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HomeMy WebLinkAbout12949 �� CITY OF DIAMOND BA�' ` ��7 DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES w 21660 E.C�pley Drive Suite 190 (909)860-3195 Farz(909)861-3117 PRESS ,".. BUII.DING PERMIT.APPLICA'Y'ION .__- FIRMLY �, ., . .� .. � JOBSITE . ` „.,,i...,, . „ ..,. ,., . .. ¢ ADDRESS��'z� d7�����Zi� '��' APPLICATION t'} �{C� PERMIT P/C o DATE ,'" t"� ~ � 1 NUMBER � # � APN LOT TRACT S ISSUE TYPE OCC p OWNER T�G t��; �{�;l� — DATE CONST. GROUP p ADDRESS/�'I� fti� t L� +� ZONING SETBACKS W cirv P t:.e�H� ZIP 7�'Y' ' TEL.��7� FRONT RW ❑ � APPLICANT TEL. REAR ❑ �,d SIDE/SIDE STREET RW G � CONTRACTOR .t-��„�s�N� � SIDE T C � ADDRESS � ✓"' � CITY ZIP TEL. PROPOSED USE ,L'/v��/L��''rl c%/L, LC-��f�'/°4 o ARCH/ENG/ ��,, DESIGNER NO.DWEL.+7 NO. NO. � ADDRESS UNITS / STORIES BEDRO�MS � CITY ZIP TEL. � cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDERDECiARATION . . .- SFWADD/REM O p I HEflEBY AFFIRM UNDER PENALTV OF PERJURV THAT 1 PM IXEMM fROM THE CONTRACTORS U- G8fd9BIC3f{)OfI LL CEN9EUWFORTHEFOILOWINOREA90N(3EC.7o3t.5BU51NES3ANDPROFE33bN5CODE:ANVCITYOR (n V COUNTYWHICHREOUIRESAPERMITTOGONSTRUCT,ALTER,IMPROVE,DEMOLISH,ORREPAIRANYSTRUF W P8ti0/DBCk �Z TURE,PRIOR i0 ITS ISSUANCE.ALSO HEQUIRES THE APPLICANT FOR SUCH PERMIT TO FIIE A SIGNED �W S7ATEMEPf�THAT HE OR SHE I5 LICENSEO PUii5UAN7 TO THE PROVISIONS OF THE C9M'RACTORS LI- w CENSE UW(�1PTEH 9(COMMENCINO WiTH SECTION 700D)OF DIVISION 3 OF THE BUSINESS ANO PRO- � POD�Spfl FESSIONSCODE)ORTFUITHEORSHEISEXEMPTTHEREFROMANDTHEBASISFORTHEALLEQEDEXB+IP• (� iION.MIYVIOLA710NOFSECT10N703/.6BVANYAPPLICANTFORl1PERMRSU&IECTSTHEAPPLICANTTO Z Re-Rooi r, �CMLVENALTYOFNOTMORETHMIFNEHUNDRED�OLLARS(S5a0).): � ❑I,ASOWNEROFTHEPROPERTKORMVEMPIOVEESWITHWAGESASTHEIRSOLECOM7ENSATION, � CommBICi81 - WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OFl OFFEREO FOR SALE(SEC.704a,BUSI- J N NESS AN�PpOFESSIONS WOE:THE CONTRACTORS LICENSE UW DOES NOTAPPLv TO AN OWNER OF j PiqPEFlTY NRiO BURDS OR IMPROYESTHEREON,AND WHo DOES SUCi7 WORK HIMSELF OR HERSELF OR � THi10U(iMHISORHEROMMEIAPLOYEES,PROYI�EDTHATSUCHIMPROVEMENTSARENOTINTENDE00R m 0 ,OFFQiEDWR5ALEIF,HOWEVER,7NEBUI�DINGORIMPROVEMENT155oLDwITHINONEYEAROFC041PLE- � TIpN,THE OWNER-BUILDEP WILL HAYE THE BURDEN OF PROVIN6 THAT FiE OR SHE OID NOT BUILD OR = IMPROVEFORTHEPURPOSEOFSALE). �y,� ❑I.ASONMEROFTHEPROPERTY.AME%CLUSIVELVCAN7RACTINOWfTHLICENSEDCONTRACTORS � TO CONSTRUCT THE PqQ1ECT(SEC.101r,9USMESS AND PROFESSIDNS CODE:THE CONTMCTORS LI- V8IU8IIIX1 ADJ.AREA � CENSEUWOOESNO�APPIVTOANOMMEROFAPROPERT/WNOBUILDSORIMPqOVESTHEREON,AND VhbOONTRACTSFORSUCHPRQIECTSWITHACONTRACTOR(S)LICENSEDPURSUANTTOTHECON7RAC- QUANTITY DESCRIPTION FEE � 70RSL10EN6ELAW.�. O ❑I AM EXEMPT UNDER S�C. B.8 P.C.FOR THIS REASON Q 3 � � � DATE, OWNER � �'� U � W LICENSED CONTRACTO S DEC ATION -� � w I HEREBY 11FFIRM UNOER PENALTV OF PERIURY TMAT I AM UCENSED UNDER PROVISIONS OF CHAPTER � � B(COMMENCINp WITN SECiqN 7000�OF DNISION 30F THE 8U5MES5 AN�PROFESSiONS CODE,AND Z Xy� MY LICENSE IS IN NLL FORCE AND EFFECT. m L1J 0 LICENSE CLASS LIC.NO. j V pnrE CONTRACTOR d w � WORKERS'COMPENSATIONDECLARATION � Q . � I NEREBYAFflRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWINO DECLARATIONS: Z O I HAVE AND WILL MAINTAIN A CERTIFICA7E OF CONSENT TO SELF-INSURE FOH WOFKERS' 2 � CAMPENSATION,AS PROVIDED BY SECTION 37o00FTHE IABOR COOE,FOR THE PERFOqMANCE 'U OF7HE WORK FOR WHICH THIS P6RMIT IS ISSUED. � 0 W _I HAVE AND WILL MAINTAIN WONKERS'CAMPENSATION INSURANCE,AS REQUIRED 9Y SECTION Q a7ooOF7HELABORCODE,FOfiTHEPERWRMANCEOFTHEWORKFORWHiCHhIISPERMITIS ISSUED.MVWORKERS'C�MPENSATIONINSURANCECAPRIERANDPOLICYNUMBERARE: CONSTRUCTION � � � CARRIER PLAN REVIEW Z PaICVNUMeER ELECTRIC �C 0 (IHsSEclKMUNE�r�o78ECO1rH.ETmoFnEPEahYiISFOROMEHIx�FtEDoalN�lS(Etao)ORLESS�. PLUMBWG Z 1 CEFTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSl1ED.I MECHANICAL (�} SHALLNOTEMVLOVANVPERSONINANVMANNERSOASTO6ECAMESLIBJECTTOTHE y WORKERS'COMPENSATIONUWSOFCALIFORNIA,ANDAGREETIiATIFiSNOULDBECOME INSPECTIONFEE S SU&IECTTO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 3�0o Of THE LABOH CODE,I3HALLFOqTHWITHCOMPLYWITHTHOSEPROVISIONS. ISSUANCE � � � � p �ATE: APPLICANT. SMIP � �... n �n n �&� . J �I WARNING FAILURE TO SECURE WORKERS'COMVENSATION CAVERAGE IS UNLAWFUL,ANO SHALL BE ENERGY P/C �H ry �' � i y y y LL ,' SUBJECTANEMPLOVERTOCRIMINALPENALTIES/W�CIVILFINESUP700NEHUNDREDTHOUSAN� ENEflGYPERMIT�Y 1„ ' DOLLARS�5700,OOD),INAODITIONTOTHECOS70FCOMPENSA710N,�AMAGESASPROVIDEDFOR�N �y a` *l _ J '' SECTION3lOeOFTMEtABORGODE,MTEREST,AN0AT70RNEYSFEES. RETENTIONFEE: .+ ( � ' BI�H.��7:�:'�.-. �y:" ��.�;��. � CONSTRUCTION LENDING AGENCY � PRE-ALT FEE: O � IHEREBVAFFIRMUNDEHPENALTVOFPERJURYTHATTHEREISACONSTRUCTIONLENDINGAGENCY FOR THE PEPFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.9097,CIV.C.). . Z W � LENOER'S NAME - F�' LEN�ER5ADDRESS /� � ICERTIFY?HATIHAVEf7EPDTHISAPPLICATIONANDSTATETHATTHEABOVEINFORMATION�SCORRECT. TOTA�FEES ( r0� ��6i � I AGREE TO CAMPLV WITH ALI.CYfY AND COUNTV ORDINANCES AND STATE LAWS RELATING TO BU�LDING �% ��' � CONSTRUCTION,ANDHEREBVIIUTHORIZEREPRESENTATIVESOFTHISCOUNTVTOENTERUPONTHE ABOVE�MENTIONED PftOPERN FOfl INSPECTION PURPOuES. �"�,.. f COMMENTS _ ,�c� ���I ��r�yr� m PEflM�TTEE NAME(Pflllfn " � � ;��r' �.v-�-��/ ,/'/ �r"'. /-��-y `i � SIONANREOFPER EE OATE p ., 1 .....,, _ � RECPT.NO. 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