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HomeMy WebLinkAbout16868 (39) CITY OF DIl�MOND BAR ���� -----1�`��--- DEPARTMENT OF COMMLJNTI'Y&DEVELOPIvvIENT SERVICES ,,. �r` 21825 E.Copley Drive � � �``" (909)860-3195�ax(909)861-3117 PRESS `"'%.�r^��� I BUILDINGPERMITAPPLICATION "` FIRMLY o� JOBSITE �,�„ � APPLICATION �, r� PERMIT ���y ��g P/C ADDRESS���� �s�� �� DATE � NUMBER �i' *� # o ISSUE 7YPE OCC T° APN LOT�_ iRACT ��� �,�� DATE CONST. GROUP LLOWNER ` ' —(_�, . "' '�=`,.� _ ADDRESS /�,�_I,�y � ��� i 1/ �- ZONING SETBACKS I z CITY .fC.y=��`Y,.at ZIP�," � TEL� `� FRONT RW ❑ � APPLICANT TEL.���3 REAR ❑ Z SIDE/SIDE STREET RW ❑ � CONTRACTOR o- � � ,�.�` s�.lJ9� SIDE ❑ Q ADDRESS � =M' � ,,, PROPOSED USE � CITY �'" ZIP :i�: f�`fEL. � `��� Q ARCHlENG/ ��y'' w DESIGNER NO.DWEL. NO. NO. ; a. ADDRESS UNITS STORIES BEOROOMS ' � CITY 21P TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION . p� OWNEF-BUIIDER DECLAFATION SFR/ADD/REM O , p I HEFEBY AFFIRM UNDER PENALTY OF PERJURV THAT I AM EXEMPT FROM iHE CON?flACTORS LI- G3fB9E/C8fF10rt W ' CENSEIAWFORTHEFOL�OWINGREA50N(SEC.7031.5B11SINE55AN�PROFE5510h5CO0EANYCITYOri (n . '�. U ' COUNiYWHICHRE�UIRESAPERA�ITTOCONSTRUC7AL7ER,iMPROVE,DEMOLISH,ORflEPAIFANYSTflUC- W Patio/Deck ' W 'TURE,PRIOR i0 ITS ISSl1ANCE,lyL50 REOUIRES THE APPLICANT FOR SUCH PERMIi TD FILE A SIGNEO � . ' STATEMENT lHRT HE OR SHE IS UCENSED pURSUANT TO THE PROVISIONS OF THE CONiRACTORS LI- �'I � 'CENSELAW(CHAPTER9(COMMENCING;WITHSECTION7aao)OF�IVISION30FTHEBUSINESSAN�PRO- LL' POOVSPfl 'FESSIONSCO�E)OflTHATHEORSHEISEXB.APTTHEREFP.OMANOTHE8A51SFOflTHEALLEGEDE%EMP- . II � TION.ANYVIOLATIONOFSEC710N7031.5BYANYAPPLICANTFORAPERMITSUBJCCiSTHEAPPUCANTTO Z Re-Roof - � AqVIL PENALTY OF NOT MORE THAN FIVE HUN�RED DOLLARS(S5o0).): i � 0 ❑I,ASOWNEFOFTHEPflDPERTY.ORMVEMPLOVEE5W17HY✓AGESASTHEIRSOLEWMPENSATION, � CORIRIEfClB� - ' Z WILL DO THE WORK AN�TH6 STRUCTURE IS NOT INiENDEO OR OGFERED FOR SALE�SEC.7044,BUSI- J '' ,NE55 AND PRDFESSIONS CDDE:l'HE CONTRACTORS LICENSE lAW OOES NOT APPLY i0 AfY OWNER OF � ,PROPERTVWHOBUILDSORIMPROVESTHEREON,ANDWHODOESSUCHWORKHIMSELFORHERSELFDR � ' � �.THROl1GHHI50RHEl70WNEMPLl7VEES,PROVIDED7HATSUCHIMPROVEMENTSARENOiINTENDE�OR m Q '�OFFEREDFORSALE,IF,HOWEVER„'TiEBUIL�INdORIMPROVEMENTI550tDWITHINONEYEAROFCOMPLE- Z �,,TION,THE OWNEq-BUILDER WILL'HAVE THE 6URDEN OF PqOVING THA?HE OP SHE DI�NOT BUILD OR � 'IMPROYE FOfl THE PURPOSE OF 5ALE�.� W. � ❑I,ASOWNEROFiHEPftOPEHTI',?.MEXCLUSNELVCONTRACTINGWRHLICENSEDCONTflAC70RS � ',TO CANSTRl1C7 THE PflOJECT(S�G 7044,BUSINE55 ANO PflOFES510N5 CODE;iHE CDNTflACTOFS LI- VBILdtI0f1 ADJ.AREA W ',CENSELAWDOESNOTAPPLYTOANON4JEfiOFAPflOPEPTVWH08UILD50RIMPROVES7HEREON,AN� �'; ��,,WHOCONTRACTSFORSUCHPROJECTSWITHACONiRACTOR(5)UCENSEDPURSUANTTOTHECONTRAG (�U DESCRIPTION FEE - � .TORSLICENSELAW.). � �� �, � �. ❑I AM IXEMPT UNDER SEC._ ,B.8 P.G FDftiH15 REASON U � � � .. LL �DATE .OWNER �" Z ' W � � UCENSED CONTRAC70RS DECLARATION W ¢ � 'I HEREBV AFFlflM UNDER PENALT%OF PERIUflV THAi IAM LICENSED UNDEft PFlOVISIONS OF CHAPiER � d ',9(COMMENCNGWIiHSEC710N7600)OFOIVISIDN30FTHE0USINESSANOPROFESolONSCGDE.AN� Z w 'MY LICENSE IS M FULL FORCEAND EFFECi ���+�{[p,(s m � LICENSE�'�]CrlA��SSf ��� � LIC.NO. `� +�-� r� ��' j ~' ��DATE_;�f�� CONTRACWR .. .' .�'f'�'f'� a W � � �p�'�,p . � WORKERS'COMPENSATION DECLARATION j a � U �' IHEREBVAFFIRMUN�ERPENALTYOFPERJUflYDNEOFTNEFOLLOWMG�ECL4RATIONS: "—' a � �IHAVEANDWILLMAINTAIN'ACERYIFlCATEOFCONSENTTOSELF-INSUREFOfiWOflNERS' _ CAMPENSATION,AS PROVIDED BV SECTION 370o OF iHE LABOR CODE,FORTHE PEFFORMANCE U a� ,�OFTHEWORKFOFWHICH.THISPERMITISISSUED. � �' � IHAVEPNDWILLMAINTqIN,WORMERS'COMPENSATIONINSURANCE,ASRE�IIIREDBVSECTION ' QG � 37000FTHELABOfiCO�E;FORTHEPERFORMANCEOFiHEWORKFORWHICHTHISPERM1T15 ISSUE�.MYWORKERS' ENSATIONINSURA�CARRIEFANDP LIGYNUMBERARE: CONSTRUCTION �. i;,. � CAflRIeR � �-T� -� __ PLAN REVIEW vy . � POLICY NUMBER�� �� ' �. F— .'�"'�'..�.,,�.^m^-���,._„-.- A.i"S � ' � ELECTRIC � Z , q �� l.,:.\ ..: . `.... ,..Y. � (iHISSECTIONNEmNO76ECOMPLEfEDOFiHE?ERMRISFORIXJEHUNDREDG_YLPAS($IOO�ORL65). PLUMBING ; - - Z I CERTIFYTHAT IN iME PEF{FOPMANCEOf THE WORK FOR WHICH THIS PERMITIS ISSUED,I MECHANICAL () SHALL NOT EMPLOYANY P�RSON IN ANV MANNEP SO AS TO BECOME SUeJECT TO THE � s' r�S � ' ' � � WORKERS'COMPENSPTIONLAW$OFCALIFORNIA,ANDAGREEiHATIFISHOVLDBECOME INSPECTIONFEE! � � SUBJECTTOTHEWOfiKERS'COMPENSATIONPRO NSOFSECiIIXJ o D 7 R � }� � coo isF+n� OflT.WITHC�MPLY s isio s. ISSUANCE p �ATE: � � APPLICAN: �' , ; . . . >`� M SMIP ��y'T�°�..._._ e . v-.:_...,�..,..�s' . j WARNING FAIW E TO SECURE WORKE95'COMPENSATION COVERAGE IS UNLAWFUL,AND SFIALL BE ENERGY P/C _. ' - - __ � SUBJECTANFNPLOYEflTOCRIMINALPENALTIESANDCIVILFINESU7TOONEHUNOREDTHOUSAND ENERGYPERMIT �OLLARS(5100,000),IN AODITION Tb THE�COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN J SEGTION37aeOFTHELABORCODE,IN7ERE5T.ANDA7TORNEY'SFEES. RETENTIONFEE: � g CONSTRUCTION LENDING AGENCY PRE-ALT FEE: O � IHERE6YAFFIWv1UN0ERPENALTY�.OFPeRJUFVTHAiTHEREISACONSTflUC710NLENDINGAGENCV FOR THE PERFORMANCE OF THE WOqK FOR WHICH T HIS PEFMIT IS ISSU W(SEC.309].CIV.G.1. Z LLf . � LENDER'S NAME I— LENDER'SADDRESS , � ICERTIFYTHATIHAVEflEADTHISAPPLICATIONANDSTATETHATTHEABOVEBJFOflMATiONISCORflECT. TOTAL FEES �� \��� � IAGREETOCOMPLYWITHALLCITYANOCOUNTYOFDI�ANCESAND57ATEL4WSRELATINGTOBUIIDING �.,,9 � CONSiRUCTION.AND HEREBV AUiHORIZE REPRESENTATIVES OFTHIS COUNTY TO ENTER UPON THE Z ABOVE-MENTIDNED PROPERTY FOR P2CTION PUR? es. COMMENTS � q � �� � - m PE (P I � .. � � �. �.�� � � SIGNA�REOFPERMITf'cE , D ,` = RECPT.NO. PAID BY G�iG- 3 ALIDATION ~ WHITE—�epartment Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENft06—File Copy,GREEN—Applicant's Copy , ,. _. . ,.,. _ , , . �.. , 3 . ;: , .��..,;.,� ,.,: �- ., � .,��,; ,.,„�,< . . .,, :r- : . .. � € e k p c�' y: 6�.;�m d. Y , ...5. _ �. .. . .c �.. . .. Y � .. .. "...Y .. e . 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