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HomeMy WebLinkAbout15184 ___---�-.� ___ � � CITY OF DIAMOND BA� �� � ----��-- DEPARTMENT OF COMMiJNITY&DEVELOPMENT SEI2VICES � g� f} 21660 B.C o ple y Drive Suite 190 �� U �/ I (909)860-3195 Fax(909)861-3117 � PRESS . q��,..� . . .. - , BUII:DING PERMIT APPLICATIOT�i°"� , � FIRMLY _ _ _ . � ,, .� �,,. �...,.. ..r ,. y JQBSITE ��`^� ���`a�� �, APPLICATIO PERMIT � P/C a ADDRESS � DATE - NUMBER # � ISSUE � TYPE OCC APN LOT TRACT DATE CONST. GROUP p OWNE� � ��9:Tt'_3.� " ApDRESS sA.b�.Rc ZONING SETBACKS � CITY �a�'�`�`� r�- ZIP `� TEL. ��"'�� FRONT RW ❑ APPLICANT TEL. REAR ❑ � SIDE/SIDE STREET RW ❑_ � CONTRAC70R - L �' ��Ct�S' SIDE O � ADD �- "'� — � CITY ZIP TEL. PROPOSED USE o ARCH/ENG� ,.z. DESIGNER NO.DWEL. NO. NO. 7i ADDRESS UNITS STORIES BEDROOMS � CfiY ZIP TEL. N DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANA�UATION � OOWNER-BUILDER DECLARATION SFR/ADD/REM � � � I HEREBY AfFiRM UNDEfl PENAL"n'OF PERJUHV THAT I AM EXEMPT FROM THE CONTRACTOFS LI� G2fHJB/CBfPOft � � CENSEUWFORTHEFOLLOWINGREASON(SECJa37.5B11SINESSANDPHOFESSIONSCODE:ANYC�TVOH (n COUNTYWHICHREOUIRESAPEFlMrTTOCONSTRUGT,ALTER,IMPROVE,OEMOLISH,ORREPAIRANV57i3UG W Patio/00Ck T/pE,PRIOR TO ITS IS3UANCE,AL50 RE�I11RE5 THE APPLICANT FOR Sl1CH PERMIT TO FILE A SIGNm W STATEMENT THAT NE OR SHE IS LICENSED PURSUANT 70 THE PROVISIONS OF 7HE CONTRACTORS LI- � CENSE LAW�CHIIPTER 0(COMMENCM�WITH SECTION 7W0)OF DIVISION 3 OF TME BUSINESS AN�Pfl0- � POOVSP2 FESSIONSCOOE)OR7HA7HEORSHEISEXEMPTTNEREFROMANDTHEBASISFORTHEALLEGEDEXEMP- (� TION.ANYVIOLATIONOFSEC7'ION7031.6BVANYAPPLICANTFORAPERMITSUFUECT5IHEAPPLICANTTO Z Re-Roof � ACML PENALTY f1F NOT MORE'iHAN FNE HUNDRED DOLLARS(f5o0).): � �I,ASOWNEqOFhIEPPOPERTY.ORMYEMPIOYEESWI7HWAGESASTHEIF50LECAMPEN5AT10N, � COmf1lBfCl81 '- WILL DO THE NbqK,/WD THE STRUCTURE IS NOT IM'ENDED'bP OFFEiiE�FOi1 SALE(SEC.7oad,BUSI- J NE55 M10 PF�FESSIONS CODE'.THE CONTRAGTORS 110ENSE-LAW�OES NOT APPLY TO AN OWNER OF N FROPERTYVhIOBURDSOPIMPROYES7HEREON.ANDWHODOESSUCHWORNHIMSELFORHERSELFOR � � TMf10U6HHI50RHEROWNEMPLOYEES,PROVIDEOTHATSl1CNIMPROVEMENTSARENOTMTENDE00Fi m � OFFEREDtORSALE.IF,HOWEVER,7HEBI11L01N60RIMPROVEiAEMI550L�WITHINONEYEAROFCAMPLE- z TION,THE OWNER�BUILDER WILL HAYE THE BURDEN OF PROVIN6 hIAT NE OR SHE Di0 NOT 9UIlD OR = IMPROVEFORTNEPURPOSEOFSALE). � ❑I,AS ONTIER OF TNE PROPEFiTV./�M E%(:IUSIVELY CONTRACTWG WITN�ICENSED CONTRACTOFS � TO CONSTRUCT 7HE PRQIECT(SEC.70tI.BUSINE55 AND PROFESSIONS CO�E:THE CANTRACTORS LI- VdIUB[IOII ADJ.AREA W CENSEUWDOESNOTMPLY70AMOWNEROFAPROPERTYN7HOBUIL�50RIMPROVESTHEREON,AND � W/qCONTRACTSFORSUGHPROJECTSWITNACONTMCTOR(S)LICENSEDPURSUANTTOTHECON7RqP Q�JqNTITY DESCRIPTION FEE � TOPS LICENSE LAWJ. O I AM E%EMPT UNDER S�C. B.8 P.G FOR THIS REASON Q � U � � DA7E OWNER_ _ U , W � LICENSEO CONTRACTORS DECLARATION W � � 1 HEREBYAFFIRM UN�ER PENALTY OF PERJURV TMAT I AM IICEN5E0 UNDEA PROVISIONS OF CHAPTER � � D(COMMENCINQ WITH SECTION 7000)Of DIVISION 3 OF THE OUSINESS AND PROFESSIONS CODE,AN� Z X MY UCENSE IS iN FULI FORCEAND EFFBGL � m G . ��'Sr- LLI �*�j �''� � a � UCENSE CLASS �-^J� LIC.NO.����� � �.�-^�' J V DATE �d`Z�"'�� CONTRAGTOR_�"��-.-.__ �'- W � WORKERS'CpMPENSATION DECLARATION Q � IHFREBVAFFIRIAUNDERPENALTYOFPF_RJUFlVCNEOFTHEFOLLOWING�ECLARATIONS: U � Z Q � _IHAVEANDWILLMA�MAINACEFTIFICATEOFCONSENTTOSELF-INSUREFORWDi7KER5' 2 � COMPFNSATION.AS PFOVIDED BY SECTION�70o OF TME IP,eOq COOE,FOR THE PERFORMANCE W OFTHE WORK fOR WHICHTHIS PEFMITIS 45SUED. �. 0 w __I HAYE AND WILLMAINT0.IN WORKEFS'COAAPENSATION INSUfiANCE,AS REQUIaED BY SECTION Q 370o OF THE LABOFi CO�E,FCR 7ViE PERFORbIANCE OF THE WORK FOR W41CH THIS PERMIT IS ISSUEO.MYWOPKERS'COMPENSATIONINSUPANCE,r�(c yRIER�ApN�POLICYNUMBERAFE: CONSTRUCT�ON jCARRIER �Z�� v"""q �'t�`I�h'-S PLAN REVIEW Z PaICYeiuMeER ��� �«��� EIECTRIC Q � fnasstct�rvr��rioreecnu.afFrIDOFn-�a�r+rrswaowErnxara�oalar�sryioolon�Ess} PLUMBING wa r ar..� w Z ICERTI�'TMATINTHEPERWflMANCEOFTHEWORKiOP.WHICHTHISPERM1715153UED,l MECHANICAL 1�' � SHALLNOTEM7LOYPN/PERSONINPNYMRNNERSOASTOBECOMESUBJECTTOTHE � WORKERS'COMPENSATION LAWS OF CAIIFOPNiA,ANO AaREE THAT IF I SHOU4'�BECOME INSPECTION FEE � SU&IECT TO THE WORKERS'CAlAPENSATION ROWSI9NS.DE,�CT�ON 37000F THE LA60R � CODE,ISHALLPORTHWITNCOMPLYWI OSEPROVISION". �\ ISSUANCE to1�7 C] !1 r/���__ SUtN f.� �1 p �ATE:���'�� APPLIGANT; .� "�J SMIP .". .... � ' T��� w `� ENERGY P/C _�'�Q�'�1�1v+O � � J WARNING FAIWRETOSECUflE WORKERS'COMPENSATION COVEFAGE IS UNLAWFUL,AND SHALLBE J (+�'[�'�(,,, LL SUBJECTANEMPLOYERTOCRIMINALPENALTIESANDCIVILFINESUPTOONEHUNDREDTHOUSAND ENERGYPERMIT RT�.p�T�TN�p_�C AND l!1[��✓ DOLLARS(f1 D0.000).IN AODITION TO THE COST OF GOMPENSATION,DAMAGES AS PROVIDEO FOR IN .., � $ECTbN370BOFTHELABOHCODE,INTEREST,ANDATTORNEY'SFEES RETENTIONFEE: � CONSTRUCTION LENDING AGENCY PRE-ALT FEE: � I HEREBYAFFIRM UNDER PENALTY OF PERJURY THATTNERE IS ACOYSTPUCTION LENOING AGENCY n- FORTNE PERFORMANCE OF THE WORK FOR WHICH THIS PERMR IS ISSUED(SEC.3087,GIV.G.). ` z li���il�"�,,,�' � ' � LENDEP'SNAME____ �IlI�I. ,�� �' — F_ LENDER'S AOORESS _._—._ - /1 W IGERTIFVTHATIHAVEqEADTHISAPPLICATIONANDSTATETHATTHEABOVEINFORMATIONIS�'ARRECT T�TAL FEES ���' ° '� .�� �—/ � � 1 AGREE TO COMPLY WITH AlL CITY RND COUNTY ORDINPNCES AND STATE LAWS RElA7MG TO BUILDING � ' 0 � � � CONSTRUCTION,AND HEREBV AUTHORIZE REPR'eSENTATIVES OG THIS COUNTV TO ENTER UPON THE � � ABDVE-MEN1'IONE PROPERTV FOR INSPECTION PUF OSES. 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