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HomeMy WebLinkAbout17270 (50) CITY OF D[AMOND BAR - - �' DEPARTMENT OF COMMUNTTI'&DEVELOPMENT SERVICES � 21825 E.Copley Drive (909)860-3195 Fa�c(909)861-3117 PRESS ''%ti�»' BUILDINGFERIMITAPPLICATIUN FIRMLY � JOBSITE APPLICATION PERMIT ,+ P/C Q ADDRESS,� R--- DATE �' � NUMBER �,� # o ISSUE TYPE OCC °--° APN LOT T CT_ DATE CONST. GROUP � OWNER O " ADDR SS ZONING SETBACKS Z CITY ZIP TEL. � FRONT RW ❑ � APP CAN7 TEL. flEAR ❑ o SIDE/SIDE STREET RW ❑ a CONTRACT SIDE G � ADDR — PROP S�D U� o CI �_ 21 TEL. ' D,S��r 4 wo ARCH/ENG/ w DESIGNER NO.DWEL. N . . � a ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � � OWNER-BUILDER�ECLARATION SFR/ADD/REM O p I HEREBY AFFIRM UNDER PENALTY OF PEfWURY THHT�.AM EXEMPT FFOM THE CONTRACTORS LI� Gg�3gB/CBRJOn W CENSELAWFORTHEFOLLOWINGFEASON(SEC.7037.58USINESSANDPROFESSIONSCODE:ANVCITYOR (f� U COUNTYWHICHREOUIRESAPERMITTOCONSTRUCT,AI?ER,IMPROVE,DEMO�ISH,ORREPAIRANVSiRUC- W patio�Deck w 7URE.PRIOR TO ITS ISSVANCE,ALSO RE�UIRES TNE APPLICANT FOR SUCH PERMITTO FILE A SIGNED W � SiATEMENi THAT HE OR SHE IS LICENSED PURSUANT TO THE PPON�'SIONS OF THE CON7RACTORS U- � CENSE LAW�CHAPTER 9(COMMENCING WITH SECTION 1o00)OF DIVISION 3 OF THE B1151NES5 ANO PRO- � POOUSpa 0 FESSIOIi5CO0E)ORTHATHEOPSHEISE%EMPTTHEREFROMANOTHEBASISFOflTHEALLEGEDEXEMP- V iION.ANYVIOLATIONOFSECT10N703t.5BVANVAPPLICANTFORAPERMITSl1BJECTSiHEAPPLICANT70 z qe-ROOY � � ACIVILPENALT'/OFNOTMORETHANFIVEHUNDREDOOlURS(E500�.): � pI,ASOWNEROFTHEPROPEPTV,ORMVEMPLOVEESWITHWAGESASTHEIP50LECOMPENSATION, � COrt1MBfC18I Z WILLDO THE WORK,ANO THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SA'_E�SEC,7044,BUSI- J NESS AND PROFESSIONS COOE:THE CONTRACTORS LICENSE I AW DOES NOT APPLV TO AN ONMEfl OF � PROPERNWHOBUILDSORIMPROVESTHEREON,ANDWHODOESSUCHWORKHIMSELFORHERSELFOR � [[ THROUGHHISORHEROWNEMPLOVEES,PROVIDEDTHATSUCHIMPROVEMEh'TSARENOTINTEN�EDDF m W OFFEREDFORSALE.IF,HOWNER,hIE9UIlDINGORIMPROVEMEN715SOLDNATHINONEYEAROFCOMPLE- Z TION,THE OWNER-9UILDER WILL NAVE THE 9URDEN OF PRDVING TFIAT HE OR SHE�IO NOT BUILD OR = IMVPOVEFORTHEPURPOSEOFSALE). ❑I,AS OWNEROF THE PROPERTY,AM EXCW SNELY CONTRACTING WITH LICENSE�GONTR0.CTOR5 � TO CONSTRUCT THE PROJECT(SEC.7044,BUSINE55 AND PROFESSIONS CODE THE CONTRACTORS LI� ValUd�iOn ADJ.AFiEA W CENSELAWDOESNOTAPPLYTOANOWNEROFAPROPEflTYWM06UILDSOflIMPflOVESTNEREON,AND � WHOCONTPACTSFORSUCHPROJECTSW1IHACONTRACTOR(5!UCENSEDPl1R5UANTTOTHECONTRAG QUANTITY DESCRIPTION FEE Y TORS L�CENSE UW�. � J O ❑I AM EXEMPT UN�ER SEC. B.d P.C.fOR 7HI5 REASON U � Q � OATE OWNER . � V W � LICENSED CONTRACTORS�ECLARATION i j � I HEREBV AFFIRM UNDER PENALTY OF PERJt1RY THAT I AM UCENSED UNOER PROVISIONS OF CHA7TER � d e(COMMENCMG WITH SECTION]000)OF DNISION 3 OF THE BUSIN'c55 AND PROFESSIONS COOE,AND Z 'X MV LICENSE IS W FULL FORCE ANO EFFECT. m � � � LICENSE CLASS LIC.NO, �� J U �ATE "` CONTf7ACT0 a W � WORKERS'COMPENSATION�ECLARATION ¢ � U � I HERcB�AFFIRM UNDER PENALN OF PERJURY ONE OF THE iOLLOWiNG DECLARATIONS: U� Q 0 IHAVEAN�WILLMAMTAINACERTIFICATEOFCONSENTTOSELF-INSUREFOflWORKERS' _ COMPENSATION,ASPROVIDEDBYSECTION370oOFTHEIABORCODE,FORTHEPE9FORMANCE U Q OF THE WORK FOR WHICH THIS PERMIT IS ISSUEO. � O W _IHAVEAN�WIIIMAINTAINWORNERS'COMPENSATIONINSURANCE,ASREaIJIRE�eVSECTIDN j ///���/// Q 37oa OFTHE LABOR C��E,FORTHE PERFOFMANCE OFTHE WORK FOR WHICHTN�S PERMIT IS �n� ISSUED.MYWORKERS' OMPENSAT'�ONINSUPANCECARRIEFAN�POLICYNUM1IBERARE: CONSTRUCTION v j CARRIER � a- �ye� PLAN REVIEW Z POLICV NUMBER .._� ELECTRIC Q � (iHI55EGTKKJNEmN078EOJMPLEfEDOFhfEPERPMISFORONEHUJDFiE�DOUARS(£7001�RLESS). PLUMBING Z I CEPTIFVTHAT IN THE�EFFORMANGE OFTFIE W'ORK FGF WHIGHTHIS PERMIT IS ISSUED,I MECHANICAL r � SHALLNOTEMPLOVANVPERSONINANYMANNERSOASTOBECOMESU&lEC7TOTHE (/] WORKERS'COMPENSATIONUWSOFCALIFORNIA,ANDAGREETHATIFISHOULCBECOME �NSPECTIONFEE ��+ SUBJECTTO THE WORNERS'COMPENSATION PROVISIONS OF SFCTION 370o OF THE LAEOR ~ CODE.I SH0.LL FOFTHWITH COMPLY WITH TMOSE PROVISIONS. ISSUANCE � DATE: APPLICANT: _ SMIP • �� w ENERGV P/C J WARNINGFAILURETOSECUREWORKERS'COMPEI.'SATIONCOVERAGEISUNLAWFUL,ANDSHALLBE J SU&IECTqNEMPLOYERTOCRIMINALPENALTIESANOCNILFINESUPTOONEHUNDREDTHOUSAN� � DOLLARS�51oo,000),INAODITIONTOTHECOSTOFCOIAPENSATION,�AMAGESASPRDVIDEDFORIN ENERGYPERMIT J SECTION37080FTHELFBORCODE,INTEREST,ANDAITORNEYSFEES. RETENTIONFEE: � d CONSTRUCTION LENDING AGENCV PRE-ALT FEE: Q I HEREBV AFFIRM UNOER PENALTV OF PERJURY THA7 THERE IS A�ONSTRI.CTION LENDING AGENCV � FOR THE PERFORMANCEOF THE WORH FOR WHICH THIS PEPMI715ISSUED(SEC.3o9J,CIV C.�. Z W �Z LENDER'S NAME � F_- LENDER'S ADDRES$ _ Jr G..J � ICERTIfYTHATIHAVEREADTHISAPPLICATIONAN�STATETHATTHEABOVEINFORMATIONISCORRECT TUTALFEES /71e, � W I AGREE TO COMPLY W1TH ALL CITV AN�COUNTY OROLNANCES AND STATE LAWS RELATING TO BUILpING � CONSTRUCTION,ANDHEREBVAUTHORIZEREPRESENTATNESaFTHISCOUNTVTOENTERl1PONTHE ZABOVE�MENTI D PROPERTY FOft INSPECTION PUFiPO5E5. COMMENTS � �! ! 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