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HomeMy WebLinkAbout17452 (23) CITY OF DIAMONL?BAR , ----��`" --- DEPARTMEI+tT OF COMM[UNI't'Y&DEVELOPMENT SERVICES I I * 21825 E.Copley Drive (909)8C:0-3195 Fax(909)86F-3117 PRESS ��'-v��� BUILDINGPERNIITAPPLICATION FIRMLY � JOBSITE �jy�� �� y^y� �/' � A APPLICATION w�PERMIT ��� ,p� P/C o ADDRESS (� f�'J ��/�. Fd'° DATE � �'� �� NUMBER ��� °r APN LOT TRACT ISSUE TYPE OCC DATE CONST. GROUP p OWNER P �. £SZ o A,DDRE S /� tr�'1 ZONING SETBACKS w FRONT __ RW �� z CITY a' ZIP TEL. o APPLICANT TEL. S DE/SICE STREET RW ❑ z � CONTRACTOR � Pi� C t�r� SIDE ❑ o C TRESS Z P�� TEL. � m f� PROPOSED USE r°` � � W�� o ARCH/ENG/ z DESIGNER w NO.DWEL i NO. NO. � ADDRESS � CITY ZIP TEL. UNITS '/. STORIES BEDROOMS � cn' DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION. � � p� � ���,��OWNER•BUILDERDECLARATION � SFR/ADD/REM O I HEREBY AFFfRM UNpER�PEjVALTY OF PEPJURV THAT I AM EXEMPT FROM THE CONTRACTORS LI- GBfdJO/C8fP01I � W, CENSELAWFOflTkiEFOLfAYJINGAEA50N(SEC.7,031.SBUSINESSANDPROr'ESSIONSCODE:ANVqTYOR (n U�. 'COUNTYWHICHREQUIRESAPERMITTOCCNSTRUGT.ALTER,IMPROVE,DEMOLISH,ORH=PAIRANYSTflUC- ' ' Z �.TURE,PRIORTOIi$ISSUAN��;ALSOREQUIRES',THEAPPLICANTFORSUCHPERMITTOFILEASIGNED W Pailo/DeCk W�, .STATEMENT THAT��HE OR�SHE IS 410EN$ED PUR$UANT TO 7HE PROVISIONS OF THE CONTRACTORS LI- W ��, ',CENSE LAW(CHAPTER 9�(COMMENCING�WITH SEGTION 7000)OF�NISION 3 OF THE BL151NESS AN�PRO- � PooUSpa ��. 'FESSIONSCDDE)OR'THATHEOR$FIEISE%EMPTTHEREFROMANDTHEBASISFORTHEALLEGEDEXEMP- Q', 'i TION.ANVVIOLATIONOFSEC110Niya31.56YANYP�PPLICANTFORAPERMITSVeJECTSTHEAPPUCANTTO z Re-Roof 4 S ' ' �ACIVIL PENALN OFNOT�MORE TFjAN FIVE HUNOqEO DOLLARS(55D0).): ' �'�, �I ' ❑I,ASOWNERIOFTFiE�ROPERTY,ORMYEMpLOYEESWITHYJAGE5A5THE1R5�LECOMPENSATION, ❑ Commercial - - Z�i� �.YQILL DO iHE WOdK��AN�TH STRUCTIJiiE IS NOiT WTEN�m OR OFFERED POR SALE(SECJo44,BUSI- J _ . �, NESS AND PROFES�ylON5 pODE�,T�HE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF = - PROPERTY WHO HUIl�S OFi II,APiiOVES THEREON,i AND WHO DOES SUCH W�RN HIMSELF OR HERSELF OFi �', '�;THFiOUGHHISORHEROWN�MpL!SVEES,PROVI�iEDTHATSUCH1A1PaOVEMENTS'ARENOTINTENDEOOR m � W �.OFFERE�FORSALE.AF,HOWCyUER,THEBUIL�INGO,RIMPROVEMENTISSOLDWITNINONEYEAFOFCOMPL'e- � Z Ii �,'TION,THE OWNER�UIL�ER WILL NAVE'THE BUR�EN OF PROVINO TI�IAT HE OF SHE DID NOT 6UILD OR �� .IMPROVEFORTHEPURPOSEOFSqLE�. � �. .� � �_�� '�� �❑I,ASOWNER�FTFIEPAOF�RTY,AMEXCLl/SIVELYCONTRP:CTiNGWIiHLICENSEDCONTRACTORS CC I'�TO CONSTRUCTTHE PROJE�T(SEC.7n'44,BUSIN�E55 AND PROfES510N5 CO�E:THE CONiRACTORS LI- V2lualio� ADJ.AREA LLJ! .'CENSELAWOOESt�pTAPPLYYOAN.OWNEROFly�PflOPER7YWHOBUILD50RIMPROVESTHEREON.AN� �', '�I�.,WHDCONiRACTSFORSUCHPROJECTS�WITHACONTRACTOR(S)LICENSEDP'JRSUANTTO7HECONTRAC- QUANTIN DESCRIPTION - FEE � Y "TORS LICENSE CAW.);: �� , '� � J Q i ❑I MA EXEMPT UNqEp�EC.',' B.&P.C.FORTHIS REASON Q � U � � . :pATE OWNER V . . . Z. I , ''�. . w . , ,� ' �YICENSED CONTRACTORS DECLARATION w Q 2"� I HEFiEBYAFFIRM UNDER?ENAITY OF PEftJURY THAT I AM LICENSE�UNDER PROVISIONS Of CFiAPTER � ' ' � � - � ,e�COMMBJCINGWITHSECjI4N7a0o)OFDIVISION30FTHE9USINESSANDPROFESSIa�NS�CpE,p.¢ND z 'X MY LICENSE IS IN FUGL F'OI�CE AN��EFFECT. ' y a ;.�;F j m , . F�d � � �' �LIGENSE CLASS �/ .�p y�� GC.NO. � ��-� � . � . . � V�� 'DATE /"'�N' � CONTPACTOR � �' O� � a �� . W. � W K�RS'COMPENSATION DECLARATION Q � � , ' � I HEREBV AFFIRM UNDER PEN,4Y.1'�`OF PERJURV ONE OFTaE FOLIOWING DECLARATIONS: Z , , ' � , � _IHAVEANDWILL;M/It�7AINA�CERTIFlCAT�OFWNSEMiOSELF-INSUREFORWORKERS' _ � � � ,Q CAMPENSATION.�%iSPROY,IDEDBYSECTIbN37ooOFTHELABORCODE,FORTHEPERFORMANCE W Q . OFTHEW�RKF(JP��YCFI'T3iIS''�pERMITISISSUED. � ' . ' ' � '_I HAVE AND WILL A7/1�f�TAIN YdOWCEflS'COMPENSATION MSURANCE,AS RE�UIRE�BY SECTION (�j !'� � ,- Q 37oaOFTHELABdRCD�E',FOR'�THEPERFORMANCEOFTHEWORKFORWHICHTHISPERMITIS y �{, ISSUE�,MYWORNEAS COMPEAISATION URANCE ARRIERANOPOLICYNUMBERARE: CONSTRUCTION I 47 A' ' � j cqqRiEq � ��� �R' _ PLAN REVIEW 0 POUCYNUMBERi� 'L,'"'�� �K'L� �= ELECTRIC � � � ¢ � � -,-.T �..,ti p (�HISSECTIONNEFANQ`fBE��OJMF?IEfEDOFTHEPERMffISWRONEHUNDRED00LtARS1570�ORLESS). PLUMBING �—'` �- � - � " , Z� ICERTIFVTHAT�NYH6PE�lFORMANCEO�FTHEWORKFORWHICHTHISPERMITI5ISSUED,I MECHANICAL ',� ('3� SHALLNOTEMF4b�'�AWYPERSQNINANY'�MANNERSOASTOBECOMESUBJECTTOTHE ( � � �f , � � � [� WORK�RS'CONP.NSATI(�NLAWSOFCALIFOFNIA,ANDAGREETHATIFISHOUL�BECOME INSPECTIONFEE $ , � SU6JECTTOTHE��d�,iyK'�FS�'COM?ENSATIONPROVISIONSOFSECTION37000FTHELABOR � '"�� � � CODEISHAL,LyFOyAThydITH'COM1IPLYWITHTH R9O�VISION-S. ISSUANCE �'^ g-� � � u'U' R � �!�^� .��y�.�+l�s SMIP ' _",7- � �1y . � k PLIGANT: ��a , - . p DATE: e,_. -- —..:_ __.._.'_.'__'__ J WARNI I�U�O�UP�, COMP�ENSATIONCOVERAGEIS�UNLAWFUL,ANDSHRLLBE ENERGYP/C �� �� �' . SUBJECTANEMPLOYER'KC7iCR'IANI ALPENALTIESANDCIVILFINESUPi00NEHUNDREDTHOUoAN� ENERGYPERMIT . DOLLARS(51000C0},IN/+b01T'RN�d,THECOSTOkCOMPENSATIDN,OAMAGESASPROVIDE�FORIN �' SECTION3]OeOFTHELAB FiCOqE',INTEREST,ANDATTORNEY'SFEES. � .� ., RETENTION FEE: O �� GpIVSTRUCTIONLENDINGAGENCY PRE-ALTFEE: � ,� IHEREBVAFFIRMUNDERPENALI`�4�QFPERJURYTHATTHEFEISACONSTRl1CTIONLENDINGAGENCV . ' FOR 7HE PERFORMANCE OFTH���WORK FOR WHI'CH THIS PERMIT IS ISSUED(SEC.309�,CIV.C.). � � W ' � . j� LEN�ER'S NAME ' . 9 ' F— . LEN�EH'SADDRESS ' ��" ICEFTIFYTHATIHAVE�RE4D7H�SAPPLICATIONAFI�STATETHAT7HEABOVEINFORMATIONISCOPRECT. TOTAL FEES �: ��' ' �' � I AGREE TO COMPLY WITH ALI�qN ANO COUNTYIORDINANCES ANO S?ATE LAWS RELA7ING TO BUILOING , ,�. 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