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HomeMy WebLinkAbout16989 (26) CITY OF DLAMOND BAR � --�'� - DEPARTMENT OF COMIvIUNTI'Y 8c DEVELOPMENT SERVICES I 21825 c.Copley Drive (909)860-3195 Fax(909)861-3117 PRESS � `'<»�7"' BUILDING PERMIT APPLICATION FIRMLY Q DDR'ESS I`'� p�� �V� ��/N �� APPLICATION .-�h ,.� PERMIT P/C p DATE =t� � NUMBER '�� # � ISSUE TYPE OCC APN _ L�T TRACT__ pATE CONST. GROUP p OWNER � �� � AD�R S Z. O ` //G✓N_�y�� ZONING SETBACKS oCITY IP '��I TEL. FRONT RW ❑ APPLICANT TEL. REAR ❑ � SIDE/SIDE STREET RW ❑ 4 CONTRACTOR �� SIDE O o CDDRESS Z �"" , ZIP TE . PROPOSED USE ��L��� �L�n F'o'�� bl�CJ� o ARCH/ENG! � �z DESIGNER NO.DWE4. NO. NO. a ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � � DESCRIPTION SQ.FT. FqCTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER OECLARATION SFRlADD/REM O 0 1 HEREOY AFFlPM UN�ER PENALTY OF PERJURV THAT�AM EXEMPT FROM THE CONTflACTORS LI- G8f090/CflfPOff W C3�15ELAWFORTHEFOLLOWINGREASON�SEC.�031.58USINESSANOPROFESSIONSCODE:ANYCITYOR (f� U COUNiYWHICHREOUIRESAPERMITTDCqNSTRUCT,ALTER,IMPROVE.DEMOUSH,ORREPAIRANY5TRl1C- W paIIO/DBCIC � TURE,PRIOR TO ITS ISSUANCE,ALSO REQUIRES THE APPLICANT FOa SUCH PERMIT 70 FILE A SIGNED w STATEMENT THAT HE OR SHE IS IJCENSED PURSUANT i0 THE PROYISIONS OF THE CONTFACTORS L'� W � CENSE LAW(CHAPTER 9(COMMENCING WRH SECTION 7000)OF�IVISION 9 OF THE BUSMESS AND PRO- LL' POOUSpd FESSIONSCODE)ORTHATHEORSHEISEIIEMPTTHEREFROMANDTHEBA5ISFORTHEALLEGEDEXEMP- (� � TION.ANYVIOIATONOFSECTION7031.5BYANVAPPLICANTFOFAPEFMITSUOJECTSTHEAPPIICANTTO Z RB-R001 A CIVIL PENALTY OF NOT MORE THAN FNE HUNDRED�OLLAPS(E5D0).): � pI,A50WNEROFTHEPROPERTY,ORMYEMPLOYEESWITHWAG'cSASTHE��.RSOLECOMPENSATION, � COfnRIBfC18I WILL�O THE WORK,AND THE STRUCTURE IS NOT INTENOED OR O=FERED FOR SALE(SEC.7044,6USI- J � NE55 pND PROFESSIONS CODE:IME CONTRAGTORS LICENSE LAW�OES NOT APPLY TO AN OWNER OF � PROPERTY WHO OUILOS OR IMPROVES THEFEUN,AND WHO�OES SUCH WOHH HIMSELFOR HERSEIF OR � THFiOUGHHI50RHEFOWNEMPLOVEES,PROVIDEDTHATSUCMIMPROVEMENTSARENOTIN'ENDEDOR m pOFF'eREDFORSqLE.IF,HOWEVER,iHEBUIIDMCORIMPROVEMENTI550LD1Mh1!NONF.VEAROfCOMPLE� � TION,THE OWNER-BUILDEfl WILL HAVE THE BURD[N OF PPOVING iHAT HE OR SHE DID NOi BUIIA OR � IMPROYEFOflTHEPURPOSEOFSAIE). ❑1,AS ONMER OF THE PROPERTV.AM EHCLUSIVELY CONTRACTI4G WITH UCE45 ED COli�TRACTORS � TO CANSTRUCT TME PROJECT(SEC.]O6a,BUSINESS pND PROFESSIONS CODE:TNE CONTRFCTOPS LI- V81118t1Of1 ADJ.AREA W CENSELAWDOESNOTAPPLYTOANOWNEROFAPROPERTVWHOBUILDSORIMGROVESTHEREON,PNO � WHOCONTFACTSFORSUCHPRQIECTSWITHACONTRACTOR(5)LICENSEDPURSUANTTOiHECONTRAG QUANTITY DESCRIPTION FEE Y TORSUCENSELAW.). � J O ❑I AM E%EMPT UNDER SEC. B.&P.C.FOfl THIS REASON Q / � � � � �ATE OWNER U � LICENSED CONTRACTORS DECLARATION W Q I HEREOY AFFIRM UNDeFl PENALTY OF PERJURV THAT I AM LICENSE�UNDER PROVISIONS OF CHAPTER � /i.�� Q , d 9(COMMENCING WITH SECTION 70W)OF�IVISION 3 OF THE BUSWESS AN�PROFESSIONS CODE,AN� Z W �� w MV UCENSE IS M FULL FORCE AND EFFECT. .�7 m � � � LICENSE GLA55 S„L=,� UC.NO.__� ` // � J U DATE CONTRAC70R d W � WORKERS'COMPENSATION DECLARATION a � 1 HEREBY AFFIRM UNDEH PENALTY OF PERJURY ONE OF THE FOLLOWING�ECLRRATIONS�. U � Z Q Ll IHAVEANDWILLMAINTAINACERTIFlCATEOFCONSENTTOSELFINSUFEFORWORKERS' _ � COMPENSATION,ASPROVIDEDBVSECTION37ooOFTHElA80RCODE,FORTNEPERFORMANCE `U OFTHE WORK FOR WHICH THIS PERMIT IS ISSUED. ,� � W �G�-IAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REOt11RED BY SECTION Q 37000FTHELABORCODE,FORTHEPERFORMANCEOFTHEWORKFORWHICH7HISPERMIiIS � ISSUEO.MV WORI� RS'CAMPENS TION�Iy�7U�RANC�)'CARRIEii ANO POLICV NUM9ER ARE CONS7RUCTION j caaqiea yw �+—r*� PLAN REVIEW /y/.—� � POLICVNUMBER /I 1 O OO� ELECTRIC ___���� , h� d -o p (IHISSECTIONNEmNJTBE�+RETEDOFhiEPERhLTFSWRONEHUi`1DflED00LLAfi3($1aC)ORLE55} PLUMBING � ���_ Z I CERTIFY THAT IN THE PER�ORMANCE�FTHE WOFK FOR WHICH THIS PERMI715ISSl1ED,1 MECHANICAL (;J SHAIL NOT EMPLOV ANV PERSON IN ANY MANNER SO aS TO BECCME SlJBJECT TO THE � WORKERS'GOMPENSATIONLAWSOFCAUFOHNIA,ANDAG EETHATIFIS U B ME INSPECT�ONFEE � SUBJECTTOTHEWORKEFIS'COMPENSATIONPROVISI F ECTION cLABOF ISSUANCE 't C ,I SHA4L FOPTHWITN COMPLY WITH TH P � ► l' p DA7E: �y APPLICAN7: SMIP � ENERGY P!C .__— —. ___ J WARNINGFAILURETOSECUREW�RKERS'COMPENSF'IONGOVERAGE'�.SUNLAWFUL,ANDSHALLOE LL SUBJGCTANEMPLOVERTOCRIM:WLPENALTIESANDCIVILFWESUPTOONEHUNDREDTHOUSAN� ENERGYPERMIT DOLLAflS(§100,000�,IN ADDITION 70 THE GOSTOF GOMPENSATION,DAMAGES AS PROVIDW FOR IN � SECTION37080FTHELABOPCO�E,INTEREST,ANDATTORNEY'SFEES. RETENTIONFEE: a CONSTRUCTION LENDING AGENCY PRE-AL7 FEE: � IHEREBYAFFIRMVNDERPENALTYOf'PC(iJURVTHATTHEREISACONSTRUCTIONLENDINGAGENCV 0. FORTHEPERF�qMANCEOFTHEWORKFORWHICHTHISPEflMITI5155UE0(SEC.3o9�,CIV.C.). Z W S LENDER'S NAME � 1= LEN�ER'SA�DRE55 ,/�n � ICERTIFYTHATIHAVEREADTHISAPPLICATIDNANCSTA`ETNAiTHEABOVEINFORMATIONISCORNECT. TOTAL FEES � IPwA � W 1 AGREE TO COMPLY WITH ALL qTY AND COUNTY ORDINANCES AND STAT[UWS RELATING TO BUILDING � � CONSTRUCTION,AND HEREBY AUTHOqRE REPRESENTATNES OF THIS COUMY TO ENTER VPON THE ZAOOVE TIONE�PROPERTV FORIN gGFnoN auaaosEs. COMMENTS � '�v�f cazT` � G�'ah�-- m PE ' EE 1 '--'- Q �-� .-e� / � - -- Uj A7 FPERMiTT � DATE = RECPT.NO. 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