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HomeMy WebLinkAbout16438 � � _�� CITY OF DIAMOND BA8 DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES _ 21660 E.Copley Drive Suite 190 ` .w • ` ,.,.,A�,.,,. (909)$60-3195 Fax(909)861-3117 �'f,� PRES$ BUII.DING PERMIT APPLICA'�'I�N l/'`-- FIRM Y �,.,. . , ,.._.,,..,:. QJOBSITE �J`�'�3 �{'��f ��.fl��� DATE CATION J�_20_� � NUMBER `+� #/C ��� I W 4 ADDRESS o'� '!-' � J � ISSUE l (j TYPE OCC APN LOT TRACT DATE J r� CONST. GROUP p OWNER E � � � p ADDRE S �� '''� �` ZONING SETBACKS � —� FRONT __"__"_RW----� ❑ CITY �`��9 ZIP TEL. REAR ✓`�Y ❑ APPUCANT T L SID STREET RW � CONTRACTOR�lGL�/�C� _ ¢ ADDRESS Q CITY ZIP TEL. PROP ED`USE � �� � � wo ARCH/ENG/ Q � �,y� �_ p�-_r`_--- � DESIGNER 0"�� G�'[� • NO. WEL. NO. NO. ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. v� cn DESCRIPTI N SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER DECLARATION SFR/ADDIREM O I HEFEBY AFFlRM UN�ER PENATY OF PERJURV THAT I AM EXEMPT FROM THE CONTRACTORS LI- G0f090/CBfpOft � CEtdSELAWFORTHEFOILOWINGREASON(SEC.7031.5BUSMESSANOPqOFESSIO�SCODE:ANYCITVOH (n COUNTYNMICHRE9UIRESAPERMfTTOCONSTRUCT,ALTER.IMPROVE.DEMOLISH,OHREPAIRANVSTRUC- W PytlO/D6Ck NRE,PRIOR TO IT3 I5SUANCE,ALSO HEQUIRES THE APPLICANT FOR St1CH PERMIT TO FILE A SIGNED W STATEMENi THJXT��HE bR SHE IS LICENSEd PUi15UANT TO THE PRON$IONS OF THE CON7RACTORS LI- � CENSE lAW{CHAPTEq 0(COMME'NCINO WITH SECTION 7000)OF DINSION 30F TNE BUSINE55 AND PRO- � POOUSpe FESSqNS COOE)OR THATHE OR SHE IS EXEMPT TliEREFROMANO THE BASIS FOR THE ALLEOE�E7(EMP- (� TqN.ANYVIOLATIONOFSECTION7031.5BY�NYAPPLICAfiTFORAPERMITSU&IECTSTHEAPVLIGANTTO Z Re-Roat � ACMLPENAI,T/OFNOTMORETHANFIVEHUNDREDDOLURS(55oo).): ❑I,ASOWNEROFTHEPROPERTY,ORMYEMPLDYEESWITHWAGESASTHEIRSO�ECOMPENSATION, C� CORIRI0�CI3I g WILL DO THE WORIf,AND THE STRUCTURE IS NOT MTENQED OF OPFERED FOR SALE(SEC.7041,BUSI- J y NESS AND PROFESSIONS CODE:THE CONTRACTORS LICENSE UW DOES NOT APPLV TO AN OWNER OF = PqOPERTY VhlO BUILOS OR IMPFiOVES THEREON,rW�WFIOOOES SUCH WORK HIMSELF OR HEpSELF OR � THHOLIOHHISORHERONMEMPLOYEES,7ROVIDE�THATSl1CHIlAPROYEMENTSARENOTINTENDEDOR m � OFfEHEDfORSALEIF,HOWEVER,THEBUIl01NGORIMPROVEMENTISSOLDWITHINONEVEAROFCOMW_E- TION,THE ONMER-BULDER WILL HAVE iHE BURDEN oF PROVING THA7 HE OR SFIE DID NOT BUILD OR � IMPROVEFORTHEPURPO6EOFSALE�. W ❑I,ASONRlEROFTHEPROPERTY.IIMEXCi_USIVELYCONTHACTINCiW17NL10ENSEDCONTRACTOF3 � TO CONSTRUCT TNE PROJECT(SEC.7o1q BU31NES5 AND PROFESSIONS CODE:TME CONTRACTORS ll� V8IU8IIOf1 ADJ.AREA � CEN9EUWDOESNOTAPPLYTOANONMEROFAPROPERTYWHOBUILD54RIMPflOVESTHEREON,AND – - -' N}qCONTRACTSFORSUCH�R0.1EC7SWITM.ICCNJTqACTOR�S�IJCENSEDPUNSUANT70TMECONTflAG .QUANTITV DESCRIPTION.*. �-q �E � TORS LICENSE UW.). J 1 ❑I AM EXEMPT UNDEF SEC._____.____ .. B.8 P.C.FOR TMIS REASON Q � U � _� V � � DATE �y OWNE � � � W . '�� _'..4.,y� �Q LICENSED CONTRACTO �N w ... '-. ,J ' fL I HEflEBY AFFiRM UNDER PENALTY OF PERIURY THAT I AM UCENSED UN�ER PROVISIONS OF CIiAPTER (� O�COMMENCINQWITHSECTION7000)OFDIYISION30FTHEBUSINESSANDPROPESSIONSCODE,ANO Z f Y� � � � MY UCENSE IS IN FULL PORCE AND EFFECL �-- � „ . , - . .M1 N 0 LICENSE CLASS LIG.NO. j � �\�—�� ^ J y� V DATE GONTRACTOR __ 0. ^ � � W � � WORKERS'CQMPENSr�TION DECLARATION � C�, C -�� � IHEREBVAFF l/NDERPENALTYOFPERJUPVONEOFiHEFOLLOWINGDECLAqATIONS: Z L, _IHAVEAN WILLMAINTAINACERTIFlCATEOFCONSENTTOSEIF-INSUREFORWORKERS' $ �~ � Q COMPENSA ,AS PROVIDED BY SECTION 3'IDo OF THE LPB9R GODE,FOR THE PERFORMANCE �U oF TME WOH OR WMICH THIS PEFMIT IS ISSUE�. � O � _I MAYE ANO WILL INTAIN WOPo(ERS'COMpFNSATION INSURANCF,AS REqUIR[�BV SECTqN Q 3�oa OFTrIE V 70 DE,FORTHE PERFOP.MANi:E OFTHE WORK FOR VlHICHTH�S PEFMIT IS ISSUEU.MY WORKER MPENSpTION ItJS'JHANCE CARRIERAND POLICY NUMOERARE CONSTRUCTION �� jcnAaies_..�. __ PLANREVIEW . ZaoucvNUMeeR_.._ _�. — ELECTRIC _ Q � (THiSSEC.I/JNNEFANOTBEmMR.EfIIJ hIEPF.WMI�ISFORONE141NDREUDd1A1L4(E1ro�06iLESS�. PLUMBINC� Z I CERTIFYT4AT INTHE PERFORMANCE OFTf WOAK FOR WHICHTHIS PERMIT IS ISSUED,1 MECHANICAL �:3� SHA�L NO7 EMPLOY ANY PERSON IN ANV MANN SOAS TO BECOME SUBJECTTO TME (n WORKERS'GOMPENSATION:AWSOFCALIFORNIA, �AGFEETHATIFISHOULDeECOME INSPECTIONFEE j SU&IECTT07HEWORKERS'COMPENSATIONPROVI NSOFSECTIIXJ37000fTHELA60R p CAOE,I SHPLL FORTHWITM COMPLY WITN 7HpSE PRO IONS. �SSUANCE ..O Y.��__ Q SMIP p DA7E: APPLICANT: . _ , � ' ENERGY P/C V � WAFlNING:FAILURE TO SEc.'UFE WOflKERS'COMPENSATION CAYERFGE 15 UNLAWFUL,AND SHALL BE � SU&IECTANEMPLOYERTOCRIMINALPENALTIESANOCiVILFMESUPTOONEHUN�REDTHOUSAN� ENERGYPEFMIT � DOLLARS(5100.000),IN ADDITION TO THE COST OF COMPENSA710N,DAMAGES AS PROVIDED FOR I� � SECTbN37080FTHELA80RCODE.INTEREST.ANDATTORNEV'SFEES. RETENTIONFEE: � d CONSTRUCTION LENDING AGENCY PRE-ALT FEE:�� a � • � IHEREBYAFFIR RPENRITYOFPERJURVTHATTHEREISACONSTRUCTIONLENDINGAGENCY ___ � FOF THE PERFORMANC E WORK FOP WHICH THIS PEPMIT IS ISSUEO(SEC.3oe1,CIV.C.). — Z W — � LEN�ER'SNRME 1 � LENDER'SADDRESS .______.____..._ __ 'y^� /� � ICERTIFVTMATIHAVEFEADTHISAPPLICATIONANCSTATETHATTNEABOVEINFORMATIONISCORRECL TOTAL FEES _,��(j�] '{rt�'' � I AGREE TO COMPLY WITHALL CITV FNO COUNTY ORGINANCES AND STATE LAWS REUTING TO BUILDING � ��1/���� '�'^�� t M O � CONSTRUCTION,ANO HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TD ENTER UPON THE ' 1 W . / r1 Z ABOVE-MEMIONEDPROPERTYFORINSPECTIONPURP0.SE5. COMMENTS » � ���, L'` grl�/�_�_� J � L v fj•p�W m PERMITTEE N Q � � SIGNA7U ITTE DATE d _ �- RECPT.NO. 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