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HomeMy WebLinkAbout16294 (23) - __._...� ..�._.,. _ _ _ .--_.,.... �.�..�... ._. _ _ , ....., _�a,�,�-.......r,,..-.,. _ , _ .�--T4- «�r��,--,-�, ���d�� ,� ��� _ CITY OF DIAMOND BAR `�� ���� / � DEPARTMENT OF COMMiTNITY&DEVELOPMENT SERVICES }-3 -.,.w 21660 E.Copley Drive Suite 190 (904)860-3195 Fa�c(909)861-3117 PRESS �•u i9t{'!f . BUII.DING I�'�RMTl'A�PLICA'Y'IO1V . FIRM��Y ,, ..� ,, ,,;:. _ , � o� JOBSITE APPUCATION , PERMIT P/C ADDRESS (�3�U 511+�f.4�- L�PP�'�►,k- �'Z. DATE � ��}NUMBER I�� # 4� ISSUE TYPE OCC APN LOT_�_ TRACT DATE CONST. GROUP p OWNER (osLri� "- ADDRIESS `J11.�'�2, - j.. ZONWG SETBACKS .' " ' o .. �`� CITY iX�AlV1fJ��A �'�� ZIP TEL. " � FRONT RW ❑ � APPLICANT ` �'a TEL q��'��Z� S DE/SIQE STREET RW ❑ � CONTRACTOR_�ar50wi t�a'�?' SIDE ❑ ¢ ADDRESS���-f"'s U..�S�e�i�- R.'b o CITY Qa:cO. 4c+ta�p, �b„ ZIP�� TEL 4�'3�L�'� PROPOSED USE �y �l'tiYlz4._SL_1 �►+�W -W=.."('�A'�+1�� '�lii e� ►G w ARCWENG/ J� r �1�4t,t� o �� �crn SaFvc - DESIGNER izu NO.DWEL. NO. NO. a ADDRES5 � UNITS STORIES BEDROOMS � CITI' � ZIP _ TEL. �n DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER DECLAR0.TION SFR/ADD;REM O I HEREBY AFFIIpA UNDER PENALTY OF PEFW RY THA7 1 AM F.%EMPT fROM 7HE CAN7RACTORS LI- ('jaf8y8/C81�JOi1 W CENSELAWFORTHEFOILONfINOREASON(SEC.7o31.6BUSMESSANOPROFE9310N5C'ODE:ANYCITVOR (f) C7 COUNTrWHIGHqEOUIRESAPEFMIT7000N5TRUC7,ALTER,IMPROVE,DEMOLISM,OpREi�AIRANYSTRUC- W PdtiO/DBCk W NfiE,PPpR TO ITS i55UANCE,AL50 fYEQUiRES THE APPLICANT FOR SUCH PERMIT TO fILE A SIGNED W STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS ll- � CENSE LAW(CHAPiER 9(COMMENqNO WITH SECTION 7000)OF pIVISION 3 OF THE BUSINESS AND PRO- �'i' POOUSpB FESSIONSCOOEIOqTHATHEOHSHEISEXEMPTTHEREFROMANpTNEBASISFONTHEALIEGEDEXEMP- (� TION.ANYYKKATIONOFSECTION7031.5BVANYAPPLICANTFOHAPF_RMITS�&lECTSTHEAPPLICANTTO Z Re-Root r A CM�PENALTV OF NOT MORE TNAN FIVE HUN�HEO DOLLARS(f5A0).)� � ❑I,ASOWNEROFTNEPROPERTY,ORMVEMPLOYEESWITHWAGESASTHEIRSOLECOIAVEN§ATION, O COmmBfCi81 - VJILL DO THE WOPoC.Ml�THE STRUC7URE IS NOT INTEND6D QP AFiEREO F4R�SALE'(SEC.7oaa,�BUSI- J � NESS AND PROFESSIONS CODE:THE COMRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF � PROPERTY WHO BUILDSOR IMPROVES THEREON.AN�WFiO L�OES SUCH WORK HIMSELF OR NERSELf 6R CL hiROUGH H5 OR HEROWN EMPLOYEES,PflOVIDED THAT SUCM IMPROVEMENTS ARE NOT INTENbE00fl m QOFFEREDFORSALEIF,HOWEVERIHEBUILOMGORMPRbVEMENTI550LDWITMNONEYEFROFCOMPLE- Z TION.THE OWNER-BUttAEfl WILL HAYE TNE BURDEN OF PHOVING THAT HE OR SME tll�NOT BUILD OR � IMPRDVEfORTHEPUflPOSEOFSALEI. � '.'.', �'� � W ❑1.FS OWNER OF THE PROPERTV,AM El(C�.USIVEINCANTRAC7INQ WITH LICF.MSED CONTRACTORS [t To rbNS7RUC7THE PROJEC7(SEC.7ola,BUSWESS AND OFlOfES51oN5 LY>DF.�7FIF CONTpACTORS�J- VaIU&tiOn ADJ.AREA W CENSE LAW DOES NOTAPPLY TO AN OWNER OF APROPER^/WHO BUILDS OR IAIPqOVES THEREON,AND . F WVIqCONTRACTSFORSUCHPROJECTSNATHACQtJTRACTOH�S�LICFNSEDPURSUANT70THECONTRAF QUANTITY DESCRIPTION FEE Y TORSUCENSELAW.). - � ❑IAM EXEMPT UNpER SEC. _9.d P.C.FOR YHIS REASON J 0 ___ Q � ----- U � -- ¢ DATE oWNER��`. U �j --- W � LICENSED CONTRACTOPS DECLARATION W � I HEHEBY AFFIRH UNDER PENALTY OF PERJURV THAT I AM UCENSED UNDER PROVISION50F CNAPTER � � e�COMMENCINOWITiSECTK1N7000)OFDIVISION3qFTHEBUSWESSANDFROFESSION5CO0E,AND z ��� MY LICENSE IS IN FULL FQ$QE AND EFFECT. � m � � 0 IiCENSE CLAS 1�;�','y,�UC.NQ _ � V DATE ~ _�y COMRACTOR_ � � _ d � � � ✓W6Rfc FiS'COMPENSATIONDECLARA N �f � � 1 HEREBYAFFIRM UNOER PENAI.TY OF PERIURY ONE OF THE FOILOWING DECLAflATIONS: Z O _IHAVEANOWILLMAINTAINACERTIFICA7EOFCONSENTTOSELf-INSUREFORWORKEFiS' d Q CAMPENSAT�ON,AS PROVI�ED 8Y SECTION 370o OF iNE LA90R COOE,FOp THE PERFORMANCc' W OF TNE WOPK FOq WNICH THIS PERMfT IS ISSUED. � O w _iHAVEPNDWILLMAIIY�AtNWORKEPS'COMPENSAT{ONINSUFiANCE,ASREOUIREDBYSECTION Q 370a Of TNE LABOR CO�E,FOR TNF PERFORMANCE OF THE WORK FOR WHICH THlS PERMIT IS ISSUEO.MY WOf1KFf1S'COMPENSATION INSURANCE CARRIER pND POLICY NUMBEP.ARE: CONSTRUCTION jcnRRiER___�,�._ PLAN REVIEW _ Z Poucvr�uMeea ---------------------------- ELECTRIC a 0 (THISSEGTIJNN�NDTPEQJMPLETmC7FhEPEWWiISFONONEI�iLMDREDWLLAAS(E100)ORlESS�. PLUMBING __ L z I CERTIFY THAT IN7HE PERfORMANCE OFTHE iNORK FOR WHICH THIS PERMI7IS ISSUED,1 MEGHANICAL __ �'}� SHAI.LN�TEMPLOVANYPERSONINANYMANNeRSOASTOBECOMESUBJECTTOTHE � WORICERS'IX�MPENSATIONIAWSOFCAL1FnRN1A,ANDACREETHATIFISHOULDOECOME INSPECTIONFEE � SUBJECT TO THE WOHKERS'COMPF.NSATION PRQVISIONS OF SECTION 370o OF THE IABOR � CAO[,I SHq�4,FORTHWITH COMPLY WITHTHOSE PROVISIONS. ISSUANCE Q p DATE:__ APPUCANT: _ SMIP _, J WAqNING:FAILl1RE TO SECURE W(7RKERS'COMP'cNSATION COYERAGE i5 11NLAWFUL,AND SHALL LE ENERGY P/C � SUBJECTANEMPLOYERTOCRIMINALPENALTIESAN�CIVILFINESUPTOONEHUNDREOTHOUSAND �NF_RGYPERMIT DOLLARS(S70o,000),IN ADDITION TO7HE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN - � SECTION 37oe OF iHE LABOR CODE,INTEREST,ANO ATTORNLV'S F[E5. RETENTION FEE: a CONSTRUCTION LENDING AGENCY pqE-ALT FEE: O � I NEREBV AiFIFM UNOER PENAITY OF PERJURV THAT THERE IS ACONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE OF THE WORi fOR WHICH THIS PERMIT IS ISSUED(SEC 3D9�,CN C.). Z W - � LENDFWSNAAIE __ _ F- LENDER'SADDRESS � W ICERTIFVTNATIHAVEREAOTHISAPPLICATIONANDSTATETHATTHEABOVEMFORMATIONISCORRECT. TOTAL FEES � ��� 1 3 Q I AGREE TO CAMPLY WITH ALL CI7V ANO CAUNT'ORDINANCES ANO STATE LAWS RELATING TO BUILDING � lA �' � COfJSTRUCTION,AND NEAEBY AUTHORIZE REPRES'cNTA71VE5 OF 7HIS COUNTY TO ENYER UPON THE ABOVEMENTIONED PqOPERTV FOR INSPECTION PURPOSES. COMMENTS � ��} � �i• ����i � m PERMI��[ AME(FPINT) -f UJ � 't C�" �} - ' � SIONATUR FPERM17TE DATE � � . �� � = RECPT.NO. 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