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HomeMy WebLinkAbout15845 (22) !"�._' �_�.,,` CTTY OF DIAMOND BAB DEPARTMENT OF COMMIINITY&DEVBLOPMENT SERVICE �, :� aic�o E.coP�eynr;�e s�i�i90 PRESS (909)860-3195 Fax(909)8613117 ��.,.� BDILDING PERMI�f4PPLIC TIUN �/��j'(/� ,� �,zd� � FIRMLY � JOBSITE APPLICATIO �^' ¢°�� PERMIT / o ADDRESS �� � � � DATE '" �+� �' NUMBER � li�� � $ ISSUE TYPE OCG APN LOT. TRA , ��-��� DATE CONST. GROUP p OWNER "y ' ��'� `�'3 �� ZONING SEfBACKS `` ADDRESS ' � �� � � - z CITY..���➢�F.i'4s 21PJ2��[� TEL��� 1�`����d"��" EART RW ❑ g APPLICANT TEL. SIDEISIQE STREET RW ❑ � CONTRAGTOR /// M� SIDE Ll p� ADDRESS D ' PROPOSED USE � � CITY�R.l�//�/�= ZIP���/Z 7EL.�,..��. 797-� 0 , � AR,CHlENG1 A.�, - A ' � DESICiNER I�IA�/L-(T/�S S�' /�75�?C- NO.DWEL. NO. NO. ADDRESS /S`5'"/ ���YS�'Y�/ � UNITS STORIES BEDROOMS � CITY 5i�'I.�i�9" �"AO.�- ZIP9�7oS TEL.�/�,{SSO 97 � DESCRIPTION SQ. . FACT R PSF ADJ.AREA/1lA ATION Q OWNER-BWLDER DECLARA710N SFRlADD/REM �F� �, � O �'q d� I HEflEBY AFFlqM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI- � Garaga/Carport I '� {.f � ,� � W, C@1SELAWFORTHEFOLLOWINGREASON(SEC.7031.66USINE55AN�PflOFES510NSCODE:ANYqTYOR U �COUNTYWHICHREOURE&APEFIMITTOWNSTRUCT,pLTER,IMPFlOVE,DENOLISH,ORREPNRANVSTRUC- IW pdtlWt)BCk / . � . � ', z 7URE,PRIOR TO 1T5 ISSUANCE,ALSO REW IRES THE APPLICAN7 FOq SUCH PERMIT i0 FILE A SIGNED 5�" SiATEMENT THAT HE Op SHE�IS LICENSEO PURSUANf TO THE PROVISIONS OF THE CONTRACTOFS LI- C CENSE LAW(CHAPTER e(COMMENCING WITH SECTON 7000)OF�IVISION 3 OF THE BUSINESS AND Pfl0- � POOUSpd YfE3510N3CODE)ORTHATHEORSHEISEXEMPTiHEREFROMM'OTHEBASISFOfliHEALLEGE�EXEMP- V TION.ANYVIOLATIONOFSECTION7os7.5BYANYAPPI�CANiFORAPERMITSU&IECT$THEAPPLICANTTO Z RB-ROOf � � RCIVILPENAL7YOFNOTMOflETHANFIVEHUNDqED�q.LAflS(i5ao).): � . . �. ❑I,ASOW.NEROFTHEPRORERTY.ORMYEMPLOYEESWITHWAOESASTHEIRSOLECAMPENSATION, Cot11m6fCi81 � � �WILL00 THE WOpK,MA iHE SYRUC7URE iS M1qT INTEFAEU OR OFFEREp FOR SALE(SEC.70K,.BU31- O NE55 M1D PqOFE5510N5 CODE:TXE CONTRACTORS LICENSE LAW DOES NOT APPIV TO AN OWNER OF � ��PROPERTVWHOBUIL0.SORIMPROVE$h1EREON,MI�WHODOE55UCHWORKHIMSELFORHERSELFOR � � ' ����iHqIXIOHHI50RHEflONrtJEMPLOVEES,PROVIDEOTHATSLICHIMPROVEMEMSARENOTW7ENDEDOFi � ' Q, �,.OFFEREU�ORS/LEIF,HOWEVER7NEBUIL�INGORIMPRpVEMENTI550LDW�THINONEVEAROFCOMPLE ' � �'TIOM.THE OWNEX-BNtDER WILL HAYE THE BURDEN OF PqOVING 7HAT HE OR SHE OID NOT BWLD Op / , � ;IMPROVEFORiHEPUflPO5EOF5ALE�. �� ✓ ' ❑1,AS ONMEROF THE PROPEFRY,AM EXCLUSIVELY CANTFACTiNG WITH LICENSED CONTRACTOR5 � ,.TO CONSTHUCT THE PROJECT'(SEC.�04I,6USINE55 AND VROFESSICNS CODE:THE CONTRACTOWS Lt- V81118t10f1 ADJ.AflEA � � LL7' ��CENSEUWDOESNOTAPPLVTOANOWNEROFAPFOPERTYWH06UILOSORIMPpOVESTHEREON,AND . , � WFqCONTMCTSFORSUCHPROJECTSWITHACONTiEACiOR(5)LICENS�PUfiSUANiTOTHECONTRAG QUANTITY DE CRIPTION �FEE -'� � �TOHS LICENSE L1W.). ,,�I ❑1 AM EXEM?T UNDER SEC. B.8 P.C.FOR TNIS REASON Q O tL � .UATE OWNEF �U . � . z W �d IICENSED CONTfiACTORS QECLARATION �j � � . [C I HEREBY AFFIflM t1NDER PENAITY OF PEflJl1RY THAT 1 AM LICENSED UN�ER PROVISbNS OF CHAPTER � - , , , � py B�COMMENdN(3WITMSEGTION700o�OFDIVI510NJOFTHE9U51NE53ANDPROFES510NSCODE.AND MY LICENSE IS IIJ Gl1LL FOFCE AND EFFECT. ? �"I� (� m u 0�. LICENSE CLASS // LIC.NO. -�/��� �. �`� � V�� � � �V. ��A�TEp �`�O"O/ CONTRACTOR a . 'y to���._. � �� F�'I � WORKER3'COMPENSATION DECLARATION � a �� ����� {i ' � U y IHER�gVAFFIpMUNDERPENALTYOFPERIURYONEOFTHEWLLOYlINOOECtAFAT10NS: - - ' '- �` (n / Z k .. , Q �/�y�-�jy--iHAYEM'DWLLLMAINTAINACERTIFICATEOFCONSENTTOSELF-INSLIREFORWORKERS' _ � "" -` 4� . � � - (/ COMPENSATION,ASPROVIOEDBYSECTION37�DOFTHELPBOFCO�E,FOFTHEPERFORMANCE U ¢ OFP.-IE WOpK FOR WHICH YHIS PERMIT IS ISSUE�. � . W �, 1 HAVEANO WILLMAIMAIN WPRKEflS'COMPENSATION INSIIRANCE;AS RE�UIRE�BYSECTION p �'y Q , 37000FTHELABORCODE,WRTHEPERWRMANCEOFTHEWORKFOqWHICHTNISPERMiT15 1 �^"i `ry ISSUED.MY WOvq LyE�A�S'C�OMPBJSATION INSURPNC CARRIER AND POLICY NUMBEftAqE: CONSTRUCTION i � i .a � CARRIER !i!"��C ��O tr Fi/L_�'-�r✓.�. _��• P�a,r�aEviEw Z POLICYNUMBEF��d IeC � '��/J .P� ELSCTRIC _ d Q (RI6SECTKNNE�NDi3E0�MPLETEDOFT}{�PERMRISFORONEHUM1DREDOOLIi1A4�Ef00)ORLES4� PLUMBING � � � ICERTIFYTHATIPlTHEPEfiFORMANCEOFTHEWORKFORWFIICHTHISPEFMITISISSLlE�,1 MECHANICAL u_.�_ . �J SHAf.L NOT EMPLOY ANY PERSON IN ANY MANNEI7 SO AS TO BECOF�SUBJECT To THE . ' Vy WORKERS'COMPENSATIONAWSOFCALIFORNIANJOAGREETHATIFISHWLOBECOME (NSPECTIDNFEE '. � SVBJECTTOTHEWORHERS'COMPENSATIOUPROVISIONSOFSECTION37D09FTHELABOR �SSUANCE COOE,i SHALL FOqTHWITH COMP6Y WITH THOSE PHOVISION. � Q DATE:L� �'D�APPLICANT.����'I�D��"i4j� �SMIP � � ', J � WARNING FAILURETO SECUF�WORKERS'COMPENSATIDN COVERAGE IS UNLAWFUL,AND SHALL BE ENERGY P/C � ° LL � Sll&IECTANEMPLOYERTOCRIMNALPENAL7IESANOCINLFINESUPTOONEHUNDRE�THOUSAND ENERGYPERMIT .� .OOLLAflS(57 oD.000).IN ADDITION TO THE COST O�COMPENSATION,DAMAGES AS PpOVIDEO FOR IN � �y � . ¢ �;9ECTIONeIoeOfhIELA80RCODE,INTEREST,ANDATTORNENSFEES. RETENTIONFEE: b+r.A.7n� O - CONSTRUCTION LENDING AGENCY PRE-AL, E•� - ' � �IHEREBYAFFIRMUNDERPENAUI'OFPERJURYTHATTHEREISACONSTRUCTIONLENDWGAGENCY FOR THE PERFORMANCE OFTHE WORN FOR HICH 7HIS PERMIT IS ISSUED(SEC.3�,CIY.C.). . W ,Va,�r �PUI r�— l/n,�,� a,�/�, �'�, � LENDER'S NAME � ' . H lENDER'SpDDRESS /'�y �' � ICERTIFVTliATIHAVEREADTHISAPPLICA7IONANOSTAiETHATiHEABOYEINfOF0.1ATIONISGOflREGT. TOTAL FEES "-" �t� ' �,�.,� � � � IAGREETOCqMPLVWITH0.LLCIT'ANDCDIINTYOR0INANCE5APID5TATElAWSRELATNGTOBUILDING . . . . .�. . � . . � CONSTRUCiION,ANOHEREBYAUTHORIZEPEPRESENTATIVE50FTHI5COlJNTYTOENiERUPONTHE � � , . , . Z ABOV6MEMN]NEO PPOPER7V FOR INSPEGTION PURPOSES. COMMENTS � � �� /V�s � PEHMI7TEENAF� RIM) � � v, � 2--��v. , � SIQ TURE OF PER EE DATE � - ; _ � RECPT.NO. PAID BY � VALIDATION � �` WHITE—�epartmeM Copy,YEILOW--Finance Copy,PINK—Assessor Copy,GOLDENROD—Fife Copy,GFEEN--ApplicanPs Copy � �"��""�' ��" ���� ������ ��� � �,���� �� ���.,�� ���� �������� ��,�����.�� � �"�'�`�.�i��" "� ,���.�. -�fi�&�'���:� � : .� " '"�, , �: . ..�" "��'"�.�:��.�''���:MI'�".�"�s;'�"`'���3� ;.��., � ` � z�4v �.������L3�� �''C Y�T. . ��'���j �. 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