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HomeMy WebLinkAbout10652 _...._.__.....- -- —._._ .._...,__ _._ - - � � - _________-- , `�� CITY OF DIA1v1aND BAR �� � COMMUNITY'DEVELOPMENT DEPARTMENT 21660 E.Copley Drive Suite 190 PRESS � (909)860-3195 F:ix(909)861-3117 "H�, BUILDING PERMIT APPLICATION FIRMLY � JOBSITE 2�"�c�j'r`"✓ �,rj d�` � �C,�— APPLICATION �3 p�,,Gs f+ NUMB R/����`C o ADDRESS DATE �C� 1 # � ISSUE t i�6 d�'`� `� CONST. GROUP APN__� LOT TRACT_� DATE ✓' °C OWNER � � �' O — a AD4�Es5 � P A+ ZONING SETBACKS OCIIY�� ZIP �' . TEL. rtG�a`� ° � FRONT RW ❑ APPLICANT TEL.��g����� REAR ❑ Z / SIDE/SIDE STREE'T RW ❑ m CONTRACTOR SIDE C � ADDRESS ' /"a�'�f/'�ta�AdP��/�"" `^'��� � C�Ty ZIP TEL. PROPOSE�USE � w ARCH/ENG/ _e�2� �.�A .. t z DESIGNER NO.DWEL. NO. NO. a ADDRESS UNITS � STORIES I BEDROOMS � � CITY ZIP TEL.. � DESCRI�'fION SQ.FT. FACTOR PSF ADJ.AREANALUATION cn � OWNER-BI:ILDER DECLARATION SFR/ADD/REM Q I HEREBV AFFIRM UNDEH PENALTY OF PERJURV TW1T 1 AIA E%EMPT FROM THE CONTRACTOHS LI- G8f8gBIC9fPOR W CENSELAWFORTHEFOLLOWINGREASON(SEC.7031.SBUSINESSANDPRbFES510N5CODE�.ANYCITVOR (/� U COUNTYNh11CHFEOVIRESAPERMITTOCONSTFUCT,ALTER�MPROVE,OEM:OLISH,ORREPAIRANVSTRUC- W patidDeck Z TURE,PRIOR TO ITS ISSUIWCE,ALSO REQUIRES THE APPLICANT FOR S�CH PFRMIT TO FlLE A SiGNED w STATEMENT THAT HE Ofl SHE IS UCENSED PUflSUANT N TME PROW51045 OF THE CONTFUCTORS LI- � CENSE LAW(CHAPTEH 9(COMMENCINO WITH SECTIQN 7000)OF DIVISION 3 OF 7HE BUSINE55 AN�Pp0- � POOI/Sp8 OFESSIONSCADE)OHTHATHEORSHEISEXEMPTTHEREFROMANDTHE80.515FOR7HEFLLE6EDEXEMP- V 710N.ANVVqLATIONOFSECT�ON703t.5BVANYAPPLICANTFORAPERMITSU&IECTSTHEAPPLICANTTD Z Re-Roo1 � A CIVIL PENALTY OF NDT MORE THAN FIVE HUNDRED DOLLARS(SSW).): � � 0 ❑I.ASOWNEROFTHEPROPERTV,ORMYEMPLOVEESWITHWAGESASTNEIRSOLECOMPENSATION, 0 COmmBfCiei Z WILL DO TFiE WORK,AND THE STRUCTURE IS NOT IMENDEO OR OFFERE'D FOR SALE(SEC.7a4,BUSI- J � NE55 AND PROFESSIONS COOE:iHE CONTRACTORS UCENSE LAW OOES NOT APPLY TO AN OWNEil OF � PR07ERTYWHOBUILDSORIMPROVES7HEREON,ANDWFiO�0E55UCHK'ORKHIMSELFORHERSELFOR m � THROl1GHHISORHEROWNEMPLOYEES.PROVIDEDTHATSUCHIMPROVEMENTSARENOTINiEN�EDOR QOFFEREDFORSALE.IF,HOWEVER.THE&11LDINGORIMPfiOVEMENTIS50lLWITHINONEYEAROFCONPIE- z TION,THE OWNER-BUILDER WILL HAVE TNE BURDEN OF PFOVING THAT HE OR SHE OID NOT BUILD OR � IMPROVE FORTHE PURPOSEOF SALE). ��I,ASOWNEROF THE PROPERTY,AM EXCLUSIVEIY CONTRACTING WITH LICENSED CONTRACTORS � TO CONSTHUCT THE PROJECT(SEC.70a4,BUSINESS AND PROFESSIONS CO�E:THE CONTRACTORS LI- V0Il13SIOR ADJ.AREA W CENSELAWDOESNOTAPPLYTOAfVOWNEROFAPROPERiYWF100UI1D50RIMPROVE3THEREON,AND � WHOCONTRACTSFOflSUCHPROJECiSWITHACONTRACTOR(5)LICENSQ7PUPSUANTTOTHECONTFAC- QUANTIN DESCRIPTIdN FEE � TORS LICENSE LAW). J O �1 Ah1 E%EMPT 11NDER SEC. _B.&P G FOR THIS REASON U � � Q ��" DATE � OWNER V Z W — � LICENSEDCONTRACTOR EGLARA"ION e- W 2 I NEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED VNDcR PROVISIONS OF CHAPTER � ��(/rf+.� �� � I � e(COMMENCMG WITH SECTION 70aD)OF DIVISION 9 OFTHE BUSINESS AN7 PROFESSIONS CODE,AND Z " `X MYLICENSEISINFULLFORCEANDEFFECT. m J'�„I!!�r �,..✓ �� ' I\�. � � Ab~ � !/ 7 � LICENSE CLASS LIC.NO. J U pp7E CONTRACTOR_ n- W � WORKERS'COMPENSATION DECLARfTION Q � I HEREBY AFFIRM UNDER PENALTY Oi PERJURV ONE OFTHE FOLLOWING DECLARATIONS: U � Z Q Z _I HAVE AN�VALL MAINTqIN A CERT�FICATE OF LONSENT 70 SELF�INSURE FOfl WORKERS' 2 ¢ COMPENSATIOH,AS PROVIDED BV SECTION 370oOF THE UBOR C OOE,FOR THE PERFORMANCE W OF TNE WORK FOR NMICH THIS PERMIT IS ISSUED. � � W _I HAVE AND WILL MAIIVTAIN WOHKERS'COMPENSATION INSURANCE,AS REOUIRED BY SECTION Q 37o00F THE LABOR CODE,FOR THE PERFORMANCE OF 7HE WOPK FOR WHICH 7MI5 PERMTIS ISSUE�.MV WORKERS•CAMPENSATION INSURANCE CARRIER ANU POLICV NUMBER ARE: CONSTRIJCTION � CAftWER PLANREVIEW ZPOLICV NUMBER EL IC Q ' � (IHISSECTqNNE�NOTBECQ'.WLEfE�OF1FEPE0.MTISFORONEMN�DFim00lLNi5151�a)OFilESS} PLUM �� Z I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I MECHANICAL �J SNALL NOT EMPLOY ANY PERSON IN ANY MANNER$OAS TO BEIX>ME SUBJECTTO THE � WOFKERS'COMPENSATIONLAWSOFCAUFORNIA,AN�AGREETF:ATIFISHOULDBECOME INSPECTIONFEE SUBJECTTO THE WORNERS'COMPENSATION PROWSIONS OF SECTION 37ooOF THE LABOR s � CADE,t SHAIL FOR7HWITH COMPIY WITH THOSE PROVISIONS. ISSUA � SMIP p DATE: APPLICANT: — J ENERGY P/C J WARNING:FAILURE TO SECURE WORKERS'COMPENSATION CAVERAGE I:;UNIAWFUL,AN�SHALL BE y ^ �y SU&lEC7ANEAIPLOYER7OCPoMINAIGENALiIESANOCIVILFINE5l1PTOONEHUNDREDTHOUSAND ENERGYPERMIT � 'a DOLLARS(S1o0,000�.INAD01T10NTOTHECOSTOFCOAIPENSATION,�AMl.GESASPROVIOE�FORIN � �—�.f'. � SECTION 37oe OFTHE LABOR CODE.INTEREST,AND ATTORNEV'S FEES, RETENTION FEE: u � CONSTAUCTION LENDING AGENC:Y PRE-ALT FEE: � y +� � I HEREBYAFFIRM UNDER PENALN OF PERJURV THAT THERE IS A CONSTISUCTION LENDING AGENCY �i�� ' i��I FOR THE PERPoRMANCE OF THE WORK WR WHICH THIS PERMIT IS ISSUGD(SEC.3007,CIV.C.). �' �—�ti-.�: Z W 2 LENDER'S tiAME � H LENDER'SADDRE55 /� , �J � 1 CERTIFV THAT I MAVE READ TMIS APPUCATION RND STATE THATTHEABGVE INFOHMATION IS CARRECT. TOTAL FEES /��', fe.,� w 1 AGREE TO COMPLY WRH ALL CITY AND COUNTY ORDINANCES AND S7ATE LAWS RELAiING TO BUiL01NG n" CONS7RUCTION,AN�HEREBY AUTHORIZE REPRESENTA7IVES OF THIS COUNTV TO ENTEFl UPON TFIE / � ZABOVE�MENTONED PROVERTV FO INSPECTION Pl1R ES. 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