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HomeMy WebLinkAbout17212 -- _ __ __----- � _ __ _ _ CITY OF I3IAMOND BAR � - - ��`---- DEPARTARENT OF CON�LviUI�TITY&DEVELOPMENT SERVICES �.i` I I � :_�w 21825 E.Copley I7rive (909)860-3195 Fax(909)861-3117 � PRESS '''%vri�'��" �UILI3INGPERMITAPPLICATION FIRMLY � JOBSITE APPLICATION PERMIT � o ADDRESS_��I ��jV�h�__�61G_ DATE �6 ���( NUMBE���1 "# c� ISSUE TYPE OCC APN LOT TRACT. DATE CONST. GROUP p OWNER ����,; o ADDRESfi Z � L..�s��.�e.-sa�'1 ZONING SETBACKS Z CIN — .P_�11�J—EL.��l f S�S^�.� R�ORT RW �❑ p APPLICANT TEL. tt �d,Q� SIDE/SIDESTREET RW ❑ m, CONTRACT I V' �ty�� ��„�g� SIDE ❑ oliDDRESS • � PROPOSED USE �r��t�, ��'�` ���5�.>� ciTv�,�.� ziP�'� re�. - � � � � o ARCH/ENG/� �a � �`� iz DESIGNER NO.DWEL. NO. NO. � ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER BECLARATION SFWADD/REM � � O p I HEREBY AFRRM UNDER PENfLLTy OF PEflJUFY THAT I AM EXEMPT FROM THE WNTRACTORS LI� G2fag0/CefP011 W CENSEl.4WFORTHEFOLLOWMG�REASON(SEC.7031.5BUSINESSANDPROFESSIONSCODE:ANYCINOP (n , U COUNTYWHICHREQUIflESAPEF ITTOCONSTRUCT,ALTER,IMPROVE,DEMOLISH,ORREPAIRANYSTflUP W patio/Deck Z Tl1RE,PRIOR TO ITS ISSUANCE,IILSO REQUIRES THE APPLICANT FOR SUCH PERMIT i0 FILE A SIGNE� W . STATEMENT THAi HE OR SHE IS LICENSED PUiiSUANT TO THE PFIOVISIONS OF THE CONTRACTOFS Li� W � , CENSE LAW(CHAGTEfl 9(COMMENCWG WITH SECTION 7000)OF DIVISION 30F THE BLISINE55 ANO PRO� �'t" POOUSP2 � 0 � FESSIONSCO�E)ORTHATHEOR HEISEXEMPiTHEflEFROMAN�JTHEBA515FORTHEALLEGEDE%EMP- (� . 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' TO CANSTflUCT THE PROJECT(S�C.7044,BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS U- VdlUdf1011 ADJ.AREA W� CENSELAWDOESNOThPPLYTO NONMEFOFAPROPERTYWHOBUILDSORIMPROVESiHEREON,AND ��' .WHOCONTRACTSFOpSl1CHPRO.�ECTSWRHACONTRACTOR�S)IICENSEDPIJRSIIANTTOTHECONTRAG QUANTITY DESCRIPTION � FEE Y TORSLICENSEtAW.). , �' O I AM E%EMPT UNDER SEC. B.&P.C_FOR THIS REASON U � L_L � �ATE � OWNER U Z W � LICENSED CONTRACTORS DECLARATION w ¢ � IHEREBYAFPIRMIJN�ERPE�VALTYDFPERJURVTHA7IAMLICENSEDUN�ERPROVISIONSOFCHAP7ER � d 9(COMMENCINGWITHSECTION7ba0;OFDIVISION30FTHEBUSINESSANDPROFESSIONSCOOE,AN� Z `X MY LICENSE IS IN FULI FORCE AND EFF�CT. m � IICENSE CLA55 G-( �� UC.NO. L'1�� � � U OATE ��"���� CONTRACTOR - 0- LI] ' � WORKK�RS'COMPEN5ATION 6ECLARATIDN Q = U � I HEREBV AFFIRM UNDER PENALTV OF PERJURY ONE OFTHE FOLLOWWG DECIARATIONS: Z �Z �IHA ANDWILLAMINTAIN�ACEHIIFICATEOFCONSENTTO5ELF-INSUREFORWORKEP.S' _ ¢ PENSATION,ASPROVIDE�6YSECTION37o00FTHElA90FCODE,FOFTHEPERFORMANGE �U FTHE WORK�OR WHIC4i THIS,PERMIT IS ISSl1E�. � � � � .- -I HAVE AND WILLMAIMAIM WORKERS'COMPENSATIDN INSt1flA�CE,AS REQIJIRED BY SECTION Q � � 37oaOFTHELABOFCODF�,FOR''THEPERFORMANCEOFTNEWORKFORWHICHiHISPERM1715 ` � ISSl1E�.MYWORKEiAS'�CO�MPENSATIONINSl1RANCECARqIERANDPOLICVNUMBEflARE: CONSTRUCTION " � CARRIER �"6�6�G��� �� ,/�. PLAN REVIEW _ Z POLICY NUMBEFi � ��O�'Qg� ELECTRi�.— � 6 Q , � (I}i155ECTKKJNEmNQTB�NMPLEfEDOFiNEPERMfI'ISFORONEHUt�RE��OLLARS(5100�OqLESS�. PLUMBING Z ICERTIFYTHATINTHEPEbFORA7ANCEOFTHEWORKFORWHICHTHISPEPMITISISS�ED,I MECHANICAL _ (;j SHALLNOTEMPLOYANYI�ERStiNINANYMANNERSOASTOBECOMESUeJECiTOTHE � WOflKERS'COMPENSATIO�,NLAWSOFCALIFORNIA,AN�AGFEEiHATIFISHOUL08ECOME INSPECTIONFEE SUBJECTTOTHEWORKEF�S'COMPENSATIONPROVISIO F ECTION37ooOFTHELABOR � GODE,ISHALLFOftTMW1T�7COMPLYWITHTHOSEP ISSUANCE � p DATE: ��P��� APPLIOANT: �" SMIP lJJ J WARNINGFpILUflETOSECURENI flKEHS'COMPENSATIONCOVERAGEISUNL4WFUL,ANDSHALLBE ENERGYPlC _ _ �_ �y SUBJECTANEMP�OYERTOCRIMI�JALP NALTIESANDCIVILFINESUPTOONEHi1N�ftE0THOUSAN� ENERGYPERMIT ' DOLL4RS�51oo,000�,INADDITION OTH�COSTOFCOMPENSATION,�AMAGESASPROVIDEDFORIN J SECTION37080FTHELABORCO E,INTEREST,PNDATTOFNEYSFEc'S. RETENTIONFEE: � f' OCOI�uSTRUCTIDN LENDING AGENCY PRE-ALT FEE: � � IHEREBYAFFIflMUNDERPENALT'�OfPERJURYTHATTHEFEISACONSTRUCTIONLEN0INGAOENCY � FOFTHEPERFORMANCEOFTHEWOflK�:FOflWHICHIHISPERMITI51S5UE�(SEC.309].CIV.C.). . Z W �' LENOERSNAME I-_- LEN�ER'SA�DRESS ,� TOTA� FEES � ���j � I CERTFY THqT I HAVE REA�THIS��qppLICATION AND SiATETHATTHE ABOVE INFOPMATION IS CORRECT. d IAGREETOCOIAPLYWITHALLCITD'AN�''�WUNTVORDINANCESANDSTATE:AWSRELATINGTOBUILDING _ � CONSTRUCTION,AND HEREBV AU7NOFIrE flEPRESEMATNES OFTHIS COl1NTY TO EMER�PON THE Z A60VEMENTpNED PROPERTV fOR INSPECTION PURPOSES. COMMENTS - � ��p ��o�' ¢ PERMITTEENAME�P / �q � C(j �. . 0�0��d0" (/) SIGNATU flMIT1EE ' � DATE _ � RECPT.NO. 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