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Home My WebLink About13576 (14) � CITY OF DIA1VdOND BAR ` ---�� DEPARTMENT OF COMIVIUNITY&DEVELOPMENT SERVICES ��,.s�'� ,� 21560 E.Copley Daive Suite 190 :,..M.,,., (909)860-3195 F�(909)861-3117 PRESS "�' .: ; BUQ,DING P�'1�1dITT'API"LICAT�dN " , , - ,...,�N �, ,.. ,.. , ,,. , , .:.. , FIFiML`lf :,.: , .,.,, �,,.v, , .: ,, ,,.� . ,�,.:. � JOBSITE )�b�� /��L � APPLICATION � PERMIT � P/C o ADDRESS � r� DATE � "'��"K � NUMBER ��CR"# $ APN LOT TRACT pAT�E ,4`j _�r� _c� TYPE OCC p OWNER Ts�9'!� �CONST. GROUP /a'`,� ADDRESS �' @ ZONING SETBACKS Z CITY ZIP TEL. � d REART RW ❑ Q APPLICANT TEL. SIDE/SIQE STREET RW ❑ � CONTRACTOR �r �"PI��TIn SiDE ❑ � ADDRESS_ ` PROPOSED USE �Tr- �J�� L N. � �/�Sn�.#-f. a CBTY fNp7� --,- ZIP� � TEL. Z. ��/`� �-�—G� wo ARCH/ENG/ r- d 5,�� z DESIGNER � ADDRESS NO.DWEL. NO. NO. — UNITS STORIES BEDROOMS N CITY ZIP 7EL. ____ cn DESCRIPTION SQ.Ff. FACTOR PSF ADJ.AREANALUATION � OWldER-BUILDER DECLARATION SFRlADD/HEM o I HEREBV AFFlPoA UNDEii VENALTY OF PERIURY THAT I AM E%EMAT fROAI THE CONTRACTORS LI- G3/8 JB{C81pOft W CENSEUWiORhiEFOILOWINGREASON(SEC.7097.SBUSMESSANDPROFESSIONSCODE:ANYCITVOft (� � COUNTYWHICHBEWIRESAPERMITTOCONSTRUCT,AL7ER,IMPROYE,DEMCLISH,ORREPAIRAM1'YS'IiUG (,{,J pati0/DeCR TURE,PRIOR TO ITS ISSUANCE.ALSq REQUTAES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNEO W _ STATEMENT TNAT HE Ofl SHE IS LICENSEO PUNSUANT TO THE PROYISIONS OF TME CONTRACTORS LI� � CENSE LAW I��ER B(COMMENCINO WITH SECT�ON 7000)OF OIVISION 30P THE BUSINESS AND PRO- �'�' POOUSpd FESSqNSCOOE�ORTHATHEORSHEISEXEMPTTHEREFROMANDTHEeASiSFORTHEALLEGEDEXEMP� (R TION.ANYVIOLATIONOFSECTIONTo31.58YANYAPPLICANTFORApEAMI7SUBJEC7STHEApPLICANTTo � Re-RoOf F, ACIVILPENALTV OF NOT MORE THAN FNF HUN�RED DOUlRS(f600).�: " � ❑I,ASOWNER�FYHEPROPEHTY,ORMVEMPLOYEESWITHWAGESASTHf_IRSOLECOMP[NSATION, ❑ Commerciat _ � VALL DO THE IHORK,AND THE STRUCTURE IS NOT IN'ENOED OR OFFEfiEO�FOR SRLE(SEC:7040,BU51- J � NESS AND PflOFE5510N5 COOE:THE CANTRACTORS UCEtdSE lAW DOES NOT APPIY TO AM1 OKMEfl OF = PqOPERTY WIiD BUILDS OR MAPpOYES hiEREON,AND WHO DOES GUCH WOFiK HIMSELF OR NERSELF OR OC THFbU0HHI50R�HEROWNEMPLOYEES.PROVIDEDTFiATSUCHIMPROVEMENTSARENOTINTENDEDOR � WG OFFEpEDFORSALEIF,HOWEVEii,h1EBUIlQINGOpIMPROVEMENTI550LbWITHINONEYEAROFCOMPLE- Z �TION,THE OWNER�BUIIDER UIILL HAVE THE BURDEN OF PROVWG THAT HE OR SHE DID NO7 eU1lD DR � 1MPROVEF-0RTHEPURPOSEOFSALE). ❑I,AS OWNEROFTHE PflOPERfV,APi EXC,�USNELYCONTRACTING WITH UCC-NSED CONTRACTOflS �y � TO CONSTRUCT THE PROJECT(SEC,7044,BUSiNESs A�YC PROFESS{ONS CODE:THF.CON'f�ACTpR5 LI- Vr11U8lf01i � �60 ADJ.AREA W CENSElAW00E5NO7APPLYTOMIOWNEROF0.PADPERTYWf-0O@UILDSORIMPROVE9TH�qEQN,AND ------ f VA�OCONTRACTSiOASUCHPFlQIECT9WITHACONTRACTOR�S)LICENSEDPURSURNTTOTHECONTRAP ClUANTITV DESCAIPTION FEE Y TORSLICENSELAW.). _ _ _ � O I MI EXEAtPTUNDER SEC. �0.8 P.C.FOR TVil5 REJ�SON J - O -- V � . �� — 2 4' DATE _._._ OWNER __._._.__-___.__-- U � � �Q LICENSEO CON'iRACTOFS DECIARATInN � OC I HEREBV AFFIRAd UNOER PENAL.N OF PEHJURY THAT 1 A!A LICENSEO UNDER PROVISIONS SJF CHAP'ER � p_ B(COMMENCINO WITH SECTION 7aoo}OF DIVISION a OF TkE BUSINESS AND PROFESSIONS Co6E,AN� z X MY UCENSE IS IN FULL FOflCE AND EFFEC?. � ^��':_1_�;�,}� LLJ / ,�E � UCENSE CLASS�� LIC.NO. L��-�T�t� � � �'�" DATE CUNTRACTOR C30d�,� W -�`��--- �� , � WOFiKERS'EOMPENSATION DECLAFATION Q �� x �<%'$ k. . ��+? . � IHEREBVAFFIRMU!rDEHPENAI.?YOFPERJURYONEOFTHEFOLLpWINGDECLARATIONS: Z `°� �.�." .� q�R(�.e�a�`4a j�.41�b.j?. � Q . T � _j�IHl1VEAMDWILLMAINTAINACERTtFICATEOFCONSENTTOSFLF-INSURE�OtiWORKERS' � � �"^y='��-�'+�.:�SK.3.1'�9:�.°s_��:3:';,�"'„i.::.� u Q COMPEh'SAT10N,AS PROVIDEO BY SEC710N 3iao OF THE 1A80R CODE,FOR YHE PERFORMANCE W OF THE WORK FOR WNICH THIS PERaIIT IS ISSUE6. � p �t HAVE AMD WiI.L A�NM7AIN WORKEFS'C00.9PENJSATION INSURANCE,AS REQUIREO BY SECTION /� � a7000FTHELA60RCO0E.FORTHE7ERFORMANCEOFTHEWORKFofiWHICHTHISPERMiTIS � yv�� `�1� ISSUEO.MV WORKERS'COMPEPoSAiION INSURhNCE CARRIER ANO POLICY NGMBEF AflE CONSTRUGTION _ 4�� b� � GARRtER_� � _ PLANREVIEW _.___.. � aIX.�cY�UMeER,�.� --��____ �LEC7P.IC _ Q n (141LSSECiIONNEH7tvOTBEOJMR_ETEDCF'fF!EPHiPNTlSFORQNEtRihD.4EDWLLANS�$iW)ORLESS� PLUMBING � Z' I CERTIF!THAT IN 7i1E PERFORMANCE Of THE WORK FOR WHICH THIS?ERMIT IS ISSUE4 I MECHANICAL (5 SHALLNOT EMPLDYANV PERSON IN ANY MANNER SOAS TO BECARAE S'JBJFCT TO THE �yy WORKERS'COMPENSA:IONLAWSOFCALIFORM1IA,ANDAGREETHATIFISHOULOBECOME �IJSr�'ECTION FEC _ S �� S SUHJECT Ta TNE WORKERS'CUMPENSATiON PROVI IONS OF SECTIOtd 370o OFTHE LI�BOR CODE,ISHAL4FORTMWI7HCOMPLYWITHTHOSEP OVISIONS. — sJ iSSUANCE p DATE��_� APPLICANT: �'- —�'" SMIP � �� ENEFGY P/C WARNIN(3:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUI,AN�SFIALL BE � SU&IECTANEMPLOYERTOCRIMINALPENALTIESANDCIViLFINESUPTOONEHUNDREDTHOUSANtl ENERGYPERMIT OOlUflS(5��,�),IN�DITION TO hiE CAST OF CCMPENSATION,DAMAGES NS PROYIDED FOR IN � SECT�ON37080FTHELABORCOOE,INTEREST,ANDATTORNEV'SFEES. FSETENTIONFEE: d CONSTRUCTION IENDING AGENCY PRE-AlT FEE: O � I HEREBY AFFIRM UNDER PENALTY OF PERJIIpY THATTHERE IS A cONSTRUCTiON LENDING nGENCY FORTHE PERFORMANGE OF iHE WORK FOR WHICH lHiS YERMIT IS ISSUEl7(SEC,ao9�,CN.C.). Z W — � LENOEFi'SNAME � f— LENOER'SADDRESS � TOTAL FEES `� �'/ I CERTIFY THAT I HAVE READ THIS APPLICA710N AN�STATE THAT THE ABOVE INFOFMATION IS CARRECT. � IAGREETOCOMPLYWITHALLCI7VANOCOUN7YOR�INANCESANOSTATELAWSREI.ATIN67OBUIlDING �i"Z-a r�� CANSTRUC710N.ANDHEREBYAUTHORIZEREPRESENTATIVESOFTHISCOUNTYTO�ENTERUPONTHE � � A90VE�0.1ENiIqVEOPROPERT.�FORINSPECTIONPUPPOSES. COMMENTS � ____�l-l�il��' S. �C � �J � PEflMRTEEN E�i FUM) ' I� / � �� l �..s'v.a.r �_�1�� SIGNATUREOFPERMITTEE DATE � �� - . . � RECPT.NQ. ___. 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