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HomeMy WebLinkAbout13624 (16) CITY OF DIAI�IOND BAR � ---1� DEPARTMENT OF CONIMUNITY&DEVELOPMENT'SERVICES _ � 21660 E.Copley Drive Suite 190 (909)8b0-3195 Fax(909)861-3117 PRES$ ��' Bva,nnvG�i�iu�tirr ApiPr..icA�oN ' ` FIRMLY � � .- ,,.r� ,,,, ,,, ,;,,,,,DATE.,. ` '.Y��� NUMBER�.�,,., ,, . ... � J�BSITE ��� s'' � • APPLICATION PERMIT �`� /C o ADDRESS ° " "�� �i � ISSUE TYPE OCC APN LOT TRACT DATE CONST. GROUP p OWNER C? ^�i 'sd�"'YL -. /.�.�'�A''Tst� "- ADDR S 5° �- �s �we."�C� e ZONING SETBACKS � G c' FRONT RW ❑ CITY Z P r7 ' TEL. �'i��c��f�� � C&'�rLG REAR ❑ APPLICANT TEL.<;�� ,j`� SIDE/SIaE STREET RW ❑ � CONTRACTOR _ SIDE __ ❑__ _ � ADDRESS PROPOSED USE^ �'"" � s '!� G�'fc�� G r"S` +l C Q CITY ZIP TEL. ;.� �a F[. ,i �., i L � ARCN/ENG/ _ � DESIGNER -- NO.DWEL. NO. NO. ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � DESCRIPTIpN SQ.FT. FACTOR PSF ADJ.AREr'WALUATION � OOWNER-BUILDER DECLARATION SFR/AQD/REM � I HEREBY AFFIiVA UNDEfl PENALTY OF PERri/RY TFIAT I AM EXEMPT FROM THE C.ONTRACTORS Lt- ('jafe9B/CdIF701T � CENSEIAWFORTHEFOLLOW�NOREq90N(SEC.]o3t.58U5WESSANDPFiOFESSIONSCObE:ANYCITYOR (n CqUNTYYAiICFIREQIfIflESAPEflMYfTOCONSTftUCT,AI,7ER,IMPROYE,�EMOLt9H.ORftEPAiRANYSTRUG �,j,J paf�0/DeCI( W TURE,PRIOR TO RS ISSUMICE,PL50 REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A 516NED W � STATEMENT THAi HE OR SNE IS L�CENSED PURSUMIT TO THE PROVISIONS OF THE CONTR0.CTORS LI• � CENSE LAW(CHAPTER B(COMMENCING WI'H SECTION 7000)OF DIVISION 3 OF THE BU5INESS AND PRO- u' PoOVSpa FESSbNSCOD�OR7HATHEORSHEISEXEMPTTHEAEFROMANDiHEBA515FORTHEAILEGER��P- ., � V TION.ANVVpIATIONOFSEC710N7o31.5BYANVA�PLICANTFORAPERMiTSU&IECTSTHEAPPCICANTTO .RB-RDof � � ACINLPENALTYOFMOTMORETHANFNEHUNDREDDOLLIRS(fS00)J: - ' � ' � ❑I,ASOWNEROFTHEPflOPERTY,ORAAVEMP�OYEESWITHWAGE6ASTHEIR&OLECOMPENSATION, COfIITfIBfGi81 � WILL DO hIE WORK,MID THE$TRUCTURE IS NOT INTENtlED OR OFFERED'FOR�SALE(SE0.70h4,BU51- �J NE55 ANO PROFESSIONS CADE:?HE CONTRACTOAS LICENSE LAW�oES NOT APPLY TO AN oWNEfl oF � PROPERTYWFK7BUILDSORIMPROVESTHEREON,IWOWMOOOESSUCHWORKHIMSEIFORHERSELFOR � � THROU(3HMSORHEROWNEMPIOYEES,PROV10EDTHATSUp11MPROVElAENTSAFIENOTIN7ENDEOOR m L�1 ,OFFFREDFORSALE.IF,FIOWEVERTHEeUIL�IN60RIMPROVEMEN7155QL�WITHINONEYEAROfCAHIPLE- � TION,THE OWNER-BUILDER WILL HAVE ZFiE BURDEN of pROVINO THAT H[OR SHE DI�NOT F�UILC1 OR IMPRDYE FORTHE PURPOSE OF SALE). � � � '� .�I,AS OWNER OF THE PHOPERTY,AM E%CWStVELY CONTpRCTING WITH LICENSED CANTRACTOFS ���` �.� � TO C9NSTRUCT lHE PROJECT(SEC.104a.BUSINFSS AND PROFESSIONS CODE:THE CONTHACTOflS LI� V8IU31iOlt - p�-.a��� _ ADJ.AREA W CENSEUWDOESNOTAPPIYTOANONlNEROFAPROP@RTVWH08UIL0.5QRIMPqOVESTHER D . � WHOCONTRACTSFOASUCHPqQ1ECTSWITFIA�ANTRAC70R(S)LICENS£DPURSUANTTO7 NT G OUANTITY DESC'AIPTfON FEE � roc�s uc�sE uw.�. J ^ ❑I AM E% PT DER SE0.,_.,_ _._8 B -FOR 7 ASON Q � S � C � DA7E OWNER . ?. � __4'*r'.._ __.''_L U V � W _ �.g GGENSED CONTRAC�ORS DEGLARATION --� �C W i HEREBV AFFlRM UNOER PENALTY Of PERJURY THA7IAM IICENSED UNOER PROVISIONS OF CNAPTER � � G(COMMENCiNOWITHSEC?KJN?0oo)OFDIVISION30F7HEBUSiNESSANOPqOFESSIONSCODE,AND Z �„_,_ _ XL' MY IICENSE IS P7 FU�L FOFiCE AND EFFECT. m LLI � __ � UCENSE CLASS LIC.NO. . J � DATE CONTRACTOR_ � d W � WORKERS'COAAPENSATION DECLARATION –� 4 � I HEREBYAFFIRM UNDER PENALTV OF PERJURY ONE CF THE FOLLOWING OECLAftATIpNS: I Z � 4 � _IHAVEAN�WILIMA�NTAINdCEA7'IFICATEOFCONSENTYOSELFINSUREFORWORKERS' �_ . . . ... COMPENSATION,ASPROViD£DBYSECTIOM1I3700aJFTHElABORCODE,FORTHEPERFOflAtANCE �U d OF THE WORK FOR WHICH TF11S PERMIT IS ISSUED. g g ' � f __IHAVEANDWILLMAINTAININORKERS'C[sMPENSATIqNINSURANCE,ASREQUIRE06Y5ECTION � � .w� �� QI 370o OF THE tA90N CODE,FOR ThIE PERFOAPNANCE OF FHE WORK FOR 1NFIICH THIS PERMIT IS .� — jISSUEO.MY WORKERS'�MYENSRTpN INSUR�VJCE CP,RRIER ANO POLIGY h'UMBER ARE: CONSTRUCTION `'�j CARRIEA _ �� �_ PLAN REVIEW _ n Pa�cYNUMBER .__�_._____ ELECTRIC .c,. dC 0 (iHresECTlot�IJE�rdoieEo'7MatEfIDOF7HEPEw�tttiSwf7clJEth��DtiEOIXw.Ms(S�ooIORLEss) PIUMBING -�- • �., _ w �:'�':�.:t. � I CEPTIFYTNA7IN?HE PERFORMANCE OF THE tNORK FORN'HICH THIS PERIAiT IS ISSUF.�,I �1ECHANICAI � SHAI.L NOT E1+Ial0Y APIY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TD THE �/j WORKERS'COMPENSATtON LAWS Of CALIFOPNIA,AN�AGREE THAT IF 1 SHOULD BECAME INSPEC fION FEE . SU&IECTTO7HEYlOiiKERS'COIAPENSATIONPROVISIONSOFSECTION37o00F'fHElA90R � ��, �� COOE.ISHALLFOqTHWITHCOMPLYWITHTHOSEPROV1510NS. ISSUANCE _,_ 5���x` 4^. e^.u'ta"�.Cn /� � SMIP �'&"� �' . @ ``� � �4.,•' DATE:.—__— APPLICANT: y �" WWARNING FAILURE YO SECURE WOANERS'COMpENSATiON COVERAGE IS VNLAWFUL,AND SHALL BE EtJERGY P!C $'��I� s�� ���d'�Ft 1 '.� � ���'�$^� � SVBJECTAtJEMPLOYERTOCRIMINAIPENALTIESANOCM�FINESUPTOONEHUNDREDTHOUSAND ENERGYPEftM1T �"y����� �b'fJ' � i��� `�Wr�.�� DOLLARS(S10o,Wo),IN ADOITION TOTHE C0.5TOF GOMFENSA710N,DpMAGES A9 PROVIDED FOR IN — � SECTION37080FTHELABORCODE,INTEFEST,AN�ATTORNEY'SFEES. RETENTIONFEE: d CONSTRUCTION LENpING RGENCY PqEALT FEE: � I HEflEBV AFFIRM UNDER PENALTY OF PEPJURV THAT THERE IS A CONSTRUC710N LENDMG AGENCY FOP THE PERWRMANCE OF THE WORK FOR WNICH THIS PERMIT i5155UED(SEC.3097,CIV.CJ. Z W � LENDER'S NAME_ — !_- LENDER'SADDRESS - � ICERTIFY7HA71HAVEREADTHISAPPLICATIDNANOSTATE - HEABOYEINFORMAT�NISCORRECT. TOTAL FEEa7 V � W IAGREETOCOMP ITHAILCINANDCOUNTYORDI CES DSTATEIAWSPELATWGTOBUIIDING � CANSTRUCTIO ,A, HEREBYAUTNORIZE REPRESE 7NE F THIS COUNTYTO ENTER UPON THE � zABOVE-MENT N PiiDPERTV FORINSPECTIDN P POS . COMMENTS � '' � _ � �4, I�J/�" -- m PEfl EE (PRINT) Q ^� Cn ''��iy.�...-,.f L... � TUR PEPMI TEE �PATE _ � RECPT.NO. _ PAID BY � �� VALIDATION ~ WHlTE—Degartment Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENq06—File Copy,GFlEEN—ApplicanYs Copy ���� ��� ��.������� ���� ��������`��`��� ������;� � v ������ ��� �� � �� �� , � �.. � � � �.... .:; ��a.,,,� �„��°���� � ,: ��*�� �� z,. � ' �. ,��"�, � � �� � ��a����-�'�� �'� � �..�" ��`..����"��.a.� .�.,:�. m����� :z.. .:.�.., ...: ...... 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