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HomeMy WebLinkAbout17251 (26) CTI'Y OF DIAMQND BAR `� ��`'� - DEPARTIv1ENT OF COMMUNTI'Y&DEVELOPMENT SERVICES -- I � �/�� � 21825 E.Copley Drive � �" (909)860-3195 F�(909)861-3117 PRES$ .. �"%•y��°" BUILDING PERMIT APPLICATION FIR LY � JOBSITE ,�} /^ �,, APPLICATION PERMIT i�'��J� P/C ¢ ADDRESS_---����U�'� LJ(� DATE O� � � � NUMBER J # `r APN Lf�T TRACT DATEE ` v r � ONST. GROUP p OWNER /� C � ADD SS �.�"Ir ZONING SETBACKS Z CITY E ZIP_�! _�'�fEL._ FRONT qW O p APPLICANT TE��� SIDElSIQESTREET RW 7 z ¢ CONTRACT R SIDE _ � ADDRESS � CITY �°�" �T C,L' f ZIP ZTEL. t'O PROPOSED USE � ARCHIENG/ � �. 2 DESIGNER � NO.DWEL. NO. NO. � ADDRESS — UNITS STORIES BEDROOMS � CITY Z1P TEL. � cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER DECLARATION SFRlADDlFEM O I HEREBY AFFIRM UNDER PENALTV OF PEFWURV TNAT I RM EXEMPT FP.OM iHE CQMRACTO%5 u- Gara 8/C2 O�I W CENSEIAWFORTHEF'OLLON/INGREASON(SEC.7a31.56US1NE5SANCPROFESSIONSCODE:ANVCITYOR (n 9 � U �OUNTVWHICHRE4UIflES0.PERMITTOCONSTRUGT,ALIER.IMPROVE,DEMOLISH,ORflEPAIRANYSTPl1G ' W TUpE,PRIOR TO ITS ISSUANCE,ALSO REOUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SidNED w Patlol�eck STATEMENT THAT HE OR SHE IS LICENSED PUqSUANT i0 THE PROVISIONS OF THE COMRACTORS LI- � CENSE LAW(CHAPTEfl 9(COMMENCING WITH SECTION�ODo)OF�IVISIDN 3 OF THE BUSMESS FN�PHD- U' PO01(Spa � FESSIONSCODE)ORTHATHEORSHEISEXEMP7THEREFROMANDTHEBASISFORTHEALLEGEDEXEMP- (� TION.ANY VIOLATION OF SECTION]031.5 B�ANV APPLICANT FOR A PERMIT SUBJEC75 THE APPLICANT TO Z Re-Roo1 F A CIVIL PENALTY OF NOT MOFIE THAN FNE HUNDRED DOLLARS�SSOD)J: � ❑I,ASOWNEROFTHEPROPERTY,ORMVEMFLOVEESWITHWAGESASTHEIq30LECOMPENSATION, ❑ COrtIrtl0fCi8I WILL DO THE WOqK,AND THE STRUCTURE IS NOT INTENDED OF OFFERE�FOR SALE(SEC.7044,6USI- J � NESS AND PROFESSIONS CODE:THE CONTRACTORS LICENSE LAW OOES NOT APPLV TO AN OWNEfl OF � PflOPEH'�l'WHO BUILOS OR IMPROVES 7HEREON,AND WHO DOES SUCM WORK HIMSEIF OF HERSELF OR � THROUGH HIS OR HER OWN EMPLOYEES,PPOVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR m OOFFEREDFORSALEIF,HOWEVER,THEBUILD�NGORIMPROVEMENTISSOLOWITHINONEVEAROFCOMPLE- Z TION,THE OWNER-BUIL�EF WILL HAYE THE BUROEN OF PqOVING iHAT HE OR SHE DID NOT BU:L�Ofl � IMPPOVEFOfl7HEPURPOSEOFSALE). W ❑I,FSOWNEHOFiHEPROPEfiTV,AME%CWSNEIYCONTRPCTINGWIiHLICENSEI]CONTRqCTORS � 70 CONSTRUCT THE PROJECT(SEC.7044,BUSINESS AND PFOFESSIONS COOE:TNE COMRAC70R5 LI� V811JflfI0f1 ADJ.AREA W CENSELAWOOESNOTAPPLYTOANOWNEROFAPROPEFITYWHOBUII�SOPIMPROVESTHEREON,AND � WF7000NTftACT5FOR5UCHPROJECTSWITHACONT9qCTOR(S�LICF.NSEOPURSUANTTOTHECONTRAG QUANTITY DESCRIPTION FEE Y iORS LICENS'c LAW.). � ❑I AM EXEMPT UN�ER SEC. B.8 P.C.FOR THIS REASON Q � U � __ � DATE OWNER U Z w � LICENSED CONTRACTORS DECLARATION W d � I HEREBV AFFIRM UNDER PENALTY Of PERJURY THAT IAM UCENSED UN�ER PROVISIONS OF CHA?7ER � d, 9(COMMENCING WRH SECTION 1000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIDNS CO�E,AND Z X MY LICENSE IS IN FULL FORCE AND EFFECT. f � LICENSE GI�4SS � LIQ NO.� � _'+�'� �'� � h_„ /,/� J V DATE `v ` CONTRACTO ��� n. W � ORKERS'COMPENSATION DECLARATION � � INEREBVAFFIRMIJNDEAPENALTVOFPERJUNYONEOFTNEFOLLOWINGDECLARATIONS: Z Z _I HAVE AND WILL MAINTAIN A GERTIFICATE OF CON9ENTTO SELFINSURE FOR WORKEPS' _ ¢ COMPENSATION,AS PROVIDED BY SEC7ION 3�Oo O�7HE LABOR COOE,fOR THE PERFORMANCE U Q OF THE WORIC FOR WHICH THIS PERMIT IS ISSUED. � QW �IHAVEANDWILLMAINTAINWORKERS'COMVENSATIONINSURANCE,ASHEQUIREOBVSECTION 370oOFTHELABORC00 FORTHEPERFORMANCEOFTHEWORKFORWH�CHTHISFEflMITiS � - ISSUED.MY WORKERS'C MPEN TION INSURANCE CARRIEti I�POUCY NUMBERARE�. CONSTRUCTION � CARRIER � 'T PLAN AEVIEW Z POUCY NUMBEfl l/w I����,`�_, ELECTRIC Q r � (iHISSECTIIXVNEmNOTBENMRETEDOFhiEPERMRISfGRqJEMJNJREDDIXLARS�Et[o;ORLE55). PLUMBING Z I CEFTIFV THAT IN THE PERFORMANCE OF THE WOFR FOR WHICH T4'�.S PERMIT IS ISSUED,I MECHANICAI ` C'3 SHALLNOTEMPLOVA�'VPERSONINANYMANNERSOASTOBECOMESUBJECTTOTHE � WORKERS'COMPENSATIONIAWSOFCALIFORVIA,ANDAGREETHAT'FISHOULDBECOME INSPECTIONFEE � S�BJ'eCTTOTHEYJORKERS'CONPENS4TI0 OVISIONSOFSECTION3�000 HELABOR � CO�E, HALLF THWIiHCOMP�VWITH EPROVIS N5. ISSUANCE � SMIP p DATE�� APPLICANT: J WARNINGFAILURE OSECUREWORKERS'COMPENSATbNCOVERAGEISUNL4WNL,ANOSHALLBE ENERGYPlC � SUdJECTAN EMPLOVERTO CRIMINAL PENAL71E5 AND GVIL FINES UPTOONE MUNDRED THOUSAND ENERGY PERMIT DOLLARS�E1oo,000),IN AD�IT'�ON'O THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IM1 � SECTION3�oeOFTHELABORCADE,INTEREST,ANOATTORNEY'SFEES. RETENTIONFEE: / � CONSiRUCTION LENDING AGENCV PRG-ALT FEE: O � I HEREBYAFFIflM UNDER PENALTY OF PERJURV THATTHERE IS A CANSTRUCTION LENDING AqENCY FOR THE PERFORMANCE OF THE WORK FOR WHICH?HIS PERM�T IS ISSUEO�SEC.3091,CIV C.). Z w � LFNDER'SNAME F— LENDER'SADDRESS � � ICERTIFYTHATIHAVEREADTHISAPPLICATIONAN�STATETHATTHEABOVEINFORMAT!ONISCOFFECT. TOTALFEES o�� w I AGREE TO COMPLY WITH ALL GRY ANO COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING � CONSTRUCTION,ANDHEREeYA'JTHOR2EREPRESEN7ATIVESOFTHISCOUNTYTOENTERUPONTHE Z AADVE�MENTIONE�PROPERTY FOR INSPECTION Pl1NPOSES. COMMENTS � � � m ER EE NAME(PRIM) �- Q CJ7 � I O P E DATE = RECPT.NO. AID BY VALIDATION ~ WHITE—Department Copy,YELLOW—Financa Copy,PINK—Assessor Copy.GOLDENFOD--File Copy,GREEN—Applic Y Copy _ . . .. _ ..�.., .., �.� . . '.<.t:-:� ,,...:..�... ap,..,:r.. , r r ',,,.:,:. -.x.Vw;,.s�i*ti�.�.i,R,.3,- .�.i,:. ... . .. - ... . . .. . ,.. <i. q .. , .. .. .:...... . ... .. ..>. .,-„�.. , . .... ...,. 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