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HomeMy WebLinkAbout17190 (10) r CITY oF DYAM�ND BtalR. -� --��`"--� vBPI�RTMENT OF CONIlvIUNI'TY&DEVELOPMENT SERVICES � �� 21825 E.Copley Drive (909)860-3195 Fax(409)861-3117 PRESS '`'%1wy�` BUILDIt�1G PERMI'�APPLICATYON FI R M LY � JOBSITE APPLICATION � °�,�5'"`y PERMIT �� �y P/C 0 ADDRESS� ` C� �s� DATE e.� rr' NUMBER �+� # °r° APN_ LOT _ TRACT DA EE CONST. GROUP p OWNER—��v�n�RRCY.� l�E+ic.3 -I I-�c�� p ADDRESS�' L�S L�- ���`-l-tii� �f tr1� zONING SETBACKS � CITY C.00.CGl+bt.9w��" ZIP�1 i TEL.I`713q�'-.3p�� FRONT RW ❑ � APPLIGANT TEL. REAR ❑ p SIDE/SIDE STREE7 RW ❑ aCONTRACTOR .�3a �.� fL i�� C� SIDE ❑ ADDR SS � � ' Y� . �C.� ��M': a CITY �t9b'r�°�+W� Z1P'���G�- T .�•��1�f�'`-' ' PROPOSED USE�T�'O�i/�. C.S�'F �YZ"iT'r,r+)f� �S�A�d'`' � ARCH/ENG/ w ��2 '��9-S c'A 1� CF3iM R ��t 3.x.)f���P z DESIGNER NO.DWEL. NO. n NO. ow.. ADDRESS L)NITS STORIES �E.. BEDROOMS � CITY ZIP TEL._ �` DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER DECLARATION SFR/ADD/REM O Q I HERE9Y AFFlRM UNDEfi PENALN OF PERJUflV THAT I AM EXEMP'FROM THE CONTRAC70RS LI- � Garage/Carport 'W CENSELAWFORTHEFOLLOWMGR�SON(SEC.7031_5BUSINESSAN�PROFESSIONSCODE:ANYqTYOR V CDUNTYWHICHREOUIFE3APEflMITTOGONSTRUCT,ALTER,IMPROVE,DEMOLISH,ORREPAIRANYSTRUC- W patio/Deck W TUqE,PRIOR TO ITS ISSUANCE,ALSO REQUIflES TNE AFPLICANT FOR SUCH PEFMIT TD FILE A SIGNED � STATEMENT THAT HE OR SHE IS LICENSE�PURSUANT TO 1HE PflOVI510N5 OF THE CONTRACTORS LI- '�,,� CENSE LAW�CHAPTER 9(COMNENCING�WITH SECiION 7000�OF DIVISION 3 OF THE BUSINESS AND PRO- V" POOVSpB FESSIONSCODE)OR7F44THEOFSHEISEX�MPiTHEREFROMANDTHEBASISFORTHEALIcGEDEXEMP- (,� � TION.ANYVIOLATIONOFSECTION��7031,SBYANYAPPLICANiFOFAPERMITSUBJECTSTHEAPPLICANiTO z Re-Roof � A CIVIL PENALTY OF NOT MORE Th{AN FIVE HUNDFE�DOLLARS($So0).�: '�'„ ❑I,ASOWNEROF7HEPROPERTY,bRMYEMPLOYEESWIiHWAGESASTNEIRSOLECOMPENSATION, O COR1RIBfCIdI -� WILL DO THE WORK,ANO TkiE STRUCTURE IS NOT INTEN�EO Ofl OFFERE�FO%SALE(SEC.7044,BU51- J NESSAND PflOFE5310NS CADE:THE CON?PACTORS LICENSE LAW�OES NOiAPPLY70 AN OWNEA OF � ��PROPERTVWHOBUILDS00.',IMPROVES.YHEPE-0N,ANOWHO�OESSUCHWORKHIMSELFORHERSELGOR � �'. .THROUGHHISOFHEROWNEMPL,OY�ES.PPOVIDEDTHAiSUCHIMPFOVEMENTSARENOTWTENDE�OR m - '"-W' ,OFFEREOFORS/LLE.IF,HOWEVER,RHEEUILOMGORIMPROVEMENTISSOLDWI7HINONEYEAROFCOM7LE- ��,�", �'��.�.TION,THE OWNER-BUILDER Wlll HpVE 7HE BURDEM OF PROVING THAT HE OR SHE DID NOT BUIL�OR ;�, '���IMPROVEFBRTHEPURPOSEOFSALE). � ❑I,AS OWNEROFTHE PROPERTY,PM EXCWSIVELV CONTFACTING WITH LIGENSED CONTFACTORS '�,�� '��TO CANSTRUCT THE PROJECT(SEC.7oba,BUSINE55 AND PROFESSIONS CODE:THE CONiRACTOR5 LI- VHIl18tI0f1 ADJ.AREA '.W .'CENSELAW�OESNOiAPPLVTOANOWNER�OFAPROPER7YWHDBUILD50RIMPROYESTHEREON,AND ;� �WHOCANTRACTSFORSUCHPFWECTSWITHACpNTRACTOR�S)LICENSEDPURSUANTTOTHECQNTRAC- QUANTITY DESCRIPTION FEE Y TORSLICENSELAW.j. � �,� � ❑I AM E%EMPT UNOER SEC., B.S P.C.FUflhiIS REASON Q - � U tL � � DATE OWNER 'U � W �.� � LICENSED CONTRACTOAS DECLARATION W Q �,� I HEREBY AFFIRM UNDER PENALTY OF PERJURV THAT I AM 410ENSED 11NDER PROVISIONS OF CHAA7Ea .� d 9(COMMENCINGWITHSECTION700o)OFDIVISION30F7HEBUSINESSANDPflOFE5510NSCODE.AND Z IX ' MY LICENSE IS W FULL FOflCEAND EFFECi. fp'�T µd/�! /� m �o LICENSE CLASS C�3� Yi,�'�`c LIC.NO. + ,`p��`�' �''��j �� � �� �AT� � GONTRACTOR R O�1 /C'�+"65P+" �� a '^� �. �WORKERS OMPENSATION DECLARATION a �' I HEFIEBY AFFIRM UNDEA PENALN OF PERJURY ONE OFTHE FOLLOWING DECLARATIONS: U f� a � IHAVEAN�WILIMAINTAINACEFTIFICATEOFCONSENTTOSELF-INSUREFORWORKERS' _ Q CAMPENSATION,AS'PROVIOED'BYSECTION37ooOFTHELABORCO�E,FORTHEPERFOFMANCE U �d'HE WORK FOp WHICH THI$�ERMIT IS ISSUE�. W ^ c� ��'i..... W /I HAVE AND WILLMAINTAIN WORKERS'COMPENSATIDN MSUMNCE,AS RE�UIRED BV SECTION �� n 370oOFTHELABORCODE,FORTHE.PEPFDRMANCEOFiHEWORKFOftWHICHTHISPERMiT15 / ' ISSVED.MYWeORKERS'COMPENSATIONINSURAnIJG,EGARRIERANDPOLICYNUM6ERARE: CONSTRUCTION �' �I ,y ���" � CARFIER 47�1J1P '�� �-d� Mg '}�+�'�°la� PLANREVIEW � POUCY NUMBER L.�C�S•-� IL��r{�" f�'� ELECTRIC �-"'�� � tt .. :`".,`, . �' (fHISSECTONNEEDNOYBEOJMPLEfEDOFTFEPEMifTISWRONEHIPARE000LL4R5�S1W)ORLESS). PLUMBING €� " �� ICEfiTIFYTHAYINTHEPEbFORMANCEOFTHEWORKPoFWHICHTHISPERMITISISSUED.I MECHANICAL �' « _ � SHALLNOTEMPLOYANYPER50?11NANYlAANNERSOASTOBECOMESl18JECT70THE �E ��� � L � WOrIKERS'COMPENSATbNLAW50FCALIFORNIA,ANOAGREETHATIFISHOULDBECOME INSPECTIONFEE J ' SII6JECi TO THE NlORKERS'COMPENSATION PROVISIONS OF SECTION 37oa OF THE LABOR � ^ C"�.f'�y� ~ CODE.ISHALLFORTryWITHCOMPLYWITHTHOSFPROVISIONS. ISSUANCE � / \ � q�';� , � DATE: . APPLIGpNT:_ __ SMIP �`"°"' +�� W � � .�.___" -��_�._._ �' WARNING FAILURETO SECUflE WORKEAS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL 6E ENERGY P!C �.-- -----� �y, SUBJECTANEMPLOYERTOCRIMINALPENALTIESPNDCIVILFINESUPTOONEHUN�REDTHOUSAND ENERGYPERMIT DOLLARS(510o.oa0).IN ADDI710N Tp THE COSTOF COMPENSATION,DAMAGES AS PROVIDE�FOR W a� SECTION37090FTHELABOFCOUE,INTEREST,ANOATTORNEY'SFEES. RETENTIONFEE: pw_.:. CONSTRUCTION LENDING AGENCY PRE-ALT FEE: O � IHEREBYAFF�RMUNDERPENALTY�iOFPERJURYTHATiHEPE1SACONSTflUCTIONLENDINGAG[NCV n- FOR iHE PEflFORMANCE OFTHE WDRK FOR WHICHTHIS PERMITIS ISSUEO(SEC.3097,CIV.C.). 2 W. ' ��� LENDER'S NAME � F-'. LENDEP'SAopREss �ry /(! �� ICERTIFYTHATIHAVEREADTHiSAPPLICATIONAN�STATEiHATTHEA90VEINFORMATIONISCOFRECT. TOTAL FEES � / �,�y �". I AGREETO COMPLV W1TH ALLGTYAND COUNTV ORDINANGES ANO STATE LAWS RELATING TO B'JILDING E O� �';�,�. 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