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HomeMy WebLinkAbout16784 (40) CTTY OF DIAMOND BAIZ % C%°`� � --�"'��-- DEPARTMENT OF COMMUNI2"Y&DEVELOPMENT SERVICES r� � �� 21825 E.Copley Drzve � (909}�60-3195 Fa�r(909)861-3117 PRE$$ ''%4r»'��' BUII,IDING PERMIT APPLICATION FI LY a� JOBSITE �� `��� �`'�— � APPLICATION > � � PERMIT P/C ADDRESS „�y � /S/ZTz �� /_ DATE ' NUMBER ' # � ISSUE TYPE OCC APN LOT TRACT DATE CONST. GROUP o OWNER I ADDRES,^Z J�. LG- ZONING SETBACKS � CITY�/�/Y1�'t��� ZIP TEL. " � 0 FRONT RW ❑-� p APPLICANT TEL. SIDE/SIQE STREET RW ❑T QZ SIDE ❑� CONTRACTO p� ADDRES o C1T1C�P��Qp'_.�,,,�_ ZIP ` TEL. t 3 �OpOS�jE�D�US �ji. Ti w ARCHIENG/ iz DESIGNER � NO.�WEL. NO. NO. �fY a ADDRESS UNITS STORIES BEDROOMS �� � C1TY ZIP TEL. � �' DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANAL ATION p��� OWh1ER-BUILDER DECLARATION � SFWADD/REM O 1 HEREBY AFFIftM 11N�Eft PENAL7Y OF PERJURY THAT I AM EXEMPT FRDM THE CONTRACTORS LI- Gdl'dgOlCdf�JOR W �CENSELAWFORTHEFOLLON'ING;REASON(SEC.7037.56t15ME55AN�PflOFE5510N5CODE:ANYCITYOR (n . C.� COUNTYWHICHRE�UIRESAPERMITTOCONSTRl1CT,ALTER,IMPROVE,�EMOLISH,ORaEPAIRANVSTRUC- W pgt10/DBCk W�.�TURE,.PRIOR TO ITS ISSUANCE,qLSO REQUIRES THE APPLICANT FOR SUCH PERMIT i0 FILE A SIGNED W '�STATEMFNT THAT HE OR SHE IS LICENSED PUFSUANT TO THE PROVISIONS OF THE CONTRACTORS LI- . ����,CENSE LAW(CHAPTER 9(COMMEIJCING WITH SECTION 7oo0)OF DIVISION 30F THE BUSINE55 AND PRO- � Pool/Spa �FESSIONSCO�E)ORTHATHEORSHEISEXEMPTTHEREFROMANDTHEBASISFORTHEALIEGEDEXEMP- � � V ,TIpN.ANYVIOLATIONOFSECTION�.7031.56YANYAPPLICANTFORAPERMITSUBJECTSTHEAPPLICANTTO Z R8-HOOf ��',ACIVII.PENALTY OF t�TMORE T}iAN FIVE HUNDRED DOLLARS(5500).): ~ ' ❑I,ASOWNEqOFTHEPROPERiY.ORMVEMPLOYEESWITHYlAGESASTHEIF750LECOMPE�SATION, � ��'WILL DO THE WORK,ANO THE S7flUCNFE I$NOT INTENDED OF OFFEREO FOR SALE(SEC.7044,6USI� J C'OfI1R1EfCi01 -- �� �,NESS AN�PROFESSIONS CODE:T,HE CONTRACTORS LICENSE lAW�OES NOT APPLV TO AN OWNEF OF � ', ',PROPERTYWHOBUILDSORIMPROVESTHEREON;ANDWHO�OESSUCHWORKHIMSELFORHEFSELFOR ' � [_, ''�'�.7HROUGHHISORHEROWNEMPLOYEES,PROVIDEDTHATSUCHIMPPOVEMENTSARENOTINTEN�EDOR 'm �Q",�;�OFFERE�FORSALE.IF,HOWEVER,TNEBUILDINGOqIMPflOVEMENTI550L�WiiHINONEVEAROFCOMGLE- Z'�,;'�,'�.TION,THE OWNER-BUILbER WILL HAVE THE BUROEN OF PROVING THAT HE OR SHE 01�NOT BUILD OR �,;.,IMPROVEFORTHEPURPOSEOF$ALE). W": ❑I,ASONMEROFTHEPFOP,ER71',AMEXCLUSNELVCONTRACTINGWITHLICENSEOCONTflACTORS [[" ,TO CANSTRUCi THE PROJECT(SEC.7044,BUSINESS ANO PFiOFE551INJ5 CODE:THE CONTFFC70R5 LI� VflII18IlOf1 ADJ.AREA � W '�CENSELAWDOESNDTAPPLYTOANOWNEROFAPROPERTYWHOBUILDSORIMPROVESTHEREDN,ANO � �' ��.,WHOCONTPACTSFORSUCHPROJECTSWITHACONTRACTOR(5)LICENSEDPIJRSUANTTOTHECONTRAC- QUANTITY DESCRIPTION FEE Y �'TORSLICENSELAW.). CL Q O.. ❑I AM IXEMPT UN�ER SEC.�'� 0.&P.C.FOH THIS REASON �. � � � DATE OWNER _�_ ` U W � LICENSED COYTRACTORS DECLARATION �j � C � IHEREBVAFFIRMUN�ERPENALTI'OFPERJUFVTHATIAMLICENSEDl1N0EftPROVI510N50FCHAPTER � . , � 9(COMMENCINGWI7HSECTION70ao)OFDIVISION30FTHEBUSINESSANDPROFESSIONSCODE,AND Z LX MV UCENSE IS IN FULL FOqCEAND EFFECT. m � LICENSE CLASS LIC.NO. � j � � J V DATE CONTFAC70R �- W. � WORKERS'COMPENSATION DECLARATION � ¢ � IHEflEOYAFFlRMUNDEflPENALTYOFPERJURVONEOFTHEFOLLOWINGOECLARATIONS�, U C/� a � IHAVEANDWILLMAINTAINACERTIFICATEOFCONSENTTOSELF-INSUREFORYYORKERS' _ Z COMPENSATION,AS PROVIDE�BV SEC710N 3�0o OF iHE LABOR CO�E,FOfl iHE PERFORMANCE U a OFTHEWORKFORWHICHTHISPEftMITI515SUE0. � � W `I HAVEAND WILLMAINTAIN WORKERS'COMPENSATION INSUflANCE,AS REOUIRED BYSECTION S� /� Q3]o00FTHELA80RCODE;FORTHEPERFORMANCEOFTHEWORKf-0RV✓HICHTHISPERMRIS I�I �II � �. ISSUED.MYW�RKEA�"COMPENSATIONWSURAN CqRRIEFiANDPOLICYNUM9ERARE: CONSTRUCTION I& �� � CAflRIER C �_ PLAN REVIEW __ �' POLICY NUMBER ' ��--'I��" d � ELECTRIC _.. d (IHISSECiIONN�NOTBECOMPLEfEDOFTNEPERMlTISFOAONEHUI�REDOOLLARS(57W)ORLE55} PLUMBING W Z ICERTIFYTHATINTHEPERFOflMANCEOFTHEWOflKFOfl'NFiICHTHiSPERMITI515SUED,1 MECHANICAL (J SHALLNOTEMPLOYANYPERSONINANYMANNERSOASTOBECOMESUBJECiiOTHE � (n WOFKERS'fAMPENSATIONLAWSOFCALiFOflNIA,ANOApREETHATIFISHWLDBECOME INSPECTIONFEE � � SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF S'cCTION 3]oa OFTHE LABOR ` „ � CO�E,ISHALLFORTHWITHCOMPLYWITHTHOSEPROVISIONS. ISSUANCE ` p��-�✓' � SMIP « P �y DATE: APPLICANT: ,.Wj � ENERGY P/C J WARNING,FAILUflETOSECUREWORKERS'COMPENSATIONCOVERAGEISVNLAWFUL,AN�SHALLBE � SUBJECTANEMPLDVERTOCiiIMINALPENALTIESAN�CIVILFMESUP700NEHUNDflE�7HOU5AN� ENERGYPERMIT � '� DOLLAR3�51oo.oao�.INADDITIONTOTHECOSTOFCOMPENSATION,DAMAGESASPROVIDEDFORIN -- � SECTION3]080FTHELABORCODE,INTEREST,AN�ATTORNEY'SFEES RETENTIONFEE: i � CONSTRUCTION LENDING AGENCY PRE�-ALT FEE: O � IHEREBYAFFIRMUNOERPENALiY�FPERJURVTHATTHEREISACONSiRUCTIONLEN0INGAGE�CY II FOfl THE PEflFORMANCC OF 7H€WORK FOR W HICH THIS PERMIT IS ISSU=D iSEC.30W,CIV.C.). W S IENDER'S NAME � F'�". LENDER'SAD�RESS � ��K �� �' ICERTIFYTHATIHAVEREPUiHISAPPLiCATIONANDSiATETHATTHEABOVEINFORMATHJNISCORRECT. TOTAL FEES w IAGREETOCOMPLYWITHALLGITYANOCOUNTVORDINANCESANDSTATEL4WSRELATINGTOBUILOING �� '•CONSTRUCTION,ANDHEREBYAU7Fj��aIZEREPPESEMATiVESOF7HISCOUNTYTOENTERUPONiHE ��' ABOVE-MENTIONED PRO RTY F INSPECTION PURPOSES. 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