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HomeMy WebLinkAbout17473 (23) � CITY OF DYAMOND BAR � DEPAR7'IvfENT OF COMMiJNI`PY&DEVELOPMENT SERVICES � 21825 E.Copley Drive ^ (904)�60-3195 Fax(409)861-3117 � ��"��, 1, PRE�J$ �'���^°+.w BUII..vI19'G FE T APPL„ICATION ��_..�' �� FIRMLY o� JOBS�TE /� �a p�_ _ APPLICATION w �,I PERMIT ' C ADDRESS L��Y O '-^�b���^-'f ���. �-�'✓4.� 1 DATE � �—����i NUMBER �__ � ISSUE TYPE OCC APN LOT TRACT DATE CONST. GROUP p OWNER " ADDRESS ZONING SETBACKS z CITY ZIP TEL. FRONT RW ❑ � APPLICANT TEL. REAR ❑ � . s�. SIDE/SIDE STREET RW ❑ z ¢ CONTRACTdR � t- t hQ �,C SIDE . ❑ � ADDRESS PROPOSED USE p b �� _ � CITY ZIP�2�eLTEL.I/[L�d L/y2l I o ARCH/ENG/ iz DESIGNER NO.DWEL. NO. NO. i a ADDRESS UNITS STORIES BEDROOMS = CITY ZIP TEI. ' � DESCRIPTION SQ.FT. FACTOR PSF ADJ,AREANALUATION p� OWNER-BUILDER DECLARATION SFR/ADDlREM O p I HEREBY AFFlRM UNDER PENALTY OF PERJURY THAT I AM E%EMPT FROM THE CONTRACTORS LI- GeI8JB/CdfPOlt LLI CENSELAWFORTHEFOLLOWINGREASON(SEC.703i.58USINE55ANDPROFESSIONSCODE:ANYCITVOR (/� � COUNTYWHICHRE�UIRESAPERMITTOCONSTRUC7,ALTER,IMPROVE,DEMOLISH,ORREPAIRANVSTRUC- W PdiI0JD0C1( � li w TUP,E,PRIOp TO ITS ISSLIANCE,AL50 REQUIRES THE APPLICANT FOft SUCH PERMIT TO FILE A SIGNE� w STFTEMENT THAT HE OR SHE I5 LICENSED PUflSUANT i0 THE PROVISIONS OF THE CONTRACTORS LI- � CENSE LAW(CHAPTEq 9(COMMENCING WITH SECTION 7oo0)OF�IVISION 3 OF THE BUSINESS AND PRO- � POOUSPB FESSIONSCAOE)ORTHATHEORSHEISEXEMPTTWEREFROMANDTHEBASISFORTHEA�LEGEDFJ(EMP- (� �� TION.ANYVIOLATIDNOFSECTION7o31.5BVANYAPPLICANTFORAPERMITSU&IECTSTHEAPPLICANT7O Z RB-ROOf A CIVIL PENqLTY OF N�T MOflETHAN FIVE HUNDflED�OLLAftS(5500).7: �� ❑I.ASOVMEROFTHEPROPEHTY.ORMYEMPLOYEESWITH3NAGESASTMEIRSOLECOMPENSAiION, � COfItrt7BYCleI - ' Z WILL DO iHE WORK,AND THE STRUCTURE IS NOT IPfTENDED OR OFfEREO FOR SALE(S=C.7044,BU51- J �„ NESS AN�PROFESSIONS CADE:THE CONTFACiORS LICENSE LAW DOES NOT APPLV TO AN OWNER OF � PROPEHTY WHO BUILDS OR IMPROVES THEREON,AND WHO�OES Sl1CH WOflK HIMSELFOR HERSEIF OR � .THROUGHHI90RHEROWNEMPLOVEES,PROVIDEOTHATSUCHIMPflOVEMENTSARENOTINTEN0E00R m �; DFFERE�FORSALE.IF,HOWEVEfl,THE6UILDINGORIMPflOVEMENTI550L�WIiHMONEYEAROFCOMPLE- Z. .710N,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PpCVING THAT HE Oq SHE DID NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALE). � �j' ❑I.ASOWNEROFTHEPROPEf7TV,AME%CWSNELYCONTRACTINGWI7HLICENSE�CONiFACTORS � ��. 70 CONSTRUCT THE PRQIECi(SEC.7C44,8�51�'E55 AN6 PflOFE5510N5 CODE:TF1E GONTRACTORS Ll- VdIUBllOf1 A�J.AREA W 'CENSELAWDOE3NOiAPPLYTOANOWNEROFAPflOPERTYWHOBUIIASORIMPROVESTHEREIXJ,AND �' ,WNOCONTRACTSFORSUCHPFOJECTSWITHACONiRACTOp�S)LICENSEDPUPSUANTTOTHECONTRAG QUANTITY DESCRIPTION FEE � Y 'fORSUCENSELAW.�. � ❑I AM EXEMP7 UNDER SEC. 8.8 P.G FORTHIS qEA50N U � Li � DAiE OWNER U Z W �. LICENSED CONTRACTORS DECLARATION W Q CL IHEREBVAFFIRMUN�ERPENALTYOFPERJl1PVTHATIAMLICEN5E0UNDERPROVI510N50FCHAPiER � p_ 9(COMMENCING WITH SECiION 700a)OF DIVISION 30F THE BUSINESS AN�PflOFE5510NS CO�E,q��D Z X MYLICENBE IS IN FULL FOqCE ND EFFECT. Q LICENSE ClASS r` ' `� LIC.NO. � �,�,___ � U DA7E �2�,� ��CONTRACTOR �� �et ��� �- a�'S WORKERS'COMPENSATION DECLARAT N 3 U" P� a _ �� IHEREBYAFFIRAAUNDERPENALTYOFPERJURVONEOFTHEFOLLOWINGOECLARATIONS: Z �� _IHAVEAN�WILLMAINTAINACERTIFICAiEOFCONSENiTOSELK-INSUREFORWOflKERS' _ CAMPENShTION.ASPFOVIOEDBYSECTION37ooOFTHELABORCODE.FORTHEPERFORMANCE U Q OFTHE WORK FOR WHICH THIS PERMIT IS ISSUED. � , L�LI IHAVEANDWILLMAINTAINWOflKERS'COMPENSA710NINSURANCE.ASRFAWREDBYSECTION � � Q 370oOFTHELABORCODE,FO THEPERFDflMAN�C OFTHEWOAKFORWHICHTHISPERMITIS ISSUE�.MY WORK N INSUFMArCE CARflIER A'Njp POLICY NUM6ERARE: CONSTRUCTION e 7 CARRIER T U� '" PLAN REVIEW !u� z POLICYNUMBER ELECTRIC a (fHI55ECi1JNNEmNOT6ECOMPLEfEDOFTHEPEPMRISFORQVEHUt9PEDDOLL1R5�gI00�ORLE55J. PLUMBING � Z � ICERTIFVTHATIN7HEPERFORMANCEOFTHEWORKFORWHICHTHISPERMITISISSUE�],I MECHANICAL ' �' SHALLNOiEMPLQYANVPERSONINANYlAANNERSOASTDBECOMESUBJECTTOTHE � WORKERS'COMPENSATIONLAWSOFCALIFO IA,AND REETHAiIFISHOULDBECOME INSPECTIONFEE F; SUBJECTTOTHEWORKERSCOMPENSATI�N ROVISIO SOFSECTiON o00FTHE OR r"^�/ ' � CODE,�SHALL FOR HWITH GOMPLY WITH SE PRO IONS. ISSUANCE �=` lt� Q �1 p DATE: � `� ��� APPLICANT. SMIP J� WARNING'FAILURETOSECUREWORKERS'COMPENSATIONCOVERAGEISUNLAWFUL,AN�SHALLOF ENERGYPlC ' + ' � SLIBJECTANEMPLOVEflTOCFIMINALPENALTIESANDCI`lILFINESUPTOON�HUNDREDTHOUSAND ENERGYPERMIT �OLLARS(E1ao,0oo7,IN AODiTIONTO THE COSTOF COMPENSATION,DAMAGES AS PROVI�ED FOR IN Y 3ECTION 9]OB OF TF7E Lf$OP GODc,INTERESi AND ATTORNEY'S FEES. RETENTION FEE: � a. CONSTRUCTION LENDING AGENCY pRE-ALT FEE � ���� �.� IHEREBVAFFIFMUNDERPENALTYOFPcRJURYTHATTHEREISACONSTflUCTIONLENDINGAGENCY � FOR THE PERFORMANCE OF iHE WOPK F�R WHICH THIS PERMIT IS ISSl1E�(SEC.309],CIV.C.). —��� � � �� '� ., �; .LENDER'S NAME F= 'LEN�ER'SADDRESS ��� � � � ICEFiIFYTHATIHAVEREADTHISAPPLICATIONANDSiA-ETHATTNEABOVEINFORMATIONISCORRECT. TOTAL FEES ' �' I AGRCE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND ETAiE LAWS RE6ATING TO BUILDING �" CONSTRUC710N,AND HEREBYAUTHORIZE REPRESENTATNES OF THIS COUNTV i0 ENTER UPON THE ���,' A90VE-MeNTIONEO PROPERTV FOft IN PECTION PURPOSES. COMMENTS � 6 _ ��ht`�-�-�� � - ----- ---- ' ���� PERMITTEE AME(P T) � � • � Q,. � �. 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