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HomeMy WebLinkAbout16810 (39) CITY OF DIAIv10ND BAR ---� -- DEPAItTMEN'I'OF COMMUIv1TY&DEVELOPMENT SERVICES � 21825 E.Copley Drive � (909)860-3195 Fax(909)861-3117 PRESS "''<y��>��' BiJILDING PERMIT APPLICATION ' FI R M LY � JOBSITE �"'7/I ���,x2,._�� d �� � , APPLICATION � � � PERMIT � P!C ¢ ADDRESS ���' ����P � DATE NUMBER # � — ISSUE TYPE OCC APN LOT TRP,CT DATE CONST. GROUP p OWNER fjft/� � " ADDRESFi�T.��i/�'��^'' _ � ZON�NG SETBACKS Z CI��'�°'""� � ZIP l'9�,5 TEL �'��S�� FRONT _ RW ❑ S APPLICANT I TEL. REAR ❑ SIDE/SIDE STREET RW ❑ � CONTRACTOR � d�� SIDE ❑ o ,ApDRESS ��- �Ce'dt�z '�" PROPOSEDUSE �� ��N�- � o CITY+d✓� �-�' ZIP �r l.�� TEL. �jl�J-12-5� o' ',ARCH/ENG! iz DESIGNER I NO.DWEL. NO. NO. � 'ADDRESS I UNITS STORIES BEDROOMS � CIT`f � ZIP TEL. � � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATIQN p� .O IWNER-BUILDER DECLARAT{ON SFRlADD/REM � � O, 0 , I HEAEBY AFRRM�UNOEfi P AlN OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI- � Garage/Carport ' W� CENSELAWFORTHEFOLLAWING EASON(SEC.7031.5BUSINESSANDPROFESSIONSCOOE:ANYqTYOR U�, COUNTYWHICHFEWIRESA�ERMTTOCONSTRUCT,ALTEH,IMPROVE,OEMOLISH,ORREPAIRANYSiRUC- � I. �., ,TURE,PRIQR TO ITS ISSUANCE.A SO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED W PetiO/DeCk . � "STATEMENT THAT HE Op SHE IS'ICENSE�PURSl1ANT TO THE PROVISIONS OF THE CONTRACTORS LI� � ,'��„ ',CENSE LAW(CHAPTER 9(COMM'c CING WITH SECTION 7000�OF DIVISION 3 0F THE BUSINESS AND PR0- LL' POOI/SPe . '��FESSIONSCAOE)ORTHATH�COR HEISEXEMPTiHEREFFOMANDTHE6A&ISFORTHEALLEGEDEXEMP- (� �" �TION.ANVVIOLATIONOFSECT�ON'.031..5BYANYAPPLICANTFORAPEFMITSUBJECTSTHEAPPLICANTTO z Re-Roof �, pCIVILPENALTVOFNOTMORET NFIVEHUN�RED�OLLARS(SSOD).): ❑I,ASOYJNEROFTHEPROP flTY,ORMYEMPLOYEESWITHYJAGE5A5THEIR50LECOMPENSATION, Q Z�� Commercial - �WILL d0 THE WOflK,AN�.THE�ST�UCTURE IS NOT INTENDED OR OFFERED FOR SALE(SECJobb.BUSI- J �� �NESS AND PHOFESSIONS Cb�E: E CONTRACTORS LICENSE LAW DOES N07 APPLY TO AN OWNER OF ? � , ' �PROPERTY'WHOBUILDSORIMPR VESTHEREON,ANDWHODOESSUCHWORKHIMSELFORHERSELFOR �'�� I'THROUGHHISORHEROWNEMPLIJVE�S,PROVI�EDTHATSUCHIMPFOVEMENTSARENOTINTEN�EDOR m Q'� OFFEWEDFORSALE.IFHOWE�ER,�IfI-IEBUILDINOORIMPROVEMENTISSOL�WITHINONEYEAFOFCOMPLE- • Z� TION,7HE OWNER-BUI4DER WILL�AVE THE BUR�EN OF PROVING THAT HE OR SHE DID NOT BUIL�Oft , . IMPROVEFOIiTHEPURPOSE'OF LE�. I wl,��� ❑I,ASOWNEROFTHEPROP RTY,�AMEXCLUSIVELYCONTRACTINGWITHLICENSEDCONTRACTORS '. ��,' '�'TO CANSTRUCT THE PflOJECT(SEC,7u44,BUSINESS AND PROFESSIONS CO�E:THE CONTRACTORS LI- Valuatlon ADJ.AREA ' W� �, CENSELAWOOESNDTAPPLV,iO NO`NNEROFAPqOPERTVWH09t11L�SORIMPROVESiHEREON,AND '� �, ''.'WHOCAN7RACTSFORSUCHPRO�ECTSWITHACONTRACTOP(S)LICENSEDPURSUANTTOTHECONTRAG QUANTfTY DESCRIPTION FEE� ,, Y' '��TORSUCENSELAW.). . I�, 0�',� ❑I PM EXEMPT UNDEk15EC. B.&P.C.FOflTH15 REASON Q �'�, �. �� , U I W � �� �, ' �ATE OWNER U �� �.Z�� �� w !, .���� LIC,EN ED CONTRACTORS DECLARATION W I, �', � I HEREBY pFFifltd UNDER PEI�'IAIT OF PEflJIJRV THAT I AM LICENSE�UNDER PROVISIONS OF CHAPTER � �D , � ' , I .d'�. 9(CDMMENCINGWITHSECTIQN700)DFDIVISION30FTNE6USINESSANDPROFESSIONSCODE,AND Z ��� �i X'��. .MY LICENSE IS IN FULL FORCE AN� FECL � t 'f� ��, ��� LICENSE CLASS � � �i LIG.NO. r ������ � � DATE �'� CONTRACTOR� � I W ''�, '�I, WORK RS'COMPENSATION DECLARATION Q craj U �, �.� 1 HEREBV AFFIFMi UNOER PENAL OF PERJURY ONE OFTHE fOLLOWING DECLARATIONS: Z �I, .Z'' _IHAVEANDWILLMAINTAI ACEfiTIFlCATEOFCONSENTTOSELF-INSUREFORWORKERS = i ¢„ CAMPENSATION,ASFRO IOEOBVSECTION3]O�OFTHELABORC�DE,FORTHEPERFORMANCE IU ' OFTHE KFOR'.WHIC THISPERMITISISSUED. � � I W . ��I O ,1 H�WILLMAINTAI WORKEflS'COMPENSATION IN FANCE,AS FEQUIRED 6Y SECTION ', 370o OFTHE L � � �D�.FOR'�THE PE F E WORK FOR WHICH THIS PERMIT IS _..1 ISSUED.MY RN S'C�MPENSATIO INS A RIERANOPOLICVNUlABERARE: CONSTRUCTION I j�� c.eaaiea ��I I ' _ * PLAN REVIEW i� ',Z POLICVNUMBER_ ;; ELECTFlIC I ¢ " � � ',Q (iHISSECTIONNEFANDTB O�MREfE�OF7HEPERMfTISWRONEHUNDRED00LLAF6�$10�ORLESS). PLUMBING � w ICERTIFYTHATINTHEPE FORMANCEOFTHEWOPoCFORWHICHTHISPERMITISISSUE�,I MECHANICAL � ' �, � '� SHALLNOTEMPLOYANYFERSONINANYMANNERSOASTOBEGOMESUBJECTTOTHE ' I(n � WORNERS'COMPENSATIC�NLAWSOFCALIFORNIA,ANDAGREETHATIFISHOUL06ECOME INSPECTIONFEE � SUBJECT TO THE WO,RKERIS''COM2ENSATION 7ROVISIONS OF SECTION 370o OF iHE LABOR A\ � CO�E,I SHALL FORTHWITry COI:IPLV WITHTHOSE PR�VISIONS. ISSUANCE � 6 lJ � SMIP �,, �p DATE: �� A PLICANT. ' � �J WARNING�FAILURETOSECUFiE ORKEAS'COMPENSATIONCOVERAGEISUNL4WFUL.AN�SHALLBE ENERGYP/C � Sl1BJECTANEMPLOVERTOCqIM ALP�,ENALTIESANDCIVILFINESL1Pi00NEHl1NDREDTHOL15AN0 ENERGYPERMIT ODLIARS(§100,000),IN AOOITION O THE COSiOF COMPENSATION,DAMAGESAS PROVIDEO FDR IN � SECTION37oeOFTHELABOfiCO E,INTEREST,ANDATTORNEY'SFEES. RETENTIONFEE: � ,�O �'�CO STRUCTION LENDINGAGENCY PRE-ALT FEE: ,���, I HEREBV AFFIRM UNOER PENALT�OF PERJURY THATTHERE IS A CONSTRUCTIOtJ LENDING AGENCV FOR THE PERFORMANCE OF THE ORIC FOR WI�ilC41 THIS PERMIT IS ISSUED(SEC.3091,CIV.C.). . Z W' S� LENDER'S NAME I �. 1—� LEN�Eft'SADDRESS ,W'. 1 CERTIFY THAT I HAVE RFAD THI^��IAPPLICATION ANO STA7E THAT7HC ABOVE INFDAMATION IS CORRECT. TOTAL FEES y�� '�"'. I AGREE TO COMPLY WITH ALL CITYI AND COUNTY DINANCES AND STATE LAWS R�LA7ING TO BUILOING � �'�. CANSTRUCTION,ANDHEREBYAUTHORIZ RE ENTATIVESOFTHISCOUNTYTOENiERUPONiHE � ABOVE-MENT/^IO�NEOPROPERTYF� O PuaPosEs. COMMENTS - � ��_ m', PERMITTEE NA1 RI � � ���� � � SIGNATURE OF P MITTEE �ATE � � RECPT.NO. ,PAID BY VALIDATION ' WHITE—Departmenl Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—ApplicanPs Copy _ . _..._ _ ,.. . _ _.._ , . -:., ._ , . ,: , _ , ,. ,a,:�� � .. ,:: ,.,�::;�: , . m.. ,. . ,,.. . , �.�� a �B�� ,, � �.��� . n . . -'� � ' m .. 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