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HomeMy WebLinkAbout16885 (40) CITS'OF D�M�ND BAR ` - -�'�`' -- DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES I I � 21825 E.Copley Drive " � ' '~`" � (909)860-3195 Fsx(909)86P-3117 PRES$ \'yN���'' �iJILDINGPERMI'�APPLICATION FIRMLY � JOBSITE / �� DAPEICATION PUMBER ����� #/C o ADDRESS�!� -�� ��1� � �� � �-" o ISSUE TYPE OCC °-° APN LQT TRACT DATE CONST. GROUP p OWNER I�e3�'16�JAI�"� �s %'�Ic:���'S �s ADDRESS `� �� '� ��c�'In %c� � E�� ZONING SETBACKS OCITY ,��'t���' ZIP '���� � TEL.�'9" ��"� � FRONT RW ❑ APPLICANT TEL. REAR ❑ � SIDE/SIDE STREET RW ❑ z ¢ CONTRACTOR Sl�E ❑ � ,ADDRESS � .,, � CITY ZlP TEL. PROPOSED USE o ARCH/ENG/ r iz DESIGNER NO.DWEL. O. NO. � ADDRESS UNITS STORIES BEDROOMS = CITY ZIP TEL. � �ESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-BUILDER DECLARATION SFR/ADDlFEM O � I HEftEBY AFFIRM UNDEfl P�IALTY OF PERJUHV THAT 1 AM EXEMPT FROM THE CONiRACTORS LI- � Garage/Carport W � CENSELAWFORTHEFOLLOWINGREASON(SEC.7u31.5BUSINESSAN�?ROPESSIONSCODE:ANYqTYOR CJ COUNTYWHICHREOUIRESAPERMITTOCONSTRUCT.ALTER,IMPROVE,DEMOLISH.ORREPAIRANYSiRUC- W Patio/DOCk Z. TUFE,PRIOR TO ITS ISSUANCE,ALSO REQUIRES YHE APPLICANT FOR SUCH PERMIT TO FlLE A SIGNE� w STATEMENT THM1T HE Oq SHE IS LICENSE�PURSUANT TO 7HE PROVISIONS OF T4E CONiRAC70RS LI- W � CENSE LAW(CHAPTER 9(COMMEt�CING WI7H SECTIDN 7000)OF DIVISION 3 OF THE BUSWESS ANO PRO- � PooUSpa � FESSIONS CODE)Oft THAT HE OR$HE IS E%EMPT THEREFROM ANO THE BA515 FOfl THE ALLEGED EXEMP- O TION.ANVVIOLATIONOFSECTION7a31.5BYANYAPPLICANTFORAPERMIT5U8JECTS7HEAPPLICANTTO Z RB•RODf � ACIVIL PENALN OF NOT MORE THAN FIVE HUN�R'eD DOLLARS(S5oaJ.): � ❑I,ASDWNEROFTHEPROPEPTY,ORMYEMPLOYEESWITHYJAGESASTHEIRSOLECOMPENSATION, ❑ CofnrllefCi81 -� Z. WILL DO THE WOAK,AN�THE STfiUCTURE IS NOT INTE��E�OR�FFERED FOR SALE(SEC.7�44,Bl1Sl- �J NESS ANO PROFESSIONS CADE:THE CONTRACTOFS LICENSE LAW OOES NOT APPLV TO AN OWNER OF �� PROPERTYWHOBUILDSORIMPRDVESiHEREON,ANDWHODOESSUCHWORKHIMSELFORHERSELFOR � �, TMROUGHHISORHEPOWNEMPLbYEES,PROVIDEOTHATSUCHIMPROVEMENiSAflENOT1NTENDE�OR m 0,, DFFEHEDFORSALE.IF,HOWEVER,;YHEBUILDINGOHIMPROYEMENTISSOLDIMTHINONEYEAflOFCOMPLE- Z, TION,THE OWNER-BUILDER WILL NAVE i HE BUflOEN OF PROVING THAT HE OR SHE DID NOT BUIID OR �; IMPROVEFORTHEPURPOSEOF�ALE). W^ ❑4ASOWNEROFTHEPROP RTY.AMEXCLUSNELVCONTRACTINGWITHLICENSEDCONTRACTORS .��. TO CANSTRUCT THE PROJECi(SEC.7064,BIJSMESS ANO PROFESSIONS CODE:THE CONTRACTORS LI- V3IU2l�lOf1 ADJ.AREA W�'�, CENSELAWDOESNOTAPPLVTOANOVTIEROFAPROPERTVWHOBUILDSORIMPROYESTHEREON,AND ,�, WHOCONTRACTSFORSUCHPRO,fECTSNITHACONiRACTOR(5)UCENSEOPURSUAN770THECONiRAF QUANTITY DESCRIPTION FEE � �" TOqS LICENSE LAW.). CC. Q �� ❑I AM EXEMPT UNDER SEC.�, B.&P.C.FOR THIS REA50N � C� U , LL' OATE � � OWNEFl ��x'�:���� J E � �f�� U . Z ' W ��. �. LICENSED CONTRACTORS DECLARATION W - � IHEREBYAFFIRMUN�ERPENALTY OFPERJl1RYTHATIAMLICENSEOUNDERPROVISI0N50PCHAPTER � � d� 9(COMMENCINGWITH.SECTION7000)OFDIVISION30FTHEBUSINESSANDPP,OFESSIONSCODE,AN� Z X MY LICENSE IS IN FULL'FORCE ANb EFFECT. W' � ��,, � LICENSECLASS , LIC.NO. � J � �. U� DATE CONTRACTOR _____.___._____._. a W � WORKERS'COMPENSATION DECLARATION -� ¢ � IHEREBYAFFIRMUNOEf1PENAlT�'OFPERJURYONEOFTHEFOLLOWINGDEaARRT10N5: Z z IHAYEAI�WILLMAIN7AIM1�ACERTIFICATEOFCONSENTTOSELF-INSUREFORWORKERS' 2 CAMPENSATION,ASPROVI�EDBYSECTION3�ooOFTHELABORCODE,FORTHEPERFORMANCE U ¢ OFTHE WOflK FOR WHICH THIS PERMIT I5155UE�. � �. W� I HAVE AND WILL MAINTAII�WOFKERS'COMPENSATIDN INSURANCE,AS RE4UIRED BY SECTION Q 370o OF iHE LABOR COD�,FORTHE PERFORMANCE OFTHE WORK FOP WHICH THIS PERMIT IS ISSUED.MY WORKERS'COMPENSATION INSURANCE CARRIERAND POLICV NUMBEfiARE: CONSTRUCTION Q > CARRIFA PLAN REVIEW ZPOUGYNUMBER ' ELECTRIC ¢ Q (fHISSECTIONNEmNOTB�COMPLEfE00F11-EPERMITISFORONEHUNDREDDOLL4RS(5100)QRLESS). PLUMBING . .....__���--�--� Z�, I CERTIFV THAT iN iHE P IRFORMANCE OF THE WOftK FOft WHICH THIS PEftMIT I5 155UED,l MECHANICAL{- - ' •—a"'S'B (}� SHALL NOT EMPLDYANY�ER50N IN ANY MA�NER SOAS TO BECOME SU&IECT TO THE g " � WORKERS'COMPENSATIONLAWSOFCAL1FOFiNIA,ANJAGREETHATIFISHOULDBECOME INS?ECTIONFEE _ SlJ9JECT TO THE WOFKEI75'COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR � � CODE,ISHALLFORTHWIi�FICOMPLYWITHTHOSEPROVISIONS. �SSIIANCE � (�� ------���y�� � SMIP �� I I�I-�J �1 � �lJ4 —=� p DA7E: Ah'PLIGANP. �� —g�-�—v-- J I ENERGY P/C I� � � J WARNING:FAILURETOSECUREI"rORKERS'COMPENSATIONCDVERAGEISLINLAWFUL,ANDSHALLBE '�,` �—y SV6JECTANEMPLOYEFTOCRIMNALPENALTIESANDCIVILFMESUPTOONEHUNDREDTHOUSAN� ENERGYPERMI� � I I \�i'f�(�� Z fi '} �OLLARS(51oo,aoaJ,IN ADDI110N O THE COST OF COMPENSATION,DAMAGES AS PROVIDE�FOR IN �—�.�, )� J� SEGTION3lo80FTHELABORCO E,INTEREST,AN�ATTOqNEY'SFEES. RETENTIONFE : ! �'� CO STRUCTION LENDING AGENCY PRE-ALT FEE: O I � IHEREBYAFFIRMUN�ERPENALiIY�FPERJURYTHATT4EREISACONSiRUCTIONLENDIN0A0ENCY FOq THE PEFFORMANCE OF THEIYJORK FOR WHICH THIS PEflMIT IS ISSUED(SEC.309],GIV.G.). . � I.IJ j LENOER'S NAME � F� LEN�ER'SA�DRE55 W ICEflTIFYTHAiIHAVEREADiHI$APPLICqiIONANDSTATETHATTHEABOVEMFORMATIONISCORRECT. TOTAL FEES ���a � I AGREE TO GOMPLY WITH ALL CI Y AN�COUNiY ORDINANCES PND STATE LAWS RELATING TO 6UIL�ING � CONSTAUC710N,ANDHEREBVA THORIZEREPRESEN7A71VESOFTHISCOUN7YTOcNTERUPONTHE _ �. ABOVEMENTIONED PROPERTY FOR INSPECTIdN PURPOSES. 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