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HomeMy WebLinkAbout12901 (13) � --_1�-- CITY OF DIAMOND�AII� DEPARTMENT OF COMIVIUNI'�Y&DEVELCIPMENT SERVICES � 21660 E.Copley Drive 5uite 190 PRESS (909}860-3195 Fax(909)861-3117 '.. ' BUII.ri�t�`p��1%TTT AP�'I.ICATYON .. ,� -,� . ...- ,;'.. ..... ..�._��. ,�i. .. ,... . .. .�..e. ,...�.;. , :. ....i'. . .� ..ei. � , . .-. a, ..a }�.::. .f� ��k^ « :L...1Ck�.vb�` _, �t FIRMLY ,..��< . .. ... .. >,,.a�i��h �5.,4a,c�. ar�,c r;:: . � �.i�.�I-.- . �, . ;.ti�,�,.,.t .. � JOBSITE � < APPLICATIdN PE'�I��ulll�' �� P/C o ADDRESS t%��� �/����'�� ��� � DATE,�,�' NUMBER � # $ ISSUE NPE OCC APN LOT TRACT DATE CONST. GROUP � �WNER O o ADDRESS ' = '�' �- _ � ZONING SETBAGKS Z CITY Z P TEL. FRONT RW ❑ APPLICANT 7��, REAR ❑ — c�j — SIOEISiDE STREET _ RW ❑ � CONTRACTOR C.�' '�/�i'��-��2'��/ C. S{DE _ ❑ o C,DRESS i � —� I'�}��TEL �'"J�_��?�Js� '' PROPOSED U5E w ARCWENG7 �C c "� d�`���!/° e�a��T cU � DESIGNER � � NO.DWEL. NO. NO. � ADDRESS UNITS STORIES BEDROOMS � G�Ty ZIP TEL. � D�SCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � � OWNER-BUILDEA DECLARATIOh1 SFR/ADD/REM O 1 HEREBY AFFIFiM UNOER PENAlT7 OF PER.tt1RY THAT I AM EXEMPT PROM THE CONTRACTof15 LI- G2ragBlCelpOft L�i„I CENSEIAWf-0RIHEFOLLON'INGflEASON(SEC.7031.58USINESSANfS�pfiOkE$510NSCODE:AN1'CITYOR (n . C� COUNTVWHICHREOUIRESAPERMITTOC�NSTRUCT.ALTERIMPRbVE,DEAA00SH,CRREVAIRANYS7RUG . W P3(i�(DeCk � TUAE.PRfOH 70 fTS 1SSUANCE.AL50 AEql11RES TNE APPLICANT FOA SUCt1 PF,FlMiT TO FILE A SIGNED W � 6TATEMENT TNAT HE OR SHE IS UCENSED PUfiSUANT TO 7HE PhOV151ON5'OF THE C,ONtRAC7AR3 LI� � CENSE lAW(CFiAP7EH 9(COMMENCINa WiTH SECTION)aau)OF DIVISION 3 OF THE BUSINESS pN0�PR0� �'�' PoOVSpd FESSIONS COOE7 OR THAT HE OR SHE IS EXEMP77HEREFROM ANO'THE BA515 FOR THEAIIEGEb EXEMP• TKKJ.ANYVIOLATIONOFSEC710N7031:58VANYAP6LICANTFORAPERMRSU&1ECTSTHEAPPCICANT70 Z RB-ROpf � qCMIPEN�LTVOFNOTMORETMANFNEHUNORE000L1AR5(S500J.). �'�'� � �I,ASOWNEROFTHEPROPERTY,ORMYEMPIOYEESWITHWAGESASTHEIRSOIECOMPENSATION, � Commercial WIIL DO THE WORK.AND THE 5TRl1CTURE IS NOT INTEN06D oP OFKERED FOR SALE(SEC.7o4a,BUSI- _! � NESS RNO PqOFESSIOti3 CC1DE:TNE CONIAACYOAS UCENSE LAW�OES NOT APPLY TO AN OWhIEF OF j PHOPEH'�Y WHO BUILDS OR IMGROVES 7HEREaN,AF10 WHO DOES SUCN WOFK HIMSELF OR HERSECf OR � THROUGHFPSORHEROWNEMPIOYEES,PiiOVIDE6hIArSUbHIWiPROVEMENT5ARENOTIN7ENPfDOR m QOFFEpEbFOR3ALEiKNOYYEVER7MEBUIIDING'bpIMPROVEMENT�550lDWITHINONEYEAROFCOMPLE- a TION,THE OWNER-BUICDEH WILL HAVE THE BIJR�EH OF PRdY1NC�THA7 HE OI�BH��ID NOT BV�LO Ofl � IMPROVE FORTHE PURPOSE OF SALEy � � ❑6ASONMEROFTHEPqOPER'fY,AMEXCLUSIVELYCONTRACTINGWI7HLICEUSEDCONTRACY"OR$ TO CONSTRUCTTHE PHOJECT(SEC.�]o44.9l1SINESS AND PROFESSIbNS CO[i5:7HE�CONTf7AC70A5 U- VelUetiDn ADJ.AREA �jJ CENSE lAW�OES NOT APVIY'SO AN OWNER Of'A PP.OPSRTY WHO 9U1L05�R IMPP.OV[S TF3ENEON,ANO � WIiOCONTRACTSFORSUCNPROJECTSWITFlACOA'TRACTOR(S)LICENSEDPURSUANTT07HECONTRAG QUANTITY DE.�,CRIPTION FEE TORS UCENSE LAW.�. � ❑I AM EXEMPT UNDER SEG 8.6 P.C,FOR THIS REASON U � � li" DATE OWNER V .a.. - � __ . ' , t . ;.'.�t'. Z W � LICENSED CONTRACTORS DEGL4RATION —� � � I HEREBY AFFIRM UNDER PENAI.TY OF PEFiJUflY 7HAT i AM LICENSED UN�ER PROVIS�ONS Of CHAPTER � a„ e(COMMENCING WIThi SECTION 7000)OF DNIS�ON 30FTHE BUSINESS ANO PROPESSIONS CODF,AND� Z X AlY LICENSE IS IH FULI FORCE AND EFFECT. W f � � LICENSE CLASS 4�.'^ ��� LfG.NO. �����"'�' _ � OATE � � � .._ CONTRACTOR_��t_�,rt'r.a' ^�� � �- r 3 t` . ) f ua ! .•., , '�'.�'' 1 ��1,... C C� � WORKE 5'COMPENSATlON DECLARATION �p Q �;.jVj�� - G`. . 6J� t/D ��� � 1 HEREBVAFFIRM UNOER PENAIT'OF PERJURY ONE�f THE FOI.COWING�EGLARA'f10N5 rI V Q Q i- G IHAVEANDWILIMAINTAINACER77FIGATEOFCONSENTTOSELF-INSUREFORWORKFRS' ;L Q 'COMPENSAl10N,AS PROVIDED BV SECTION 3700 oFTHE LABON CooE,FOR 7HE PERFORMANCF � OF THE WORIC FOR WHICH THIS PEflMiT IS ISSUED. c� � W ,t NAYEANO WIIIMAINTAIN WOPoCERS'C�MPFNSA'f1�N MSURANCE,AB REQUIRED BY SECTION � 370aOFTHELABORCODE,FORTHEPEHFOR6IANCEOFTHEWORKFORVJHCCHTNISPERMITIS ISSUEO.MYWDAKERS'COMPENSATIONINSUpANCECARRIERANDPOLICYNUMBERARE: CONSTRUGTION � cnr�AiEA �.�"-�/�,��'� �, v.�r7 PLAN REVIEW � POLICV NUP.6ER�E��p^" ��+��4�e' A�*i ��� ` ELECTRIC . 1 � i�ussEc�NEm�TeEooa.�ErEoa��ar�'�sraRONekuHoaEoca�.aas{a�m�oa�Essl. PLUMBING�; _ Z 1 CEftTIFV TNAT 6J THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSGEO,I�-�� CHANICA ,,.s� � ��....._.L (!j SHAILNOTEMALOYANYPER50NINAPJYMANNER50ASTOBECOMESUBJECTTOTHE INSPECTIONFEE Vj WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME �ry S SUBJEC?TOTHEN/ORKERS'COMPENSATIONPqOVtS10NSOFSECTIOM37aoOFTNEIAeOR SUFCNCE ����""�* , CA�E.ISHALLFORTFiWtTHCAMPLYWITHTH EPROV1510N5. � 0 �'� ��/`� 9 �'2..✓�'' fi7ltP.�� p DATE:.��_1�v-� APPUGANT: — � � � ENERGY P!C � WARNING;FA0.URE 705 URE WORKERS'COMPENSATION COVEPAG&IS UNLAWFUL,AN�SHAL4 BE ' �y, SU&IECTANEMPLOYFRTOCRIMMAIPENAL7IESANDCIV!LFINESUPTOONEHUN�REDTNOUSANp ENERGYPERMIT OOLLARS($ta0,a00�,W�OPI710N 70 THE COSTOF GOMPENSATIOk.DAMAGES AS PROVIDED fOR IN � SECT10N37a00FTNELA60RCO0E,fNTEREST,ANDATTDANEY'SFEES. RETENTIONFEE: - W CONSTRUC710N LENDING AGENCY PRE-ALT FEE: 1 � d p ... v... �. !i Q I HEREOVAFFIRM UNDER PENALiV OF PERJURY THAT THERE IS A CON51'RUC110N LENDINO AGENCY •- '- ��,_��� FORTHEPERFORMANCEOFTHEWORKFORWHICHTHISPERMIY�SISSUED(SEC.5o9'r,dXC.j. � '�� , � W � LENDERB NAME t• F�- LENDER'SADOflESS - - � � ICERTIF/THATIHAVEREADTHISAPPUCATIONAND9iATETHATTMEA60VEINFORMATiON�SCORRECT. �OTAL FEES � IAGREETQ C4MPlY WITH AIICYfY AND COUNTY ORDINANCES AN�STATE LAWS RELkTWG TO BUR.pING � CONSTRUCTION.ANOHEREBVAU7HORIZEflEPRESENTATIVE50FTHISC0UN7YTOENTERUPONTHE -: , � AeOVEMENTfONEDPROPERT'/WRINSPECTIONPURPOSES. COMMENTS . �'���'��'�'°�'� ! p �� f /1 I �i . �'�.14 t t� � �� ��r �.""l.�'� / � + .. m � ¢ PERMI7TEE NAME(PRINT) _n - � N � �- �. ��. -� I Il+;o;.� + V...p ; �J SIGNATUREOFPERMITTEE -����� � � RECPT.NQ. 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