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HomeMy WebLinkAbout12610 (13) ---�� CITY OF DIAIVIOND BAR '` ' '' � � � DEPARTIVIENT OF COMMUNTTY&DEVELOPMENT SERVICES ; � 21b60 E.Copley Drive Suife 190 " � , ... . .._ , :. .,. ;... ;-: � � PRESS (909)860-3195 Fax(909)8b1 3117 � '""_...�' $Uu.D�iv���1�MI`�'A�PLICATION FIRMLY �,� , .. �,..,.,. . a. . �.,.. .. , _.._ . ,.,,,, ..,. _. � . , f., , � JOBSITE � . ;r. � � �:: , , .<�.,.; , >- +� � ; � � APPLICATIQN ,.. �„ � PERMIT '"�� /C o ADDRESS?`'�'�"�� :1 ��" f OATE � NUMBER # � APN LOT .TRACT pATEE NPE OCC p 01NNE� �.S a.•7 ' d`"da CONST. GROUP .� d c /�z.`�s>�, � AODRE S_�2.a��'U„�- _ �, l�d s+� '`�..��' ZONING SETBACKS w FRONT � CIIY�:��•-a;,sts✓ +�<�"ZIF�1� TEL Rw � Af'PLICANT TEL. S DE/SI�E STREET RW ❑ � ChNTRACT�R � °wr r�` G�^/.�'�'�" % �"'1 �e� StDE ❑ AbDRESS t " "% +� � � CITY..S�"�.;; d_�. �C^ ZIP�7���"TELB.."�f''" :i'"1 t ')�� » PROPOSED USE o ARCWENG/ z DESIGNER � ADDRESS NO.DWEL. NO. NO. � CITY ZIP TEL. UNITS STORIES BEDROOMS � v3 DESCRIPTION SQ.FT: FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER DECLARATION SFR/ADD/REM O p I HEREBV AFFIRM UNDEF PENALTY OF PERJURV THAT I AM EXEMPT FROM THE CONTRACTORS�I� G9Yfl B/C8 OfT W CEPlSELAWfORTHEFOLLOV/INGREA50N(SEC.�0.7i.5BUSINESSANDPROFESSIONSCODE:ANVCITYOR (/� g � U �)y7yWH�(,y{REWIRESAPERMITTOC�NSTRUCT,ALTER,IMPROVE,DEMOLISH,ORqEPAIfiANYSTRUC• � PatiolDeck Z TURE,PRIOR TO ITS ISSUANCE.I1LS0 REQUIPES THE APPLICANT FOR SUCN PERMIT TO FILE A SIGNE� �W STATEMEN?THAT HE OR SHE IS LICENSEO�PURSUANT 70'fNE ppOVISIONS-OF?!iE CONTRAtjTORS U� W CENSELAW�CHAPTER9(COMMENCINOWIhISECTIONi000)�oFpNfSION30FTHEBUSINESSRND'PHO� LL' PDoVSPB FESSIONSCODE)ORTHATHEONSHEISEXEMPTTNEREFROMANpTHEBASISFORTHEALIEGE�EXEMP� (� TIGN.ANI'VIOLATIONOFSECTION7031.5BYANYAPPLICANTFORhPERMITSU&lECT57HEAPPLICAfJYTO Z Re-ROOf � AGMI PENALTY OF NOT MORE THAN FlVE HUNDRED�OLLARS(5500).): ' � - � ❑I,ASOWNEROFTHEPROPERTY,ORMYEMPLOYEESWITH9JAGESASTHEIRSOIECAMPENSATION, Commeroia� . - WIIL 00 THE WORK,AND THE STRUCNRE IS NOT IMENDED OR OFGEREO FOR SALE(SEC?o<a,BU54 � � NE85 ANO PqOFESSIONS CADE THE CONTPAC70RS LICENSE LAW DOES NOT APPLY TO pN OWNER OF � PROPERTY Vh10 BUILDS OR IAIPROVESTHEREON,AND WHO DOEE SUCH WORK HIMSELF oR HER�EL�OR � THpOUGH HIS OR HEROWN EMPLOYEES,PROVIOEDT}1ATSUCN IlIPR6VEMENTS ARE-NOT INTE'NOED OP m 0 ,OFFERWFORSALEIF,F�IOWBVERTNEBUIIAMGORIMPRDYEMENTIS3OLDWITHINONEYEAR'tlF�f:OMPIE� z TION,THE OWNERAUILDER W�LL HAVE 7HE BUPOEN OF�PROYING THAT�HE OR�SNE DI�NOT'BUILD OR = IMPROVEFORTHEPURPOSEOFSqLEZ ' � � �' ❑I,AS OWNEH OF THE PROPERTY,AM EXCLUSIVEIY CONTRACTING WITH LICENSEO CONTtYACTORS � TO CONSTRUCT 7HE PRQIECT(SEC.�014.BU$INE55 AND PROFESS10N5 CODE�.TH�CONTPACYORS Lb ValUation ADJ.AFiEA W CENSEUWOOESNOTAPPLYTOANOWNEROFAPFOPERTYWH�BUIL�SORIMPRbVESTHERE04,AN0 — � WF4000NTRACTSFORSUtliPR0.1ECTSWITHACANTRACTOP(S)LICENSE�PURSUANTTO7HECONTRAG QUANTITY DESCRIPTION FEE 70RS LICENSE LAW.). ..j � ❑I AM EXFMPT UNDER SEC. B.8 P.C.FOR THIS REASON Q �~�-�G,. �-''��!�!c� � — � �-� � DATE OWNER � � � �n � ��`� y�-� � � G" � LICENSED CONTAACTORS DECLARATION W - ' � OC IHFREBYAFFIRMUNDERPENALNOFPER1UflYTHATIAMLICEN5E0UNDERPROVISIONSOFCHAPTEfl � p� 9(COAAMENCINO WITH SECTION)OOD)OF DIVISION 3 OF THE BUSINESS ANO PROFESSIONS CODE,AND � X MY LICENSE IS IN FULL FOfiCE AND EFFECT. r'y ,r ' '`5'"� g � LIGENSE SS ~r� LIC.NO.. � ~ DATE r� l ' 'a.' .. -- U � °'� __ CONTRACTOR ^°�-� �� +- F` °� 0. ' LLt � WORKERS'COMPENSATIONDECLARATION ���`'� r Q � �HGREBVAFFIRMUN6ERPENALTVOFPERJURYONEOFTHEFOLLAWING�DECLARA'fiON� �`� Z �- � __IHAVEANDWILLMAINTAINACERTIFICATEOFCANSENTTOSELP-INSUREFORWORKERS' � S COMPENSATION,AS PAOVIDE�9Y SECTION 31�0 OFTHE LABOR CODE,FOR THE PEqFORMANCE W Q �OFTHE WORK FOR WNICH THIS PERMIT IS ISSUED. � W ', Ir' _1 HAVEAND WILL MAINTAIN WORKEFIS'COMPEN$A710N INSURANCE,AS REQUIRED BY SECTION � 37a00FTHE!A80RWDE,FORTHEPERWflMANCEOFTHEYdORKFORWHICHTHISPERMiT15 ISSUE�.MY�NORKERS'COMPENSATIDN I SURANGF'.,'CARRIER ANO POLICV NUMBER ARE: � CONSTRUCTION � 9,�` � CARRIER��'A�� �j �r''`_✓` � PLAN REVIEW Z POLICY NUMBER_..��v f+�N 6� ` y�_� �� Q ' 0 (iHSSECi%XJNE87NOTBECO?.PLETEDOFhIEPEM4TISFOA04EHU�^AFiEDIXXUW5�S7ao)ORLE55} PLUMIBING W Z I CEPTIFY THAT IN THE PERFORMANCE OF TNE WORK FOR WFIICH THIS PERMIT IS ISSUEO,I MECHANICAL C!S SHALLNOTEMPLOYANYPERSONINANYMANNERSOASTOBECOMESUBJECiTOTHE y WORKERS'COMPENSATIONLAWSOFCALIFORNIA,ANDAGREETHATIFISHOUL�BECQME INSPECTIONFEE � SUBJECTTOTHEW6RKERS'COMPENSATION7RDVISIONSOFSECTION3'1o00FTHELABOR - � coo,i sH r-oaniwirn co�nP�v w� THUSE PROVISIONS..- �;/" , ,�. ISSUANCE o � OATE: � A� a/� APPLICANT:� i- � �'�r C���� SMIP �1II�II�_�_�[]�PI W WARNING:FAILUFETOSECUREWORKERS'COMPENSAX� NCWEflA ISUNLAWFUL,AN03HAlLBE ENERGYP/C l��r v� } ' SU&IECTANEMPLOYERTOCRIMINALPENALTIESANOCNILFINESU 70CNEHUNDREDTHOUSANO ENERGYPERMI�TY�R�����r'E��A'p '. DOiLARS(Stao,000LMADDITIONTOTHECOSTOFCOMPENSATION,DAMAGESASPflOVIDEOFOflIN ��a r�r,t�� WSECTION 37oe OF iHE LABOfi CO�E,INTEREST,AND ATTORNEV'S FEES. � T�T������ aC RE7ENTION FE ��.,,,,q� A rn�� � O CONSTRUCTION LENDING AGENCY PRE-ALT FEE: � �HEREBYAFFIRMt1NDERPENALNOFPERJURYTHATTHEREiSACANSTRUCTIONLENDINGAGENCY � ' � FORTHE PERFORMANCEOFTHE WORK f4R WHICH THIS PERMIT IS ISSUE�(SEC.3097,CIV.CJ. . Z W � LENOER'SNAME �� � - � � . � " ' �' 0— LF.W[IEWSA�DRESS � TOTAL�EES a � �CEpTIFV THAT I HAVE flEAD TMIS APPUCATION AND STATETHATTHEABOVE INFORMATION IS CORRECI: W tAGRESTOCOMPLVWRHALLCITYANDCOUNTYORDINANCESANDSTATELAWSREUTINGTOBUIL0ING Q_ � CONSTRUCTION,AN�HEREBYAUTHOR2EREFRESENTATIVESOFTHISCOUNTYTOENTEHUPONTHE � Z ABOVE-MENTIONEO PFiDPEflTY FOR INSPECTION PURPOSEfl . � �� y^/ COMMENTS Gti l.,%.'�t��.s" /-'l�.,��-.,�'. � .�-/7�C. � P AIITTE AME(PflINT} . ' �, :� � . �: ��` ;-°-�.'' /°I �° �,= i, � � SICSNATU OFP'cRMIT'fF� C1ATE. '. �'.. :.'... . 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