECT. "�n UCENSECLASS_ � �`"a LIG,No.�^' ����� j N � ��.� `� J t� � DATE CONTRAGTOR d � WORKERS COMPENSATiON•DEG RT ¢ AlJ' `%LiJ4r'/Q y') �,,,,,, E7 S} , -�^� � IHEREBYAFFlHi.tUM6ERPEN�iLTYOFPEA7URYC?NEOF EFO�,kd�Nf OECI.ARAT�ONS: Q 'l ��`,f �, t �y4G7 ��� ! . 6.+^'a+i F..✓ p 4 � ,,,_it{AVEANOW�LIM/JNTA:NAGEflTSFiGATEOFCAC�"TTOS F-INSUftEFOflWORKEHS' S / t. j COMpENSA7qN.AG PROVIOEO BY SECTION 37uo OFTME LA F CODE,FOR THE 7ERFOFMANC6 W � C�" 3���L1 H 1�'�y > ! ky: � OF THE WORN FOR WHICH TMIS pERMIT IS IS5UEp. � .�i � '�, /y�,��� �J ���, �-- W T .. �,_I HAYE Mld WILL MAINTAIN WORKER5`COMPENSATION INSURANCE,AS REQUIRED BY SECTION � 370�4�THf 1.A80R GW E.FOR THE PER�ORkANC£OF TNE WQRK FOR WHICti TH15 PERMIT IS i5SVE6.MYWORNERS'G9MPENSATI I RANCECRRRIERANOPOI,ICYNUMBE%ARE' CONSTRUCTIQN � CMRIER C_+��Y�O ti"1 1��'��O'�0.�. PIAN REVIEW ..—.. �w� G1 POLICv NUMBER,_!%I I�..IZ GC� �����_.� � ELECTRIC . � (iHI55EC�1(:fNNEBJNOT9E00MfLE7EDC1f7HEPERIKT�SR%70NE1-0.MI%'i[oDq.I.ARS(StaDJORLE55} PLUMBING _...., . ._._� � ICER"fIFViHATINTHEPERFORMANCEOFTME`NORNFURWNIGHTHISPERMITI5ISSUEG,1 MECHANICAL ,_����__ (� SHALL NOT EMPL4YANY PERSCNV IN ANV MANNER SO AS TO BECOME SUBJECT TO THE � Y4a�RKERS'C'AMPENSAtF.7NLAW50FCA11fOqNi OAG ETHATIFISHWlD9ECbME IFdSPECTI{)F+IFEE 4K � SUBJEGTTOTHEWORKERS'COMPE45ATIONPRO ION6 SECTON3]ao/f?F�y��ABOP -^'�� COD,1 SHA' 4RTHWITH COlAPLY'vYITH THpSE pAoVtS C/ lSSUANCE -- (� DATE:� Z ��� APPLICANT: r�� � . SMIP .. _ W ' ENERGY P/C � WAfWINd:FAILUREToSECUFEWORKERJ'COA�MENSATIbN�CAV AGEISUNLAWFUL,ANDSHALLBE --- — — � SU&IECT M!EMPLOYERTO CqIMINAL PENALT�S ANp C�1VIC FIN UP TO aNE HUNDRF,D TNnUSANp ENERGY PERMIT [YOCURS{StQO.aW},7NAp0iTlINiTOTHECOSJfOFCbMP.£N5A ,6AMAGESASPRON6EDFORIN — -�-- � SECTN,}N 3lOB OF THE LA60R COpE.INTEREST ANO,FTTOpNE FEES. RETENTION FEE: ,,, _ � CQNSTRUC'Yy(3JSF"LEND� G AGENCY PRE-ALT FEE: ,.,�,�__ C'�' !HEREBY AFFIRid Vt�ER PENtdTY�PER7t1RY FHA'THERE IS A CONS7Rl7Ci7QN IENDiNG AGENC:Y d- FOft TME PERFORMANCE OF�ME WORK FOR WNICH 7HI5 PERMIT IS ISSUED(SEC.3oe7.CIV,C.). �' -" "' W _..... . � LENDER'S NAME __...._ N 4£N6ER'SADDRESS_,,,_ /� � t CERTffY THAT 3 HAVE RERD Ttt4S APPt.iCATiON AN6 STA7E 7HAT 7ME A80VE INF�MATpN IS C6RRECT t�,, Q IAGREETOCOMPLYWITMALICIIYANpCAUN7VOfipINANGESANOSTATELAWSRELATINGTOBUILDING Tt�iA�FEES '✓� � 'r• � CONSTRUCTKIN,ANOHEflEBYAUTHORI2EREPRESENTATIVE50FTWSCOUNTYTOENTEAUPONTNE � ABOVE-MENTKKtED PROPERTY FOR Xi&PECT19N PURP45ES. COMMENTS y.�,,,, ___ � Lr�-1 fi(�'�..{�. S `'�1� f S A�'' � __ � PERMITfEE NAMy{PRWT � Q } ) "�.✓�'�r'� „ S/a � �` ~} � SiGNATURE P OATE � r' RECPT.NO. � " PAID BY .. 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GiiOUP p OWNER � _`_ p ADDRESS^� � ZONING SETBACKS � CITY ZIP TEL. FRONT RW ❑ � APPLICANT TEL. REAFi ❑ � SIdElStDE STREET RW �� � CONTRACTOR SIDE � ❑ � ADDRESS '� PROPOSED USE o CITY ZIP 6L7TEL. U � � ARCH/ENG/ z QESIGNER w NO.QWEL. NO. NO. c� ADDRESS = CIFY Z�p T�� — UNITS� STdR1ES SEDROOMS cn - cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-BUILDERDECLARATIpN SFFIADQlREM �Q �. 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W GI,AS4WNEROFiHEPRpPERTV,AMEXCLUSIVELVCOYTflACTINGWiTNucEN5E0CUNTHACTORS (,'[ TO CQNSTRUCT 7NE PROJECT(SEC.7Qd4,BUSINESS AND PRCFESSIpNS CODE THE CANTRAGTORS ll� VAIUdf70(t __ADJ.AREA_, U.1 CENSEtAWOOESNOTAPPLYTqANpWNEROFAPR�PERTVWHpel1ILD50RIMPPOVESTNEREpN.ANp � WHOCONTRACTSfpRSUCHPflqJECTSWITIIAGONTRACTOR(5)UCENSEDPURSUANTTOTNECdNTRAG QlJ/�NTiTY DESCRIPTlON FEE 70RS lICENSE IAW.}. � Cl i AM E%EMPT UNOER SEC. ,,,,__ &&P.Q f-0q TNIS REASON Q �f 'p L �r- �' LL .....-.— � QV �!Y� � � t'. , � �ATE GWNER_..._ _�__.....—� � „ � � �, � LlGENSED CONTRACTORS DECLARATiON � ^ ( d W � A � CC I HER6BV AFFIRM UNDER P[NALTY OF PERJUFiY THA7 1 AM 41GENSED UNDER PROV1510NS OF CHAPTER � ) � F{COMRiENOiNG WITti SECTbN TOw)OF QIYISION 3 OF TN[BUSiNE55 ANO P£?OFES5KKJ5 C.'a6E,AND Z j� � `X MV LIO[NSE IS IN FULL FORCE AN6 EFFECT. m `,� �k�� �� � LICENSE SS_('—f C?._,,,� LIC.No, ��r.�✓';�t/ = cs t . � , `CjA- / . 1 WpA7E B'��/'���„� CONTRAG . d C'�L�' WORKERS'COMPEN5ATIdN DECLARATION Q ),� .-� � IHEREBVAFFIqMUNDERPENqLTYOFPERJURVONEOFiHEFOLL�WWG�ECk.ARaTIONS: Z ' � _I HAVE AN�WILL MAINTAIN A CERTIFlCATE OF CONSENTTO SELF-INSURE FOR WOfiKERS = � CAMPENSATION,AS PROVIOED BY SECTI�N 3J0o OF THE tR80R COOE.fQR iHE PeRF6RMANCE U � OFTNE WdHK FOR WHICH THIS PERMITIS I55UEb. � � _I HAVE AND Wllt MAINTAIN WORKERS'COMFEN90.TION INSURANCE,AS REOVIRED BV SECiiON � 37000FTHElABORCOf1E.FORTHEPERFOqMANCEOFTHEN'OfiKFORWHICMTH15PEPMITIS ISSUED.MY WORKERS'COMPENSATlON INSVRANCE CARRIER AND PQ�tGY NUM&EN AftE' CONSTRUCTIOPI � cAAa�ER =,���/ _.__ a�n,N aEviEw _ ^'�' � aoucvwur�aEa ,t'�',.,,,,,_ �07� ,..._,. ELECTRIG �J �• ¢ ...___....-. � �TtiSSEcrcMttJE@MOTBE�iF''LErEDOF7}tEaEat.57tSrt3Rar�fFVWoriEoall.taRs(&iro}�tlEss). PLUMBING W Z I CEFiTIFY TNAT IN THE PERFOflAtANCE OF TH[WORK Fbft WH�CN TH15 PERMiT IS ISSUED,i h9ECNANICAI. � ('",} SHALLNOTEMPIOYANYPERSqN'�NANYMANNERSOASTOBECOMESU9JFCTTOTHE �������� � WORKERS'COMPENS/TION�AWS OF CALIFC1RNIq,PNC AGREE T'HAT If I S LD OME INSPECTION FEE i,,, � SU&)ECTTOTHEWORKERS'CQMPENSATIONFROVI SOF C'16N 4 H I.A80R ,.j � C�� ISMA FORTHWII'HCOMVLV OVIS ISSUANCE , _ ��. : �_ � � � p OA7E:v �1 _�,,..-_ AFPLI NT SMIP . . J WARNIMG:FAt4URE7Q5'tCVREWQRKEftS'IXJMPENSATKKiCGVERAGE15UNtA 4.,AWSHRtIBE �NERGYPJC ___ „___„ _ � SUBJECTANEMPLOVEFlTOCRIMINALPENALTIESPNUCIVILFINESUPTC70NE DFiEDTHOUSAN� ENERGYPERMIT _,.,, r DOLLARS({100,000�,IN ADOITION TO THE COST OF GOMPEN5ATIpN,DAMAGES AS PFOVIDEb FOR IN ��� — ' ....._ � sECT�pN3ro6oFTri=�nBOftcIX)E,INTEREST,ANDA770RNEY'SFE£5. RETENTIONFEE: _, —��`�--` � CQNSTRUCTlON I.ENDING AGENCY PRE-A�T FEE: , ., � I NEREBV AFFIRM L'NDFF PCNALTV 0=PERJURY THAT THERE IS AGONS�'RUCTION LENDINGAGENCY . fOR TNE FEqF6RMANG[OF FHE WOftN FOft WH1GN THIS PEHMiT I$t55UED{SEC.303T,CIY.C.}. """"- '—" U.1 = GENp'cR'S NAAiE y _ ..�._'—_ __ y ._...... .. .. I'_ IEN�ER'SA�DRES5__A _. __,. ,,,,. � I CEFTIFV THAT I HAVE READ TH19 APPLICATION AND STATE i HAT THE PdOVE INFURMATION IS CORpECT TOTAL FEES � � -... • r �'`) � 1AGflEETQCOIAPLYW1TtiALLCiTYANC�COUNTYOR0INANGESANOSTATE[AWSRE(.ATINGT08U�.�ING 4 � CONSTRUCTION,ANp HEAEev AUTHORIZE REi'RESENTATNES OFTHIS COUNTVTO ENTER UPON iHE " ABWE�MENTIONEO PROPERTY fOR INSPECTION PURPOSES. �QMMENTS 6 —..--fJL.� e _. ,_...._.. .. 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