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HomeMy WebLinkAbout16616 CITY OF I7IAMOND BAR ---�Q` --- DEPARTMENT OF CO1VlMUNTfY&DEVELOPMENT SERVICES � I I � 21825 E.Copley Drive (9U9)860-3195 Fax(909)861-3117 PRESS '°-.�ry�' BUILDING PERMIT APPLICATION FI LY � JOBSITE APPLICATION��y y�, PERMIT P/C o ADDRESu"I°d�� � fi�� ,/��� ,��t�'� DATE W V � NUMBER � # o� ISSUE TYPE OCC AP � TRACT �7�3 C DATE CONST. GROUP °C OWNER � �° ! O "- ADDRESS d "" J y=� ZONING SETBACKS Z CITY ' ZIP ~ TEL. .��[!��.��/� FRONT RW ❑ o APPLICANT ,+�¢°�sJ��,��,.,-a8 TEL. �'eC,t)�-2'��i' REAR ❑ —'--�v� SIDElSI�E STREET RW ❑ Q' CONTRACTOR SIOE ❑ � ADpRESS PROPOSED USE�/���1+"��`' .��d��_ .,�i'�.�� o CITY 21P TEL. e,,ed9'�.��.a.,G� 2�a�d ���'"`�,�.*���� G1� w ARCH/ENG/ z DESIGNER �%�°��0 r�.����.d� 6"s.l�// � ADDRESS NO.DWEL. J NO. NO. � CITY ZIP TEL. UNITS / STORIES %� BEDROOMS � cn � DESCRIPTION SQ.FT: FACTOR PSF ADJ.AREANALUATION � OWNER-BUILDER DECLARATION SFR/ADD/REM � O p I HERE6Y AFFIRM UNDEfl PE�FlALTY OF PEflJURY THAT 1 AM EXEMPT FROM THE CONiRACTORS LI- G8f8CJe/CefpOrt W. CENSELAWFORTHEFOLLOWINGREASON(SEC.7031.5BUSINESSAN�PROFESSIDNSCODE:ANYqTYOR (n U� COUNNWHICHREOUIRESAPERMITTOCCNSTAUCT,ALTEfi,IMPROVE,DEMOLISH,ORREPAIRANYSiRUC- W Petla/DeGk w' TUFE.PRIOR TO ITS ISSUANCE,ALSO RE�UIRES THE APPLICANT FOR SUCH?ERMIT TO FILE A SIGNED W � STATEMENT THAT HE OR SHE IS WCENSED PUPSUANT i0 THE PROVISIONS OF T4E CONiRACiORS LI- ��� CENSE LAW(CHAPTER e(COA�ME CING WITH SECTION�000)OF DIVISION 3 OF THE BUSINESS AN�PRO- � POOI/S(1fl FESSIONSCO�E)ORTHATHEDR HEISE%EMP7THEREFflOMANOTHEBASISFOflTHEALLEGEDEXEMP- � � TION.ANYVIOLATIONOFSECTION 031.5BYANYAPPLICANTFORAPERMITSUBJECT57HEAPPLICANTTO z Re-Roof � F CIVIL PENALTY OF NOT MORE T AN FIVE HUN�RED DOLL4RS(S500J.): � ❑I,ASOWNEROPTHEPROP RTY,ORMYEMPLOYEESWITHSNAGESAS7HEIRSOLECOMPENSATION, � CommefClal -- Z WILL DO THE WOAK,AND THE ST�tUCTURE IS NOT INTENDED OR OFFERED POR SALE(SEC.7D44,BUSI- J � NES5 ANO PROFESSIONS CO�E�I�HE CONTRACTaFS LICENSE LAW�OES NOT APPLV TO AN OWNER OF � PROPERTYWHOBUILDSORIMPRPVESTHEREON,ANDWHO�OESSUCHWORKHIMSELFORHERSELFOR � THROUGHHISOFHEflOWNEMPLI�VEES,PROVIDEOTHATSUCHIMPROVEMENiSAflENOTINTENDE�OR m 0 OFFEHEbFORSALE.IqHOWEVEfl,�rHEBUIL�INOOflIMPROVEMENTISSOLDWiTHINONEYEAROFCOMPLE- Z TION,TryE OWNEF-BUILDER WILL AYE THE BUF�EN OF PPOVING THAT HE OR SHE DID NOT BUILD OR � IMPROV,€FOflTHEPURPOSEOF ALE). I,ASOWNEROFiHEPRO RTY,AMEXCLUSNELYCONTRACTINGWITHLICENSEDCONTRACTORS aa� �'�. TO NSTRUC7 THE PROJECi(S�C.7044,BUSINESS AND PFiOFESSIONS CODE:THE CONTflACTORS�I- ValUation '� o C✓Z� ADJ.AREA W' CENSELAWDOESNOTAPPLVTO,NOWNEROFAPROPERTVWHOBUILDSORIMPROVESTHEREON,AND Z WHOCONTRACTSFORSUCHPROJECTSWITHACONiRACTOR(5)LICENSEOPURSUANTi07HECONTRAC- QUANTITY DESCRIPT�ON FEE � TORS LICENSE LAW.). � � CI i AM EXEMPT UNOER SEC. &9 P.C.FORTHIS REASON Q � U '�- onrE�-- -�` / ¢ OWNEfl � z� � w � LICENSED CONTRACTORS D LARATION W Q Q IHEREBYAFFlRMUNOERPENFLTI'OFPERJURYTHATIAMLICENSEDUN�ERPFOVISIONSOFCHAP7ER � �� 9(COMMENCINGWIiHSECTION7d0a)OFDIVISION30FTHEBUSINESSAN�PFOFESSIONSCODE,AND z LLI MY LICENSE IS IN FULL FORCE ANP EFFECT, m � IICENSE GLA55 LIC.NO. j V DATE � , CONTRACTOR a W d� WORKERS'COMPENSATION DECLARATION Q � IHEREOYAFFIRMUNDERPENALT\'O�PERJURVONEOFTHEFOLLOWWG�ECLARATIONS: z ZI HAVEAND WILLMAINTAIN ACERTIFICA?EOF CONSEN7TO SELF-INSURE FOR WORKERS' _ ¢ COMPENSATION,ASPROJIOE�BVSECTION37ooOFTHELA90RCO�E,FORYHEPERFORMANCE U OF THE WORK FOR WHICH THIS PERMIT IS ISSUE�.� W � � w _I HAUE APID WILL MAINTAIt�WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION Q 370DOfTHELABORCOD�,FORTHEPEtiFORMANCEOFTHEWORKFORWHICHTHISPEfiMIT15 � `_�� ISSUED.MY WORKEAS'CCMPENSATION INSUPANCE CAPRIER AN�POLICV NUAABER AFiE�. CONSTRUCTION J : j cnRAieR � � PLAN REVIEW ZPOLICYNUMBER � ELECTRIC ¢ (�FiISSECTIONNEmNDTBEOJMPLEfEDOFiHEPERMfTISFORONEHUN�RE�DOLLIRS($100)ORLESS). PLUMBING 0 z 1 CERiIFY THAT IN THE PGRFORMANCE OF h1E WOflK FOfl WHICH THIS PERMI'IS ISSUED,I MECHANICAL �' SHALL NOT EMPLOY ANY bEflSON IN ANY MANNER SOAS TO BECOME SUOJECiTO THE � WORKERS'COMPENSATIONLAVdSOFCALIFORNIA,ANDAGFEETHATIFISHOUL�BECOME INSPECTIONFEE ""�•-^-�•.�...._... = SUBJECTTOTHEWDRKEf�S'COMPENSATIONPROVISIONSOPSECTION37ooOPTHELABOR . . W�E,ISHALLFORiHWI1HCOMPLVWITHTHOSEPROVI510N5. ISSUANCE � � � � `- p ' p OATE: ApPLICANT: SMIP 1 J WARNING:FAILURETOSECURE ORKERS'COMPENSATIONCOVERAGEISUNLAWFUL,ANDSHALLBE ENERGYP/C - � � LL SUBJECTANEAIPLOVERTOCRIMNALPENALTIESANDCIVILFMESUPTOONFHl1NDREDTHOUSAN� ENERGVPERMIT " DOLLARS(S1oo,o00),IN ADDITION�IO THE COST OF COMPENSATION,DAMAGES AS PROVI�ED FOR IN J SECTION37oaOFTHELABORCODE,INTE�EST,ANOATTORNEY'SFEES. ��r° f p� i RETENTION FEE: _ � d CO�ISTRUCTION LENDING AGENCY pRE-ALT FEE: `–'�- -'� O � I HEflEBV AFFlRM UNDER PENALTH OF PE.aJUflV THATTHERE IS A CONSTPUCTION LENOING AGENCY FOF THE PERFORMANCE OF 1'HE HJDRK PoR WHICH THIS PEflMIT IS ISSUED(SEC.309'!,CIV.C.�. . Z W � LEN�ER'SNAME F-' LENDER'SADDRESS ��. � TOTAL FEES � I CERTIFY THAT I HAVE READ THIS�APPLICATION AND STATE THAT iH�ABOVE MFORMATION IS CORRECT. �� � IAGREETOCOMPLVWITHALLCI7YANOCWNTYOR�INANCESANDSTAiELAWSRELATiNGTOBUILDING � CONSTFUGTION,ANDHEREBYAIJ,THORIZEREPRES"cNTATIVESOFTHISCOINTYTOENTERUPONTHE Z ABOVE�MENTIONEDPROPERTYFpRINSPECTiONPURPOSES. 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