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HomeMy WebLinkAbout16815 (40) __�� CI'd'Y OF d3IAMOND BAR � DEPARTNIENT OF COMMUNTI'Y&DEVELOPMENT SERVICES 2L825 E.Copley Dri�e rt (909)860-3195 Fau(909)861-3117 PRESS "'��^�� BUILDING PERMIT APPLICATION FIRMLY � JOBSITE �]�� + APPLICATION .-,y PERMIT //� r" P!C o ADDRESS_ � ���� ff"e���'iV i�f°1i� C'�� DATE / t NUMBER l F�� � # , � ISSUE TYPE OCC APN LOT�_ TR CT DATE CONST. GROUP p OWNER i''`�'iti� tr id �, .e Y� 1'r P r� ADDRESS � e CiYI� "J�'. ZONING SETBACKS oCIN ` Y ZIP �/�T TEL�TC9 Q=Q�'��- REORT RW C] o APPLICANT TEL. SIDElSIDESTREET RW C7 ' ¢ CONTRACTOR !'l� SIDE � I o AD�RESS_� � s t3�° • # v CITY ' ZIP �TEL. "'�I%�l-'Z'��/��I� PROPOSEDUSE �� �� � �. ��'' f o ARCHlENG! w DESfGNER NO.DWEL. NO, NO. a. ADDRE58 UNITS STORIES BEDROOMS � CITY ' ZIP TEL. � � �� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � O;WNER-BUILDER DECLARATION SFR/ADDA9EM , O p I HEREBY AFFIRM UNOER P�NALTV OF PEpJURV THAT�dM E%EMPT FROM THE CONTRACTORS LI- � Garage/Carport � � W CENSELAWFORTHEFOLLOWING'HEASbN(SEC.7037.SBUSfIdESSANDPROFESSiONSCODE:ANYqTYOR '� U (;OUNTYWHICHRE�UIRESAPERMITiOCON57RUCT,ALTER,IMPROVE,�EMOLISH,ORftEPAIRANYSTRUC- W patiolDeck Z TURE,PRIOR TO ITS ISSUANCE,AL50 REOUIRES THE APPLICAM FOP SUCH PERMIT TO FlLE A SIGNED � STATEMENT THAT HE OR SHE IS�LICENSED PURSUAN7 TO THE PROVISIONS OF TME CONTRAGiOFiS LI- V"� � ,�CENSELpW(CHAPTEfl9(COMMENCINGWITH6ECTION70ao)OFDIVISION30FTHEBUSINESSANOPpO- LL POOUSP2 FESSIONSCODE)ORTHATHEOR�iSHE1SE%EMPTTHEFEFROMAN�iHEeA51SFORTHEALLEGEOEXEMP- (� y� � TION,ANYVIOLATIONOFSECTIO[�70s1:56YANYAPPLICANTFORAPEFMITSUBJECTSTHEAPPLICAYTiO ,Z Re-Roof y�,�� g� �� � ACIVIL PENALTV OF NOT MORE THAN FIV6 HUNDRED DOLU4RS(f5oo).): ,d ❑I,ASOWNEROFTHEPRO ERTY,OflMYEMPLOYEESWITHYJAGE5A5TNEIR50LECOMPENSATION, � �mercial -� Z WILL�O THE WORK,AND iHE S�RUCiURE IS�NOi INTEN�ED Ofl OFFERED FOR SALE(SEC.7044,BU51- J . NESS ANO PROFESSIONS CO�E�:�HE CONTRACTORS UCENSE LAW OOES NOT APPLY TO AN OWNER OF � PROPER7YWHaBUIL�SORIMPq VESTHEREON,ANDWHO�DESSUCHWORKHIMSELFORHEPSELFOR � - Q� �.THRWGHHI60RHEHOWNEMPIJOYEES,PROVIDEDTHATSUCHIMPROVEMENTSARENOTINTENDEDOR m 0 OFFEREDFOFiSALE.IF.HOWEVER.THE6UIL�INGORIMPflOVEMENTIS50L�WITHINONEYEAROFCOMPI,E- Z TION,THE OWNEfl�6UIL�ER WIL(:HAVE'THE BURDEN OF PROVING 7HAT HE OR SHE�ID NOT BUILD OR = I�APROVEFOflIHEPURPOSEOF.SALE).', ❑I,AS OWNER OF THE PROPI�E�flN,.AM E%ClU51VELY CONTRACTING W ITH LICENSE�CONTRACTOflS � TO CANSTRUCT THE PROJECT(SEC.7044,9l1SIMESS qND PROFESSIONS CADE:THE CONTRACTORS LI- V2IUet1011 """� ADJ.AREA W CENSELAW�OESNOiAPPLYTO NOWNEROFAPROPERNWHOBUILDSORIMPROVESTHEREON,AN� � WHOCONTRACTSFOflSUCHPRO�lEC7SWITHACONTRACTOR(S)UCBJSEDPURSUANTTOTHECONTRAC- QUANTITY DESCRIPTION FEE � � TOASLICENSELAW.�. I � �� � ❑I AM EXEMPT UNDER SEC.I�, B.&P.C.FOR THIS REASIXJ U � � � DpTE �' OWNER F' z � w � � LICENSED CONTRACTORS DECLARATION W � 1 HEREBVAFFIqM UNDER PENAI OF PERJURYTHAT I AIA UCENSED UNDER PROVISIDNS OF CHAPTER � d 9(COMMENCINGWITH5ECTION�oo)OFDIVISION30F77-IEBUSINESSANOPROFESSIONSCODE,AND Z X MY LICENSE IS M FULL FORCEAN EFFECT. �� � LICENSE GLASS���__LIC.NO. r��/+ ���. y,� � , U DATE �s��=�_ COMR4C70R�'�j{/f�G' ��UC p d W i 5! ��. WORK�RS'COMPENSATION DECLARATION a � V � I HEREBV AFFIRM UNDER P'eNALTV OF PERJI.'RV ONE OF TaE F�LLOWWG DECLARATIONS z Q 0 1 HAVE AND WI4L MAINTAI A CEFTIFICATE OF CONSEN7T0 SELF�INSURE FOR WORKERS' 2 MPBJSATION,ASPROV'lIOC-DBYSECTION37o00FTNElABOflCODE,FORTHEPERFOFMANCE U a OFiHE WORK FOR WHICryTHIS PERMIT IS ISSIJED. � W I 1NAVEANDWILLMAINTAI WORKERS'COMPENSATIONINSURANCE.ASREQUIflE�BYSECTION ppp � Q 3700 0F iHE LABOR GODE FOft THE PE�aFORMANCE OFTHE WORK FOR WNICH TNIS PERMIT 15 � �� ISSUED.MV WORKERS'COMPENSATION i SURANCE CAR�ND pOU_eCY NUAABERARE: CONSTRUCTION j CARRIEP �ppaf �y� ��y' PLAN REVIEW Z POLICV NUMBER 4 d"T 7�p ���___. ELECTRIC � (THISSECTKKJNEmNOTBEI'Oa'vfl'':EIE�OF7HEPERMf�ISFORIXJEF0.I�DREDWLLARS(51W)ORLEo"S). PLUMBING Z I CERiIFV hiA71N THE PER�FORMANCE OFTHE WORK FOR WHICH iHIS GEPMIT IS ISSUED,l MECHANICAL (,� SHALLNOiEMPLOVANVPjERSONINANVh7ANNER50A5T00ECOMESUBJECTTOTNE p%j WORKERS'COMPENSATION L4W$OF CALI.=ORNIA,AND AOREE THAT IF I SHOULO BECOME INSPECTION FEE � SUBJECTTOTHEWOFKE�S'COFAPEN50.TIONPROVISIONSOFSECTION37ooOFTHELABOR ✓J°`'�p CODE,ISHALLFORTHWITHCOMPLYWITHTHOSE$P ROVISIONS. j ISSUANCE 6-��-�����`-^� ��- ��� $ p DATE: �'I�'�I APPLICANT: �ds��eCJ1'.�P1 �� 43[',/��j, SMIP ��i �, r.�`�. � .. . � �j�l� W �i � ENERGY P/C � ' J WARNING FAILURE TO SECUFE WORKEfiS'COMPENSATION COVERAGE IS UNUtWFUL,AN�SHALL BE �y y - � Y ���� � t�+; � SUBJECTANEMPLOYERTOCRIMIN�ALPENALTIESANDCIVILFlNESUPTOONEHUNDflEDTHOUSAND ENERGYPERMI � GT F��a�=a OOLLARS(f100,000�.IN ADDITIDN YOI�iHB�COSTOF COMPENSATION,DAMAGES AS PflOVIDED FOR IN �/� � SECilON3]OBOFTHE4A30RCO�E,INTEREST,ANDATTORNEY'SFEES. RETENTIONFE x F '� - W CO�STRUCTION LENDING AGENCY PRE-ALT FEE: �� ��_ �'�S r � IHEREBYAFFIPMUNDEFPENALNIOFPEft1UqYTHATTHEREISACONSTRUCTIONLENDINGAGENCY - �.:..,�"-< � �'1- FOR THE PERFOFMANCE OFTHE WQRK iOR WHICH THIS PERMI71515SUEG(SEC.309�.CIV.C.). � � ' . Z W � LENOER'SNAME i LEN�ER'SAO�RE55 �� � ICERTIFYTHAiIHAVEREADTNISAPPLICq710NAN�STATETHATiHEABOVEINFORMATIONISCORRECT. TOTAL FEES J ���� � I AGREE TO COMPLY VlITH ALL CITYiAN�COUNTV ORDINANC'e5 AND STATE LAWS RELATING TO BUILDINC+ ��� � CONSTRUCTION,PNDHEREBVAUTHOftIZEflEPRESENTATIVE50FTHI5GOUN7YTOENTEFUPONTHE � ABpVEMEN710NED PROPERTY PoR INSPECTION PURPOSES. COMMENTS - � �Phe�eer� �� ��r��r m, P RMIT E NAME(PRINT) � � ��r.� �. `7�-1�9-�1 (n�. SIGNATUREOFPERMITTEE �'�, � DAiE Z ' _ � �. RECPT.NO. 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