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HomeMy WebLinkAbout16313 (666) � �� CITY OF DIAA�IOND BAR � �� DEPARTMENT OF COMMUNTTY&DEVELOPMENT SERVICES 21660 E.Copley Drive Suite 190 (909)860-3195 Fax(909)861-3117 PRESS �"%�" � BUII.DING PERMTT API�LICATION � FrRMLY � JOBSITE (� h APPLICATION �'�/�,, PERMIT „� ',�� �/C o ADDRESS �� ���f� ,Qti ���� DATE ` ✓"'�✓ �� NUMBER � $ ISSUE ,�l,�..,.•�+'r TYPE OCC APN LOT�� TtR-AC_T DATE_ L�� Ir'�� "L CONST. GROUP p OWNER � «-�I l>L��:_�1�s '. � ADDR S � � TL���.. ZONING SETBACKS 0 z CIN ; ZIP TEL. FRONT RW ❑ g APPLICANT TEL. REAR � � SIDE/SICE STREET RW C a� CONTRACTOR � IEtiI� SIDE L; � CITY E S ZIP i�� TEL. PROPOS�/USE �i U�L S�� " IIUSS�I� Z QS� w ARCH/ENG1 "�„4'�• � - f E�j � L z DESIGNER �,.h � ADDRESS NO.DWEL. Np, r� Np, � CITY ZIP TEL. UNITS STbRIES �s� BEDROOMS � cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER DECLARATION SFR/ADDh?EM O � I HEREBY AFFIRM UNDER PENALN OF PERJURY THAT 1 AM EXEMPT FROM THE CONTRACTORS Lb GBfdJB/C2fZ10fI W CENSEUWiORTMEFOILOWINGREA50N(SEC.7031.SBUSINESSAN�PROFESSIONSCODE:ANYCITYOR (n ZCOUNTYWHICMPEWIRESAPERMITTOCONSTRUGT,ALTER,IMPROVE,�EMOLISH,ORHEPAIRANYSTFiUC� W� Pa1iO1�BCk �l� TUHE,PRIOP TO ITS 1SSUANCE,AL50 REQUIRES THE APPLICANT FOR SUCH PEiiM1T TO FILE A SIGNED W � STATEMENT THAT HE OR SHE IS LICENSED PUfiSUANT TO THE PROVISIONS OF THE CONTRACTORS LI. CENSE LAW�CHAPTER 9(COMMENCING WITH SECTIQY 7000)OF�iVISION 3 OF THE BUSINESS AND PRO� V" POOUSp3 FESSqNS OD�E)OR THA7 HE OR SHE IS EXEMPT IHEREFROAI AN�THE BASIS FOfi iHE ALlEGEO EXEMP- TION.ANVVIOLATIONOFSECTION7037.58YANVAPPLICANTFORAPERMITSU&IECTSTHEAPPLICANTTO Z� RB-RoOf L Q � A qNL oENALTY OF NOT MORE THAN FIVE HUNORED OOLtAR3(5500).): � ❑I,ASOWNEROFTHEPROPERTY,ORMYEMGLOYEESWITHWAGESASTHEIRSOLECOMGENSATION, COrt11110fC181_ � YiILL DO THE WORK,AND TME STRUCTUfiE IS NOT INTEN�ED Ofi OFFENED FOR SALE(SEC.700d,BU51- � � NESS AND PNOFESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES NOT APPI.V TO AN OWNER OF = VROPEHiY WFiO 9UILDS OH IMPROVES THEFEON.ANO WHO DOES SUCH WORK H:MSELFOR HERSELF OP � THHOUGHHISORHEROWNEMPLOYEES,PROVIOEDTHATSUCHIMPFOVEME4TSARENOTINTENOEDOR �� W OFFEREDFORSPLEIF,HOWEVERTHEBUIIDINGORIIAPROVEIAENTISSOIDWITHNONEVEAROFCOMPLE- Z TION,THE OWNER-BUILDER WILL HAVE THE BUR�EN OF PROVING THAT HE OR SHE DID NOT 9VILA OR � = IMPqOVEFORTFiEPURPOSEOFSN.E). W a1,A50WNENOFTHEPROPERTY.AME%CLUSIYEIYCOMRACTINGWITHLICENSEDCONTP.ACTORS Q TO CANSTRUCT TME PRO.IECT(SEC.7046,BUSINESS I�YD PROFEu510N5 CAGE:THE CONTHACTORS LI� VBIU�IlOf1 ' A�J.AREA W CENSELAWOOESNO7APPLY70ANONMEROFAPROPER7YWHCBUILOSORIMPROVESTHEREON,AND - — -'-- � N'FIOCONTRACTSFORSUCHPROJEC7SWITHACON7RACTOR(S)LICENSEDPUqSUANTTO7HECONTRAG QUANTITY DESCRIPTION FEE Y TOFlSl10ENSEUW.). 0¢ C I AM EXEMPT UNDER SEC. Fi 8 P.C.FOR THiS REASON J ____ Q i � U�- LL ---'__ �I _— DATE__ ONTIER_..____ __ F-r '�j W' � LICENSED CONTRACTQRS OECLARATION W; I HEREBV AFFlHM UNOER PENAL'Y OF PERJURV'HAT I AM LICENS'c�UNDEF PROVISIO!!5 OF CHAPiER d 6(COMMENCINOWITHSECTpN7ao0)OFOIV:SION90FT.HE9USINESSANDPROFESSIONSCODE,AN� zl � MY UCENSE IS IN FULL FORCE�yAN+D EFFECT. /�r m I O LICENSE]C S__C v `^�___, LIC.NO. v �v S, � ��/+ j!— V DATE {=�i.-�L_ CONTRACTOR �C�CJ�i�_ d� W � WORK�RS'COMPENSAl70N DF_CLARAT{ON Q� � I HEREBY AFFIRi1 UNDER PENA�TY C=PERIURV CYE OF7H'c FOLLGWING DECIARP.T:ONS: Z{ i � __INA4EANUWILLMAINTAINACERTIf-'�CAT[OFCONSENTTOSElFMSUREFORWOaNERS' _•. — C<MIPFNSATION,ASPRPYIDFDBYSECTION3�OOOFTHElh80RCODE.FOFITMEPEHFORIAANCE UI OF 7HE WOFK FOFl WHICH THIS PERMI715�SSUE�. �� O w _iHAVEMIQWILLMAIMAINWURNGP.E'COMPENSATIONINSURANCE,ASREClU1R'eDBVSGCTION ppp �7 Q 37000F76iELA80RCGUE,FORTHEPENFORMNICEOFTHEWCRKFORWHICHTiIUPERMiT15 _— � �Y�.y� � ISSUE'J.R1Y WOP.NFRS'C9MPE'dSATION INSL'RANCE CARaFR AND POL'CY NUMBER AaE: CONSTRUCTION `,J�� J j caRRiER ______________. __--__ PLAN REVIEW �_/�1���� � POLICYNOAS6Efl"'___'—"__'___--_—__—___"' ELECTFlIC ___—_��y�y��j,` Q i (fHSSEC'IDNNFEa�NOTGEO�A7PLETEDOFT7+'ePEFYAf�ISF:KiONEFiUNJFiEDCCILARS�510o)OR;ESS) PLUMBING ��� �����.�� _ Z ICERTIFY THAT INTHE PERFORMANCE OF'HE WOFlK FOR WHICHTH�S PERAIIT IS:SSUe'D.1 yIECHANiCAL -�_�_ ""'"' Cr3 SNALLNOT EA!PLOY WY GERSON IN MY MANNER SOAS TO BECOME SUBJECT TO THE � WORKERS'COMPENSATION U.WS OF CA.IFORNIA,pND AGREE TNAT!F i SHOUL�BECOM'e INSPECTIDN FEE ____ SUBJECT TO T4E�VORKERS'CAAAVENSATION PFlCVI' NS OF SECTK+N 37oa CF THE LABOR �j" � CODE,1 SHALL FOflT}iW1TH GCMPLY WITH(j�7'QjS'c P��S�ICgH�S.� �SSUANCE �J.f__�_�__�__ _' � p DATE:�~��.,.��� APPLICANT� �•i �1U�F�� _ __ SMIP _._.____.'__ ���_ J WARNING:FAILURE TO SECURE VJORNERS'COMPEYSATION COYERAGE IS U'L4W W:.,AND SHA.�BE �NERGY P!C ______..__._,_._ J - � SU&IECTANEMPLOVERTOCRIMINALPENi.LTIESANDCIVILFIN HUNOREOTHOUSAND �NERGY PERMIT DOLLARS 1510D.000),�N AD�ITION TOTHE CO3T OF CAMP'cNSATqN.DAMA6E5 AS PftOVIDED FOR IN ------- — J SECTION 9708OF THE LhBOR COOE.IN7ERE5T,ANO ATTORYEV'S FEES. RETENTION FEE: ¢ -- _--__—_ d CONSTRUCTION LENQING AGEIvCY PRE-ALT FEE: p -- — — � IHERE9YAFFIRMUNDER7ENnLTVOFP'eRJURVTI:ATTHcRFiSACONSTRUCTiONLEN0INGAGENCY ___ _______ FOR TNE PERiORMAtiCE OF TME WORR FOR W HICH THIS PERMIT IS ISSUE�(SEG.30N7,QV C.J. Z W � LENOEft'SNAME ___.._ ______,.___ _ F_- LENDER'SA�J�RESS /� 1 � I CERTIFY THAT I HAVE READ THISAPPUCATION AND STATE THAT THE A60VE INFORMATION IS CORRECT. Tl1TAL FE ES � � w I AGREE 70 COMPLV WITH AL�CfTY AND COUNTv ORDINqNCES AND STATE LAWS RELATING TO BUILDING � CONSTRUCTION,AND HEREBY AIPHORIZE REPRE�cNTATIVES OF THIS COUN7V?O ENTER UPON THE ZABOVE-tt��NTIONE�CHOVERTY FOR INSPECTIOy?iRPOSES. Q �� �,� COMMENTS � � -- — m PERMITfEENRM (PRI ) /!/'� � ��`�d^d' '% � SIGNATUFEOFP E OATE = RECPT.NO. 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