HomeMy WebLinkAbout16924 (1107) CI'TY OF DTAMONd)BAR �/'" ----�-- DEPARTMENT OF COMM�i1TY&DEVELOPMENT SERVICES (/` � P _ 21825 E.Copley Drive x� (909)860-3195 Fax(909)86Y-3Tfl7 PRE$S ��'%v��� BUILDdNG PERNIIT APPLICATION FIRMLY } ` ,�g «APPLICATION PERMIT � A P/C o AODDR'ESS_ � �� � � �./��� -%'T�"�'�� � DATE � ��� NUMBER LP� � # � ISSUE TYPE OCC APN �T TRACT DATE CONST. GROUP p OWNER � f�f✓C� ADDi�SS I� I d�c.m€�i .�*� e+'✓ 4 N�---J ZOMNG SETBACKS oCITY 1,J� .7��, ZIP f � T L.� y— 7 p FRONT RW ❑ o APPUCANT ,� REAR ❑ Z SIDElSIQE STREET RW ❑ Q CONTRACTOR SIDE ❑ Q ,ADDRES �`� � PROPOSED USE �� 4%C$ '� Q e+ ►'�6�.�" /2- C� r ��' CIN ZIP TEL.'7=?��;5 w ,ARCHlENG/ 1�'l.t3S�''f Z'1'`q`"" �i.� ' � .�r z DESIGNER . w NO.DWEL. O. NO. � ADDRESS _ 'CITY ZIP TEL. UNITS STORIES BEDROOMS cn -- u� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � p� O��VNER-BUILDER DECLARATION SFR/ADD/REM � � I HEREBV AFFIRM UNDER P�NALiY OF PERlURY THAT I AAA EXEMPT FROM THE CONiRACTORS LI- G8f89B/C8f(70/I W CENSELAWFORTHEFOLLOWIN(�'REASON(SEC.7031,5BUSINESSANDPROFESSIONSCODE:ANYCIttOR (f� C.� ;COUNTYWHICXRE�UIRESAPERMITTOCONSTFIUCT,AITEH,IMPROVE,DEMOLISH,ORREPAIRPNYSTfiUG W W ,iURE,PRIOR TO ITS ISSUANCE,AL50 REW IRES THE APPLICAN7 FOR SUCH PERMIT TD FlLE A SIGNE� W Patio/Deck � �,STATEMENT THAT HE OR SHE IS LICENSEO PUfiSUANT TO7HE PROVISIONS Of THE CON7RACTORS L4 � . CEN5E LAW SCHAP7ER 9�COMME�NCING WIiH SECTlON 7000)OF�IVISION 30F iHE BUSINESS AND PRO- POOVSpB �' FESSIONSCO�E)ORTHATHEORSHEISEXEMPTTHEREFROMANDTHEBASISFORTHEALLEGEDEXEMP� (� �" ',TION.ANYVIOLATIONOFSECTIO 7031SBYANYAPPLICANTFOPAPERMITSUBJECTSTHEAPPLICANTTO Z Re-Roof � 'ACIVILPENALTV OF NOT MORE T AN FIVE HUNDflED DOLLARS(S5oo).): Q � ❑I,ASOWNEROFTHEPROiEH7Y,OfiMYEMPLOYEESWiTH1^lAGESASTHEIRSOLECOMPENSATION, � Commercial - Z WILI DO THE WOpK,ANO THE Sl�RUCTURE IS NOT INTENDED OR OFFERE�FOR SALE(SEC.7044,BU51� J � ��:NESS AND PROFESSIONS CODE:IfHE CONTFACTORS LICENSe LAW DOES NOT APPLY TO AN OWNER OF � '�PROPERTYWHOBUILDSORIMP�OVESTHEREON,ANDWHODOESSUCHWORKHIMSELPOliHE6iSELFOR � �,iHROUGH HIS OR HER OWN EMPIOVEES,PROVIOED THAT SUCH IMPROVEMENTS ARE NOT INTEN�ED Ofl m . LLJ ��,OFFEREOFOFSALE.IF,HOWEVE THEBUILDINGORIMPROVEMEN?ISSOLDWITNINONEYEAROFCON.PLE- � ',TION,7HE OWNER�UILDER WIL�HAVE THE BUFDEN OF PROVING THAT HE OR SHE DID N07 BUILO OR . � IMPROVEFORTHEPURPOSEOF�uALE). ❑I,ASOWNEROFTHEPRO ERTY;AMEXCWSIVELYCON7ftAGTINGWITHLICENSEDCONTRACTORS � "�TO CANSTRUCT TME PROJECT(S�EC:7u44,BUSINE55 ANU PROFESSIONS CODE:THE CONTRACTOFS LI� V8IIJ8f10f1 ADJ.AREA W CENSELAWOOESNOTAPPLYTOy4NOWNEROFAPROPERTYWH06UILD50RiMPROVESTHEREON,AND � �.WHOCONTRACTSFORSUCHPRqJECTSWITHACONTRACTOR(5)UCENSEDPURSUANTTO7HECON7RAC- QUANTITY DESCRIPTION FEE '�;TORS LICENSE LAW.). '� �Q ❑I AM EXEMPT UNOER SEC; B.&P.C.FQR THIS FEASON Q � U LL � �ATE OWNER � Z W - � LICEN ED CONTRACTORS DECLARATON W � I HEREBYAFFlRM UNDEF PENAL7r'OF PERJURY THAT I AM UCENSE�UNDER PROVISIONS OF CHAPTER � � ,9(COMMENCING WITH SECTION 7I000)OF DNISION 3 0F THE 6USINESS AND PROFESSIONS COOE,AND Z W MY LICENSE IS IN FULI FORCE AND EFFE �� �� m � � � LICENSE CLASS LIC.NO. � V �DATE CONTRAGTOR � d W i � WOR �RS'CAMPENSATIONDECLARATION Q � IHEPEBYAFFI DERPENALT'OFPERJUfiVONEOFTHEFOLtAWING�ECLARATIONS�, Z Z _I HAVE AND WILL MAINTAI�I A CERiIFICATE OF CONSENT TO SELF-INSUR'c FOR WORKERS' _ a COMPENSATION,AS PROVIDED BV SEC710N 370o OF THE LABOR CODE,FOF THE PERFORP,?ANCE U Q OFTHE WORK FOR WHICH PHIS PERMIT IS ISSIJEO. � W _I HAVEAND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS RE�UIREO BV SECTION � 370oOFTHE LA60R COD�,FOR'fHE PERFORMA�CE OFTHE WORK FOF WHICHTHIS PERMITiS � ISSUED.MY WORKERS'�'MPENS ION INS CE CpRR1ER AN OLICY NUMBERARE CONSTRUCTION Z�i �� j caaqiEa "� / PLAN AEVIEVJ z POLICYNUMBER I ��i�G � / ELECTRIC d I Q (fHISSECTpNNEmNOT6�WMPLEfEDOFTHEPERMf�ISFORONEHUPDRE��RS(y100)ORLESS�. PLUMBING z i CERTIFYTHAT IN THE PERFORMANCEOF THE WOPK FOP WHICHTHIS PERMIT IS ISSUED,I MECHANICAL ('3 SHALL NOT EMPLOY ANV PERSON IN ANY MANNEFl SO AS TO B ME SUBJECT TO THE (/j WORKERS'COMPENSATI�NLAWSOFCA NIA,AN�AGR ATI SH LOBECOME INSPECTIONFEE = SUBJECT TO THE WORK�RS'COMPEN ION PflOVI510N5 CiY N 37 OF HE LABOR �� CODE,ISHALLFOAkIW HCAMPLYNHT ' VISI� ISSUANCE p DATE: PPLICANT: � - - _ SMIP J WARNINGFAI RET SECUREWORKERS'COMPENSATIONCOVERAGEISUNLAWFUL,PNDSHALLBE ENERGYP/C � SU9JEC7ANEMPLOYER70CRItv�INALPENALTIESANDCIVILFINESUPT00NEHUN�RE�THOUSAND ENERGYPERPAIT �OLLARS(S70a.oDo),INADDITIONITOTHECOSTOFCOMPENSATION,DAMAGESASPROVIDEDFORIN � — � SECTIDN37oeOFTHELABORCOpE,INiEREST,ANDATTORNEV'SFEES. RETENTIONFEE: nw,. C NSTRUCTION LENDING AGENCY PRE-ALT FEE: O I � IHEHEBYAFfIRMl1N�ERPENAL�V�FPERJL1RYiHATTHEREISACON5TRLICTIONLEN�WGAGENCY FORTHEPEFWRMANCEOFTH WORKFORWHICHTHISPERMITISISSUEO�SEC.309],CIV.C.). , � LLJ' _� LEN�EWSNAME � � 1—� LENDER'SA�DRESS �}'� W', ICERTIFY?HATIHAVEREADTHI�APPLICATIONANOSTATETHATTHEABOVEINFORMATIONISCOPRECT. TOTALFEES 1 4� I AGREE TO COMPLV WITH ALl CITY AND COUNTV ORDINANCESANO STATE L4W5 RELATING 70 BUILDING Cf" � CONSTRUCTION,AN�HEflEBV AUTHOR2E REPR SENTA7NE5 OF THIE COUNiVTO ENTER UPON THE ,� ABOVEMEN710NED PROPERTY FOR INSPECTIO PuaPosEs. COMMENTS Q,� � � �°i(��� i�v� ¢'� P REE Nq RI ) `] � � ( �y SI REDF �RMITfEE ' , DAT ' _ � FIEC?T.NO. PAI�BY VALIDATION � WHITE—De artmentCo YELLOW—FinenceCo PINK—AssessorCo GOLDENRO�—FiI=_Co GREEN—A IicanYsCo P PY. 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