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Home My WebLink About17140 (44) CITY OF DYAr�iOND BAR � -�'�` -- I)EPARTIO�NT OF C(3MMUNTI'X&DEVELOPMENT SERVICES - � � -, .� 21825 E.Copley Drie�e - (909)860-3195 Fax(909)861-3117 PRESS ,"',4��`, Bu�Ln�N�PE�1T�rpa.iCA'TroN FIRMLY � JOBSITE � � �', � � APPLlCATIO PERMIT ,y �, P/C o ADDRESS_ DATE ,r� L�Y� NUMBER �S # o ISSUE TYPE OCC °.° APN LOT TRACT DATE CONST. GROUP °C OWNER ' 1 0 " ADDR S5 n 'r` ZONING SETBACKS z CITY�• ZIP 9! �5 TEL. , FRONT RW ❑ � APPLICANT I� TEL REAR ❑ o SIDE/SIDE STREET RW ❑ ¢ CONTRACTO II ' SIDE ❑� � ADDRES I S' � CITY 2 I Z1P�'r 7e LTEL.�jZ�iJ`t3�?�7� PROPOSED USE o ARCH G/ , w DESIGNER i NO.DWEL. NO. NO. a„ , ADDRESS I UNITS STORIES BEDROOMS �' ,'CITY �_ ZIP TEL. � �I I DESCRIPTiON SQ.FT. FACTOR PSF ADJ.AREANALUATION ��,, �� Oi NER-BUILDER�ECLARATION SFR/ADOlREM � I O p , I HEREBY AFFIRM UNOER PENALTY OF PERJURY THA7!AM EXEMPT FROM THE CONTRACTORS LI- Gef2gC/CflfPOfl W' .CENSEIAWFORTHEFOLLOWiNGREASON�5EC.7031.5B1151NE5SANDFROrE5510N5CODe:ANYCITYOR {f� . U �,COUNTYWHICHFEQUIflESAPER ITTOCONSTRUCT,ALTER,IMPROVE,OEMOLISH,ORREPAIRANYSTRUC- W patio/�eck � w;"„'TURE.PRIOR TO ITS ISSUANCE.�'.LSO REQUIftES 7HE APP4ICANT FOP SUCH PERMIT TO FILE A SIGNE� w ��. 'STA7ElAENT THAT HE OFl 5HE'IS CENSE�PURSUANT 70 THE PROVISIONS OF THE CONTRACTORS LI- �,� ,�,CENSE LAW(CHAPTER 9(COMME CING.WRH SECTION 7000)OF DIVISION 3 OF iHE BUSINESS AND PRO- � POOUSPB �FESSIONSCO�E)ORTHA7HEOR HEISEX6UPTTHEREFROMAN�THEBASISFOflTHEALLEGEDEXEMP- �, (� '�,, � �TION.ANYVIOLATIONOFSECTIO 7037.SBVANYAPPLICANTFORAPEiiMITSU6JECTSTHEAPPLICANT70 z Re-Roof �� A qVIL PENALT'OF NOT MORE T AN FNE HUNOflED OOLLARS(E5oa).): �, � � ' ❑I,ASOWNEROFTHEPRO ERTV,ORMYEMPLOVEESWITiYJAGESASTHEIRSOLECOMPENSATION, � Commercial �� , Z, �WILI�O THE WORK,AND THE S�RUCTUHE IS NOT WTENDED Oft OFFERED FOR SPLE(3EC.7044,BIISI- J NES$AND PROFESSIONS Gq�E:tHE CONTRACTORS LICENSE CAW DOES NOT APPLY TO AN OWNEF OF � ' �" ��PROPEflNWHOBUII�SORIMPflOVE6FHEREON,ANDWHODOESSUCHWORKHIMSELFORHERSELFOR � � �.,7HROUGFfHI50RHERdWNEM IpYEES,PROVI�EDTHAiSUCHiMPROVEMENTSARENOTINTENDEDOR m Q ''�OFFEREDFORSALE.�F,HOVJEVERTHEBUILDINGORIMPRaVEMENTISSOLDWITHINONEYEAROFCOMPLE- Z ':�,�TION,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVINd THAT HE OR SHE DI�NOT BUILD OR �1MPROVEFORTHEPURPOSEOF ALE).�� w ❑I,ASOWNCFiOFTHEPROIERTV,AMEXCLUSIVELVCANTRACTWGWITHLICENSEDCONTAACTORS ,�.. � TO CONSTpUCT THE PROJECT(SIE.C.7a43,BUS�NE55 pND PROFE55lONS CODE:THE CONTRAGTORS LI- � V8IU8tIOR Q..�17 ADJ.AREA W �.CENSELAWDOESNOYAPPLYTO{�NOWNEROFAPROPEf1TYWHOBUILDSORIIAPROVESTHEREON,AND _ ;WHOCONTRACTSFORSUCHPRO�IECiSWITHACONTRACTOR(S)LICENSEDPURSUAMTOTHECONTRAG QuaNnTv DESCRIPTION FEE � Y 70qSLICENSELAWJ. , [C '-y �, � ❑IAME%EMPTUN�ERSEC. 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IHEREBYAFFIRMUNDERPENALT OFPERlURVONEOFTHEFOLLOWINGDECLARATIONS: U � � I Z �' _IHAVEAN��YILLMAINTAIryIACERTIFICA7EOFCONSENTiOSELF-INSUPEFOfiWOqKERS' _ ' Z CAMPENSATION,A$PHO��I�EDBYSECfION37w�FiHELABORC�DE,FOFiHEPERFOftMANCE 'U Q� �FTHEWORICFOR'WHIC�7HIS�;PERMITISISSUED. � ' � � IHAVEANDWILLMAINTAj WORKERS'COMPENSATIONINSURANCE,ASREQUIREDBVSECTION ) p' Q' 37�DOFTHELA9bRCOD,FOR',THEPERFORMANCEOFTHEWORKFDRWHICHTHISPERMITIS /vaFivg� ISSUEq.MYYJORK AS'C MPENSATIONINSUHANCECARRIERANDPOLICYNUMBERARE: CONSTRUCTION ��a� ¢ .�'c'6/a>J � CpRRIER -/� / PLAN REVIEW . _ _. d�'' POLICV NUMBER� ' 1 / ' ,J ELECTRIC k ��"�'-^ a'. , � . , '. f.a�.➢__� /�..�,,�. �I� 1 ., _ � (MISSEC�ON(JEm�VOiBECCWPLEfEDOFT}1EPEM0715FORONEHUNDREDOOlLARS(5100)ORLESS). PLUMBING Z.' I CERTIFY THAT IN THE P�RFORMANCE OF THE WOFK FOR WHICH THIS PEftMIi I51551JED,l MECHANICAL E ; (,�''. SHALL�.NOTEMPLOYANV ERSONINANYMANNERS�AST06ECOMESUBJECTTOTHE (� ; � WORKERS'COMPENSATI NLA'MSOFCAUFORNIA,ANDAGREETHATIFISHOULDBCCOME INSPECTIONFEE � �eS� ; � 4 SUBJcCTTOTHE�YJCIRKE 5'COMPENSATION OVISION50F5ECTION37ooOFT- L1BOR 3 ��'�� CODE,7SHALLF6flTHWlT COMPLYWI OS ROV NS. ISSUANCE ` � _ �f � j �,y� DATE:R�v I' '� �� A PLICAN � SMIP �u _�'�h,J' . w � . ,.... � LLI, . � � -� �.-._ ._.-�^-..-.� ., _: �,.. WAflNING:FAIWRETOSECURE.LO'RKEflS'COMPE�'SATIONCOVERA 11NLAWFUL, OSH L9E ENERGYP/C 'y� SUBJECT AN EMPLOY�R TQ CflIMIryAL PENALTIES ANO CIYIL FMES UP TO ONE HVNDflED THOUSAND �NERGY PERMIT DDLLARS(S��000),IN ADQI'f10N TIO THE COST OF COMPENSATION,DAIUAGES AS PROVI�E�FOR IN j� J SECTION 3]oe pFTF1�'LABOR CODE,�NTEREST,AN�ATTORNEY'S FEES. RETENTION FEE: �•� p�W,,, � CO STRUCTION LENDtNG AGENCY pRE-ALT FEE: ___ __ �� O � IHEREBVAFFIRMUNDERPENAC OFPEFJURYTHATTHEREISACONSTRUCTIONLENDINOAdENCY 0. FORTHEPERFORMANCEOFRHE�OF7K:FORW'H�CHTHISPERMIT15155UE�(SEC.3oW,CN.C.). � � Lll S�. I.ENDER'S NAME � �' i F�-- LENDER'SADDF7�55 � � ICEflTIFYTHATiHAVEREAbTHISAPPUCq710NANOSTATE7HHTTHEABOVEINFORMATIONISGORRECT. TOTA�L FECS ��a�� ' �'�.�.� IAGREETOCOMPLVWITHALLCIT�YAND�CaUNTVOR�INANCESANDSTATELAWSREIATINGTOBUILDING CONSiRUCTION,AN�HERE6YAU HOliREFEPFlESENTATNE50F7HI5COUNTYTOENTERUPONTHE �' � A8 ENTIONEDPROPERTYF RINS ECTIONPURPOSES. COMMENTS �� , �f.Y. � � � m PE EE AME(P )' " /�/ Q', I ./��I'ti . � cLa, , �i t/ _ �,�, SIONATUREO PERMITT' � �� DATE � ' = i RECPT.NO. 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