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HomeMy WebLinkAbout11305 (5) _ .,..., ..,,�.Ww„_r ,.�,.�,�, m,. , .. ,, �,.:,� ._��,-,r..�.^.�.,_-..�. -..,�,�.�,� - �.. ., , .. . —��``�--- CTTY OF DIA1viOND BAR � � COMMUNITY DEVELOPMENT D�PARTI4IENT ' : w ' 21660 E.Copley Drive Suite 190 _ ,_ PRESS �� � (909)860-3195 Fax(909)8613117 \��' BUILDING PERMIT APPLICATION FIRMLY � JOBSITE �1 C� ''?��^�, f� ��''> � /� � APPLICATtON � PERMIT P/C p ADDRESS q�J T J�.-/ /"'!�w✓ 1�..� t.�.l'� � DATE � NUMBER�_ # o ISSUE TYPE OCG °O APN L�T TRAGT __ DATE CONST. GROUP p OWNER '�9'�il� ���^,. ADDRESS C ZONING SETBACKS z C�Ty I'�.. �= ZIP� 1 k�' TEL ` -"' FRONT RW ❑ o APPLICANT �`.��=�-"Z-+' TEL _._�"`� SIDE/SIDE STREET RW D ¢ CONTRACTOR _i SIDE ❑ �_ ADDRESS � + � CITY ZIP � TEL. � ^"� PROPOSED USE �w ARCH/ENG/ z DESIGNER NO.DWEL. NO. NO. a ADDRESS UNITS STORIES BEDROOMS � CITY _ ZIP TEL. � DESGRIPTION SQ.F'f. FACT�R PSF ADJ.AREANALUATION � OWNER-BCILDER DECLARATION SFFVADD/REM C p I HEREBY AFFIRM UNOEft PENALTY OF PERJURY THAT I AM EXEMPT FR7M THE CONTRPCTORS LI- � GaragerCarport W CENSELAWFORTHEFOLLOWINGREASON(SEC.7031.5BUSINESSANDPROFESSIONSCODE:ANYGTYOp C� COIINTYWHiCHRE�UIRESAPERAIITTOCONSTRUCT,ALTER,IMPROVE,DEM041SH,ORREPAIRANVS7RLIC- � patio/Deck � TURE.PRIOR Tl�1T3 I$SUANCE.AL50 RELIUIRES THE APPLICAN7 FOR SUCH PERMIT TO K��E A SIGNE� W W STATEMENT 7HAY HE OR SHE IS LICeNSE�Pt1RSUANT TO THE PROVISIONS CF THE CONTRACTORS LI� � - - g-- CENSE LAW(CHAPTEF 9(COMMENCING WITH'SECTIfXJ 70ooj bF pIVIS16N30F7HE BUSINE5SAYJ�GRO� POOUSp� Q FESSIONSCO�E!ORTHAiHEORSHEISEXEMPTYHEREFROMANDTHEBA515fORTHEALL°GEDE%EMP- (� U TION.ANV VIOLATION OF SECTION 7031.5 8V ANYAPPLICANT FOR A PERMIT Sl19JECTS TH'E APPLICANT 70 � Re-Roof � AGIVILPENqLNOFNOTMORETHANFNEFIUNOFED70LLARSf$500�.) ��� �� � � � ��� o pI.ASOWNEROFTHEPROPERTV,ORAAYEMPLOYEESWIThIWAGE5A5THEIR50LECOMPEN5AT10Y, � COtTlmefCi81 z X'ILL D�7HE WORK,AND�'HE STRUCTURE IS NOT INTENDEO OR OFFEPED FOR SAIE(SEC.�044,BUSI� J — NESS ANC PROFESSIONS CODE:THE CONTRAC70R5�ICENSE LAW DOES NOTAPPLYTO AN OWNER OF � PROPERTYWHOBUILDSORIMPROVESTHEREON.ANDWyO�0E5SUCHWORKHIMSELfORHERSELFOR = � THROUGHMISOft11EROWNEMPLOYEES,PROVIDEOhIATSUCHIMPROVEMENTSApENOY�NTENDEDOR m " WQ oFFERE�J'�`bflSALE.IF.HOWEVEFI.7HE8UIL01NGDRIMPROVEMENT1550LOWITHINONEYEAFOPCbIvYPLE� _ Z TION,7H�OWNER-BUILDER WILL NAVETHE BUR�EN OF PROVING THAT HE nR SHc 010 NbT 9f11,LD OR � IMPROV=FORTHEPURPOSEOFSAIE). �' � ' � � �� -� � O I,AS OWNEF OFTHE PROPEP7Y,AM EXCLUSIVELY CANT�ACTING W ITH LICENSE�CONTRACTORS . � TO CONSTRUCT THE PROJECT(SEC.�]044,BUSINESS AND PROF65SIbNS CODE:THE CONTRACTOqS U� V81U811011 ADJ.AREA W CENSELAWDOESNOTAPPLYTOANOWNEROFAPROPERTI'WHOBUILDSORIMPROVE5111EREON,�ANO T WNOC6NTRACTSFOR$UCFI'Di1QIEC7SWITN'ACANTRACTOd�Sf1fCENSEDPUR5UAN7707H�CO1J7RAG QUANTITY DESCRIPTION FEE � 70RSUCEN$E'LAW.).� � - � � - � � �� ' � Y �.�.. �-; . . . J O ❑IAM'EXE?APTUNDEftSEC.' B.LP.C.FORT415REASON Q � , � LL' DATE_ — CW�Efi— . _ . U W � UCENSED CONTRACTORS DECLARAT�ON � ¢ L'L 1 HEREB�'AFFIRM UN�ER PENALTYOFPERJURV THAT IAM LICENSED UNDEP PROVISIONS OF CHAPTER � I 1 I . (i, 9(COMMENGNGWITHSECTION70J0)OFDIVISION30FTHEBUSINESSANDPROFESSIONSC�O•DE,AND Z X MV UCENSE iS IN FU4l FORCE AND EFFECT. ^� m /9 .,. � LIGENSE CLASS "`�'h� LIC.NO. ��� " �� � � `� � F— DA7E �i Z.E �� CONTPACTOR �"'��""` d- w --�--x . . ., .,. � WORKERS'COMPENSATION DECLARATION -� Q � U � IHEREBYAFFIRMUNDERPENALTYOFPERJURVONEOFTHEFOLLOWINGDECL4RATIONS: � C� IHAVEANDWILLMAINTAINACERTIFICATEOFCONSENTTOSELF-INSUREFORWORKERS' S COMPENSATID4,ASPROVIDEDBYSECTION3�oCOFTHElA80RCO0E,FORTHEPERFORMANCE V � OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. � Q � iHAVEANDWILLMAINTAINWORKERS'COMPENSATIONIM1SURANCE,ASREOUIREDBYSECTIOt�' Q 37000FTHELAGCFCODE,FOF7HEP'eRFORMANCEOFTHEWORKFORWI'ICHTHISPERU.TIS � ISSUED.MVWORKERS'COMPENSATIONINSUFANCECARRIERANDPOUCYNUMBEFl+RE: - CONSTRUCTION - Q �,j'[„��� ^��" PLAN REVIEW � CARRIER pyM� ^ . . . . Cl POLICY NUMBER__�,y�Yy.��� r_ —� Z ELECTRIC —��, ¢ 1 � '� 0 (iF11SSEC710NNEmNOTBELUPAPLETE00FTHEPERMfTIS��NEHUNCR=OCOI.lARS�'S1W)ORLESS). PLUMBING � ICERTIFVTHATINTaEPERFORMANCEOFTHEN/ORKFORWHICHTHIBPERM�,TISISSUEO.I MECHANICAL � (�7 SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SOAS TO BECOME SUBJECT TO THE :� „ �M�yy N VJOAKERS'COMPENSA710NLAWSOFCALIFORNIA.ANDAGREETHqTIFISHOULOBECOME INSPECTIONFEE � SU&IECT TO THE WORKERS'COMPENSA710N PPOVISIONS OF SECTIOPJ 370o Of THE LABOR i '� �'�+ /y 1 = ISSUANCE , �'�--��� CADE. ri�1LLF RTHWITHCOMPLYW17NTHOSEPROVi51 5. qI� O SMIP p DATE: `�.��� APPLICANT. � — � � ENERGY P!C . � WARNING:FAILURE'fOSECUFE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL.AND SHALLBE � SU&)ECTANEMPLOYERTOCRIMINALPENALTIESANpCIVILFME5t1PTODNEHUNDREDI'HOUSAND ENEFiGYPERMIT DOLI.AflS(5100,000),IN AD�ITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN � SECTION37080FTHE:.A60RCODE,INTEREST,ANDATTORNEV'SFEES. RETENTIONFEE: � CONSTRUCTION LENpING AGENCY PRE-ALT FEE: � O � I HEREBV AFFIRU UNOEA PENALTV OF PERJURY THAT THEFE IS A CONSTftUCTION LEYOING AGENCY __ FOR THE PEFFOflMANCE OF THE WOPK FOR WHICH THIS PERI�AIT IS ISSUED�SEC.3o9�,CIV G). Z W S LEN�ER'SNAME _ . — " � __ h LENOEWSADDRESS_ --- � ICERTIFVTHATIHAVEREADiHISAPPLICATIONANDSTATETHATTHEABOVEINFORMATIONI.SCARRECT TOTAL FEES � � �'-� t � � I AGREE TO COMPLY WITH AlL CITY AN�COUNTV ORDINANCESAND STATE IAWS RELATING TO BUtL01Nq ' � � �, � CONST�UCTION,AND HERE9V AIITHORIZE REPRESEVTAT',VES O;THIS COUNTI'TO ENTER UPON THE Z ABOVEMENTIONED GROPERTY FOR INSPECTION PURPOSES. COPI�MENTS � t�� � �� - -- m _- - Q PERMITTE' E(PRIN _ ' Cn � SIGNAYUREO PERMITTEE 6ATE . 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