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HomeMy WebLinkAbout14565 • CYTYOFDIAMONDBAR ���, E!�P���� --�•���-- DEPARTI"4ENT OF COMMUNITY&DEV�LOPMEN�C SERVICES ��; � 21660 E.Copley Drive Suite 190 ��j Q � Z�Oa (909)860-31951 ax(909)861-3117 PRESS ��'A�°� BUII,DING PERMIT APPLICATION FIRMLY _ -. ... . <_. _ . . . .... _. . ... . . . � L � C . } JOBSITE ( �"�I S/ ��G� 'Y/• DATE CATION "'.J�— NUMBER L � #!C o ADDRESS_ $ ISSUE 7YPE OCC APN LOT TRACT_ DATE ^CONST. GROUP p OWNER _m�IS �� p ADDRESS ZONING SETBACiCS � CI ZIP TEL. 'Z REART RW 7 APPLICAN7 TEL. SIDE/SIDE STREE'f RW � o� CONTRACTOF� SIDE 7 ADDR S d - CITY ZIP �a TEL. U- PROPOSED USE w ARCH/ENG/ �C�B z DESIGNER w NO.DWEL. VO. NO. a ADDRESS UNITS _ 3TORIES BEDROOMS � CIN ZIP TEL. — � cn DESCRIPTION SQ.FT: FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER DECLARATION SFR/ADDlFlEM O Q 1 HEREBY I1FFIqM UNDER PENALTY OF PERIURY THAT I qM E%EMPT FROM THE WNTRACTOflS LI� G&f89B(CefPOA W CENSEIAWFORTHEFOILOW�NGREASON(SEC.7031,5BUSINESSANDPROFESSIONSCOOE:ANVCITYOR � U CWNTYWHICHREp11fiE5APERMITTOCONSTRUCT,ALTERIMPRWE,OEMOLiSH,ORREPAIHANVSTRUC• W P8Si0/D6Ck Z NRE,PRIOR TO ITS ISSUMICE,ALSO REDUIRES THE APPLICPM FOR SUCH PERMI7 TO FILE A SIGNED � STA7EMENT T}IAT HE OH SNE IS I.ICENSEO PURSUANf TO 7HE PHOVISIONS OF7HE CONTRACTORS LI• � � CENSELAW(CHAPTER9(CO�IMENCINGWI7HSECTION70o0)OFDIVISION30FTHEBUSINESSANDPRO- Po0US�3 FESSIDNSCODE)OR7HATHEORSHEISIXEMPT7HEREFROMANDhiEBRSISFORTHEALLE6EDEKEMP- (� TION.MlYVIOL0.TIONOFSECTION7031.5BVANYAPPLICANTFORAPERAlIT5l/BJECTSTHEAPPLICANTTO z RB•RaOf � ACMI PENALTV OF NOT MORETHAN FIVE HUNDRED DOLURS(5500).): � ❑I,ASOWNEROFTHEPROPER7Y,ORM7EMPLOYEESWITHWAGESASTMEIRSOLECAMPENSATION. 0 CommefCial - N7LL DO THE riORK,ANU THE STqUC7Ui�IS NOT INTEND6D OR OFFERED FOR SALE(SEC.7ona,eU51- J � NES.`.AND PROFESSIONS CODE:THE CANTRACTORS LICENSE UW�OES NOTAPPLY TO AN OWNER OF � VROVENTY WFIO BUILDS OR ILlVROVES THEREON,AND WHO OOES 5UCIi WORK HIMSELF OR HERSELF OR 2 7HqOUf3F1 HIS OR HER ONTI EMPIAYEES,PROVIDEO 7HAT SUCH IMPROYEMENT9 AR�NOT INTEhDEU OR m � OFFERE�FOR3ALE.IF,HOWEVERTHEBUILDINGORIIAPROVEl�iEN71550LDWITHINONEVE0.ROFCAMPLE- Z TION,THE OWNER�BUNDER WILL HAVE THE BUROEN OF PROVING THAT HE OA SHE�IO NOT BUILD OR � IMPHOVE FOH TFE PUHPOSE OF SALq. �y ❑I.ASOWNEH OF THE PROPERiY,AM E%CLUSIVELV CONTRACTING WITH LICENSED CONTRACTORS Q TO CONSTRUGT TH[PRQIECT(SEC.7v41,BUSINESS AND PROFESSIONS CODE:7HE CONTRACTORS LI- V&IUellOfl ADJ.AREA � CENSELAWDDESNOTAPPLVTOANOYVNEROFAPROPERTYWH09UII,DSORMPROVESTHEREON,AND NHOCONTRACTSFORSUCHPRWECTSWITHACONTqACTOR(S)LICENSEDPURSUANTTOTHECONTRAG QUANTiTY DESCRIPTICN FEE Y 70HS ucENSE Uw.). � ❑I AM EXEMPT UNDER SEC. B.8 P.C.FOR THIS REASON � 0 ¢ � U u- °C — oATE oWNER � � W � UCENSED CONTRACTORS DECLARATION W — OC 1 HEREBV AFFIRM UNDER PENAIN OF PEflJURV THAT I AM LICENSED UNUER PROVISIONS OF CHAPTER � d 9(COMMENCINO WITH SECTION 7000)OF DIVISION 30F THE BUSINESS IW�PROFES510N5 CODE,AND Z MY IICENSE IS IN Fl1LL FORCE ANO EFFECT. m � ..� � IICENSE CLA55 LIC.NO.� /����� � � V DATE ^ � CONTRACTOR [.wsZ� W � l � WORKERS'COMPENSRTION DECLARATION ��� U � I H/F�R�Y AGFIRM UNDER PENAL7Y OF PERJl1RY ONE OF THE FOLLOWING OEC!AflATIONS: Z � /�i HAVE ANO WILL MAIMAMACEfiTIFICATE OF CANSENTTO SE�F-iNSURE FOR WOqKERS' _ Q tCqMPENSATION,AS PROVIDED BY SECTION 370o OF THE LABOR CODE,FORTHE PERFORMANCE �U Q OF THE WORK FOR WHICNTHIS PFRMIT IS ISSUED. � � I HAVE ANO WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BV SECTION Q �37000F TME LABOR CODE,FOR THE PERPoflMANCE OF THE WORK FOR WHIGH THIS PERMIT IS ISSUED.MY WOHKERS'COM ENSATION INSURANCE CARRIER D POLICV NUMBEA ARE: �-�STRUCTION J — — � CARRIER _ � ��_�� 'Gi. � � PLAN REVIEW _ � � POLICVNUMBER ��i --� �s � ' � —�7,�.`�--� '��5��1 ELECTRIC .L'•d.��,�:!,� � . 0 (rri�ssEcraNr��r�oreEmn��rEooFn�r+�w.urswaoraEHuroaEoactv�as�s�ooloa�l. PLUM�BI�`G � Z I CERTIFY THAT IN THE PENFORMANCE OF THE WOFK FOR WHICH THIS PERMIT IS ISSllE0,1 MECHANICAL w C�� '��� C�} SHALL NOT EMPLOY ANY PEflSON IN ANY MANNER SOAS TO BECOME SUBJECTTO THE - a �; ��„'.:.s4 ,�.�-� � WURKERS'COMPENSATIONLAWSOFC ORNIA,AN�AGREETHATIFISHOULD9ECOMC- INSPECTIONFEE ' `° SU&IECTTOTHEWORK�RS'COMPE �O PROVISIONSOFSE ' N37ooOFTHELABOR � CODE,ISHALLFOFiTMWITHCOMPLY ITHTry EPROVI$IbN. ISSUANCE __;"•'���';y�� "� � 0 OATE:"l i��APPLICA � SMIP --.r;::"7i'�f `- >a...`,... -_ ...''"'_ ' r.i.�.:.,a:.a:. . J WARNING:FAIWRE TO SECURE WORKERS'COAAPENSATION COVERAGE IS UNLAWFUL,AND SHALLBE ENERGY P/C � SUBJECTANEMPLOYEFTOCRIMINALPENAL7IESANDCIVILFINESUPTOONENUNDREDTFIOUSAND ENERGYPERAAIT DOLLARSlS10D,000).IN ADOITION TO THE COST OF COM7ENSATqN.DAMAGES AS PROVIOE�FDR IN � SECT10431oBOFiHELA80RCODE,INTEREST,ANDATTOFiNEY'SFEES. RETENTIONFEE: oCONSTRUCTION LENDING AGENCY PRE-AlT FEE: , _ � I HEREBY AFFIRM UNDER PENALTV OF PERJl1RY THATTHERE IS A CONSTFUCTION LENOING AGENCY FOR THE PERFOpMANCE OF THE WORK FOR WHICN TNIS PERMIT IS ISSUEO(SEC.30W.CIV C.). Z W � LEN�ERSNAME _ 1— LENDERSADDqESS �+ w� TOTAL FEES f— ICERTIFYTHATIHAVEREADTHISAPPLICATIONANOSTATETHATTHEABOVEMFORMATIONISCAHRECT. �Jq� �I p� IAGREETOCOMPLYWITHALLCITYANOCAUNTYOq01NANCESANDSTATELAWSRELATINGTOBUILDING � CONSTRUCTION,MvDHEREBVAUTNORIZEFiEPRESENTATIVESOFTHISCOUNTYTOEN1EqUPONTHE Z ABOVE•MENTIONED PROPERTY FOR INSPECTqH PURPOSES. COMMEN7S � ' � / t �°y� . ,,�3 _,L, m PE ITT E NAME(PRI � - .� r 1-3!��:�� 2.� �� �/j TU.E OF P OATE = RECPT.NO. 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