HomeMy WebLinkAbout15154 (666)III.\!111\II BAR
CITY OFDIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPME
21660 E. Copley Drive Suite 190
(909) 860-3195 Fax (909) 861-3117
BUILDING PERMIT APPLICATION
JOBSITE _r
ADDRESS
APN T TRACT
OWNER
ADDRESS
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APPLICA TEL.
CONTRACTORI3 � A . I-Zl�vNJ
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DESIGNER
ADDRESS
CITY ZIP TEL.
OWNER -BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT IAM EXEMPT FROM THE CONTRACTORS LI-
CENSE UW FORTHE FOLLOWING REASON (SEC. 7031.6 BUSNESSAND PROFESSIONS CODE.ANY CMYOR
COUNTY"A1CHREOURESAPERMRTOCONSTRUCT,KTER IMPROVE. DEMOUSH.OR REPAJRANYSTRUC•
TURF PRIOR 70 ITS ISSUANCE ALSO REWIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS U -
CENSE UAW (CHAPTER a (COMMENCING WITH SECTION TWO) OF DMSION S OF THE BUSINESS AND PRO
FESSIONS CODE) OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TION. ANY VIOLATION OF SECTION 7031.6 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CML PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (5600).1:
D U AS OWNER OF THE PROPERTY. OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
WILL DO THE WORT( AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE IS EC. 704a, BUSI.
NESS AND PROFESSIONS
E CODTHE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY RANO BUILDS OR IMPROVES THEREON, AND WHO DOES SUCH WORK HIMSELFOH HERSELF OR
THROUGH HIS OR HER OWN
EMPLOYEES. PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFEREDFORWLE IF,HDWEYER, THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONEYEAROF COMPLE-
TON, THE OWNER -BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE}
D L AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRICT THE PROJECT (SEC. To". BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LI-
CENSE LAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON, AND
WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACIONS) UCENS W PURSUANT TO THE CONTRAC-
TORS LICENSE LAW.).
D 1 AM EXEMPT UNDER SEC 0.A P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBYAFFRM UNDER PENALTY OF PERJURY THAT IAM LICENSED UNDER PROVISIONS OF CHAPTER
P (COMMENCING WITH SECTION 7000) OF DMSICN 3 OF THE BUSINESS AND PROFESSIONS CODE,
MY LICENSE IS IN FULL FORCE AND EFFECT
LICENSE CLASS LIC. NO.:21 Rg
U
PATE _� CONTRAC [/
WORKERS' COMPENSATION DECLARATION ^ ?j�
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELFdNSURE FOR WORKERS'
COMPENSATION, AS PROVIDED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERAN
FORMCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
1 HAVE AND WILL MAINTAIN WORKERS COMPENSATION INSURANCE. AS REQUIRED BY SECTION
3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WORK FAS, COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE:
CARRIER • _�/V
POLICY NUMBER
(RIS SECTION NEED Nor SCCN +LETEOCFTW PERMIT ISFOROfE HUNDRED DOLLARS (6100) OR USSI
1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE
j "WORKERS COMPENSA WS OF CALIFORNIA. ANO AGREE THAT IF I SHOULD BE
SUBJECT TO THE WORKERS' r NS OF SECTION 3700 OF TH eR
COVE 1 SHALL FORHN COMPLY
I /f
PATE: �j,�_ii,�jc..�L APPLICA
WARNING: FAILURE TO SECURE WORKERS COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND
DOLLARS (51 00,000), ! ADDITION TO THE COST OF COMPENSATION. DAMAGES AS PROVIDED FOR IN
i $ MION 37060E THE LABOR CODE, INTEREST, AND ATTORNEYS FEES
I CONSTRUCTION LENDING AGENCY
i
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LEND WG AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 15 ISSUED (SEC. 3057, CW. C).
I
LENDERS NAME
LENDEFTSADORCSS
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
1 AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
CONSTRUCTION. AND HEREBY AUTHORIZE RE PRESENTATNES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTONED PROPERTY FOR INSPECTION PURPOSES.
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APPLICATION/L3
PERMIT \` �� P/C .g ,
DATE
NUMBER.L
N
ISSUE
TYPE
OCC
DATE
CONST.
GROUP
ZONING SETBACKS
FRONT
RW
❑
REAR
❑
SIDEISIDE STREET RW
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SIDE
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PROPOSED USE Re»rF
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NO. DWEL.
NO.
NO.
UNITS
STORIES
BEDROOMS
DESCRIPTION SO. FT. FACTOR PSF
ADJ. AREANALUATION
SFFVADDIREM Ile
Q
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Garage/Carpert
WPallo/Deck
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0
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Valuation c9L0ZJV
ADJ.AREA
QUANTITY "' DESCRIPTION
FEE
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U
W
J
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0
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DO
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2
Q
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CONSTRUCTION
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PLAN REVIEW
5
ELECTRIC
PLUMBING
MECHANICAL
INSPECTION FEE
I -1616 a T�
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ISSUANCE
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ENERGY PIC
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ENERGY PERMIT
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RETENTION FEE:
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TOTAL FEES
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COMENTS
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RECPT. NO.
PAID BY
VALIDATION
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