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HomeMy WebLinkAbout12800 ,.----�_ �_ CITY OF DIAMOND SAR DEPARTMENT OF CQMMUrTITY&DEVELOPMENT SERVICES 21660 E.Copley Drive Suite]90 �'' (909)860-3195 Fax(909)861-311T PRES� `'*�"� BUILAING PERMiT APPLICATIOl�i FIRMI,Y� Q ADOR'ESS I S 3,� ��BUQ� APPLICATlON `L—I'�� �E�� */C DATE_ � � ISSUE TYPE OCC -- APN LOT TRACT DATE CONST. GROUP � OWNER " ADDRESS 1�,�j� IPJ1�Q(lL�,M 20NlNG SETBACKS Z CITY �1,�}A���LQ� ZIP TEL. REART � ❑ � APPLICANT_ �l. }� TEL. SIDE/SIDE STREET RW C7 � CONTRACTOR i SI�E U � ADORES 'V � PROPOSED USE '" 0 CfTY cv ZIP T . w ARCHlENG/ z DE5IGNER NQ.DWEL NO. � � ADDRESS UNITS STOHIES �r 5�� BEOR � � CITY ZIP TEL. � DESCRIPTION SQ.PT- FACTOR PSF ADJ.AREANALUATION � � OWh7ER-61nLDEA DECLARATION SFR/AWIAEAA O p I NEREBY AFFIRM IMIDER 7ENAlT'OF PEMIRY TH�T 1 AM E%EMPT FHOM 7HE COfiTMCTORS LI• GafBQB/Cerpp/t lyi CENSEIAWFORTHEFOILOWIH�REA50N(SEC.7981.58USWE55AN�CROFESSIONSCODE:ANYCITYOq (n U ODUNTYWMICHREWIRESAPEflMf{TppONS7HUCT.ALiER6.�PP�VE�DEMOUSH.ORREPAiRANYS7flUG � Paz�a��k � TUfiE,PNGH TO ITS V59UMICE.K50 iIEWIHE3 TNE APPLICANT FOR SUCH PERMIT TO iILE A SIGNED W STATEYENT 7TUT HE OR SHE IS IICENSED PIJRSUANT TO TNE PNOVISIONS OF THE COHfHACT�RS LI- � CEnL4E LAW�ql�G'f£R i(COMMENLIN�W1lN SECTIDN?000)OF DIVISIDN 3 OF THE BUSINESS AND PPP LL PooUSpe FE5.410N3 WOE)OR 71UT NE OR SME IS EXEMPT TMEREFROM AMO iHE BASIS FOflTHE PL{.E6ED EXEMP• TION.�NYVK]UTXfNOFSECTMM�v31.5BYAHYAPPLIC�W7f-0RAPEPMRSUBJECTSTHEMPLICMlTTO .ROp} O F A GMiI PEN.LL7Y OF NOT AIORE 717AM FNE HUNDREO UOLLARS(f500).)'. ^ ❑4�dMNEROFTHEPqOPERTY,ORMYEIIPLOYEESMnTNWAGESASMEIRSOLECOMPENSATON, C� (`,p(nmgfC101 - � WRA�O iME YIONK AN�THE STRUCNPE IS NOT�NTFN�EO OP OfFERED fDF SALE(SEC.]OH,BU54 �ffSS Ati)PROF65510N5 CO�E:THE CONTq�CTORS LICENSE Uw DOES NOi APPLY To AN OWNER OF i � PF7PEN7'YNAID6U0.ASOqp1PROVESTNERE�I.�OMM000E55UCNNORKHIMSELGORHERSELFOR Q TNHOWN MS OR 1�R ONM EYROYEES,VRO�ED TNAT SUCH MPROVEMEMS ARE NOT iNTENDED Dq � OFF6NEDFORSKEIF,HOWEVEFilHE6UftDiNGORIMVfpVEMEMi550lDYNTHINONEYEIIHOFCq/VLE• Z TpN,TF�pWNEFiWILDEq WILL MAV67XE BURDEN Of�qOVING THl1T HE OR SHE OID NOT PUIID OR � NIPFIONEWRTHEPURPOSEOFSALE). O 1.A6 ONMER Oi THE PH'JPERf`/,AN EXCUISNELYCOMMCTNO wRH LICENSEo CONTRACTORS Q TO COM6TRUCT 7ME PRWECT(SEC.70M BVSINE53 AND PAOiESS10NS CODE:THE CONiRACTOiiS LI- VflWafldl AOJ.AREA W CENSEUWDOESNOTAPPLYTOANONMEROFAPROPER7YWHOBUWp50P�PROVESTHEREON,AND � N1qCONfRACTSFOR5Up1PPOJECTSWITHACONTMCTOR(S�tJCENSEUPURSUNJTTO7HECONTMC- p�ANTITY DESCFtPTION FEE � roas ucs+se uw.�. ❑I AM IXFMPT I1N�Eq SEC. 8.4 P.C.FOR THIS REASON v Q � DATE OWNER V � J LICENSEO CONTRACTOR$DECLARATION W � IHEREBYAFFIfWIMDERVENALTYOFPERAlfttSHATfAMLiCEN5E0UNDERPRDVI510NSOFCMMTER � (y Y(CUIY/6NCWflWITHSEGTION7aW�OF01V15�N30FTHE&1SMESSANOGPOFESSIONSWOE,If10 Z X 1AY LIGENSE IS W Rlll FORCE AND EFFECL P m � LICENSE CU�f S � LIC.NO, §T �� � � V DATE I - � � __CONTRACTOR �� � RKERS'COMPENSATIQN DECLARATION ��y.�,,- U � 1 HEREBY UtiDER PENKP7 OF PENURY ONE OF THE FOLLOWING DECL�RATIONS: � Z Q IFUVEANDW�LLiAAMTAMACEFfIFIGTEOFCONSENTiO6�F-INSUREFORWOflKEflS' _ Z CqiPENSATION,ASPPOVIDED8Y5ECT10N31000GTHEUAOftC(XIE.FORTTSEPERFORMANCE U � OFTHE WDqK FOfl WHICH 7HI5 PERMIT IS ISSUED. W � � W _IHAVEANDYVILLMAINiANWORKERS'COAIPENSATIONINSURANCE,ASREIX/IREDBYSECTION /� � 3?a00FTMELM90RCODEFOR7MEPERFORMANCEOF7HEWORKFORWHICHTHI3PERM1T15 �j/ 0 ISSUEp.MY WORKERS'COMPENSATION INSURANCE CARRIEN AN�POUCV NUMBER ARE: 6� CANSTRUCTION _, � ���.1� j c�RRIEa��T� �L)A�L� •�T�1 PLANREVIEW � paicv r�uMeeA p�7��� ELECTRlC � Q (�}�g[�pNt�Hp7gE0�LE�EpOFTL�pEqMTIgFOppMEMR�Ai�m.vqs151m�oqlEss} PLUM9ING � ICERTIF�Tw1T W T}iE PERFORMNVCE OFTHE NK1RK FOR WHICH THIS PERMIT IS iSSUEp,l MECHANICAL . (��' SHµ1NOTEMVLOYANYPEFSONININYMMlNERSOAST08ECOME�1&IECTT�THE N YpAK£RS'WMPENS�TiONUWSOFLALIFORNt0.11NDAGREE7MATIFISHWIUBECOAIE INSPEGTIONFEE S St�JECTTOTHEwORKERS'COMPENSATIONVRONS SEGTION3laaOFTHElP80R ISSUANCE __�r���,JI�_,�_. 1 WOE,I SH,Ul FOi1THWITHCOMVLY WIh1 TFbSE P - � „I�� � SMIP 0 OATE: APPLICANT: � . . J ENEHGY P(C Ci`�nF n�QTjT)BAR WAf WIN(1:FAIIURE TO SECURE NR7RKER5'COMPENSATpN COVERAGE IS UNUWFVI.Ml�SHM,l9E � Sl10JECTNISMPLOVEqTOCH�NALPENALTIESlWDGIVILflNESUPTOONENUNDqEDTHOUSANO ENERGYPERMITB�nrt�r�NL7 CAFETX OOl1ARS(5��.�I.��DIlIGN TO THE CAST Of COMPENSAiION,OMIAGES AS PROYIOED Wfl IN ¢ SECTqN 370!OF iHE UBOR CODE.M7EREST,ANO ATTOFNEY'S FEES. RETENT�ON FEE: a GONSTHUCTION LENDING AGENCY PqE•ALS FEE: � 1 HEREBYAFFIRM UNOER PENALTV OF PE(iJUPY TMATTHENE IS A CONSiRUCT10N LENOING AQENCY FpRTHE PERiORMANCE OFTNE WORI(FOR WHiLH TMIS PERMIT IS ISSUED(SEC.9087.CIY.C.�. Z W � LENDEFYS NAME F- LENDEii'SAWNESS �-/y [�� J ' � 10EltTiFYTH11T111AYEREpDTNISAPPLIGATIONANU3TATE7}u7TNEABOVEMPoHMATpNISCORPECT. TOTAL FEES / ( 7v � IAGREETO�PIYWITHALLC�7Y�NDCOl1NTYOH0INANCESANOSTATELAWSRELATMIQTOBUILDING � CONSSRUCTION.ANC1 MEREBY RUlHORiZE RFPRESENTATIVES OF THIS CIXINTY TO EMER UPON THE `�+. //��� (/` � ABOVE-HEMIONEO VROPEHTM F�H INSPECTION PURVOSES. 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