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HomeMy WebLinkAbout17106 (40) �\ CITY OF D]AMOND BAR � � i DEPt1RTMENT OF CO.'Wv1UNITY&DEVELOPMENT SERVICES 21825 E.Copiey Drive I (909)860-3195 Far(909)861-3117 PRESS �'-� BLIILDING PERMIT APPLICATION FIRMLY ¢ DDRIESS_ / / �_� !D � ��G S PPUCATION (� PERMIT (, P/C o � � •DATE__ � I�ut NUMBER I V � � APN LOT _ T T ISSUE TYPE OCC DATE CONST. GROUP a OWNER jllc.�-+-Gu - r 4 ,l- o ADDRESS�t,�--�.o� ZONING SETBACKS � CITY !7 �'s�-!� ZIP TEL. FRONT qyy ❑ APPLICANT TEL. REAR ❑ zd SIDE/SIDE STREEi RW O aa CONTRACT R ,. ./ � �F't''G SIDE p o ADDRESS G2� ��' PROPOSED USE I CITY ZIP `�"�73OTEL J^ �l W ARCFUENG/ r z DESIGNER � ' �l "� n"'. ADDRESS NO.DWEL. NO. NO. = CITY ZIP TEL. ' UNITS STORIES BEDROOMS � N DESCRIPTION SO.FT. FACTOR PSF ADJ.AREANALUATION � OWNER•BUILDER DECLARATION ' p I SFR/ADO/REM p 1 NEREBY AFFlRM UNDER PENALTV OF PERNRY THAT I AM E%EMPi FPOu THE CONTMCTORS LI� Gdt899/CBryOR W CENSEUWFORTMEFOLLOWINGHE1l50N�5EC.)a71.68USiNE55FNOVROFE5510N5CODE:ANYCITYOR (n C� COUN7YVYHIpiREWIRESAPERMRTOCDNSTRUCT,AlTER�PaOVE.DEMOLI511,ORREPAIRANYSTRUC• w NRE PFqR TO ITS ISSUANCE.ILL50 REOUIRES THE APPLICANT FOR SUCF/PERAIIT TO FILE A SIGNEO W P21i0/DBCk SUTEMENT THAT HE OR SHE IS LICENSED PURSUANT TO TNE DROVI90N5 OF 1NG COMMCTORS L6 �� CENSEUW(d1APTERY(COMIAENCWOWITHSECTION7000�OFDIVIS�ON30FTHEBVSINESSANDPRO- �- PooVSpa FESSqNSCODE)ORTHATHEORSHEISEXEIAPTTMEFEFROMA7JOTHEBA:ISFORTH[ALLEGEDEXEMP• (� _ V TION.ANVVIOUTIONOFSECTION7031.SBYANYA7PLICANTFORAGERMIiSV&'ECTSTME�Oi�ILANTTO Z Re-Root ^' � ACML iENALTY OF NOTAIORE iHM1 FIVE MUNDREO COLURS(f500).y � � ❑I,�SOWYEROFTHEPROPERiY,ORMYEMVLOYEESWITHWAGE5A5TNEIR50LECOMPENSATICN, � COmRIBrCial WILL DO THE WORI(ANO 7HE STRUCTUAE IS NOT INTENDED OR OFFERED iOR SA:E ISEC.701�.BU51� J N NE55 AND PROFESSIONS COOE:THE CONTRALTORS LICENS[LAW DOES NOT APVLY TO AN OWNER OF VH07ERTYWTqBUILD50RIMPROYESTHEREON,ANOWHODOES5UOIWORNH11.15cLFORNERSELFOR � wTHROUGHHISORHERDNR�EMVIOVEESDROVIDEOTNAT5UCV/11APROVEI/FNTSAP'eNOTINTEN'JEDOq m Q OFFERE�FORSKEIF,MOVhVERTMEBUILDINCORM.IPROVEAIENT1550lDNATHINON[VEAROFCOMP�E� Z TqN,THE OWNEi1�BUILDER WILL HAVE TME BURDEN OF PROVINO TMAT NE OR SH[DID NOT BUI�p ON � IMPROVE FOR THE PURGOSE OF SALE} � (y,� ❑I,ASOWNEROFTNEPPOPERTY.AME%CLUSIYELYCONTRACTINGN'IiHLICEN5E000NTMCTORS � i0 CONS7RUGT THE VR0.IECT(SEC.70N.BUSINESS AND CROFESSIONS COOE�,TME COMMCTORS U� V21Ud�i0l1 AQI.AREA W CENSEUWDOESNOTAPPLYTOANOVJNEROFAVROPERTYVlMOBVILp50RIlAPRpV[STMEREON.ANO � NM1�OCDNTRACTSFORSUpiFRO.IECTSWITHACONTRALTOR(S�LICENSEDPL'RSl1ANTTO7HECONTRAC� QUANTITY DESCRIPTION FEE Y TORSLICENSELAwJ. i Q O I M1 EXEMPT UNDER SEC. B.�P.G FOR 7HIS REASON Q � U � � OATE OYMER F' � W Q LICENSED CONTRACTORS DECLARATION W oC 1HEREBYAFFIRMUNDfRPENAL7VOFPERtt/RVTHA7IAMLICENSEOUNDFRPROV1510NSOFCWNTER � a. O�COIAMENCWOWITHSECTiON7000�OFDM51d1�OfTHEBU5iNE55ANDifYOFESS�ONSCODE,AND Z X ►/YLICENSEISINFUILfORCE►NDEFiECT. ,', m L1J � LICENSE CUSS IIC.NO. j V �ATE CONTRACTOR d W � WORKERS'COMPENSATION DECLARATION I, a � IHEREBYAFfIRMUNDERPENALiYOFiER1UqYONEOFTHEfOIIOW;NGUECIAiUT10N5: Z � _IHMEANDVALLMAINTAINACEHTIFICATEOFCONSENTTOSELF-INSUREFORWORKERS' _ OOIdPENSATION,ASPROViDEO0Y5ECTION7iDOOFTMEU80RCODE,FORtNEVERFOFMANCE U Q OF THE WORK GOR WMIq/TMIS VEfiMIi I5155UED. �i � W _IHAYE�NOVALLL�AINTAINWORKERS'CAAIPENSATIONINSURANCE.�4PEOUREDBVSECTION Q �70o OF THE LABOR CODE.FOR TME PERFORMANCE OF TH WOf1N fOR WHICH 7H15 PERMIT IS ���O J ISSUED.NYWO NSATIDNIN�lS NCECAR RMDPOIICYNUMBERARE: CONSTRUCTION _ j CARRIER •J '�-� PLANFEVIEW Z vaicrr+uiueea ` '� � � ELECTRIC Q � �n+ssEcrnNr�rtmr�oreE�oocn-EVEw.rrswaa+EHunr�omuu�s,s+m�an�ssx PLUMBING .. Z 1 CEHTIFY THAT IN THE VERFORMANCE OF THE WORK FOR WHICH THIS PERAIiT IS ISSUEJ,I MECHANICAL ����"�` -�`� ` � � ' U' SHALLNOTEMPLOYANVPERSONINANYYANNERSOASTOBECOMCSL'B:ECTTOTXE � WORKERS'COMPENSATIONUWSOFCALIFOR41r1.ANDAGREETHATIFISNOVLDEECOME INSPECTIONFE � SU&IECT TO TXE WORKERS'COMPENSATION DROVISIONS OF SECTION]l00 OF TME LABOF OCOOE,I SHALLFORTNWITH COMPLV WITHTMOSE PROVISIONS. '�, ISSUANCE � � _�J��n� p OATE: APPLICANL ' (y SMIP —T J WMNMC:F�1lURETOSECUREM/ORKERS'COAIPENSA7qNCOVER�GEISUA'UWNL.ANOSHALLBE ENERGYPlC )j�.r �L �y SU&1fCTANfMPLOYERTOCRIMINALFENlLLTIESMIOCMLFWESUP100NEHUNDREDT110USAND ENERGYPERMIT��"'= '---- DOlLAF15(f 1 Do.00o).W ADDITON TO THE GOST OF COMPENSATpN,DAMACES AS PROVIDED FOR IN � SECTqN7lOeOFTHELABORLODE,INTERESi,PNDATTOHNEY'SFEES. � RETENTIONFEE: nW. CONSTRUCTION LENOING AGENCY PRE-ALT FEE: O � IHEREBYAFFIRMUNDEHPENALTVOFPERIUMTHATTHEREISACGISTRULTIONIFN�IN6AGENCY FOR THE VERFORMANCE OF THE WORK GOR WHIGH TNIS PERMIT IS ISSUED(SEC.]OY7,CIV.C.�. 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