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HomeMy WebLinkAbout17310 (10) � _ CITY OF DIAM�ND BAR � I I � DEPARTR�IEN�'�F COMMIJPIITY&DEVELOPMENT SERVICES 21825 E.Copley Drive ' -`'" (909}800-3195 Fax(909)861-3117 PRESS "'°%vri»'� BUILDIN�PERNYITAPPLICATION FIR LY � JOBSITE -��E-� � APPLlCATION�:� � PERMIT �� � P/C o ADDRESS DATE NUMBER # o� ISSUE TYPE OCC .- APN LOT TRACT DATE � CONST. GROUP � OWNER O "- ADDRESS''' � � ZONING SETBACKS oCITY�$�r2�i� ZIP .i ✓"G� TEL. FRONT RW ❑ APPLICANT TEL. REAR ❑ � SI�E/SIDE STREET RW ❑ ¢ � CONTRACTO .i-'�''�- SIDE ❑ � RDDRES � s � PROPOSED USE � CITY ZIP�Z� TEL. � � o ARCH/ENG/ � iz DESIGNER NO.DWEL. NO. O. a ADDRESS UNITS BTORIES BEDROOMS � CITY ZIP TEL. � �ESCRIPTION Sa.FT. FACTOR PSF ADJ.AREANALUATION � ,� OWNER-BUILDER DECLARATION SFRlADD/REM � O �0 I HEREBV AFFIRM UNDER PENALTY OF PEflJUflY THAT I AM EXEMPT FFOM THE CONTRACTOflS LI- � Garage/Carport W CENSELAWFORTHEFOLLOWINGAEASON(SEC,7031.50USINESSAN�PROFESSIONSCODE:ANYCITYOFi U COUNTVYJHICHREOUIRESAPERMITTOCONSTRUCT,ALTER.IMPROVE,DEMOLISH,ORREPAIRANYSTFUC- W PaUo/DeCk 'W TUqE.PFiIOR TD.ITS ISSUANCE,AL50 REOl11RES THE APPLICANT FOR SUCH PEFMIT TO FILE A SIGNE� W � STATEMENT THAT HE OR SHE IS�ICENSED 7URSUANT TO?HE PPOVISIONS OF THE CONTRACTORS ll- � CENSE LAW(CFIAPTEP 9(COMMEAICING WITH SECTION 7000)OF OIVISION 3 OF THE BUSINESSAN�PRO- LL' POOUSPe FESSIONS CODE)OR THAT HE Ofl SHE IS EXEMPT THEREFROM AN�THE BASIS FOR THE ALLEOED EXEMP- � TIDN.ANYVIOLATpNOFSECTION�;7o3t.56YANYAPPLICANTFORAPEftMiTS'J9JECTSTHEAPPLICANTTO Z Re-Root � ACIVILPENALTYOFNOTMOREiHANFIVEHUNDREDDOLLARS(E500).J: � ❑I.ASOWNEROFTHEPROPERTY,pRMVEMPLAYEESWITHYJAGESASTHEIRSOLECOMPENSATION, � COmmefCial - Z WILL�O TH�WORK,AN�THE STRl1CTl1RE I$NOT INTENDED OR OFFEREO FOR SALE(SEC.7044,BUSI- _I NESS ANO PROFESSIONS CODE:THE CONTF7A^TORS LICENSE LAW DOES NOT APPLV i0 AN OWNER OF . '� PROPERTYWHOBUILUSORIMPFOVESTHEREON,ANOWHODOESSUCHWORKHIMSELF�RHERSELFOR � '[[ THROUGHHISORHEROWNEMPI,OYEES,PPOVIDEDTHATSUCHIMPROVEMENTSARENOTINTENOE�OR m � OFFEREDFORSAIEIF,HOWEVER,THEBUIL�iNGORIMPftOVEMENTI55OLDWITHINONEYEAROFCOMPIF- Z. TIDN,THE OWNER-BUILDER WILL��HAVE�THE BURDFN OF PROVING TMAT HE OR SHE DID NOT BUIL�OR = IMPROVE FOR THE PURPOSE OF SALE)., ❑I,ASOWNER OFTHE PROPER7Y,��AM EXCWSIVELY COMRACTMG WITH LICF.NSE�CONTRACiOftS � TO CANSTRUCT THE PROJEC7(S�C.706C,BUSINESS AND PROFESSI6N5 CODE�.THE COtJrRACTORS LI- VHIU8Il0l1 ADJ.AREA W CENSELAWDOESNOiAPPIVTOANOMNEROFAPROPERTVWN06UILD50RIMPROVESTHEREON,AND �. WHOCONTflACTSFORSUCHPROJECT$WITHACONiRACTOF�SJLICENSEDPUR&UANTTOTHECONTRAC- QUANTIN DESCRIPTION FEE Y, TORS LICENSE LAW.). �. � ❑1 AM EXEMPT UNDER SEC. B.8 P.C.FOR THIS REASON � � � � DATE OWNEfl U z W � LICENSED CONTRACTORS DECLARATION � ¢ Q� IHEREBYAFFIAMUNDERPENALTYOFPERJURYTHqT1AMLICENSEDUNDERPROVI510N50FCHAPTER � d. 9(COMldENqNGWIiHSECTION7o0o)OFDIVISION30FTHEBUSINESSANDP(lOFESSIONSCO�E,AND z X MV LICENSE IS IN FULL FORCE AND EFFECT � I.ICENSE yCL'���SS�`�9,P � r LIC.NO. �O�� � j V DATE �'� ""'�����./ CONTRACTOR _ � a W � WORKERS"COMPENSATION DECLARATION � -� ¢ � U � I HEflEBYAFFIRM UNDER PEhALTY OF PERJURY ONE OFTHE FOLLOWING�ECLARATIONS: Z Q � I NAVE AND WILL MAINTAIN A C6RTIFICATE OF CONSENTTO SELF-INSURE FCR WORKERS' 2 COMPENSATION,ASPROyIDED'�iBVSECTION37ooOFTHELABORCO�E,FORTHEPERFORMANCE U Q OF THE WOPK FOR WHICH THI$PERMIT IS ISSUE�. � � w _IHAVEANDWILIMAMTAINWOFKERS'COMPENSATIONINSURANCE,ASREQUIREDBYSECTION ��� yyy�/'qy� Q 3700 OF THE LAB R CODE,FO THE PEFFOFMANCE OF 7H WORK FOR WHICH THIS PERMIT IS � ` � � ;{ o ISSUEO.MY WO S'� SATION INSU NCE CARRI q AND POLICY NUMBEFiARE: CONSTRUCTION ar J � CARRIE PLAN REVIEW Z POLICV NUMBER I ELECTRIC Q � (iliIS5ECT10NNEmNOTBEO�MPLEIEDOFTHEPERMfrISFORIX.EHUl�RE�DOIJ.ARS($700)ORLESS). PLUMBING LL � ICERTIFYTHATINTHEPERFOf�MANCEOFTHE'NORKFORWHIGHTHISPERMITISISSUED,I MECHANICAL (,'} SHPLLNOTEMPLOYANYPEHSbNINANYMANNER50AST09ECOME5U6JECTTOTHE � WORKERS'COMPENSATIPNLAYJSOFCNLIFORNIA,ANDAGREETHATIFISHOUL�BECOME �NSPECTIONFEE SUBJEC7 TO iHE WORKEAS'CbMPcNSAT10N PflOVISIONS OF SECTION 3700 OF THE LABOR "�— � CO�E,ISHALLFOPTHWITHCOMPLVWIiHTHOSEPROVISIONS. ISSUANCE �y Y � �. ' SMIP • �d� p DATE: APPLIbANT. � WAFNINGFAIWRETOSFCl1REVyORKERS'COMPENSATIONCOVERAGEISUNLAWFUL.ANDSHALLBE ENERGYP/C � SVBJECTANEMPLOYERTOCRIMINAIPENALTIESANDCIVILFINESUPTOONEHUNORE�THDUSAND ENERGYPERMIT } DOLLARS(E1oD.00O),INADDI710NITOTHECOSTOFCOMPEM1SATION,DAMAGESASPROVIDEDFORIN ��. J SECTION3ioBOFTHELABORCODE,INRER=ST,ANDATTORNEY'SFEES. RETENTIONFEE: � d CONST;RUCTION LENDING AGENCY PRE-ALT FEE: O � IHEREBYAFFIRMUN�ERPENALTYOFPERJURYTHATTHEREISACONSTRUCTIONLENDINGAGENCY FOR THE PERFORMANGE OF THE WOFk FOR WHICN THIS PERMIT IS ISSVEO(SEC.3091,CIV.C.). . 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