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HomeMy WebLinkAbout17530 (25) CITY OF DI�MOND BAR �� -----��```--� DEI'ARTMENT OF COMMUNTI'Y&D�VELOPMENT SERVICES � 21825 E.Copley Drive ' (909)860-3195 Fax(909)861-3117 PRESS "'-vn�"��w BUILDINGPERNIITAPPLgCATION FIRMLY o ADDR'ESS J��� Y �'�'r�`��� J�r DATE'CATION ���� NUMBER f���� #'C o ISSUE TYPE OCC `T APN LOT TRACT DATE �� '��� CONST. GROUP � OWNER �i�- O o ZONING SETBACKS OCITY ES� �ZIP TEL. ' � REART RW O o APPLICANT [',���Jj�.- ���'S TE�• SIDE/SIDE STREE7 RW ❑ ¢ CONTRACTOR �.- G/`C._- � SIDE ❑ � CIT`( E S r �-�-- ZIP .� TEL. � PROPOSED USE �� ��'�u""' �"`�� a„� `�� �' �,.9�' �1a--1ie..�._ ���61�,.far- "f� _ �w ARCH/ENG! z DESIGNER NO.DWEL. NO. N . d ADDRESS UNITS STORIES BE�ROOMS � CITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � � OWNER-BUILDER DECLARATION SFR/ADD/REM O p I HEREeV AFFIRM UNDER PENALTY OF PEFiJURY THAT I AM EXEMPT FROM iHE CDNTRACTORS LI- '�i� Garage/Carport � W CENSELAWFORTHEFOLLOWINGREASON(SEC.7o3159USINESSANDPROFES510N5CO0E:ANYCINOR U '(;OUNT'WHICHREOUIRESAPERMITTOCON5TRUCT,ALTER,IMPROVE,�EMOLISH,ORREPAIRANVSTRUC- Iw Py(ID/D2CI( Z TUHE,PRIOR TD ITS ISSUANCE,ALSO REOUIRES THE APPLICANT FOR SIJCH PERMI7 TO FILE A SIGNED 'W W STATEMENT THAT HE OR SHE IS LICENSEO PURSUANT TO THE PROVISIONS OF iHE CONTRACTOftS LI- � �CENSELAW(CHAPTEft9(COMMENCINGWITHSECTION7oo0)OFDIVISION30FTHEBUSINESSANDPftO- 'V' POOVSpB Q� `FESSIONSCD�E)ORTHATHEORSHEISEXEMPTTHEREFROMANDTHEOASISFDRTHEALLEGEDEXEMP- V TION.ANYVIOLATIONOFSECTION7031.5BYANYAPPLICANTFORAPERMI7SUBJECTSTHEAPPLICANTTO �I,Z Re-Roof °.�� � .ACIVILPENAL7V OF NOTMORE THAN FNE HUN�RE��DLLARS(55C0).): _ � ❑I,ASOV/NEROFTHEPROPERN,ORMVEMPLOYEESWITHWAGESASTHEIRSOLECOMPENSATION, '�� Commerciai z ,WILL�O THE WORK,AND THE STRUCTURE IS NOT INTENDE�OR OFFERED FOR SALE(SEC.7a44,BUSI- ',J NE55 pND PROFESSIONS CO�E:THE CONTRACTOFiS LICENSE LAW DOES NOT APPLY T�AN OWNER OF � PROPERTYWH�BUIlD50PiMPFOYESTHEReON,ANDWHO00E55UCHWORKHIMSELFORHERSELFOR �m �' THROIIGH HIS OR HER OWN EMPLOYEES,PROVIDEO iHAT SUCH IMPFiOVEMENTS AflE NOT INTENDED OR QI OFFEREDFOflSALE.IF,HOWEVER,THEBUIIDINGOFiIMPROVEMENTIS50LOW1THINONEYEAROFCOMPLE- Z ,TION,THE OWNER�Bl11L0EF WILL HAVE THE BUPDEN'OF PftOVING THAT HE OR SHE DID NOi Bl11LD OR = IMPROVEFORTHEPURPOSEOFSALE). w � GI,ASOWNEFOFTHEPROPERTV,AMEXCWSIVELVCONTRACTINGWITHLICENSE�CONTFACTORS � � TO CONSTRUGT THE PROJECT(SEC.�D44,BUSINESS AND PROFESSIONS CADE:THE CONTRACTORS U- VBIlIB210f1 *�°' ADJ.AREA W CENSEL4WDOESNOTAPPLVTOANOWNEROFAPflOPERTYWHOBUILD30RiMPROVESTHEflEON,AND � ���WHOCONTRACTSFORSUCHPROJECTSWITHACONTRACTOR(S)LICENSEDPURSUANiTOTHECONTRAG QUANTITY DESCRIPTION FEE , Y �TORSLICENSELAW.). � J � ❑IAM EXEMPT UNDER SEC. B.8 P.Q FOR THIS REASON U �S _ � u' �. DATE_ OWNER F W � LICENSED CONTRACTORS DECLAflATION W CL I HEREBY AFFIRM UNDER PENALN OF PEflJURV THAT IAM LICENSE�UNDEfl PROVISIONS OF CHAPTER � , � 9(COMMENCINGWITHSECTION7aoa)OFDIVISION30FTHEBUSINESSANDPROFESSIONSCO�E,AND , Z `X, MY LICENSE 131N FULL FORCEAND EFFECi m � IICENSE CLASS,�.+�� ��1iC.N0. � � � � � � � DATE �—��� CONTRACTOR � � d LL � WORKERS'COMPENSATION DECLARATION Q = U � I HEREBV AFFIRM UNDER PENALTY OF PERJURY ONE OFTHE FOLLOWING�ECLARATIONs: � Z a �' I HAVE Ah'D WILL MAINTAIN ACERi7FICATE OF CONSENTTO SE�F-INSURE FOFi WORKERS' _ MPENSATION,ASPFOVIDEDBYSECTION37000FTHELABORCODE,FORTHEPERFOftMANCE U Q �[' FTHE WOFK FOR WHICH THIS PEPMIT IS ISSUED. � W: y/\ �y °� HAVE AND WILL MAINTAIN WORKEFS'COMPENSATION INSURANCE,AS PE�l11IiE0 BY SECTION Q'��, 37uOFTHELABOflCODE,FORTHEPERFORMANCEOFTHEWORKFORWHICHTHISPEPMITIS ' �{.�.� y� ISSUED.MYWDRKER�T3'CrO�MP NSATIONINS�l4�6A.N�CE�CARR flANOPOLICYNUMBERAFE: CONSTRUCTION d `! j cpRRiEA�!L�� � �^'�-� PLAN REVIEW Z POLIcvNUMBER_��'�.a '_'" ��I ELECTRIC � (i}iISSECiIONNEmN0T8EOJMREfEDOFhIEPEFlM(fISWflONEHUNDREDDOLLAfiS(5700)ORLESS). PLUMBING d w MECHANICAL Z I CERTIFV THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I (,� SHALL NOT EMPLOY ANY PERSON IN ANV MANNER SOAS TO BECOME SUBJECT TOTHE � WORKERS'COMPENSATIONLAWSOFCALIFORNIA,ANDAGREETHATIFISHOULOBECOME INSPECTIONFEE ��� SUBJECTTOTHEWORKERS'COMPENSAT:ON?ROVISIONSOFSECTION370oOFTHEIABDR �SSUANCE � �'� O, GODE,ISH�AL�O�ITHCOMPLYWRH�i�PROVI510N. Q '� � n B p��. �ATE: � APPLICAYT: �e I��_ V��� SMIP { � w ENERGY P/C J WARNINO:FAILURETOSECURE.WORKERS'COMPENSATIONCOVERAGEISUNLAWFUL,ANDSHALLBE � SUBJECTAN EMPLOYER70 CRIMINAI PENALTIES AND CIVIL FMES UP TO ONE HUNDREDTHOUSAND ENERGY PERMIT ' OOLIARS(5100,OOOJ,IN AD�ITION TO THE C05T 0'r COMPENSATION,DAMAGES AS PROVIDED FOfl IN p�� �� SECTION37o80FTHEL4BORCODE,INTEREST,AN�ATTOaNEY'SFEES. RETENTIONFEE: d ''°"�' � CONSTRUCTlON LENDING AGENCY PRE-ALT FEE: O ' � I HEREBV AFFIRM UNDER PENALTY OF PERJURY THATTHERE IS ACONSTRUCTION LENDING AGENCY � FORTHEPEPFOflMANCEOFTHEWOflKFORWHICHTHISPERMITI5155UE�(SEC.3o9],CIV.C.). � - Z W _. LENOER'S NAME � !_— LENOER'SA�DRE55 � ICERTIFVTHpTIHAVEREADiHISAPPLICATiONANDSTATETHATTHElBOVEINFORMATIONISCOFREGT. TOTAL FEES � b��a�� W IAGP,EE TO COMPLV WIiH ALL CITYAND COUNTY ORDINANCES AND STATE LAWS RFIATING TO BUILDING � CONSTPl1CTI�N,AND HEREBY ALITHORIZE REPRESENTATIVES OFTHIS COUNTYTO ENTER UPON THE ZABOVE-MENTIONEO PROPERTY FOR INSPECTION%1ftPOSES. COMMENTS � "��'.t�A'�. � �G">' !�. �. � MI E NAME( � ���� � � NATURE OF PERMITTE �ATE = RECPT.NO. 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