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HomeMy WebLinkAbout12946 ^ _�f� CITY OF DIAMOND BAIt ��� DEPARTPviENT OF COMMUNITY&DEVELOPMENT SERVICES : � 21660 E.Copley Drive Suite 190 ;,�;,,,; (909)860-3195 Fax(909)861-3117 PRE$S Bun:nIlvG PERNITr APrLICA'�'ION -- ., � FIRMLY _ __ . . . , � JOBSITE I /� � �J APPLICATION "'] G� PERMIT P/C o ADDRESS/�10 I'►'�A�.I L✓� ` ��� DATE�,~ �� " r NUMBE # � APN �OT TRACT r J� ISSUE TYPE OCC DATE CONST. GROUP p OWNER l e !ND ��C.�'ig' p ADDRESS I' S C� "��►1`li.�. �V ZONING SEfBACKS � CITY !'�✓J ZIP 1� �'�TEL. C��JG'�Z� FRONT RW ❑ APPLICANT TEL. REAR ❑ SIDE/SIDE STREET RW ❑ � CONTRACTOR �� SIDE --�❑ � ADDRESS �M.�,��,.it��� � � CITY ZIP TEL. PROPOSEDUSE �fZ r��^F- c-�-' oARCH/ENG/ z DESIGNER W NO.DWEL./� NO. NO. o,_ ADDRESS UNITS �-> STORIES BEDROOMS � CITY 21P TEL. � rn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION Q OWNEH-BUILDER D�CLARATION SFR/ADD/REM O p 1 HENEBY AFFlRM UNDER PENALTY Of PERtt1RY iHAT I AM EXEMPT FROM THE CONTRACTORS LI- Gerd(JB/CdfpOR W CENSELAWFORTHEFIX.LOWINOREASON(SEC.7at7.69USINESSANOPROFESSIONSCODE:ANVCI7VOR (n COUNTVWHICHREOUIRESAPERMYfTOCONSTRUCT,AL7ER,�MPROVE,DEMOUSH,ORREPAIRANVSTRUG W P8fi0/DBCk W TURE.PRIOR TO ITS ISSUANCE,AL50 REQUIRES THE APPUC/UJT FOR SUCH PERMIT TO FILE A SIGNED W STATEMENT THAT HE OR SHE IS LICENSED PUq5UAN7 70 THE PROVISIONS OF 7NE COMRACTORS U- � CENSE UW(CH4PTER e(COMMENCINO WITH SECTION 7000)OF DIVI910N 9 OF THE BUSINESS AND PRO- � PooU5p8 FESSqN50�E�ORTIA7MEOR5HE15EXEMPTTMEREFHOMANDTHEBA515FORTHEAILEQEDEXFMP• (� TION.ANYYqLATpNOFSECT10N7031.6BYANYAPPLICANTFORFPERMRSU&IECTSTHEAPPLICANTTO Z Re•Root F, �CIVIL7ENALiYOFNOTMORETHANFNEHUNDRW�OLLARS(SSW).): � �I,ASOWNEROFTHEPROPERTY,ORMVEMPLOYEESWITFiWAGESASTHEIRSOLECAMPENSATION, 0 COmmerClel - NALL DO THE`AK)PK,AND THE STRUCTURE IS NOT�NTENDED OR OFFERED FOR SALE(SEC.7041.BUSI- J � NESE ANO PROFESSIONS CODE:THE CANTRACTORS IICENSE LAW OOES NOTAPPLV TO AN OWNER oF j PHOPEHTY WF/O BUILDS OR IMPROVES THEREON,ANU NMO DOES SUCH WORK HIMSELF oR HERSELF OR � 1HROUfY1HI3ORHENOWNEMPLOVEES,PROVIOEDTHATSUCHIMPROVEMENTSARENOTINTENDE00R m 1.�1 OFFEiIED FOR SKE IF,FIOWEVER TNEBUILUIN60R IMPROVEMENTIS&OlD WITHIN ONE VEAROF COMPLE z �TION,iF1E OWNER-BUILDER WILL HAVE THE BURDEN OF PROVINQ THAi FIE Oq SNE�ID NOT BUILD OR � IMPROVE FOH THE PURPOSE OF SALE). w ❑I,ASONMEFOFTHEPROPEHTI;NAE%CLUSIVELYCANTRACTINOWRMLIGEMSEDCONTRACTORS ¢ TO CONSTRUCT TME PFOJECT(SECJPH,BUSINESS AND PROFESSIONS CODE:THE CONTRACTOfiS LI- V81Ufl[i011 _ ADJ.AREA W CENSELAWDOESNOTAPPIYTOANOWNEROFAPROVEHTVWNDBUILD50RMPROVESIHEREON,AND Z WFiOCONTRACT3F01iSUCHPRQIECTSWITHACONTRACTOR(SyLICENSEDPURSUANTTOTHECONTRAG QUANTITY DESCRIPTION FEE � TORSUCENSElAW.1. ❑I AM EXEYPT UNDER SEC. B.&P.G FOR THIS REASON Q 3 c� � DATE ONMER �� U � W LICENSED CONTfiACTOR DECLARATION -� � W I HEREBYAFFIRM UNDER PENQTY OF PERIURV THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER � � Y(COMMENCINf3 WITH SECTKKJ 7oao�OF DNISION 30F THE Bl1SINESS ANO PROFESSIONS CA�E,AND z �� AAY UCENSE IS Ml FULL FOHCE AND EfFECT. m � LICEN5E CLASS LIC.NO. j � J V DATE CONTRACTOR d W � WORKERS'COMPENSATION DECLARATION a � 1 HEREBV AFFlRM UNDER PENALTV OF PERJURV ONE OF THE FOLLOWING DECLAFlATIONS: Z � _IHAVEANDWILLMAIfiTNNACERTIFICATEOFCONSENTTOSEIF-INSUREFORWORHERS' ¢ 2 COMPENSATION,AS PflOVIDEU BV SECTION 37o00FTHE LABOR CA�E,FOR THE PERFORMANCE �U OFTHE WORK FOR WHICH TNIS PEqM�T IS ISSUEO. � 0 _i HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REOUIPED BV SEC710N Q 37000FTHELARORCODE,FOPTHEPERFORMANCEOFTHEWORKFORWHICNTHISPERMITIS �^�� �� ISSUED.FAY WOFKEFS'COMPENSATION INSURANCE CAFRIER AND POLICY NUMBER ARE: CONSTRUCTION V.� i jCARRIEfl PLAN REVIEW Z roucYNUMBER ELECTRIC ¢ 0 (iH6SECT10NNEH1NOT8E00ApLETEDOF7V�PEPMfTISFi�RONEHUNDRWDd1ARS(51oo)ORIESS� PLUMBING W Z I CERTIFY iHAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I MECHANICAL ��C.�1F76� (,'j SHALL NOT EMPLOY ANY PERSqV IN ANV MANNER 50 AS TO BECAME SUBJECT TO THE - (q WORKERS'COMPENSATIONLAWSOFCALIFOFNIA,AN�AGREETHATIFISHOVLDBECOME INSPECTIONFEE S i SU&IECTTO THE WORKERS COM7ENSA710N PROYISIONS OF SEC710N 3'7o00F THE LABOR CADE.I SHALL FORTHWITH COMPLY WRFI TNOSE PROVISIONS. ISSUANCE � � SMIP Jl41Y �_T�QQ4 p DATE: APPLICAM: � J ':' WARNING FAILURE TO SEWHE WORKERS'WMPENSATION COVERAGE IS UNLAWFUL,ANO SHALL BE ENERGY P/C � SUBJECTAN EMPLOVER TO CRIMINAL PENALTIES AND CI41L FINES UP 700NE HUNDPED THOUSAND �t y pF g��,a,tyq���-� F;�R�Y OOI.IARS(5100,0OO1.INADDITIONTOTHECOSTOFCOMPENSAT�N,DAMAGESASPiiOVIDE�FORM ENERGYPERMIT �T,y-. ,�C[��.�� �(�ti�_V�,1� � SECTION3'IoeOFTHEtABOPCODE,M7EREST,ANDATTORNEY'SFEES. RETENTIONFEE���-+��`.-� .�._'�'��'.� _ _ ' ' a CONSTRUCTION LENDING AGENCY PRE-AlT FEE: O � IHEPEBYAFFIfiMUNDEPPENPLTYOFPERJURYTHATTHEREISACONSTFUCTIONLEN0INGAGENCY FOR THE FERFORMANCE OFTHE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.3097,CIV.C.). Z W � LENOERS NAME 1=– LEN�ERSA�DFESS W ICERTIFY7HATIHAVEREADTMISAPPLICATIONANDSTATETHATTMEABOVEINFORMATpNISCORRECi. TOTAL FEES � � � � I AGREE TO COMPLY WfTH ALL CRY AND COUNTY ORDINANCES AND STATE UWS RELATING 70 BUILOING � � CONSTRUC710N,ANDHEREBYAUTHORIZEREPRESEN7ATIYESOFTHISCOUNTYTOENTERUPONTHE Z ABOVE�MENTIONED PROPERTY FOq INSPECTION PURPOSES. COMMENTS � K� 4� T/��'I (�//�Q>��� - ,. . ..,.... � . m —�� Q PERMITTEE NAME(PRINT) UJ 7 � SNiNANRE OF EE DATE � � RECPL NO. PAID BY - VALIDATION WHITE—Dapertmant Copy,YELLOW—Finanoe Copy,PiNK—Assessor Copy,GOLDENROD—File Copy,GREEN—ApplicanYs Capy . . .. . . . . . . .... .. .. ;r..... �...,,-..�; -., �.,;r; :p:..� .�w_aJ,,,i � ,s��,l r�� ° � . .. . . .t� . , .� . ., � . . . . _ .. .. .. . � .. -�..: ..,,�. . ;:c,;, . '.�a. ,..� .. �-.;��..., r..�r.�. - yiiy 7-, r'. 4i£" ,. 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