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HomeMy WebLinkAbout16669 (39) � � CITY OF DTAMOND BAR ��� "+ ---��-- DEPARTIvi�NT OF COIvLA�1UNTfY&DEVELOPMENT SERVICES f I , N 21825 E.Copley Dri�e �` (909)860-3195 Fax(909)861-3147 PRESS '-»�'"' ' BUILDING PERMIT APPLICATION FIR Y � JOBSI7E _`� APPLICATION PERMIT �f�� P/C o ADDRESSL:�`-�� ' DATE - � � NUMBER l # � __.-...-. ISS UE TYPE OCC APN---���� LOT TR�T'L,� DATE CONST. GROUP °C OWNER 1��M. ��'y 1�' OO ADDRESS ZONING SETBACKS z CITY ZIP TE `� � FRONT RW ❑ 0 APPLICANT TEL. � S DE/SIDE STREET RW ❑ Z Q CONTRACTOR_ SIDE ❑ � ADDRESS �„„.. � GITY ZIP TEL. PROPOSED USE �w ARCH/ENG/ z DESIGNER W — NO.DWEL. N � NO. a ADDRESS UNITS ST IES BEDFi00MS � CITY ZIP TEL. ' � pESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER DECLARATION SFRlADD/REM � � � O 0 I HEREBY AF�IRM UNDER PENALTY OF PERJUpY THAT I AM EXEMPT FROM iHE CONiFACTORS LI- � Gaf2ge/CafPoff W �CENSELAWFORTHEFOLLOWING',flEASON�SEC.]031.5BUSINESSANDPROFESSIONSCODEANVCITYOR 2U COUNTYWHICHREOUIPESAPERMITTOCONSTRUCT.ALTER�h�PROVE,DEMOUSH.OflREPAIRANYSiRUG W PgSiO/DeCK TURE.PRIOR TO 175 ISSUANLE,AL50 RE�UIRES THE APPLICANT�FOP SUCH PERMIT TO FILE A SIGNED W �STFTEMIENT THAT HE OR SHE IS�LICENSE�Pt1RSUANT TO THE PROVISIONS OF iHE CONiRACiDRS LI- � � ,CENSE LAW(CHAPTER 9(COMMENCING WI7H SECTION 7oaa)OF DIVISION 3 OF THE BUSMESSANO PRO- � POOUSpO ,FESSIONSCODE)ORTHATHEORSHEISEXEMPTTHEREFROMANDTHEBASISFORTHEALLEGEOE%EMP- (� . V 'TON.ANVVIOLATIONOFSECTION�031.5BYANVAPPLfCANTFOFAPERMITSUBJECTSiHEAPPLICANTiO z Re-Roof ' r ACINLPENPLTYOFNOTMOflETNANFIYEHUN�REDOOLLARS(SSo�)): ❑I.NSOWNEROFTHEPROP�RN.ORMYEMPLDYEESWITH_WAGESASiHEIR50LEWMPENSATION, �� Commercial � �.WILL 00 THE WORK,AND iHE STRUC7URE�S NOi INiENDEO OR OFFERED FOR SALE(SEC.7044,BUSb J � �� �'�.NE55 AND PROFESSIONS CODE:TVIE CONTRACTORS LICENSE LAW DOES NOTAPPLY 70 AN OWNER OF � �,PROPERTY WHO BUI40S OR IMPROVES THEREON.AND WHO DOES SUCH WORK HIMSELF OA HEPSELFOR � '�.THROUGHHISORHEROWNEMPLOYEES,PFOVIDEDTHA7SUCHIMPROVEMENTSARENOiIN7ENDE�OR m W ��OFFERE�FORSALEIF,HOWEVEH,IiHEBUIL�INGOflIMPROVEMENTI550L�WITHINONEYFAROFCDMPLE � :!TION,TNE OWNEfl-BUILDER WILL}fAYE YHE BURDEN OF PROVING iHAT HE OF SHE DI�NOT BUI�O OR � :��,IMPROVEFORTNEPURPOSEOFBALE).� , W ❑I,ASOWNEROFTHEPROP�RTY,AMEXCLUSIVEIYCONTRACTMGWIiHLICENSEDCONTRACTORS . [L', ,TO CANSTflUCT THE PROJECT(SEC.7044,BUSINESS ANO PROFESSIONS CO�E:iHE CO�YTRACTORS LI� VaIUdS10f1 ADJ.AREA - W ;CENSELAWDOESNOTAPPLYTOANOWNEROFAPflOPEflTYWH06UILDSORIAAPROVESTNEREON.AND - �. WHOCONTRACTSFORSUCHPROJ,ECTSWITHACON7RACTOR(S)LICENSeDPl1R5UANiTOTHECONTRAG QUANTITY DESCRIPTION FEE TORS LICENSE LAW.). � J C. j,� Q ❑IAM EXEMPTl1NDERSEC. B.&P.G FORTHIS REASmJ 1°� � ! V" DATE OW � UC�NSED CONTRACTORS DECLARATION W . � I HEREBYAFFIRM UNOER PcNPLTY'�.OF PERJURY 7HA71AM LCENSED LINDER PROVISIONS OFCHAPiEF � , d, 9(COMMENCINGWITNSECilON7000)OFDIVISION30FTHE6USINESSANDPROFESSIONSCODE,AND Z �X MYLICENSEISINFULLfOHCEANCjEFFECT_ m � LICENSE CLASS LIC.NO. j � J V �A7E CONTRACTOR � W � WORKERS'COMPENSATION DECLARATION Q � IHEREBYAFFIRMl1NDERPENALTYk]FPCRJURVONEOFTHEFOLLOV✓ING�ECLAflAipNS: Z O _IHAVEAN�WILLMAWTAINACERTIFlCATEOFCONSENiTOSELF-INSUREFORWORKERS' _ C CDMPENSATION,AS PROVIQm 0V SECTIDN 3/�o OF THE LABOA CO�E,FOR THE PERFORMANCE U Q OFTHE WORK F�N WMCH THIS PERMIT IS ISSUE�. g � W _IHAVEANDWILLMAINTAINV/ORKER5COMPENSATIONINSURANCE.ASRE�UIREDBYSECTION ��w,✓' Q 3�OOOFTHELA90RCO0E,FORTFiEPEflFORNANCEOFTHEWOflKFOFWHICHTHISPERMITIS �� ISSIIE�.MVWORKEA5'COMPENSATIONINSl1FNNCECARRIERANOPOLIGVNl1MBERARE: CONSTRUCTION . ���� J y cnaaieq � � PLAN AEVIEW 0 POLICY NUMBER ' ELECTRIC r Z Q � (iHI55ECTIIXJNEmN076ECOMRETE�OFTHEP6dJf�4SFORONEHJN']RE�OOLtARS(£100)ORLESS�. PWMBING Z� I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSl1ED,I MECHANICAL _._._ ('3 SHALLNOTElAPLOVANYPERSONINANYMANNERSOASTOBECDME5UBJECTTOTHE � WORKERS'COMPENSATIONtAW50FCALIFORNIA,AN�AGREETHATIFISHOULDBEC0IAE �NSPECTIONFE SUBJECiTO THE WORK=RS!COMPENSATION PROVISIONS OF SECTION 3l0o OF THE LABOR �� CODE,I SHAILFORTHWITH COMPLY WITHTHOSE PROVISIONS. ISSUANCE ��_ �=' �� SMIP �. .rµ. ' p. DAlE APPLICANT. �p ; �'� ' ENERGYP/C �' C1 j 7�,'j ` J�, WARNING;FAILURETOSECUREWOR�KER6'COMPENSATIONCOVERAGEISUNLAWFUL,ANDSHALLBE w�� SUBJECTANEMPLOVERTOCRIMINAIPENALTIESANOCIVILFINESUPTOONEHUNOREDiHOUSANO ENERGYPERMIT � '� �OLLAFlS(5100,�00),INAOOIiIONTOITHECOSTOFCOMPENSATION,DAMAGESASPROVI�E�FORIN � ' J.�' 5ECTION3�08OFTHELA90RCO�E,IN7EREST.ANpATTORNEV'5FEE5. RETENTIONFE � � � , . r aamn�.� d CONSTRUCTION LENDING AGENCY PRE-ALT FEE: ° . .. N � . . ---�--�_.'—._-..____=-... � I HEPEBVAFFIRM UNpER PENALTY OF PERJLJFY THAT iHERE IS A CONSTFLICTION LENDING AGENCY FOR 7HE PERFORMANCE OF iHE WdRK FOR WHICH THIS PERMI715 ISSUEO(SEC.3097,CI V.C.), . Z W ' ' � LENDER'S NAME F-- LEN�ER'S AODRESS � � TOTAL FEES � .ICERTIFYTHATIHAVEREADTHISAP('LICATIONANDSiATETNATiHEABOVEINFORMATiONISCORPEGT. � a� W .IAGREETOC�MPLYWI7HALLCITYAN�COUNTYOflDINANCE5AND5TATElAWSRELATIN0T06UILDING �w i' � CONSTflUC710N,ANDHEFEBYAU7HORIZEflEPRESENTATNE50FTHISCOUNTV70ENTERUPONTHE z ��AdOVE�MENTIONED PROPERiV FOR IN ECTION PURPOSES. COMMENTS � �1 i� m - RMI E IN � ��.: � ' � . � � GNAUitEOFPER , �'. � E r � Z � RECPT.NO. P PAID BY. VALI�ATION ~ WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—ApplicanYs Copy _ � . . . ...:, . . ._. _.,..�_„ `-'-: prv.'..'..,: .*K;,''.,�,'4y�,':_" .,�„'f: _. - ' � . , . � ... #; { A t .sw,��". �.€ 'F. 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