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HomeMy WebLinkAbout12960 (11) ..... ... ...- -- .. .� _ . ...�.. _._.. _.. _,.�.y,, . ._.. . ...... :. �,,.,,J� ._.,......_.. �____._._.._�.__.__..,.,._,,�._.,..a- CITY OF DIAMOND BAR �=� COMMUNITY DEVELOPMENT DEPARTMENT -.,.� 2166�E.Copley Drive Suite 190 (909)860-3I95 Fax(909)R61-3ll7 � PRE.SS �'""' BUILDING PERMIT APPLICATION FIRMLY � JOBSITE ��`� � ��yf /�J�/� �� DATECATION " C NUMBE � � '�lC���ri'.�-� i� o ADDRESS f--a•-� �J _ $ ,� f C ISSUE A r> ^�� TYPE OCC .- APN LOT TRACT 7 - � DATE �^l `�'���'f � CONST. GROUP p OWNER �J�_ll��, � �� p ADDRE ZONING SETBACKS � gCITY � b TEL.;�� �.+ FFiONT _ RW �_� APPLICANT i�L. REAR ❑ z ' � •, SIDE/SIDE STREET RW �7 m CONTRACTOR y�f � � �-,�N"� �FJ�_. SIDE i-� � ADDRESS C 3 .> __ ' .r`� t, , -� , � � CITY CN//�� ZIP �7 % TEL.� „ S PROPOSED USE �. > �-! � _,I �� ;, � .,( � �. w ARCH/ENG/ �7rJ� --- ' z DESIGNER � /°��- �/��-- — w Z-� �� NO.DWEL. NO. NO. a ADDRESS cn l� G/ UNITS__ STORIES BEDROOMS � CITY ZIP� : TEL.� cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-BI:ILDER DECLARATION SFRlADD/REM O I HEREBV AFFIRM UNOER PENALTY DF PERlURY THAT I AM EXEMP7 FROM THE CONTPACTORS ll- G8f8 B/CafpOR 0 9 W CENSELAWFORTHEFOLLOWMIGREASON(SEC.70a1.5BU5MESSANDPROFESSIONSCODE:ANYC�TYOR (n U CWNTYWHICHREQUIRESAPEHMITTOCqNSTRUCT,ALiER,IMPROVE.DEMOUSH,ORREPAIRANYSTRUC� W PafID/DBCk � W TURE,PRIOR 70 ITS ISSUANCE,AL50 RC4UIRE5 iHE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED W ' � STpTEMENT THAT HE OR SHE IS LICENSED PURSUIWT TD THE PROVISIONS OF THE CONTRACTORS LI� � �, �. � CENSE UW�CHAP7ER 9(COMMENCING WITH SECTION 7000�OF DIVISION 3 OF THE DUSINE55 ANO PRO� POOVSpO , e' (;� � FESSIONSCADE)ORTHATHEORSHEISEXEMPT7HEREFROMANDiHEBASISFORTHEALLEGEDEXEAIP� (� V TION.ANYVIOLAiIONOFSECTlON7031.5BVANYAPPLICANTFORAPERIAITSUBJECiSTHEAPPLICANTTO z Re-Roof � A CIVIL PENALTV OF NOT MOR�iHAN RVE NUNDHED DOLLARS(i5oo�.): � �I,ASOWNEROFTHEPROPERTY,ORMYEMPLO�'EEbWITHWAGESASTHEIR50l.ECOMPEN5ATION, � Commercial Z WILL 00 THE WORK,JWO THE S7RUCTURE IS NO7INTENDED OR OFFERED fOR SA!.E(SEC 70a,BU51- J � NESS AND PROFESSIONS CODE:THE CONTRAGTORS LICENSE LAW OOES NOT A7PLY TO AN OWhER OF � PROPERTY WHO BUI�pSOR IMPROVES 7HEREON,AND WHO OOES SUCH WORK HIMSFLF OR HERSELF OR WTHROUGH HIS OR HEii OWN EMPLOVEES,PHOVIDED THAT SUCH IMPROVEAIENTS ARF NOT INTENDEOOR m 0 OFFEREDFORSALE.IF,FqWEVER,iHEBUILDINGORIMPqOVEMENT1550LDWITNINONEVFAROFCOAIPLE- Z TION,iHE OWNER�BUIL�ER WILL HAVE THE BLIRDEN OF Pq�VING THA7 HE OR SHF_OID NOT BUIL�OR � IMVFOVEFORTHEPURPOSEOFSALE). � CI,ASOWNEROFTHEPROPERTV,AMEXCLUSIVELVCONTRACTINGWITHUCENSEDCONTMCTORS / � TO CONSTRUCT THE PROJECT(SEC.704C,BLISINESS AND PROFESSIDNS CODE:THE CONTRACTORS LI- V81U8I1Of1 - L i C_%�.� AQI.pREA W CENSEUW�OESNOTAPPLYTOANOWNEROFAPROPERTYWHOBUILDSORIMPROVESTHEFEON,AN� � WFIOCONTR�CTSFOFSUCNPROJECTSWITHACONTRACTOR�S�L'CENSEDPURSUANT70THECONTflAC- QUANTITY DESCRIPTION FEE � TORSLICENSELAW.�. � 7 1 AM E%EM7T UNDER SEC. __ B,8 PC.FOR THIS qEA50N Q �� 1 „i L' � !�" � U � DATE DWNER F'� �n � W � LICENSED CONTRACTORS DEC�RATION W ¢ � IHERE9YAFFIHMUN�ERPENALTYOFVERJURVTHATIAMLICENSF.DUNDERPROVISIONSOFCHAPTER d 9(COMMENCIN6 WITH SECTION 7000)OF DIVISION 30F THE BUSINESS AND PROFESSIONS CO�E.AND Z i�,�p ; ��r 'X A1V LICENSE IS IN FULL FORCE AND EFFECT. w �� d �'"'�7 {-' m � ; x/1�j�\..'�' 1 - Q LICENS/E C/IJa S�S�`�'�J ) LIC_NO_ � Jq��1��/� _ � � � �7 . , � � ~ DATE��/G CONiRACTOR,Q�H'�I�AY�_� J - + /t D � C � ' / WORKERS'COMPENSATION DECLARATION Q, i' / � I MEREBv AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLIOWING DECLARATIONS U n � - V' - � I `n a _ r� �1,. '�% (,'G � � _I HAVE ANO WILI MAINTAIN ACERTIFICATE OF CONSENTTO SELF-INSURE FOR NqRKERS' _ COMPENSATION,ASPqOVIDEDBVSECTION37ooOFTHELABORCODF.,FORTHEFERFORMANCE U o OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. � QW _I HAVE RNO WILLMAINTAIN WORKERS'COMPENSATION MSURANCE,AS qE0U1RE0 BV SECTIDN � /[ 3700 OF hiE LABOR CODE,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMI715 �/ /? � ISSUED.MY WORKER' MPENSATION Ip5U AIV(jE CARRIERAND POLICYNUMBERANE: � CONSTRUCTION �v+"�( (J _"1 y/ � � j CARRIEfi ���/�lJ��'f ���� PLAN REVIEW .L-�'�7 s �%(� ZPOLICYNUMBER� .�_"^� ~' ¢ -- ELECT_gIC, _ � � i � (1}155ECTIONNEmNO7BE00NREfEDOFiHEPERlMISFORONEMNOREDOOUAAS(E�ao�ORLESS} PLUMBIfVG �� � w �,� ��� �� ' Z �CEHTIFY THA7 IN 7HE PERFORMANCE OF THE WORK FOR WHICH THIS PERIAIT IS ISSUE�.I MECHANICAL se C'3 SHALLNOTEMPLOYANYPERSONINANYMANNERSOASTOBECAMFSUfl1ECT707HE (n WORKERS'CDMPENSATION�AWS OF CALIFORNIA,Mp A RE THAT IF I ULD BE E INSPECTION FEE � � SUBJE TTOTHEWORKERS'COMPENSATIONA xalD E OFTHE �� �, / � � COD SHALL F RTHWITH COMPLY WITH THO$ 51 ISSUANCE r� � � li 0 / `p DATE:+ APPLICANT: ''7 _-- �---1--l��� SMIP _ �'�---'—� r o J � ENERGY P/C �� A' J WARN :FAILUR TO SFCURE WORKEFS'COMPENSATION CAVERAGE IS UNIAWFUL,ANO SHALLBC �('', � } SUBJECTANEMPLOYERTOCRIA11NAlPENALTIESANOCIVILFINESUPTOONEHUNOREDTHOUSANU ENERGVPERMIT �"l.� y �� DOlURS(5100.000�.IN AD�ITION TO THE COST OF COMPENS�TION,DAMAGES AS PROVIDE�FOq IN —� t � .J SEC710N 37oe OF 7HE LABOR CODE,INTERES7,AND A7TORNEV'S FEES. ! � RETENTION FEE: .��'�q1���� o CONS7RUCTION LENDING AGENCY PRE-ALT FEE: �'j� :��iT�" � I HEREBV AFFlRM UNDER PENALTV OF PERJURv THAT TMERE IS A CONSTflUCTION LENDING AGENCY ___ FOR THE PERFORMqNCE OF TNE WORK iOR WMICH TMIS PERMIT IS ISSUEO�SEC.3087,CIV L�, Z W � LENDERS NAMIE ____ � LENDER'SADORESS W iCERTIFYTHATIHAVEREADTHiSAPPLICATIONANDSTATETHATTMEABOVEINFORMATIONISCORRECT. TOIAL FEES `,�.�� �j i �:' �� � � � { d IAGREE7000MPLYWITHALLCINANDCOUNTYORDINANCESANUSTATELAWSfiFIATINGToOWLDMG '�I �� � CONSTRl1CTION.AND HEREBV AUTHORIZE REPRESENTAiIVES OF T1-0S CAUNTY TO Et�TER UPON iHE z R80VE-A1 NTIONEUDROPERTVFO/q�PECTIONPURPOSES. � � '� Y C.�S�A/�dG/L� COMMENTS_ � --- m //�-/� �// � PERIA.IC- py���{�l_C!6/^v U�l�{.d"/L ' . }� / .� � (n SIQNATURE OF PERMITTEE pp7E --�� � � , ` � ' " � PAiD 8Y•, .. ����.�;��',. 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