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HomeMy WebLinkAbout16970 �� CI1'Y OF I3IAMOND BAA �- i -----�"`---- DEPART'MENT OF COMMUNII'Y&DEVELOPMENT SERVICES /� �. �./ 21825 E.Copley Ilrrive - " (909)86U-3195 Fax(9Q9)861-3117 • PRE$$ "`-�r�'° �uii.nnvG r�x�T�ra.ica°rioN FI R M LY o JOBSITE � Y°��� �I ������ � DATE CATION �p�� �` NUMBER ���� # ��! PERMIT P`� P!C ¢ ADDftESS_ [ � � 4 � I5SUE TYPE OCC , APN a' ' LOT �r TRPCT ��-� DATE CONST. GROUP p OWNER _ : • {'� I r��t�_�,�i o ADDRESS �,1 f� � �°` ��f�'i"1"!��2- �,'Z�. ZONING SETBACKS z CITY d� � �r'Ta,� r`�"LIP �7�,i�EL. ri�l�^" I3���s� FRONT RW ❑ � APPLICANT I�'1'A,YY�n �/L.. �Gj-� TEL. � �''�,5""`� `�� REAR ❑ , � ° SIDE/SIDE STREET RW ❑ z ¢ CONTRACTOR SIDE ❑ ADDRESS � CITY ZIP TEL. PROPOSED USE �� �" � ARCH/ENG/ �, i z DESIGNER �� �'��� ��''�.�JCo W NO.DWEL. NO. NO. a ADDRESS "7-��i i'3' t2-�Yr� �� � ''+�1n/ UNITS STORIES BEDROOMS � CITY�?��s�d(� �6 f'r�7.�L. ZIP `�� 7EL. "��! - ir � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � p� OWNER-BUILDER DECLARA�fION SFFUADD/REM O �� 1 HEREBY AFFIRM UNDER PENALTY OF PEflJURY THAT I AM EXEMPT FROM THE CONTRACTOR5 LI- GRlBgE/C2fPOft W "CENSEIAWFORTHEFOLLOWINGREASCN(SEC.7035.5BUSINESSAN�PRCFESSIONSCODE:ANYCITYOR (/) . '. C� COUNTYWHICHREQUIRESAPERMITTOCONSTAUCT,ALTER.IMPROVE,DEMOlISH,ORPEPAiRANVSiRUG W pdtl0/DECk '� w� .TURE,PFIOR TO ITS ISSUANGE,AL50 REQUIRES 7HE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED W STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI� � ��", �CENSE LAW(CHAPTER 9(COMMENCING WITi SECTION 7oDo)OF�IVIS!ON 30F THE BUSINESS AN�PRO- �',' PooUSpa Q�''�,',FESSIONSCODE)ORTHATHEORSHEISEXEMPTTHEflEFROMANDTHEBA515FORTHEALLEGE�]EXEMP- (� V.� TION.AN�VIOLATIONOFSECTION7a31.56VANYAPPLICANTFOR0.PERMITSUBJECTSiHEAPPLICAN7T0 Z Re-Raof � +.A qVIL PENALTY OF NOT MORE THAN FNE HU��DRED OOLLARS(SSoo�.): � 0', � ❑I,ASOWNEROFTHEPRpPERTY,ORMYEMPLOYEESWITHYYAGESASTHEIR50LECOMPENSATION, 0 Commercial - z� �,WILL DO THE WORK,AND THE STRUC7URE IS NOT IN7ENDE�OR OFFEREO FOR SALE(SEC.70d4,BUSI- J �.'. NESS AND PROFE3SION5 CO�E:THE CONTRACTOFS UCENSE LAW DOES�OT APPLY TO AN OWNER OF ? PROPERTY WHO BUILDS OR IMPROVES THEREON,AN�N'HO OOES SUCH WOflK HIMSELF OR HEFSELF Oq �' '�THROUGH HIS OR HER OWN EFAPLOVEES,PROVI�EDTHATSUCH IMPROVEMENTSARE NOT INTENDED OR m �. OFFERE�FOR SALE.IF HOWEVER,THE BUILOING OR IMPROVEMENT ISSOLD WITHIN ONE VEAR OF COMPLE- Z I.TION.THE OWNER-BUILDER WILL HAVE THE BURDEN OP PROVING THA7 HE OR SHE DI�NOT BUILD OA MPROVE FORTHE PURPOSE OF SALE). (_ '� OI,ASOWNEROFTHEPROPERTY,AMEXCLUSIVELYCONTRAGTINGWITHLIGENSEOCONTRAGTORS [[ . TO CANSTRUCTTHE PflOJECT��SEC.7D44,BUSIhESS AN�PROFESSIONS CODE:THE CONiRACTORS LI- V3IU2tlOfl ADJ.AREA _� �.CENSE LAW DOES NOTAPPLYTOAN OWNER OF A PROPERTV WHD BUILDS Ofl IMPROVES THEREON,AN� , � �WHOCONTRqCTSFORSUCHPqOJECTSWITHACONTqACTOR(5)LICENSEDPURSUANTTOTHECONTRAG QUANTITY D SCRIPTION FEE Y TORS LICENSE LAW.)_ ' - � ��� ❑I AM EXEMPT UN�ER S�C. 8,&P.G FOR THIS REASON U � DATE ^� OWNER � ���� U Z' W � � LIGENSED CONTRACTORS DEGLARATION � ¢ � IHEREBYAFPIRMUNDERPENALTYOFPERJUflYTHATiAMLICEN5E0UNDERPROV1510NSOFCHAPTER � d, .9�COMMENCMG WRH SECTION 7a0o)OF DIVISION 3 OF THE BUSINESS AN�PROFESSIONS CO�E.AND Z �X MV LICENSE IS IN FUIL'�FORCE AND EFFECT. m ��� LICENSE CLASS LIC,NO. j F- J V DATE CONTRACTOR d - W � � WORKERS'COMPENSATION DECLARATION ¢ "�'� NIHEREBYAFFWMUNDERPENALTYOFPEfiJUftVONEOFTHEFOLLOWING�ECLARATIONS: Z C] IHAVEAN�WILLMAIMAINACERTIFICATEOFCONSENTTOSELF-INSUpEFORWORKER5 = CAAIPENSATION,ASPROVIDEDBVSECTION370oOFTHEL480RCODE,FORTHEPERFOPMANCE U Q OF iHE WORK FOR WHICH THIS PERMIT IS ISSUED. � � w I HAVEAND WILL MAINTAIN WOPKERS'COMPENSATION INSURANCE,h5 REOUIRED BY SECTION a� ,/� .p Q 370o OF THE LABOR CODE,FOR THE PEFiFORMANCE OF THE WORK FOR WHI(7iTH15 PERAIIT i5 1�4„'�+► ISSUED.MYWORKEFlS'COMPENSATIDNINSURANCECAFflIERANDPOLICYNUMBERARE: CONSTRUCTION �� ".d J 4 � CARRIER PLAN REVIEW �� .. J L] POLICYNUMBEP ELECTR� ' "" _�,a.���� �, a'_"'.,-:.-. Q � �u---'� ��'+ _ � Q (IHISSECiIONNEmNOTBECi�MPLETEDOFiHEP67MITI5FOPqJEHUNDRE�NLIARS(5100�ORLESS�. PLUMB N.E�-� - 2� I CERTIFY THAT INTHE PERFORlAA�CE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I MECHA ICAL,�1 ��� ('_� SHALL N07 EMPLOY ANY PERSON IN ANY MANNER SOAS TO BECOME SUBJECTTO THE ( � Uj WORKEftS'COMPENSATIONLAWSOFCA_IFORNIA,ANOAGRe6THATIFISHOUL�BECOME INSPE�ION�� '" �" y SU&IECT T0 THE WORKERS'COMPENSATION PROVISIONS OF SECTION 3�oa OF THE LABOR p � CODE,ISHALLFORTHWITHCOMPLYWITHTHOSEPROVISIONS- ISSUAI�CE _ � � ~ $S� �a Q 4 y�. p DATE: APPLICANT. SMIP ��''�,To � ,,.w,i ENERG�PY�`�,v,�.....__.. _ _ _., J WARNlNGFAIWRETOSECUREWOAKERS'COMPENSATIONCOVERAGEISl1NLAWFl1L,ANDSHALLB'c LL SU�JECTANEMPLOYERTOCRIMINPLPENAL:IESAN�CIViLFlNESUP700NEHUN�REDTHOUSAND ENERGYPERMIT � OO�LAFS(51 W.000),IN ADDITION TD THE COST OF COMPENSATION,�AMAGES PS PROVI�ED FOR IN � SECTION 37oe OF THE IABOR COOE,INTEREST,ANDATTORNEV'S FEES. RETENTION FEE: _ _ bCONSTRUCTION LENDING AGENCY PRE-ALT FEE: '', � 1 HEREBVAFFIPM UNDER PENALiV OF PERJt1RY THATTHERE IS A CONSiRUCTION LENDING AGENCV FOR THE PERFORMANCE OF THE WORK FOR WHICH THI&PEPMIT IS ISSUED�SEC.3097,CIV.C.). . � C� �� LENDER'S NAME I"- LEN�ER'SAOORE55 � ICEflTIFYTHATIHAVEREADTHISAPPLICATIONANDSTATETHATTHEABOVEINFORMATIONISCORqECT. TOTAL FEES Y j�, ��, I AGREETO COMPLV WIiH ALL CITV AND COUNTY OROINANCESANO STATE LAWS RELATING 70 BUILDING �• �, CONSTFUCiION,ANDFIERE6YAUTHORIZEREPRESENTATIVESOFiHISCOUNTYiOENTERU?ONTHE ABOVE-MENTIONED PROPERTV F INSPECTION PURPOSES. COMMENTS - � �Q� ��/II � .,��/� �r^�1:7 ���°� � '' � PERMITTEE NAME(PRI�ITj� � �� �� `Q � u� � ����i� (/� SIGNA7UREOFPERMITTEE OATE y �� � RECPT.NO. 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