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HomeMy WebLinkAbout17294 (10) CITY OF I�IAMOND BAR �;� -----�����---- I3EPARTMENT OF COMMWi TI'Y&DEVELOPMENT SERVICES I I � 21825 E.Copley Drive �" (909)860-3195 Fax(909)861-3117 PRESS `�'%��^�� BUILI2ING PERMIT APPLICATION FIRMLY y JOBSITE /"LL�, ,�.. �j���� J �„����� DATECATION��4'�1_ � NU B R ��a�y#/C o ADDRESS T�� �ti <.a��r v��rr � IssuE —�TYPE OCC r APN---y�� LOT TRACT DATE CONST. GROUP p OWNER KfJSC?lJ'Ja9s�—��I ol1�� � ADpRESS ZONING SETBACKS Z CITY ZIP TE � FRONT RW ❑ � APPLICANT T��, REAR ❑ � SIDElSIDE STREET RW ❑ Z ¢ CONTRACTOR SIDE ❑ � ADDRESS �� ,�_ PROPOSED USE � CITY '� � u Y�. TEL. w ARCHIENG/ a.ewood,�A; �9792 WDESIGNER NO.DWEL. NO. NO. n. ADDRESS UNITS STORIES BEDROOMS ' � CITY ZIP TEL. cn �i � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION ', p� OWNER-BUILDER DECLARATION SFR/ADDIREM � O ' 0 I HEREBV AFFIRAA 11N0ER P�NALTY OF PERJl1RV THAT I AM EXEMPT FROM THE CDNiRACTORS LI- GgfdgE/Cflf(JOI't W CENSELAWFORTHEFOUAWMGREASON(SEC.7o31.5BU51NESSAN�PPOFESSIONSCODE:ANYCITYOR (n � 'COUNTVWHICHREOl11RE5APERMITTOCANSTRUCT,ALTER,IMPf70VE,DEMOLISH,ORREPAIPANYSTqUG W pgtiolDeCk � TURE.PRIOR TO ITS ISSUANCE,ALSO RE�UIfiES THE APPLICANT FOR SUCH PEFMIT TO FILE A SIG!JED STATEMENT 7HAT HE OR SHE.IS IIICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS L4 W �. CENSE LAW(CHAPTER 9(COMM��ICING".WITH SECTION]000)OF�IVISION 3 OF THE BUSINE35 AND PRO- � PoollSpa FESSIONSCOOE)ORiHATHEORSHEIS'EXEMPTTHEREFROMANOTHEBASISFORTHEALLEGEDEXE�AP- (� � '.TION.ANYVIOLATIONOFSECTION7o31.6BYANYAPPUCANTFORAPERMITSUBJECTSTHEAPPLICANTiO Z Re-Roof � A CIVIL PENALTV OF NOT MORE THAN FIVE HUNDRED OOlL4R5(3500).): C I,AS OWNER OF THE PROP�RTY,OR MY EMPIOYEES W ITH WAGES AS 7HEIR SOLE COMPENSATION, Z� � Commercial - WILL DD 7HE WORK,AND THE 5TRUCTVRE IS NOT IMENDED OR OFFERED FOR SALE(SEC.7044,BU51- J � NE55 AN�PROFESSIDNS CODE:TiHE CONTRACTOflS LICENSE LAW DDES NOT APPLY TO AN OWNER OF � � ,PROPERTYWHOBUILDSORIMPqOVESTHEPEON,ANDWHODOESSUCHWORKHIMSELFORHERSELFOF � � Q �iHROUGHHI50flHEROWNEMPL`UYEE5,PflOVIDEDTHATSUCMIAdPROVEMENTSARENOTINTEYDEDOR m �i 0 �OFFEflE�FOflSAIE.IFHOWEV�R,THEBUIL�INGORINPROVEMENTISSOLDWiTHINONEYEAROFCOMPLE- �, Z 'iION,THE OWNER-BUILDER WILL FiAVE THE BUROEN OF PflOVING THAT HE Ofl SHE�IO NOT Bl11LD OR �i = 'IMPROYE FOfl THE PURPOSE OF S�ALE).' C I,AS OWNER OF THE PRdP�Fi�;AM EXCLUSNELY CONTRACiING WITH LiCEN5E0 COYiRACTOflS � i0 CONSTqUCT THE PROJEC7(SEC,7044,BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS ll- VdIUetI0f1 ADJ.AREA , W 'CENSELAWDOESNOTAPPLYTO�NOWNEROFAPROPEflTYWHOBUILO50RIMPHOVESTHEREON,AN� ' � � WFiOCONTRAGTSFORSUCHPROJ,ECTSWITHACOMRACTOR(S)LICENSEOPURSUANTTOTHECONTRAC- QUANTITY DESCRIPTION FEE � TORSLICENSELAW.). � ❑I AM EXEMPT UNDER 5EC. B.&P.C.FOR THIS HEASON U � LL � DATE �'.DWNER U W � � LICENSED GONTRACTORS DECLARATIDN W �. � I HEREBYAFFIRM�UNDER PENALTY OF PERJURYTHAT IAM LICENSED UNDFR PROVISIONS OFCHAPTER �. ' � �� I"� . �'` d ,9(COMMENCINGWITHSECitON70W)OF�IVISION30FTHEBUSINESSANDPflOFESS:ONSCO�E,AN� z [1 v `X 'MY LICENSE IS M FULL FORCEAND EFFECT. m J� �v,/5 Q � . LICENSE CLASS d ' LIC.NO.�/ fJ � j h . J V ' DATE � CONTRACTOR a W [� � WORKERS'QOMPENSATION DECLARATION -� = U � IHEREBYAFFIFMUNDERPENALTYOFPERJl1FYONEOFTHEFOILOWWGDECLARATIONS: - V! Q � _IHAVEANDWILLMAINTAIN'ACERTIFICATEOFCONSEN7TOSELFINSUREFORWORKERS' _ COMPENSATION,AS PROVIOED BY SECTION 97oa OF THE LABDR CODE,FOfl THE PERFORMANCE U ¢ OFTHE WORK FOfi WHICH'�THIS pERMIT IS ISSl1E�. � 0 � ��IHAVEANDWILLMAINiAINWORI�ERS'COMPENSATIONINSURANCE,ASREQUIREDBYSECTION QQ ' 37o00F THE LABOR COOE,FOR7HE PERFORMANCE OFTHE WORK FOR WHICH THIS PERMIT IS ISSUE�.MY/W��O.RKERnS'G�O¢M'�Pf�N SAT/IO'pN�INSURANCE CARRIER AND POUCY NUMBERARE: CONSTRUCTION � CARRIER.r0�/'�s/��/ 4°7/OL.. PLAN REVIEW 0 POLICVNUMBER �J� �ILP� , ELECTRIC Q . Q (iFiI55ECT10NNE�NOTBEWMPLETEDOFT}iEPEWMISFORONEHUPDRED00LLAR5�51Q010R1E5S). PLUMBING �� � Z ICEFTIFVTHATINTHEPERFORlAANCEOFTHEWORKFORWHICHTHISPEFMITISISSl1ED,l MECHANICAL ('} SHALL NOT EMPLDYANY PERSOM IN ANY MANNER SOAS TO BECOME SUBJECT TO THE � WOFKERS'COMPENSATIONLAWSOFCALIFORNIA,ANDAGREETHA7IFISHOUL09ECDME INSPECTIONFEE .--�-����-•���• _°"""' SU&IEGTTOTHEWORKERS'COMPE:VSATIONPftOVI510N50F5ECTION370oOFTMEIABOP p°"` �'` � � - �` � issuaNce .'�`� �,l.,�. } . ` � .,�-'i �6 CODE, S,✓H�ALL F�RTHWITH COMRLY WITH T'n'�SE ROVISIONS. a PI� W� ' p DATE: APPLICAM: SMIP ��� � � � � W � ENERGY P/C � ti J WARNING FAIW RE TO SECURE WORKERS'COMPENSAiION COVERAGE IS UNLANlFl/L,AN�SFIALLBE � SUBJECTANEMPLDVEfl70CRIMINALPENALTIESANDCIVILFiNESUPTOONEHUNOREDTHOUSAND ENERGYPERMITr; 4 D011AFi5(E1 W,000),IN A�DITION TOTHE�'�COST OF COMPENSATION.DAMAGES AS PROVI�E�FOR IN . V� J SECTION 3709 OF THE LABOfl CODE,INTEREST,AND ATTORNEV'S FEES. RETENTION FEE��—. �� W CONSTRUCTION LENOING AGENCY $�,=,;�-' '` _`:�-.--�t �,---:-"---''"�d a, PRE-ALTFEE. - -- . � IHEREBVAFFlFMUNOERPENALTYOFP6RIURYTHATTHEREISACONSiRUCTIONLEN�INGAGENCY n- FOq7HEPERFOFiMANCE�FYF7EWORKFOFIWHICHTHISPERMITISISSUED�SEC.309],CIV.CJ. � Z W . Z LENDER'SNAME � F- LENDEfl'SAD�RESS , _ w ICERTIFYTHATIHAVEREA�THISAPPLICA710NANDSiATEhIATTHEABOVEWFORMATIONISCORRECL TOTML FEES �J���� � .,IAGREETOCOMPLVWITHALLCIiYANDCOUNTYORDINANCESANOSTAiELAWSRELATINGT08UiLDING � CANSTRUCiION.ANDHEREBYAUTHORIZEREPRESENTATIVE50FT4{�SCOUNT'TOENiERUPONTHE Z .ABOVE ENTIONEDPFOPERTYFORINSp,ECTIONPURPOSES. COMMENTS � ��-h�r-��t. 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