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HomeMy WebLinkAbout17612 (25) __ _ _ CITY C)F I}�AMOND BAR —�`�"' —� DEPAFt1'MENT OF COh�MUPtI'TY&DEVELOPMENT SERVICES ,L'� _ � - Z 1825 E.Copley Drive � `� (909)860-3195 Fax(909)861-31 i7 , PRESS `'%.��'�'" BUILD7NG PERMIT APPLICATTON FIRMLY o A�D RIESS�� �` ��� ls'Vt�f��. �� DAPECA 10� ��v NUMBER �f � #lC 6 ISSUE TYPE OCC `� APN LOT TRACT DATE CONST. GROUP p OWNER f� 11 ADDRE S ZONING SETBACKS oCITY� ZIP TEL. � � REOART RW ❑� o APPLICANT TEL. Q SIDE/SIDE STREET RW ❑ a CO;NTRACTO � ` ( SIDE G " � � p� ADDRESS � � T� PROPOSED USE 0 S � �` I � CITY �"" � ZIP . TELLL��� eJ ,S ' 4.�- o ARbH1ENG/ r - �"� � ��r �'�, � D�59GNER' NO.DWEL O. ' NO. ` a ADDRESS UNITS STORIES __�___BEDROOMS � CI7Y ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREA/VALUATION '�. � � OWNER-BUILDER DECLARATION SFRlADD/REM � (, I HEREBY AFFIpM UNDER PENAI.T`!OF PERJl1RV THAT I AM EXEMPT FROM THE CON7RACTOFS LI- � Garage/Carport W�' CENSELAWPoRTHEFOLLOWINGREASON(SEC.7031.5BUSWESSAN�PROFESSIDNSCO�E:ANYqTYOR (J COUNTYWHICHRE�UIRESAPERMITTOCON6iRUCT,ALTER,IMPROVE,�EMOLISH,ORREPAIfiANYSTRUC- W PSilO/�6Ck W'� TURE,PRIOR TO ITS ISSUPNCE,AL50 RE�UIRe'S THE APPL�CAN?FOR SUCN PEAMIi TO FILE A SIGNED W �,.' STATEMENT THAT HE OR 51iE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI� .�,, CENSE�LAW(CHAPiER9(COMAdENCINGWITHSECTION70oo}OFDIVISION30FTHEBUSINESSANDPRO- � POOUSpe �i � FESSIqNSCODE)ORTHATHEOPSHE�SEXEMPTTHEREFROMANpTHE6A51SFORTHEALLEGEOE%EMP- i, �, TION.ANYVIOLATIONOFSECTION7o37.iBYANVAPPLICANTFORAPEFMIT5U8JECT5THEAPPLICANTTO z Re-Raof . � AqVILPENAITYOFNOTMOREiHANFlVEHUNORE��OLLARS(SSoa).j: �� ❑I,ASOV✓NEROFTHEPROPEFTY,ORMYEMPLDVEESWITHYJAGESASTHEIRSOLECOMPENSATION, � COA'IRIEfCIflI - Z' �WILL DO THE WORK,AND 7HE STRl1CiURE IS NOi IN7ENDE�OR OFFERED FOR SALE(SEC.7oeq gU5!- J ���NESS AND PROFESSIONS COOE:THE CONTRACTORS LiCENSE LAVJ DOES NOT APPLY i0 AN OWNER OF N ����PROPERTYWHOBUILDSORIMPPOVESTHEREON,ANDWHOOOESSUCHWORKHIMSELFORHERSELFOR � �. 'TNqDUGHHISORIIEROWNEMPLOY'eES,PROVIDEDTHATSUCHIMPROVEMENTSAflENOiINTENDEDOR m Q; ".OFFEREDFORSALEIF,HOWEVER,THEBUILtlINGORIMPROVEMEUtISSOIDWITHINONEVEAROFCOMPLE- " Z,, �,710N;THE OWNER-BUILOER WILL HAVE THE Bl1R0EN OF PROVING iHAi HE oR SHE Di�NOT 8UI�0 OFi j �� 'IMPPOVEFOqTHEPURPOSEOFSALE�. � OI,ASONMEROFTHEPROPERTY,AMc'%CLUSIVcLYCONiRACTMGWIiHLICENSEDCON7RAC70RS r�� �. 'TOCONSTRl1CTTHEPROJECT(SEC.104a,0USME55AN�PflOFF5510N5CODE:THEWNTRACTORSLI- Vd�LIflfI0f1 Qa✓ ADJ.AREA CIJ '�'CENSELAWDOESNOTAPPLVTOANOWNEROFAPROPERTYWIIOBUILDSOflIMPROVESTHEflEON,ANO �. '�WHOCONiRACiSFORSUCHPROJECTSWITHACONTRACTOH(S�LICENSEDPURSUANTTOTHECONTRAG QUANTITY � DESCflIPTION FEE Y' �70RS LICENSE LAW.�_ Q ❑IAM EXEMPT UN�ER SEG B.8 PC.FOR THIS REASON � ' �", � � �ATE OWNER_ � ' � W � LICENSED CONTRACTORS DECLARATION W CC . I HEREBY AFFIRM UNDEft PENALTY OF PERJl/RY THAT IAM LICENSE�UN�ER PROVISIONS OF CHAPTEfl � d .9(COMMENCINGWIiHSECT10N7000JOF01VISION30FTHEBUSINE55AM1DPROFESSIONSCODE,ANO z X � MY LICENSE IS IN FULL FORCE AND EFFECT. � ' �(p, � ,�.�- m � Q LICENSE CLA S � 7 LIC.NO. � �� �� j I Ir OATE �"�� GONTRACTOR '�^^��•'�'� d � � WORKERS'COMPENSATION DECLARATION Q , � IHERE9VAFFIPMUNDERPENALTYOFPERJURYONEOFTHEFOLLOWINGDECLARATIONS: U � Z Q O _IHAVEANDWILLMAINTAINACERTIFICAiEOFCONSENTT03ELF-IN3UREFORWOflKERS' _ � COMPENSATION,AS PROVIDED BY SECTION 3'l0o OFTHE UBOP.CODE,FOR THE PERFORMANCE U � OF�-IE WORK FOR WHICH THIS PEPMIT IS ISSUED. � W ��/ -}� I HAVE ANO VlILL MAINTAIN WORKERS'COMPENSAiION INSURANCE.AS REDUIr�EO BY SEC710N p� c�f � " '""37ao OF 7HE LPBOR CODE,FOR THE PERFO.qMANCE OF iHE WORK FOR WHICH THIS PeflMIT IS �{./�' f� � ISSUE�.MYWORKFAS' OMPE SATIONINSU CECARflIERANDPOLICYNUMBERARE: CONSTFUCTION 1 � �, cnaaiEa _p _ PLAN REVIEW d POLICY NUMBER_���,���_ I's 1 ELECTRIC -- -" - � � (fHI55ECiKKJNEmNOTBEOJhiPLEfEDOFTHEPERM�TISFOftONEHUN��tEDDOIURS(b100)ORLESS). PLUMBING ' � � ' W I CERTIFVTHAT IN THE PERFOftMANCE OFTHE WORK FOR WHICH PHIS PERMIi IS ISSUED,I MECHANICAL �' (fJ� SHALL NOT EMPLOY ANY P=fl50N IN rWY MANNER SOAS TO BEGOME SUBJEGTTO THE �j� � WORKERS'COMPENSATIONLAWSOFCALIFORNIA,ANDAGREETHATIFISHOULDBECOME INSPECTIONFEE � � @� t�` ��" "�� jJ � ? SU9JEC7TO THE WORKERS'COMPENSATIQ I PpDVISIONS OF SECTION 3]OD OF THE LABOR ISSUANCE i .a�1S. ' COOE,I SHALL F RTHWITH COMPLY WITH THOSE PROVISIOW ' ��:.��,� -- -�.. C3 C3' p� �ATE:„��Q APPLICANT:��""""""" � SMIP �_'T.. __ > . __.___...�__._..____..__. � ENERGY P/C � � � � ��� � WAflNINGFAIWpETOSECUREWOflKEfiS'COMPENSA710NCOVERPGEIaI,'NLAN'FUL,AN�SHALLBE �y,:� SUBJECTANEMPLOYERTOCRIMINALPENALTIESANDCIVILFIf:ESUPTOONEHUNDREDTHOUSANO ENERGYPERMI7 � DOLLARS(51o0,a0o�,IN AD�ITION 70 THE COSiOF COMPENSATION,DAAAAGES AS PftOVIDED FOR IN /g �' SECTION37oe OFTHE IABOR CO�E,INTEREST,ANO ATTORNEYS FEES. RETENTION FEE: /^ � p�Q',,� � �CONSTRUCTION LENDING AGENCY PRE-AL7 FEE: �'+�� IHERE6VAFFIRMUNDERP€NALTYOFPERJURYTHATTHEREISACONSTRUCTIONLENDMGAGENCY ��n'' FORTHEPERFOflMANGEOFTMEYfORKFORWNICHTHISPEflMITI5155UED(SEC.309],CIV.G.). . � W �� 4ENDER'SNAN�E F=',� LEN�Efl'SAD�flESS__� .�y �'� I CERTIFY THAT I HAVE READ THIS APPLICATION AND SiATE THAT THEABOVE INFOPMATION IS CORREC7. TOTAL FEES �J^}� l'� �'� IAGFEETOCOMPLYWITHALLCITVANDCOUNTYORDINANCESANDSTATEL4WSRELATINGTCBUILDING �;, CONSTRl1C710N,AN�HEPEBYAUTHOHRcFEPRESENTA7NE50FTHISCOUNTYTOENIERUPONTHE Z�. ABOVE-MENTIONED PROPERTY FOR INSPECTION PURP03ES. � � COMMENTS � °~s°t� i�f,��' �i.�!'`''c�'' I � —(7'a � PERMI7TEE NAME(PRINT� � � @ ,.���-+-. f 4 us c_,�. �' _ 1—��'°�3 2� �' SIG� 7ERMI . 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