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HomeMy WebLinkAbout16340 (23) �k���e� _�� _ CITY OF DIAMOND BA& DEPARTMENT OF COMMtI1vITY&DEVELOPMENT SERVICES `�3�~c� � 21660 E.Copley Driae Suite 190 (909)860-3195 Fax(909)861-3117 PRESS `rz9N'�., BUILDING PERMIT APPLICATION . FI LY ¢ ADDRESS ZL�"T� �I �� 5.... _. ,. .... , _, � JOBSITE ��� i7 D ' APPUCATION � PERMIT � P/C o f� �'' DATE NUMBER c� — ISSUE 6 nP� OCC APN LOT TRACT _ DATE CONST. GROUP p OWNER W�� "" ADDRESS i =' � i'�l ZONING SETBACKS W CITY f�e Av►I C�lid� l3/.YY�z ZIP TEL. G FRONT RW ❑ � APPLICANT d)2t�/ {�w17 /,�'lV 7'EL. �t{.` ) y REAR ❑ � � �' SIDE/SIQE STREET RW ❑ CONTRACTOR ��A+'' ��_ .A"Y s�, _ SIDE ❑ p� ADDRESS�L [��- � ''�?'J ` ROPOSED USE o cirr�l.r�la�w�g3�a ziP ,�ii�, ._G,zE�•� c,,�-� /P wo ARCH/ENG/ � DESIGNER NO.DWEL. NO. NO. AQDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. y DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OOWNER-BUILDER OECIARATION SFR/ADD/REM Q I HERFBY AFFlNN UNDER PENPLTY OF PEiUURV THAT I AM EXEMPT FROM THE CONTflACTORS 4�� � GaragelCarpoR W CENSEUWFORTHEFQLLOWINOREASON(SEC,7o31.5BU5ME55ANDPROFE5510NSCO�E:ANYCITYOR � COUMYWNICHREWIRESAOERMITTOCONSTRUCT,ALTER,IMPqOVE,DEMOLISH,ORftEPAIRANVSiRUC- W PatiolDeck TUHE.PR�OH TO IT5 ISSUANCE,AL50 REDUIRES THE APPLIGANT FOF SUCH PERMIT TO Fl4E A SIONED w � STATEMENT THA7 HE OR SHE�S LICENSEO PURSUANT TO THE PROVISiONS OF THE CONTRACTORS LI� � CEMSE LAW(CHAPTEP 9(COMMENCINO WITH SECiION 7000)OF DIYISION 3 0F THE 6USINESS AND PRP u' POOVSpB FES9pNSCOOE)ORTH�THEORSHEISEXEMPTTHEREFqOMANDTHEBASiSFORTHEALLEGEOEXEMP� (�} TION.ANVVIOLATIOIVOFSECTION'7031.69YANYAPPLICANTFORAPEFMITSUBJECTSTHEAPPUCANTTO Z Re-Roof � �CINL PENALTY OF NOT MORE THAN FNE HUNDRED DOLURS(550oJ.): Q � ❑I,ASONRlEROFTHEPROPERTV,ORMVEIAPLOYEESWITHWAGESASTNEIRSOLECOMPENSATION, COfi11118fCi81 - N7LL 00 TNE WORK,AND THE STRUCTURE IS NOT INTENDEU OR OFFERED FOR SAIE(SEC.7041,BU51� J NE55 ANO Pf10FES5�ONS COOE:THE CANTRACTORS UCENSE LAW DOES NOT APPLY TO AN OWNER OF � OROPERTYNMOBUILDSORIAIPROVESTMEREON,ANDWHODOESSUCHWORKHIMSELFORHER5ELFOR � � THROUGFIMISORHEROVMEMPLOVEES,PROVIDEOi4ATSUCHIMPROVEMEMSARENO7INTENDEDOR � Q OFFEREDFORSALEIF,HOWEVEP,iHEBUILDMGORIMPiiOVEMEMIS50LDWffHINO1�VEAROFWMPLE� � TION,7HE ONRiER�BU0.pEfl Wltt NAYE THE BURDEN OF PHOVINp THAT HE OR SHE DID NpT BUI�p OR IMPROVE FOR hIE PURPOSE OF SALE�. w ❑I,ASOWNEROFTMEPFlOPEHTY.AMEXCLU5IVELYf.ONTRACTINCWITHLICENSE�CANTRAGTOFS � TO CONS7RUCT THE PRQIECT(SEC.7044,BUSINESS AN4 PFOiESSIONS COpF.:iHE CONTRACTORS U� ValUflii011 ADJ.AREA W CENSELAWOOESNOTAPPLYTOANOWNEROFAPROPERTYWMOBUILDSOflIMPROVESTHEflEQl,AND � WFIOCONTMCTSfOR3UCHPRQIECTSW�THACONTqAC70R�5�LICENSEDPURSUM7TTOTHECOMRAG Q�J/�N11TY DESCRIPTION FEE � TORS LICENSE LAW.} Q ❑i MA E%EMPT UNDEF 5£C._ 8.8 P.C.FOR THIS REASON Q � � � � OA7E OWNER U O LICENSED GONTRACTORS DECIARATION �j � �NEREBY AFFIRM UN�EF GENALTY OF PERJURY TNAT I AM LIGENSEO VNOER PROVISIONS OF CHAPTER � L" �� � Y(COMMENCINO WITH SEGTION 7ofwj OF DIYISION 3 OFTHE BUSINESS AND PROFESSIONS CODE,ANO � MY LICENSE IS IN fULL FOFCE ANO FFECT. m � q t/� � �}^+^�� !" � UCENSE CUI �~� _ LIC.NO. S � V'�,,y� � j V DATE 1 �____.._.— CONTRAGTOR_y_ ��v L p- '— W ,,,CCC���...,,, -�� �� � . WORKERS'GOMPENSATION DECLAfl� Q � U � 1 HEPEBY AFFlqM UNDER PENALTY OF PERJURY ONE OF THE FOLLAWING DE RATtONS: C!1 Q � - INAVEANDWILLMAINTdINACERTIFICATEOFCONSFNTTOSELF-INSUREFOflWORKERS' 2 � CAMPENS/.TION.ASPFi�VIDE�BYSECT!ON3�ooOFTHELA80RCODE,FORTNEPEPFORMANCE �..� i Gf THE WORK FOp WHICH THIS PERMIT IS ISSUED, � � W _I HAVE AND WILL MAIMAIN WOflKERS'COMPENSATION INSUFANCE,AS FEOUIRED BV SECTION q � 370oO�TMELABORCO�E,FOR?HEPERWRMANCEafTHEWORKFORWHICHTHISPERMITIS ------ " ISSUED.MYWORKERS'COMPENSATIONINSUFANCECARPoERANDPCLCYNUMBERPRE: CONSTRUCTION � i cAaRiEn _ __ PLAN REVIEW � aouCYNU�eER___ �— ELECTRIC !�^ 0 , ��ssecttxaN�rroTeEcan�.ErfooF�r�wartsronorveruroaedoa.w�s(5+a>oA�Ess1 PLUMBING S�'I�!/ .�� /�� �(J�.. 710�``.' W �'CEFlTIFY TNAT INTF{E PERFORMANCE OFYHE WtlRK FOR WHICH THIS PEPMIT IS ISSl1E[l,I MECHANICAL Z (3 $/SHALLNOi EMPLOY ANY 7ERS�N IN ANY MANNER 50A5 TO BE0.'1ME SUBJECTTO THE � WORKERS'COMPENSATIONLAWSOFCALIFORNIA,ANDAGREETH0.TIFISNOULDBEWME INSPECTIONFEE ___ _ � SU&IECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 370o OP THE LABOR ~ � CO Errtt H� PoRT WITHCOMPLYWITH7HOSEPRO�VISJIONS ISSUANCE —_— p DATE:�� APPIICANT: ✓��`�v ��'� C� ��� SMIP - . . .. ..'. W ENERGY P/C �P R n�`._ J WARNING FAILURETO SECURE WOPKERS'COMPENSATION COVERAG[IS UNLAWFUL,AN�SHALL BE LL SUBJECTANEMPLOVERTOCRIMINALPENALTIESANOCIV�LFINESUPTOONEHUN�REOTMOUSAND ENERGYPERMIT DOI.LAflS(5700.OW1.�N ADDITION i0 THE COST Of COMPENSATION,DAMAGES AS PROVIDEO FOR IN � SECTION3']OBOFTHELABORCODE,MTEREST,ANDATTORNEY'SFEES. RETENTIONFEE: � CONSTRUCTION LENDWG AGENCY PRE-ALT FEE: _ . � I HEREBY AFFIRM UNDER PENALTV OF P&RJURV THATTHERE�S A CONSTRUC710N LENDMG AGENCV FOR THE PERFORMANCE OF THE WORK FOR WFi1GH THI3 PERMIT IS ISSUEO(SEC.306],CIV.C.). Z W � LEN�ER'S NAME _ _ - F_- LENOER'SADDR[SS �^ � ICER7IGYTHATIHAVEREADTHISAPPLICATIONANOSTATETHATTFIEABOVEINFORMATIONISCARRECT. TOTAL FEES 1 �!� �� W IAGREETOGOMPIYWITHAIICITVANDCOUNTYDR0INANCESANDSTATELAW5REL4TINGTOBUILDING ��� � CONSTRUCTION,ANDHEFEBYAUTHORIZERcPRESENTATNE50FTHI5CWNTVTOENTEFUPONlHE Z ABOVE-MENTIONEDPROPERTYFORINSPECTIONPURPOSES. COMMENTS � _ ('�Z��f° �t-1 (:% ��'✓ m P6RMITTEE NAME(PRINT) � Q , G '��`7 � �^��`r�����(� � ,. r/ L`i-^a..-. N SIGNATUR" MfTTEE � � DATE = RECPT.NO. PAID BY--Y����VALIDATION---� ~ WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—Applicant's Copy .. . .._,.:. ..,�.� ..di,�e,:.,..�.,. .. ,,::... ,. �, ,. �., . . -,,.;�. 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