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HomeMy WebLinkAbout15272 CITY OF DIAMOND BA� ���G� g �"�— DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES G G� ` � 21660 E.Copley Drive Suite 190 � � (909)860-3195F�(909)861-3117 PRESS �'`�'` BUILDING PERMIT APPLICATION FIRMLY o� JOBSITE �� � � �� �.+� DATE CATION � �NUMe q��#/C ADDRESS � APN � ISSUE /��TYPE OCC � DATE � (1 UCONST. GROUP °C OWNER � OO p ADDRESS�� � r ZONING SETBACKS W CITY �IQ�"� � ZIP TEL. FRONT RW ❑ � APPtICANT TEL. REAR ❑ � SIDE/SIDE STREET RW ❑ CONTRACTOR A SI�E ❑ ADDRES .� � CIN ' �!�� ZIP � TEL. PROPOSED USE o ARCH/ENG! W DESIGNER NO.DWEL. NO. NO. � ADDRESS UNITS STORIES BEDROOMS = CITY ZIP TEL. � �n DESCRIPTION SQ. FACTOR PSF ADJ.AREANALUATION � OWNER-BUILDER DECLARATION SFR/ADDlREM O I HEREBYAFFIflM UNDER PENALTY OF PERIURY THA71 AM EXEMPT FAOM THE CONTRACTORS LI- GdfBJBJC8ip01� W CENSELAWFORTHEFOIIOWINGREA30N(SEC.7031.58USINESSANDPROFESSIONSCAOE:ANYCITYOR (/) � COUNTYWMICIIREDUIRESAPERMITTOGONSTRUCT,ALTER.IMPROVE,DEMOUSI1,OHflEPA1RANYSiRUG- W patio/DeCk W TURE,Pfl10R TO ITS ISSUANCE,AL50 REQUIRES THE APPUCANT WR SUCH PERMIT TO FILE A SIGNED W � STAiEMENf THA7 HE OR SHE IS LICENSE�PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI� CENSE LAW I�PTER n(COMMENCINO WRH SECTION TODo)OF DIVISION 30F THE BUSINESS ANp PR0- � POOVSp2 PESSIONS�E�OHTHATHEORSHEISEXEMPTTHEREFpOMANDTHEBASISFORTHEALLEGEDEXEMP� (� TION.ANVVIOI.ATIONOF5ECTION7091,68YANYAPPLICANTFONAPEPAlIT5U8JECTSTHEAPPLICANTTO Z Re-Roof � A GVILOENALTV OF NOT MORE THAN FIVE HUNDRED DOLLARS(S5oo).�: � ❑I.ASOWNEROFTHEPROPERTY,ORMVEMPLOVEESWITHWAGESASTHEIRSOI.ECOMPENSATION, COfI1m0tCi71 - VALl00 iHE WOflK AND THE STRUC7URE IS NOT IN?QJOED OR OFFERED FOR SALE�SEC.7044,BUSI- � � NESS PND PROFESSIONS CODE:THE CONTRACTORS LICENSE UW DOES NOT APPLY TO AN 06VNER OF � PROPERTV WFiOBUIL05 OR MPROVES THEREON,OJJD WHOOOES CH WORK HIMSELf OR HERSELF OR WiFIROU(3H FIIS OR IIEROYVN EMPLOYEES,PROYIDEO THATSUCH I OVEMENTS ARE NOT INTENDED OR m 0 OFFEREDWRSALEIF,HOWEVERTMEBUILDIN�ORIMPROVEMENI'IS OLDWITHINONEYEAROFCOMPIE- z iION,THE OWNER�BUILDEfl NfILL HAVE THE BUROEN pF PROVI 0 AT NE OR SHE DID NOT BUIIA OR = IM�AOVE FORTHE Pl1RPOSE OF SiILE). W OI,ASOWfVEROFTHEPROPERTv,AMEXCWSNELYCONT C NOWITHUCENSEDCOMRACTORS �. 1 �[ TO CONSTRVCT THE PROJECT(SEC.IOM,BUSINESS ANO PRO ES IONS CODE:THE CONTRACTOPS LI- VdIUaIIOR � v qDJ.AREA W CENSELAWDOESNOTAPPLVTOANOWtJEROFAP PERTYW O UILDSORIMPROVESTHEREON,AND � Y.TiOCOPlTMCTSFORSUCHPRQIECTSWITHA CTOR� LI ENSEDPURSUANTTOTHECANTRAG QUANTITY DESCRIPTION FEE � � TORS�UJCENSELAW.). �/ _ � .O1�MIEXEAI TUNDERSEC. B.SP.4FOR7HISREASON Q '�V 3 � � � Z D/1TE � _ oWNER � y W � � LICENSED CONTRA QRS DECIARATION W � 1 HEREBYAPFIRM UNDER PENALN OF PEflJURV T T I AM LICENSE�UNDER PROVI ON OF CHAPTER a Y(COMMENCINO WRM SECTION 7000)OF DIYISION 3 OF TME BUSINESS AN�PROFE 51 5 CODE,AN� Z �� � X MY UCENSE IS IN NLL FOFCEANqD EFFEC7. �u� �, `3 / � '��'G: � LICENSE C S LIC.NO. � ' !�"*/\. � L�4� V DATE �_�� CONTRACTOR ��� d W � W06iKEAS'COMPENSATION DEC RATION Q N �HEREBY AFFIRM UNDEN PENALTY OF PERIURY ONE OF 1HE FOLL WING DECLIRATIONS: Z G __iHAVEANOWILLMAINiA1NACERTIFICATEOFCONSENTTOSELF-INStJREfORWORKEFS' _ q COMPENSATION,AS PROVIDED 6Y 3ECTION 3700 OF THE LABOR CODE,FOR THE PERFORMANCE � OF iHE WORK FOR 6UHICH THIS PERMR IS ISSUEO. � 0 W _I HAVE AND WILL AIAIMAIN WORKERS'COMPENSATION INSURANCE,AS REWIREO AV SECTpN �� � � I o Q 37000FTHELA80RCO�E,FORTHEPERFORMANCEOFTHEWORKFOFWHICHTHISPERMITIS � ISSUED.MY WORKERS'CAMPENSATION INSURANCE CARRIEflAND POLICY NUMBERARE: CONSTRUCTION � J ? CARRIER PLAN REVIEW � Pa.�cYNUMeER_ ELECTRIC ¢ � (fHSSCCilOf1NE�NOTBE00MPLETmOF11iEPEiMtlT15 ONEHIMDHEDDOU..ARS(E10o�ORLESS�. PLUM8ING � I CERTIFV THAT IN THE PERFORMANCE O'THE WOfiK R WHICH THIS?ERMIT IS ISSUEO,I MECHANICA� (f SHALLNOT EMPLQY ANY PERSON IN AN ANNER 5 5 TO BECOME SUBJECT TO THE �,� (fj WORKERS'COMPENSATION IAWS OF C IFOftNIq AGREE THAT IF I SHOVL�BECOME �NSPECTION FEE � j SUBJECi7TO7HEWORKEHS'COMPENS IDNPROV IONSOF 37000FTHELABOR - p : COO SH ORTHWITHCUMPLYWI THOSE OVIS . �SSUANCE O �._ p DATE: �`� APPLICANT. '' SMIP ����� f � ENERGY PJC WARNING FAIL RE TO SECURE WORKERS'C PENSATION COVERRGE IS UNLAWFUL,AN�SHALL BE � SU&IECTAN@.1PLOVERTOCRIMINALPENALIESANOCIVILFINESUPTOONEHUNORED7HOUSAND ENERGYPERMIT� �yJ�'(y DOI.LARS(5100,0001,IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN ,p��7 7*V•�-{tY?-�'lFf4-�$#'�! � SECTION 37ae OF THE LABOR COOE,INTEREST,AND ATTORNEY'S FEES. 4 �.1 b �,JL'L�> RETENTION FE�T r a CONSTRUCTION LENDING AGENCY PRE-ALT FEE: ��� O � I HERE9Y AFFIRM UNDER PENALTY OF PERJURY THATTHERE IS ACONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE OF THE WORK FOfl WHICH THIS PERMIT IS ISSUEO(SEC.309�,CIV.C.j. Z lxl � LEN�ER'SNAME 1_ LEN�ER'SADDHE% _ � TOTAL FEES ��3� � � � I CERTIFY TMAT i HA pEAD THIS APPLICAiION AN�STATE THATTHE HBOYE INFORMATIUV IS COpRECT. W I AGREE TO COMP� ITH ALL CITV AND COUNlY OR�INANCES AND STATE LAWS RELATING TO BIJILDING � CONSTRUCTION,A HEREBYAUTHORIZEREPRESENTAl7VE50FTHI5WUNTYTOENTERUPONTHE Z ABOV MEI�TIONE RO RTV F-0R INSPECTION PURPOSES. COMMENTS � ����, ���,.��...f � m PER EE N (P cn Lt�'" G`'' " � SIG EOFPEiUAI EE DA = RECPT.NO. 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