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HomeMy WebLinkAbout13748 (17) w� 1� 1 CITY OF DIA.MOND BAR DEPARTMEDIT OF COMMUNITY&DEVELOPMENT SERfJICES 21650 E.Copley Drive Suite 190 (909)8G0-3195 Fax(909)861-3117 PRESS ' ����� BUILDING P'ERMIT APPLICATION FIRMLY � JOBSITE APPLICATION� �. ( PERMIT � � P/C o ADDRESS�__�����'�l�ff��>�� DATE � �_ NUMBER ` � # � ISSUE NPE OCC APN LOT TRACT_ DATE CONST. GROUP p OWNER �L��f%L?� C��`,,�5�'Z�G.-L�/ — — ADDRESS�-�•57��''.�dG.�'ic�i�/,� .9�Z ZONING SETBACKS oCITY' �F12� it` ZIP��TEL j I��T_�T���_ FRONT RW G APPLf ANT TEL. REAR ❑ b SIDE/S!CESTREE� RW C � CONTRACTOR . ���tC�JF� �.k_GI�'���' l��l.`_ SIDE __ C � ADDRESS B- '�'��`.� �~' j' �'-�% °' pROPOSED USE a CITY �/� C_�atifti ZI��'f�� TEL���� wo AACWENG/ z DESIGNER NO.DWEL. tJO. NO. � ADDRESS UNITS_ aTQRIES BEDROOMS � CITY _ ZIP TEL. � DEBCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � � OWNER-BUILDER DECLARATION SFR/ADD/REM O p I HEHEBY AFFIRl�1 UNDER PENAL7V OF PERIl1RY THA7 I AM EXEMP'FRCM T7iE CON7RACTORS LI- � GaragelCarport W CENSEUWFORiHEFOILOWNGAEASON(SEC.�o31.5BUSINESSANOPiiCFESSION5CO0E:ANVCIT'OR U COUNTYWH(CHREIXIWESAPERMITTOCONSTRUCT,ALTER.IMPROVE,DEMOLISH,OARcPAIRANVSTRUC- W Pa[io/Deck w TURE,PqpR TO ITS ISSUANCE,ALSO REQUIRES THE APPLICANT FOR SJCH PERMIT TO FILE A SIGNED w _ � STATEMENT THAT ME OR SHE IS LICENSED PURSUANT TO 7ME PROVISIO�.JS OF THE CONTRACTOHS ll- � CENSE LA�N(��ER 9�COMMENCING WITH SECTION 7000)OF�IVISION 3 OF THE BUSINE55 M70 oqp. � POOVSpa _ FESSIONS COOE)OR T4AT HE OR SHE IS E7(EMPTTHEHEFHOM PJrD TNE BASIS FOA THE AILEGED E7fEMP- TION.ANYVIOLATIONOFSEC710N7o31.5BYANYAP7UCANTFORAPERMITSUBJECTSTHEAPPLICANTTO Z Re-ROof � A CML PENALTV OF NOT MORE T'AN FIVE HUNDRED DOLLARS�SSoo).): � ❑I,ASOWNEROFhIEPROPERTV,OAMVEMPLOVGESWITHWAGESA:>THEIRSOLECOMPENSATION, Q COrt1RI0fCIdI WILL 00 THE WORK,M!D THE STRUCiURE IS NO7 INTENDED oR OFFERED FOR SALE(SEC.7044,BUSI- J NESS AND PROFESSIONS CODE:TNE COlJTRACTORS LICENSE LAW DOES NOT A7PLY TO AN OWNER OF � PFOPERTYWFiOBUIlDSOFIMPflOVESTHEREON,ANDWH000E55UCHWORKN!MSELFORHERSELFOq = � 7Hp01:CHiHHI50RHEROVYNEMPLOYEES,PROVIDE�THATSUCHIMPROVE�dENTSARENDTINTEN�EDOR m WQ OFFEREDFOHSALE.IF,HOWEVER7NEBUILDINGORIMPROVEMFNTISSOLDWITHINONEYEAROFCOMPI.E- Z TION,THE OWNER-BUILDER WILL HAVE 7HE eURDEN OF PFlOYING THA7 kiE OR SHE DID NOT BUIID OR � � IMPROVE FOHTHE PURPOSE OF£PLE). W CI,ASOWNEROFTHEPROPERTV.AM'cXCIUSIV'cLYCONTRACTINGYI,THIICENS'eDCONTRACTORS W EN EUSVUDOESHNOTAPPLYTOANOWNEROFAPRO�flNWHOBU�DSOR�IMPROVE3TH£REON,AtiD Valuation __ ADJ.AREA_ __ � WHOCONTRACTSFORSUCHVFOJECTSWI7HACl7NTRlICTOR�S)LICENSEC�PU�SUANTTOTHE.L9NTRAC- QUANTITY�DESCRIPTION FEE TORS IICEPSE UW.). J O ❑I AM EXEM"VT UNDER SEC. _B.6 P.G FOR THIS ACASON Q I LL �ATE ONRJER___ —__— _— —_� � � LIGENSED CONTRACTORS DECLARA'"ION w T � I HEREBYAFFIFM UNDER PENALTV OF PERJURY THAT 1 RM L'CcMSE'�UhD_R PFOUSIONS OF CHAATER _� d B(COMMENCING WITFI SECTION 7�C0)OF DIVISIO�a OFTH'c BUSINESS AND PROFESSIONS CODE,AND � X MY UCENSE IS IN FULL FORCE ANO EFFECT. L1J o LICENSE CLAfiS ��� L�C.NO. f"'����� � / C -�y'�.�nr� — U DATE '�� •.. a ._—_--'— CONTRACTORy.2v��:.7fa.� GOL�GI.(6�+�j w F/�•'-YT>�c'� — � 't�ORK.ERS'CUMPENSATlO�DECLARfTION �"�� � _ 7 8�, ^�f VI C1) �..'�o� ' � 1HEaEEYAFFIiS�9U17DEHPENAL1YOf7ERJURYONEOFTHEFOLIOWING�cCLARA710NS: � �a � (�i i G ,_IHAYEANDWILLMAINTA'NACr.RTIFICATEOFCANSEtiTTCSELF-IN$UPEFORWORKERS' = S=� � CAMPENShT1aY,.4S P9CVIDEp 8Y SeC510N 37GOOF TYE LAfiOR GOOE,FOR hiE PERFOflMANCE W}— — OF THE WORF FOR WHICH THIS.'E^nM1T IS ISSUED. � � � _I HAYE hND WILL WAINYAIk WORKEaS'CAMPE�SAT!OV INSURANCE.AS RECUIRED BY S'cCTIOY Q 3700 OF THE LABOfl CODE,FO�THE AERFGiMA�CE CF THE WOFN FOFl WHICH THIS PERMIT IS --- — ISSUEO.MY VJOHKERS'CAMPEMSA7IUN INSURAfiCE CARRIER P.N17 POL:CI'�UME�ER ARE: I CONSTRUCTION � CARRIER +1�c'�d?—f��'��_F-rC'----- �LAN REVIEW ---- - --- z PafCY NUr�BER_1�i��.�t1�'�_'����t-�� ELECTRIC _____. ¢ 0 (iH65C{:LNNE�NDTBEOJAAPLE�E�OF7F'EPi:fNN�LFOHCNJf.HI:!.pFiE�DJLAR5�55�)CR:[SS� PLUMBIIJG _ __ ________ � W MECHANICAL � '�� ,'Z I CEP.TIFV'(HA?Ihi THE PERF'JRMANCE OF TFIE WORK FOR WHICI-�THiS PERMIT IS ISSU�O,I ------ (� SHALLNOTEMPLOYANYPERSONINANVMANN.EfiSOAST09ECOMESUB.,ECT70THE � WORKERS'COMPe45A?IONLAWSOFCALIFORNIA,AN�AGREETNATIFISHOULD�[CO?AE INSPECTIONFEE µ S �'"`7 /'� SU&IECTTOTHEWORKERS'COMPENSATIONPFlOVISI SOFSE�:T10Y37000F'NELA80R �• %�+�� � OGQOE,IS rOF�THWITHCOMPLYWITi�MO� ?R ISIONS lSSUANCE _,____ _ _ � i�, a �t , � y �,��:� — — sMIP DATE:__1�.__ APPLCANT: --- ___—_ — W ENERGY P/C `° ' �'" J WMNINGFA�LURETOSEWFEWOqKER3'COMPENSATIONCAVERAGEISUNIAWFUL,AN�JSNALLBE ---w...,,„, .,. �,,,,�,�. — � SUBJECTANEMPLOYERTOCRIMiNALPENALTIESANDqVILFIM1ESUPTO�IJEHUNDFEDTHOUSAND ENERGYPERMIT � DOLLARS(5100.DOO;.INADDITIONTOTHECOSTOFCDMPENSATION,DAMi\GESASPROVIDEOFOR!N I .,• . , . :4.Z J SECTION37080FiHELABORCO�E.INTEREST.ANDAT'fORNEY'SFEES. RETENTIONFEE: � d CUNSTRUCTION LENDINGAGENC:Y � PRE-ALf FEE: __ ___ � INEREBYAFfIRNUN�EHPENAL'�OFPEFJURVTHAT7HERE�SACOYSY�UC:IONLENOINGAGENCY ______ a- FCR TNE P[RWRMANCE OF THE WORK FOR WHICI I TH!S PERMIT IS ISSUEO(SEC.3087,CIY.G.). �— � Z ___ W � LENDER'S NAME ____—_ — — _ _ __ S F-� LENOER'SADDRE33 ____— — � ICERTIF:THATIViAVEREADTHISAPPLICATIONANDSTATETHAT7HEAB()VEINFONMA'fION:SCORRECT. TO iAL FEES • � I AGREE TO COMPLV WITH PLLCITY AND COUNTV ORDIYANCES AN�STATE LAWS RELATING TO BUILDING CONSTRUCTION,AhD HERE6YAUTNORIZE FEPRESENTATIVES OFTHIS C7UNiV TO ENTER UGON THE ZABOVE•M N�IONEDPROPERTYFORINSPECT�ONPUftPOSES. 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