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HomeMy WebLinkAbout15227 (19) ��� � CITY OF DIAMOND BA� � DEPARTMENT OF COMMUI�TITY&DBVELOPMENT SERVICES 21660 E.Copley Drivc Suiu 190 � (909)860-3195 Faa�(909)861-3117 PRESS �'�"� BUII.DING PERMIT APPLICATION FlRMLY Y JOBSITE '1,�� (Z,(��t��fl ��. APPLICATION /� PERMIT �S,�I] P/C a ADDRESS �� �J�� �� n DATE � `� NUMBER � ��'� 1 � � APN LOT TRACT ISSUE TYPE OCC °C OWNE�- ►�C�V DATE CONST. GROUP O p ADDRESS S►'�N� ZONING SETBACKS � CITY ZIP TEL. BIPO-' �Z� REART RW ❑❑ APPLICANT TE�. SIDE/SIDE STREET RW ❑ � CONTRACTOR �e'��'S �'�'�'^Q ' SIOE ❑ Q ADDRESS i 0 �S' Vu y}{ �. . � CITY S• -S- ZIP O b�U 7EL�0$��G1$�t PROPOSED USE �E�L'��c S �^' �^f f� o�.1 $ c� S n.w�- s tz� �+ ARCH/ENG/ � DESIGNER NO.DWEL. NO. r1 NO. ADDRESS UNITS STORIES ` BEDROOMS CITY ZIP 7EL. cn y DESCRIPTION SQ.Fl: FACTOR PSF ADJ.AREANALUATION � OWNER-BUILDER DECLARATION SFR/ADD/REM O I NEPEBY AFFlAM IMlDER DEN�LN OF PERRIRY THAT 1 NA EXEN�T FROM THE CONfMCTORS L6 Garage/CarpoR 11J CENSELAWFORTIEFCILLOWINOREASONISEG7031.6dV5V1ESSANDPROFES510N5W0E:M1YqTYOfl (n C�7 COUNTYNMICHREOUIRESAGEWMTOCONSTAUCi,ALTEiLIMPROVE.OEAbUSH,Oqi1EPAIRANYSiAUG W p3fiO/DBCk Z IURE,PR�OR M ITS ISSUANCE.ALSO REWIRES THE APPLICAN7 FOR SUq1 FERMIT TO FILE A 510NE0 «� ST�iEIJENT THAT HE OR 6NE IS LICENSEU PUR6UAM TO 1HE PROVISIONS OF THE CONTMCTOR6 LI� W � CETLSE LAM1�QIAPTER 0(Gp/YENCWO N77H SECTION 70a0)OF DIVISION 9 OF h1E BUSINE55 AN�PR6 � POOVSp9 FE99qN5 f.bDE)OqTFNT HE OR SHE IS EXEMPThiEREFRON AND TNE 6!SIS FORhIE ALLEOED EXEMP• (!i T10N.ANVVIOlAT10lIOFSECTION7031.6BYWYAP7LK:UfTFORAPEWI1TSl/61ECT5TNEAPPLICANTTO Z qe-Roof � r AqVll PEwLLTY OF NOT NOqE THAN FlVE HUNpRED DOILAHs�5ao).): � OI,ti4UNMEROFTHEPROPERTV.ORMVEMPLAVEESYVI11iWAOfSASTNEIR$OLECOIJVENSATION, 0 COff1111BlCI8I IYR100 THE Y7lDRK,AND TFIE STRUCRIHE IS 190T INTENDED OH OfFEREO FOP SALE(SEC.7ou,BU51- J �'-'� � �88 MD PAOFE5510NS COOE:TF�CON�fl�CTORS LICENSE UW DOES NOT APPLY TO AN QNR/EH Of ? PNOPERTY MIO BIlAD9 OR IIAPROVE57HEREON.ANO MMO DOES SUCH M"ORK MIMSELi OR HERSELF ON Q T1i101HW HIS Oil HEHOkM EMf�LOYEES,PpOVIDEO THAT 6UCH WPqOVEMEHTs ARE NOT ttJTEN�ED O(1 m � .OF�EDWHS�LEIF.HOWEVEltTNEBURDINGORN/PROVEMENTI55IXDVrtIHtNONEYEIIHOFCOURE � TIOH,TTiE ONRER�IILDER YYIt,L HIWE THE BURQEN OF PROVM�THAi HE OR SHE DIO NOT OURD ON IYPHDVE FOR THE PURPaSE OF&LLE} w ❑I,ASOWNEqOFTHEPqOPERTV,AME7(CLUSNELYCONfMCTMGWITHLICFNSEDCONTRACTONS � TO CONSTRUCT THE Pi�JECT�SEC.7041.BUSINE43 AND PROFESSIOWS CODE:THE COMMCTORS LI• V8IU0110f1 ADJ,AREA W CFHSEUWDOESNOTMPL�TOANOWNEROFAPROPERTYWHOBUMDSOR111PRDVESiMEREdi.N1D � MINOCONTRACTSFORSUpIPROJECTSWITIACONTMCTOp{S)UCENSEDWRSUNtTTOTiECONTRIIF QUAh1Ti DESCRIPTION FEE � 100.5UCEN5EtAW.�. O i N1 EXEMGT INAEN SEC. B.8 P.C.fOR 7MIS REASON Q U � ¢ OATE OWNER V W � UCENSED CONTRACTORS DECLAflAT10N W 1 FIEPEOV AFFIftlA UNDEH PENA�TY OL PEiUURY THA71 AM UCENSED IMIDER PRUVISIONS OF CHAPTEN � � •�CpYENCM(iYV17HSECTiJN70W)OFDIVISION30FTMEBUSINESSANDPFOFESSIONSCODE.AND Z MY L�EN3E IS W FUl FORCE ANO EfFECT. �7 � UCENSE CUSS � LIC.NO. r Z��j� � ~ DATE 7�r 1 '���CONTRACTOR - A U w � WORKERS'COMPENSATION DECIARATION � � � I MEHEBY AFFIPoA UNDER PENALTY OF PERIURY ONE OF THE FOILOWING DECtAMT1ON5: Z y � �IIUVEA1WWIlLAUMTA!NACEHfIFlCATEDF�NSENTTO3ELF-MSURECORWORKER5' _ � COYPENSATION.115PROVIDEOBYSECTION3IOOOFTHEU80RCWE,FOq7HEPERFOPMANCE 'U OF 7ME WOAN iOR WHICH THIS PERMIT IS ISSUE�. ` � w �_IHAVEMDNlILLMAINfAMWORKERS'CDYPENSATiDNINSUMNCE.ASREWIREDBYSECTION �� �� Q �7ao OF iHE LA90R GODE,FOR 7ME PERFORMANCE OF THE WORK Wfi WFI�CH 7HI9 PERMIT IS �SUEO.MY�/_y�c ERS'WNPENSATION,INS!URANCE CARR�ER AND POLICV NUMBERARE: CONSTAUCTION jc/a+raEP `� ���/� �`���� /'� PUW REVIEW � pp��'�MMFR R�L � �(�� ELECTRIC , � (f1�SgEC7pNt�pqiPEap,qEfIDpFnEpEP/eri44FOnor.IEMRDaEnpOLtAiLS�S1w)oriLEss? PLUMBING � ICERT�FViTfATINTHEPERFOPIAANCEOFTHE470RKFOflWHICH7Hi5PERMITI5155UE0,1 MECHANICAL (f SHALLNOTEMPLOYANYPERSd/MANYMIANNER50A5T08ECOMESUBJECTTOT4iE � WO�IKERS'C%�PENSATKKJLAWSOFCALIFORNI,\ANDAGREEiN�7iLI5HOUlOBECOME INSPECTIONFEE __� � SUBJECT TO THE WOPKERS'COMPENSATqN PROVi510N5OF SECTKKi 37000F TME 1A80H WDE,I SHALLFORMWITiCOMPLY WITHTHOSE PRONSIONS �SSUANCE �, � SMIP G p pp7E: qpPLICANT: w ENERGY P/C "'� WARNNJ(i:F/JWRE TO SECURE N'ORKERS'WMPFNSATION COVER4GE IS UNUWFIR.AND SHALLBE J �y SUBJECTAN EMPLOVER TO CRIM�NPL PENALTIES AN�GIYiI FINES Ui TO ONE HUNOHED TMOUSAND ENERGY PERMIT ODLtARS(f10o,000),IN IDDITION TO THE COST OF CO/APENSATION,pAMAGES AS PROVIDED FOq�N � SECTION a70!OLTHE LABON CWE.INTEREST,ANDATTOqNEYS FEE3. RETENTION FEE: � CONSTRUCTION LENDING AGENCY PRE•AlT FEE: O � IHERE9V11FFIRMUNDERVENALTYOFPFNJURYTHATTHEREI$ACOt�lSTRUCT�ONLENDIN011QENCY Z FOR THE PERFORMANCE�F TME WOFK WR WHICH THIS PEiWI715155UED(SEC.30B7.CIV.G). W � ��NDEFY3NAME F LENDER'SAODRE55 /�[� � ICERTIfYTHATIHAVEREADTHi9�PPLICATIONAN�STATETHATTHEABOVEINWN.�ATqNISCORqECL TOTAL FEES 1 a J - � 1 AGREE TO COMPL�NIITN ALL CRV AND COUNTY ORDMANCES IWO STATE UV/S REUT�HG TO BUILDMG , � CONSTRUCTION,AN�HEREBYAUTHDFREREPRESENT�TNESOFTHISCOIINTYTOENfERUPONTHE � ABOVE-MENf EUPROPERTVFORINSPECTIONPURPOSES. COMMENTS � � �o � J � CERMtTTEE NnME I �. � (, O Q � I � SIONATURE OF P HM E DATE � RECPT.NO. 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