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HomeMy WebLinkAbout14649 (20) i. /�. / ^ ��� _ CITY OF DI,�MOND BAR ��, , '� DEPARTME::vT OF COMMUNITY&DEVE�,OPMENT SER.VYCES � W 21660 E.Cople;�+Drive Suite 190 (909)860-3195 Fax(909)861-311'7 `� PRESS ����^�� BUII.DING 1'ERMIT APPLICATION FIRMLY y�, JOBSITE �j�� . �^ APPLICATIOIJ� � () jJ PERMIT j (� P/C o ADDRESS���x�yr>. �'��i..��) ��t.j�cE�e�. DATE NUMBER� w # � — ISSUE TYPE OCC APN LOT TRACT_ DATE CONST. GROUP p OWNER � ��iN '�' ..�. +,.%� p ADDR,�SS � '3�.. ���Y;-++�.a i� �,��-C,.� ZONING SETBACKS � ` s'";�: �'r _ FRONT p�11/ � CI7Y- ZIP� TEI.. ,] APPLICANT "�.€��� TEt_. � � S DAE/SIDE STREET RW ❑ � CONTRACTOR T�l��. � �:ClE3•�ia�.Bls LP-�4�, SIDE ❑ p� ADDRE S ��' aI . � �l.-� 'w.s L i�t.C3�e1 �� • � � CITY �.+^' '"1 "-�FR� ZIP��/Y TEI_. .�I`���'Si7�" PROPOSED USE ,�'a..zi iT l� c+2 ���x�.�41�nt -L� C�•«: ;L.. 0 �A �• C• i.os�t ,�r�t!.l 'o �eE1. fl.. � w ARCH/ENG/ z DESIGNEFi 9'� �' �� `g� ����� w —' NO.DWEL. NO. NO. a ADDRESS � UNITS ST�RIES BEDROOMS � CITY .�J--- ZIP TEI_. v� DESCRIPTION SQ.FT. FACTOR FSF ADJ.AREANALUATION � OWNER-BUILDER DECLARATION SFR/AODIREM O _ I HEREBY AFFlRM UNDER PENALT/OF PERIURY THAT I AM IXEMPT FROM THE COMRACTORS LI- 'Gg�9B/CefPOft W CENSELAWFOHTFIEFOLLOWINGHEASON(SEC.70.11.5BUSINESSANOPRf)FESSIONSCADE:ANVCITYOR (n U COUNTYWHICHpE0U1pESAPERMiTTOCONSTRUCT,ALTER,IMPROVE,DEMOLISH,ORREPAIRANYSTFUC- W P8ti0IDeGlc Z 7URE,PRIOR TO ITS ISSUANCE,ALSD REIX11RE5 THE APPLICANT GOR SUCH PERMIT TO FILE A SIGNED W STATEMENT hIAT HE OR SHE IS LICEIJSEO PURSUANT TO THE PROYISIONS OF THE CANTPACTOqS LI- W � CENSE LAW(CHAPTER D(COMMENCING WITH SECTION 700D)OF DIVISION 3 OF THE BU6INESS AND PRO- V' POOUSPB FESSqNS CODE)OR hIAT HE OR SHE IS E%EMPT TNEREFROM AND THE BJ515 FOR 7HEALLEGEO E7CEMP- TqN.ANYVlOLATIONOFSECTION7091bBYANYAPPLICANTFOqpPERMl1"SU&lECiSTl1EAPPUCRNTTO Z Re-Root S� � ACML PENALTY OF NOT MOflE THAN FlYE HUNDRED DOLLARS(S500J.): � ❑I,ASOWNEROFTHEPROPERTV,ORMYEMPIAYEESWITNWAGESASTHEIRSOLECOMPENSATION, � Commercial - WILL 00 THE WOAN,AND THE STRUCTURE IS NOT INTENDED OR OFFERE:D FOR SALE(SEC.7oaa,BU51- J � NES:AND PROFESSIONS CODE:THE CANTRACTORS LICENSE LAW OOES NOTAPPLV TO PN OWNEP OF � PROPERTV NM1iO BUILOS OR IMPROVES THEREON,/W D VMO DOES SUCN N�ORK HIMSEIF OR HERSELF Ofi � THROUGHHISORHEROWNEMPLOVEES,PROVI�EDTHATSUCHIMPROVEMENTSM'cNOTINTENDEDOH m � OFFEpEDWR3ALE.IFHOWEYER71iEeUILDINGORIMPROVEMEMISSd2�WRHINONEYEAROFCAMPLE Z TION,THE OWNEfl�BUiIAER WILL NAVE 7FIE BURDEN OF PROVING THAT��fE OR SY.E OI�NOT BUILO OR = IMPI�VE FOR 7HE PUHPOSE OF SILLE�. W ❑I,ASOWNEROFTHEPROPEHiV,AMEXCIUSIVELYCONTRACTINGWITHIACENSEDCONTRACTORS � TO CONSTRUC7 THE PHQIECT(SEC.7041,BUSWESS AND PNOFE551045 CADE:THE CONTRACTORS LI- V8IU3NOf1 �'��'^�`"F ADJ.AREA � CENSELAWOOESNOTAPPLYTOMIOWNEROFAPROPERTVWHOBUILDEORIAAPR0I;ESTNEREON,AN� WFiOCOMMCTSFORSUCHPRQIECTSWfTHACONTRACTOR�S�LICENSEDPURSUANTTOTHECONTRAG QUANTITY OESCRIPTION FEE � TORSUCENSEIAW.). ❑I AM E%EMP7 UNDER SEC. _&H P.C.FOR THIS REASON Q 3 �' � � DATE OWNER � � W � LICENSED CONTRACTORS DECLAR/1'ION W � IMEqE6YAFFIRMUN�ERPENALTYOFPER1URYiHA71qMLICENSEDUNDeRPROVISIONSOFCHAPTER � d B(COMMENCINOWITHSECTION)000)OFDNISION30FTHEBUSINESSANDPROFESSIONSCODE.AND Z X MV LICENSE IS W FUIL FORCE AND EFFECT. m ' L1J 0 LICENSECLASS � � � LIC.NO.� '� j V DATE � ��'�C'? CONTHACTOfi�� �� � A W � WORKERS'COMPENSATION DECLARfTION ��� -� v=i � U � 1 HEREBYAFFlRM UNDER PENALTY OF PERIURY ONE OFTHE FOLLOWING DECLARATIONS: Z O IHAVEAPIDWILLMAINTAINACERTIfICATEOFCONSENTTOSELF-INSUREFORWORKERS' _ Q COMPENSATION,ASPROVIDEDBYSECTION37000F7HELABORCADE,FORTHE7ERFORMANCE LU Q OFhiE WORK FOR WHICH THIS PEflMIT iS ISSUED. � W _1 HAVE AND WILL MAINTpIN WONNERS'C00.9PENSATION IhSURANC'c,AS HEQl11RE0 BY SEC710N � Q 370D OFTHE LABOR CODE,FOR THE PERWRMANCE OF THE WOR{FOH WHICH THIS PEP,MIT IS ISSUED.MV WORKERS'COMPENSA�(ON INSURANCE CARRIER AN[1 POLICY NUMBEfl ARE: 1 CONSTRUCTION _ t. � CARRIEFi ��'�!E- "�'°/�-i� PLAN REVIEW _ Z POLICY NUMBEFi . _.'v"�� C>���� %��/ �yI� ELECTRIC , 4 � (IH@SECTIONNE�NO7BECOI�LETmOF'fY{EPERMSR7ROI:EHI�ADR'cD00LLaAS(S!00)ORL6�. PLUMBING Z ICEflTIfYTHATINTMEPERFORMANCEOFTHEWORKFORWHICHTHISPERMITISISSUE�,I MECHANICAL 'Cj SHALLNOT EMPLOYANY PERSON IN ANV MANNER SO AS TO BECC�ME SUBJECT TO THE (A WOFKERS'COMPENSATION LqWS OF CAUFORNIA AND AGREE THAT IF I SHOUTA BECAME INSPECTION FEE __ h� ��'�f���_—__���� �� �,� SU&IECTTOTHEWORKERS'CCAAPENSATIONPROVISIOtiSOFSECTION3700'OFTHEI.A90q � ��E �7�! � CODE,ISHALLFORTHWITHCOMPLYWITNT.HC)S�O�(110N5.]•�{J�� ISSUANCE �°��` J p DATE:����� APPLIGANT: �4f�'�.�',� SMIP � J WARNING:FAILURETOSECUREWORKERS'COMPENSAiIONCOVERAGEISUNLAWFUL.ANDSHALLBE ENERGYP/C _ �y SU&IECTANEMPLOYERTOCRIMINALPENALTIESANDCIVILFINESUPTO<NJEHUNDREDTHOUSAND ENERGYPERMIT :�"" DOLLARS(510D.000�,IN ADOIl10N TO THE COSTOF COMPENSATION,DAMPOES AS PROVIDED FOR IN � SECTION3]o80F7HELABORCODE,INTEREST,ANDATTORNET5FEE5. ' S`��'���=1�- � RETENTION FEE: !� y W �� d.�/1.� .•e�iS.�Y.�1�411'.iY'.te.. O CONSTRUCTION LENDING AGENCV PRE•ALT FEE: � 1 HEREBVAFFIFlM UNDER PENALTV OF PERJURY THAT TFIERE IS A CONSTF.UCTION�ENDING AGENCY ___ FOR THE PERFORMFNGE OFTHE WORK PoR WHICH THIS PEflM1T IS ISSUE:D(SEC.3oe7,CIY.C.j. Z W � LENDEWSNAME F-- LENDE' HESS W ICERTIFYTHATIHAVEREADTHISAPPLICATIONIWDSTATETHATTHEABOVEINFORMFTIONISCOFRECT. TOTAL FEES � � IAGREETOCOMPLYWITHALLCITYANDCOUNTYORDINANCESANDSTATF:UIWSREIATINGTOBUIIDING � CONS7RUC710N,ANO HEREBY AUTHORIZE REPRESENTATIYES O:THIS COUN7Y TO ENTER UPON THE Z ABOVE�MENTIONEDP PERTVWRINSPECTIONPURPOSES. COMMENTS 0 � � '�,'��j � PERMITT�p A�ME�(PRIPIT) ���/yr�,�,, l`p�,. — ,,��9 �i�,p � � '"'��� �'""G�-�.�V_, J '�I a7��'�(� � � 510N�TUREOFPERMITTEE OATE = RECPT.NO. J PR.ID BY VALIDATION ~ WHITE-0e ertment Co YELLOW—Finance Co PINK—Assessor Co GOLDENROD—File Co GREEN— P PY, PY. PY. 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