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HomeMy WebLinkAbout17359 CIT'Y OF 1�IAMOND BAR � --- �''�'`'-- DEPAF2.TME�IT OF COMMUNTTY&DEVELOPMENT SERVICES � � � � Z 1825 E.Copley Drive `"" (909)&60-3195 Fax(909)861-3117 PRESS '"'-.v����' BiJYI:]DING PERNIIT APPLYCAT[ON FI R M LY � JOBSITE � � APPLICATI�N a t � O PERMIT «�N P/C v ADDRESS DATE__ (�� NUMBER_r r�1�__ # o ISSUE TYPE OCC °� APN LOT TRACT DATE CONST. GROUP p OWNER �� ADDRESS �L,,, ZONING SETBACKS oCITY�%�� Fi/FL_ ZIP TEL. � � REART RW o o APPLICANT TEL. SIDE/SIDE STREET RW ❑ z ¢ CONTRACTO C� SI�E ❑ p� ADDRE�S � CI ZIP TEL. PfiOPOSED SE o ARCWENG/ �� � W ,DESIGNER NO.DW L. r O. , � ADDRESS UNITS STORIES BEDROOMS I � GITY ZIP 7EL. � � �ESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-BUILDER DECLARA710N SFR/ADD/REM O 0 I HERE6V AFFIpM UNDER PBJALTY OF PERJURY THAT 1 AM EXEMPT FROM THE CONTRACTORS LI- � Garage/Carport � W CENSELAWFOR7HEFOLLOWINGflEASON(SEC.7o37.5BUSINESSANOPROFESSIONSCO�E:ANYqNOR Z, COUNTYWNICHREOUIRESAPERMITT6CONSTRUC7,ALTER,IMPROVE,DEMOLISH,ORREPAIRNNYSiRUC- W patio/Deck W. TURE,PRIOR TO ITS ISSUANCE,'AL50 REQUIFES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNE� w �STA?EMENT THAT HE OR SHE IS LICENSED PU(iSUANT TO THE PROVISIONS OF T4E CONTRACTORS LI- �. CENSE LAW(CHAPTER 9(COMMENCING Wli}i SECTIDN 7000)OF DIVISION 3 OF THE BUSINESS ANO PRO- � POOIISp2 FESSIONSCOOE)ORTHATHEDFSHEISE%EMPTiHEREFROMANC7THE8ASISFOPTHEALLEGEDEXEMP- � � �TION.ANVVIOIATIDNOFSECTION7031.39VANYAPPLICANTFORAPERMITSUeJECTSTHEAPPUCANTTO z Re-Aoof A CIVIL PENALTY OF NOT MORE THAN FlVE HUN�flED DOLLAFS(S5o0).): Z�. ❑I,ASOWNEROFTHEPROPERTY,ORMVEMPLOYEESWITHIVAGESASTHEIRSOLECOMPENSATION, ❑ Commercial - - WILL�O THE WORK,AN�THE STRUCTURE IS NOT INTENDED OR OFFEFED FOR SALE(SEC.7044,BU51- J NESS ANO PROFESSIONS CODE:THE CONiRACTORS LICENSE LAW�OES NOTAPPLY TO AN OWNER OF � ���PHOPERTYWH09UILDSORIMPROVESTHEREON,ANDWHODOESSUCHWOFKHIMSELFORHERSELFOR = �. �THROUGHHISORHEROWNEAAPLOYEES,PROVIDEOTHATSUCHIMPpOVEMENTSARENOTINTENDE�OR m � OFFEPE�FORSALE.IF,HOWEVER,THE6UfL01NGORIMPROVEMENTISSOLDWITHINONEYEAROFCOMPLE- Z ,TION,THE OWNER-Bl11LDER WILL HAVE THE BURDEN OF PROVMG TFIA7 HE OR SHE DID NOT OUILD Oq �. 'IMPROVEFORTHEPURPOSEOFSALE). w.�. ❑I,ASOWNEROFiHEPROPEIiT;�AMEXCLUSNELYCONTRpCTINGWITHLiCENSEDCONTFACTORS [[', �.TO CONSTRUCT THE PROJECT(SEC.7044,HUSINE55 ANO PROfE5510N5 CODE:THE WNTRACTORS LI- V8IU2110f1 A�J.AREA W� �CENSELAWDOESNOTAPPLYTOANOWNEftOFAPfiOPERTYWHOBUILD50RIMPROVESTHEREON,AND �� WHOCONTRACTSFORSUCHPROJECTSIMTHACONTPACTOR(5)LICENSEOPURSUANTTOTHECONiRAP QUANTITY DESCRIPTION FEE � Y .7oRSLICENSELAW.). � ❑I AM EXEMPT UN�ER SEC. B.6 P.C.FOR THIS REASON � �' � � DATE OWNER � Z W � LICENSED GONTRACTORS DECLARATION W ¢ � I HEREBYAFFIRM UN�ER PENALTY OF P'cRJURV THAT IAM LICENSED UNDER PROVISIONS OF CHAPTER � p_;' 9(COMMENqNGWITMSECTION700o)OFDIVISION30FiHEBU51NE55AN�PPOFE5510N5CODE,AN� z `X�' MY UCENSE IS IN FULL FOftCE AND EFFEGT. m � LICENSECLASS LIC,NO. � � V �ATE I"� �' J CONTRACTOR � a W � WORKERS'COMPENSATION DECLARATION -� Q � U �, IHEREBYAFFIRMUNDERPENALTYOFAERJl1RYONEOFTHEFOLLOWWGDECLARATI0N5: z � _IHAVEANDWILLMAINTAINACE,RTIFICATEOFCONSENTT03ELF-INSUREFORWORKERS' _ C�MPENSATION,ASPFOVI�ED�BYSECTION3'loaOFTHELAeORCODE,FORTHEPERFORMANCE U ¢ OFTHEWOfiKFORWHICHTHISPERMITI5ISSUED. � 0 W _IHAVEANDWIILMAINTAINWOI�KERS'COMPENSATIONINSURANCE,ASRE�UIREDBYSEC710N j� d 37000FiHELABORCO�E,FORTHEPERFORMANCEOFTHEWORKFORWHICHTHISPERMITIS v �� ISSUE�.MY WO/RK�EAS'COMPEN�TION IN ANC�E^C�A�RIERAND POLICY NUMBEFiARE: CONSTRUCTION R j�� caaaiEa �s��, t/[i_� - PLAN REVIEW Z' PDLICYNUMBER I �, ,���______.___ ELECTRIC Q 0 (iFi�SS�iIONNE�NOTBENMFLEfE�OFh�PERMfiISFORONEHUNDREDDOlLARS($100)oRLE55). PLUMBING Z I CEPTIFYTHAT INTNE PEFFOR'MANC'e OFTHE WORK FOR WHICHTHIS PERMIT IS I55�E�,l MECHANICAL (3 SHALL NOT EMPLOY ANV PERSON IN ANV MANNER SOAS TO BECOME SU&IECT TO THE Uj. WORKEFS'COMPENSATIONLA�JSOFCALIFORNIA,ANDAGREETHATIFISHO�LDBECOME INSPECTIONFEE � SUBJECTTOTHEWORKEr�S'COMPENSATIONPROVISIONSOFSECTION97000FiHELABOfl CO�E,I SHALL FORTHWITH W�1PLY WIiH THOSE PROVISIONS. ISSUANCE /7� � �� � SMIP i(/ p DATE: APPLI¢ANT: - �� WARNINGFAIIVflETOSEWREWOFK�flS'COMPENSATIONCOVEFIAGEISUNLAWFUL,ANDSHALLBE ENERGYP/C � �� SUBJECTANEMPLOYERTOCRIMINAL�ENALTIESANOCIVILFINESUPTOaNEHUNDRE�THOUSANO ENERGYPEfIMIT �OLLARS(5100,000),IN ADDITION TO THE COST OF COMPENSATION,�AMAGES AS PROVIDE�FOR IN � SECTION 370B OF THE LABOR CODE,IN7EREST,ANDATTORNEY'S FEES, RETENTION FEE: -s^ ��� CONSTRUCTION LENDINGAGENCY PRE-AL7FEE: O � IHEREBYAFFIRMUNDERPENALT'DF pERJUFYTHATTHEREISACONSTRUCTIONLENDINGAGENCV FOR THE PERFOflMANCE OF THE�WORI�FOR WHICH THIS PERMIT IS ISSUED(SEC.3097.CIV.C.). Z W �, LEN�ER'S NAMe F_' LENDER'SA�DRE55 . � TOTAL FEES � 3�, �D � ICERTIFYTHATIHAV'cREADTHISAPPI;ICA7IONANDSTATETHATTHEABOVEINFORMATIONISCORRECT. W' IAGREE TO CO�UPLV WITH ALL CITV AN�COLJNTY ORDINANCES AND STATE LAWS RELATWG TO BUIL�ING � CONSTAUCTION,ANOHE4iEBYAUTHOF�IZEREPRESENTATIVESOFTHISCOUNTYTOcNTERUPONTHE �'� ABOVE-MENTIONED P OPERN FOH IN$PECTION PURPOSES. Q. � , �� COMMENTS � � � m PERMIiTEE �PRINT) - � � � SIGNATUFlEOF EE . DATE = RECPT.NO. 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