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HomeMy WebLinkAbout16819 (37) _�� CITY OF DYAMOND BAR DEP�4RTNI�NT OF COMMUNITY&DEVELOPMENT SERVICES � „� -3 21525 E.Copiey Drive �' (909)860-3295 Fa:c(909)861•3117 PRESS ''°-.qr�'" BUILDINGPERh�IT APPLICATIOI�T FI MLY o� JOBSITE /j,�.�y ��� �Qr'�p� DATEICATION �J � � NIJMBER�'Xe #lC ADpRESS1 CJ ,C( _ d roo ISSUE �"'1 TYPE OCC APN L T TRACT DATE �s� CONST. GROUP p OWNER � '�4 L� `` ADDRESS F' ' � ZONING SETBACKS z CITY ZIP TE � FRONT RW ❑ � APPLICANT i TEL REAR p � SIDE/SIQE STREET RW ❑ z m CONTRACTO '�Pi' O5?A` O SIDE ❑ a AODRESS ' '� PROPOSED USE � CITY ZI PG�dLt_ TEL,�j� w ARCH/ENGI T� ' z DESIGNER NO.DWEL. NO. NO. a ADDRESS � UNITS STORIES BEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANAWATION u� � OVJNER-BUILDER DECLARATION SFR/ADD/REM O � I HEREBV AFFIRM 11N�Efi PENAL7Y OF PERJI/PV iHAT I AM EXEMPT FROM THE CONTRACTORS LI� GdldJB/CBfpOfl W CENSELAWFOflTHEFOLLOWWG�REASON(SEC.7037.58USINE99ANDPROFESSIONSCO�E:ANYCITYOR (n C.7 COUNTYWHICHRE�UIRESAPER I7TO�ON5TRUCT,AL7ER,IMPROVE,�EMOCISH,DRREPAIRANVSTRUC� M � PatiolDeck Z � TUflE.PRIOR TO ITS ISSUANCE,AL50 REQUIRES iHE APPLICANT FOR SUCH PERMIT TO FlLE A SIGNED STATEMENT THAT HE OR SHE IS I�;.ICEN$ED PURSUANT TO THE PROVISIONS OF THE CONTRACiORS LI.. � �,CENSE LAW(CHAPTEq 9(COMMENCING�,WITN SECTION 70002 OF DIVISION 3 OF THE BUSINESSANO PRO� V' PooVSpa . FESSIONSCO�E�ORTHATHEORSHEIS;EXEMPT7HEREFROMANDTHeBASISFORTNEALLEGEOE%E�UP� . � ' iION.ANVVIOLATIONOFSECTION�i7o31.5BYANYAPPLIGANTFORAPERMIiSUeJECT5TIIEAPPLICANTTO � Re-Roof t , �� ACIVILPENALiYOFNOTMORETHANFIVEHUNDREDDOLL4RS�55oo).): o ❑I.ASOWNEROFTHEPROp�RN.ORhIYEMPLOYEESWITHWAGE5A5THEIR50LECOMPEN5A710N, � COrtIfIt8fC18I - . Z ,WILL DD THE WORK,AND THE STRUCTURE IS NOT INTEN�ED OR OFGEREO FOR SALE(S'cC.7044,BUSI- � J , �. � NE55 AND PROFESSIONS CODE:TIHE CpNiRACTORS LICENSE LAW OOES NOT APPLV TO AN OWNER OF = ' PROPERTYWHOBUILDSORIMPROVESTHEREON,ANDWHODOESSUCHWORKHIMSELFORHERSELFOR C[ THHOUGH NIS OR HEp�WN EMPLOYEES,PFiOVIOE�THA75UCH IMPROVEn9ENT5 ARE NOT INiENOE�OR m Q �OFFEflEDFORSALE.IF,HOWEVER,IfHEBUILDINPORIMPROVEMENTI550LDWITHINONEYEAROFCOMPLE z .�710N,THE OWNER-BUILOER WILL I�AVE THE BIIR�EN OF PROVING THAT HE OR SHE DID NOT 6UIL�OR = IMPROVEFORTHEPURPOSEOF�LE).'� CI,ASOWNEROFTHEPROP FTV,AMEXCWSIVELVCONTRACTINGWI7HLICENSEDCONTRACiDRS Q i0 CONSTRUCT THE PROJECT(5 C.�044,BUSINESS AND PROFESSIONS CODE:THE CONTRACiOPS LI- V8Il18IlOf1 � ADJ.AREA_. W CENSEL4W�OESNOTPPPLY70ANOWNEROFAPROPERTVWHOBUILDSOpIMAROVESiHEREON,AND � WHOCONiRAGT5FOR5UCHPROJECT5W17HACONTflACTOR(5)LICENSEDPURSUANTTOTHECONTPAC- QUANTITY OESCRIPTION FEE Y TORS LICENSE LAW). . � ❑IAM EXEMPT LINDER SEC.'� B.8 P.C.FOR THIS REASON Q � U W � DATE "�OWNER U _`K p Z W �i I � � LICENSED QONTRACTOAS DECLARATION W l �,�A/ • � IHEREBYAFFIRMUNDEflPENAL7YOFPERJURYTHATIAMLICENSEDUNDERPROVI510NSOFCHAPTER � .�.,/► �—L d� 9(COMMENCINGWITHSECTION7aaojOF�IVISION30FTHE6l151NES5ANDPROFE5510N5CODE.AND Z �Y'� �Lf► W MYLICENSE IS IN FULLFORCEAND EFFECT. G m � LICENSE� � ��LIC.NO.�// � �r��� J V DATE CONTRACTOR � � - �'7r�'" �- W � WORKERS'¢OMPENSATION DECLARATION Q = U � IHEflEBYAFFIRMUNDERPENALTYOFP�RJURYONEOFTHEFOLLOWINGDECLARATIONS: z `—" a � __IHAVEAN�WILLMAINTAINACEF#TIFICATEOFCONSENTTOSELFINSUREFOflWORKERS' Y CAMPENSATION,ASPROVIDE�BVSECTION37ooOFTHELABORCODE,FORTHEPERFORMANCE U ¢ OFTHE WORK FOR WHICH tHIS pERMIT IS ISSUE�. � W � IHAVEANOWILLMAINiAINWORKERS'COMPENSAiIONINSURANCE,ASRE�UIREDBYSECTION 2 '�p � y� Q 370oOFTHELABORCODE;FORTHEPERFOiYMANCEOF7H WORKFORWHICHTHISPERMITIS ,G� _1.,� Y I a (� 0 ISSIJED.MYWOR 'COM NSATIONINS�NCECARR .ANOPOLICYNUMBERARE: CONSTRUCTION � ��f � J � CARRIER PLAN REVIEW � PoLICYNUM3ER � ELECTRIC d I � (iHISSECTIONNEmNOT6EO�MFL',IEfE�OFhIEPERMfrISFORONEHIW�RED00LLARS�$100)ORLESSj. PLUMBING W ICERTIFVTHATINTHEPERFOpMANCEOFiHEWORKF FWHICHTHISPERMITISISS�ED I MECHANICAL Z �} SHA'�_LNO7Eh1PLOYANYPEF50IJINANYMANNER50 iOBECO ESUBJEG OTH �".."'�:- ^"�^°""_^ _ __ � WOflKEftS'COMP NSATION IAW�$OF CALIFORNIA A AGFEET IF I SHO BE INSPECTIO(J FE�_, /i`, � SUBJf�TTOT WORKERS'COY,�APENSATIONPRO IONSOF TION370 T R - ' -�� - � . � L ORT ITHCOMPLYWITHTHOS ROVISI ISSUANCE��ry '�' � � - ' �� � SMIP � � �� F . p �A7E: ABPLICANP. _.. , W � ENERGY P C I J . WARNMG:FAIL �ETOSECUREWORKE�S'COMPENSATIONCOVERAGEISUNLAWFUL.ANOSHALLBE � SU&IECTANEMPLOYERTOCRIMINALP�NALTIESAN�GNILFINESUP700NEHUNDREDTHOl15AND ENEFGYP�B�.T � r DOLLAF75(S10o.000),IN AaDI710N TOTH�COST OF COMPENSAiION,DAMAG'cS AS PROVIDED FOF IN � J SECTION37080FTHELP.BORCODE.INTEREST,ANDAiTOflNEV'SFEES. � � RETENTIO.�� .. �....'--.._-----...,,._.._.. ___.� . OCONSTR�iUC710N LENDING AGENCY PRE-ALT FEE: � IHEREBYAFRRMUNDERPENALTYOFPERJURVTHAiTHEREISACONSTRUCTiONLENDINGAGENCY � FOFTHEPERFOFiMANCEDFTHEWORK�ORWHI i SP'RMITISISSUE�(SEC.3091.CIV.CJ. - � Z W � � LENDER'SNAME __ ..._.. ' F- LENDER'SADORESS �� p'''y� � � �� c ✓w � I CERTIFY iHAT I HAVE FEA�THIS APPLIGAiION AND SiATETHA77Y.EABOVE INFOflMATION IS CORREGL TOTAL FE ES W IAGREE TO COMPLY WITH ALL CITY ANO LOUMTY ORD'NANCES ANO STATE IAWS RELATING TO BUILDING � CONSTRUCTION.ANDHEHEBYAUTHORI}�EFEPRESENTATIVESOFTHISCOIJNTYTOENTERUPONTHE Z �, ABOVE-MENTIONEOOROPER7YFORINSiECiIONPURPOSES o �' �, aG.�.-" COMMENTS _ � ¢ PERMITTEE ,E�PR �I �ppp6, � � � � SIGNA FiEOF RMITTEE i� 0 _ � FiECPT.NO. 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