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HomeMy WebLinkAbout16849 �� CITY OF DLAMOND BAR � � � DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES „ � 2 L 825 E.Copley Drive (909)860-3195 Fax(909)861-3117 PRESS "�"?��»��� BUILDING PERMIT APPLICATION FIRMLY o A�DDRESS J �+,5 ' `�.�'C �"E""(" T' ` DATECATION �� �� NU B R�� / � p/C � ISSUE TYPE OCC APN LOT TRACT DATE CONST. GROUP p OWNER ��LV ? �j , C�-j_ (�. o ADDRESS G� 'T ZONING SE76ACKS z CITY t ZIP TEL A $ FRONT RW -1 p APPLICANT '2.V`"ELA.�^�'3-N TEL � Z�i+�'3-S�f ' SI�SIQESTREET RW rJ z ¢ CONTRACTOR ' lr ��✓�" SIDE ❑ Q ADDRESS iN ,,��� PROPOSED SE -- ` i..:. o CITI' 1-�Gc- ZIP��TEL.(r�.�'�;'L�.7t��_�r/ ��y,,,, t� Q, , c- o ARCH/ENG/ �, �-jd�. i� N �z DE3IGNER NO DWEL. NQ N . '�y�� n_ ADDRESS = CITY ZIP TEL. UNITS STORIES BEDROOMS � cn i DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� � OWNER•6UIL�ER DECLARATION � SFR/ADD/REM � O I HEREBY AFFIRM UN�ER P i NALTY OF PERJURY THAT 1 AM EXEMPT fROM THE CONTRACTORS LI� G2l89E/C2fPOII . W CENSELAWFORTHEFOLLOVJWGREASON(SEC.7D3t.5B1J51NE5SANDPROFE5510N5CO0E:ANVCITYOR (n U COUNTYWHICHRE�UIRESAPEflMA�ITTOCONSTRUCT,AITER,IMPflOVE,DEMOLISH,ORREPAIRANYSTRUG W TURE,PWOR TO ITS ISSUANCE.�LSO,HEqUIPES.THE APPLICANT FOR SUCN PERMIT TO FILE A 51GNED W Patio/DeCk � �STATEMENT THAT HE OR SHE IS ICENSEO PURSUANT TO THE PROVISIONS OP THE CON7RACTORS LI� � 'CENSELAW(CHAPTER9(CdMME CINGWITHSECTIdNY000)OFDIVISION30FTHEBUSINESSANDPRD- POOVSP2 Q� ',FESSIONSCDDE)ORTNATHE.OR HEISEXEAdPi?HEREFROMANDTHE9ASISFORTHEALLE6EDEXEMP- � V, TION.ANYVIOLATIONOFSECTI0�7o31.5BVANYAPPLICANTFOflAPERMI7SUBJECTSiHEAPPLICANTTO Z Re-Roof .�� � �� ��A CIVIL PENALTY OF NOT MOflE TMLAN�FIVE HUNDRE�DOLLARS(b5oo).�: 0 ❑I,ASOWNEROFTHEPROP�RTY,ORMYEMPLOYEES�WIiH:WAGESleSTHEIR50LECOMPENSPTiON, � Commercia� -� Z� �WILL DO THE WORK,ANO THE 5T UCTURE IS NOT!NTEN�ED OFi OFfEREO FOR SALE(SEC.7044,OUSI- ,J � '�.NESSAND PROFESSIONS CODE: HE�CONTRACTORS LICENSE LAW DOES NOT APPLY i0 AN OWNER OF 'PROPERTYWHOBUIlD50RIMPR VESiHENEON,ANDWHO�0E55UCHWOFKNIMSELFORHEflSELFOR �� �' 'THHOIJGHHI50pHEROWNEh1PL YEES,PROVIDE�THATSUCHIMPROVEMENTSARENOTINTENDEDOR m Q'�, '„�;OFFEREDFOPS4LE.IF,HOWEVER,ITHEBUILDINGORIMPPOVEMENTISSOLOWITHINONEVEARO-CCMPLE z, ,'TION,TF{E OWNER-BUILOER WILLIHAVETHE BURDEN OF PROVING THAT HE OR SHE�IU NOT BUILD OR �. ,,�iIMPROVEFORTHEPURPOSEDF$ALE). �. , ❑I,AS OWNEF OFTHE PRO�ERiI;AM EXCLUSIVELY CONTRACiING WITH LICENSED CONTRACTORS Q �'�'�TO CANSTRUCT 7HE PRQIECT�S C.7Q44,BUSINESS�AN�PROFESSIONS CODE:THE CONTRACTORS LI- V2II1Btl�7 S .��CJ." qDJ.AREA. W �',CENSELAWOOESNOTAPPLYTO NOWNEHOFAPROPEHNWHOBUIL�SORIMPROVESTHEREON,AND � �WHOCONTRAC75FORSUCHRRO�ECTSWITHACOMRACTOR�S)LICENSEDPUFSUANTTOTHECONTRAP QUANTITY DESCRIPTION FEE Y 70RS LICENSE LAW.). . � . ❑I AM IXEMPT UNOER SEC.I� B.&P.C.FOR THIS REASON �Q ' � G� � � �DATE I OWNER .0 � I W � � LICEN$ED CONTRACTORS�ECLARATION �w ���'I HEREBYAFFIRM UryDER PENALTI OF PERJURYTHAT IAM LICENSED UNOER PROVISIONS OFCHAPTEF � (i 9(COMMENCINGWITHSECTI�N700)OFDIV1510N30FTHEBUSINESSAN�PROFESSIONSCDDE,AN� z W �MYLICENSE IS N FULL FOIiCEAN EFFECT. m � . LICENSE CLASS . LIC.NO.� O _ j � - V DATE �I�-�I'P!7Z.-�, GONTRACTOR � d � WORK�RS'COMPENSATION DECL ATI N ���~ ¢ � I HEREBV AFFIRM 11N�ER PENALTw OF PERJURY ONE Of THE FOILOWING DECLARATIONS: Z Z _IHAVEANDWILLMAINTAII ACEATIFICATEOFCONSENTTOSELF-INSUREFORWORKEflS' ¢ M 2 ¢ WMPENSAiION,l�SPROVIDE�BYSEC710N37ooOFTHELA80FCODE.FORTHEPERWqMANCE U � OFTHE WORK FOF3 WHIC14 THIS PERMIT IS ISSl1E�. � 0 _ AVE AND WILL MAINTAIN WORKERS'COMPENSATION INSUflANCE,AS RE�UIRED 6Y SECTION 37o�OF7HELA9qRCO�,FOqTHEPERFORMANCEOFTHEVJORKfOFWHICHTHISPERMITIS �,�� ?'�� J ISSUE�.MYWORW R' �MPEN/�n_T/ION�INSU�RANC/E�,CA�RRIER,A/N4 POLICYNl1MBERARE CONSTRUCTION j caaaiEa ''���"C-�'C�- / •'p✓ A PLAN REVIEW Z POLICY NUMBER I 'CA I'J� ��Z� .�'�5��� � ELECTflIC Q � (iHISSECiIONNEbNOTB�O�MPLEfE�OFTFFPEFUAfiISWRONEHUNDFEDDOLLARS(5100)ORLESS). PLUMBING Z I CERTIFV THAT IN l}{E P�RFORMANCE OF THE WOFK FOR WHICH THIS PERMIT IS ISSUE�,I MECHANICAL (� SHALL NOT EMPL4Y ANY ERSON IN ANY MANNER SOAS TO BECOME SUBJECT TO THE ' �� WORKERS'COMPENSqTI N LAWS OF CALIFORNIA,ANJ AGREE THHT IF I SHOULO OECOME INSPECTI ON ` � � � SUBJECTTOTHEWORKE�lS'CQMPENSATIONPROVISIONSOFSEGTION37000FTHELA60F � 1a, ^�� � � CODE,I SHALL FORTHWI'f�1 COMPLY WITH E'PROVISI�O 5�./ ISSUANCE ��,._. r�- (t _.�j'L"�``5\ �y o �j � • � / j�/�'1,�.- � ..�,� ..��f W �A7E: �v �Q'�, PLICANT. 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