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HomeMy WebLinkAbout14598 �`,�,. ^ _1� CITY OF DIAMOND BAB � DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES 21660 S.Copley Drive Suite 190 � � (909)860-3195 Fax(909)861-3117 PRESS �•s�°'� ' BIJILDING PERMIT APPLICATION ___ FIRMLY � _ . _ _: _ QJOBSITE n APPLICATION ` PERMIT � P/C Q ADDRESS L�I�C�C7 �Qp e�''�. `_G�'�,�L�- DATE L! �I �� NUMBER � # ���� c� ISSUE��-TYPE OCC � APN LOT TRACT DATE CANST. I ��J GROUP �_ p OWNER YY�� � ADDRESS '`iJ L, L!J e V�G-� ZONWG SETBACKS � .�t`7 � FRONT _ RW ❑ CITY UYI� S ZIP TELq a REAR ❑ P A TELGJ d`Z�t)' �f SIDE/SIQE STREET RW ❑ 4 SIDE ❑ CONTRACT R ' �G G,Z�. � CITY �O u N'TaMA`� �PF.�W�q TEL�Z!�/ Z L� PROPOSED USE �rlr��� ��'"'�`�it'} 'J�lC�Y` � L + '—.—_— Y�- �, ARCHlENG! V ' �f yL7 0$ '�l.t 7 p _ 5.... .: ..,,�, _z DESiGNER NO.DWEL. `^• NO. NO. � ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. c�ii "DESCRIPTION SQ.FT. FACTOR'PSF ADJ.AREANALUATION s QWNER-BUILDER DECL4RATION SFR/AD�/flEM O ,'p I HEREBV AFF7RM UNDEq PENALTV OF PERJl1FiV THAT I AM E%EMPT FROM THE CONTRACTORS LI� ' �ara9B/CdI�Ort . . , , � �. .� " �.�W �:CENSEUIWFORTHEFOLLOWING&iEASON(SEC.7031.58USINESSANDPROFESSIONSCADE:ANYCITYOR� (n , (U ���COUMYWHlCHRC-0UIRESqPERMITTOCONS7FUC7,ALTEB,IMPROVE,DEMOIISH,ORREPAIRANYSTRUC- W P8110JD8Ck ' ���',W�, '"TUHE.PRIOR TQ ITS 133UANCE,ALSO RC9UIRES THE APP�ICANT FOR SUpi PERMIT TO FIIE A SIQNED � W �STATEMENT THA7 HE OR SHE I5 LICENSED PURSUANT Td TNE PROVISIaNS oF 7HE CONTHACTORS U� ' � �'�' �CENSE.LAW(CHAPTER 9(C.OMMENCI&Q WITH SECTION 70U0)OF UIYI5ION 30F THE 6USINE$SAN�.PflP �' POO�$p3 � i FESSIONSCODE)ORTHATHEOR5HEISEXEMPTTHEREFHOMANDTHEBASISFORTHEALLEGE�EXEMR ..(� � ' . Y i 0315 YANYAPPLICANTFOPAPERMITSU&IECTSTHEAPPLICANTTO � . � . T .AN VIOLATIONOFSEC ION . 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I,;I��� . . . , .,. i .��� ','TO CON3TRUCT THE PRQIECT(9EC.laM,BU9INESS AND'.PROFESSION9 CODE:THE CONTRACTORS LI-�, V81118[I � ADJ.AREA ' .� � ��� W CENSEWWDOESNOTAPP�YTOANOVdNEROFAPROPERTYWNOBWLDSORIMPftOVESTHEREON,AN� ' ," "',�" �, YMHOCONTMCTSFORSUCHPROJECTSWITHACONTRACTOH�S�IJCENSEOPURSUANT707HECONTRAG 'QUANTITY -�ESCRIPTION � FEE � �� mRs ucErase uw.�. / p , o ❑I AM IXEMPT UNDEH S�C.. B.&P.0.FOF THIS REASON Q ( �-SX� T ���l P -/1/ � ��.r^°'" , �. ���'��. .. � � . � � � �Y �.���.�0 C'4'�r ' . , W Y OATE OWNER U � �� � � � W � LICENSED CONTRACTORS DECLARATION �j , � . .. . . d , '. , , . �. INEREBYAGFIRMUN�ER.PENAI.NOFPERIURYTHATIAMLICENSEDUNOERPROVISIONSOFCHAPTER � , 'd� B(COMMENCINfiWITH5EC71QN7000)OFDIVISION30FTHEBUSWESSANDPROFESSIONSCODE,MD Z. . X MY IICENSE IS IIJ FULI.FORCE AND EFFEGT. � W � �7 m o�� LICENSE CtASS •'� ' '�S/-����, � � .,.':�,� LIC.NO. ,�`'�� --- ,� '~'�,. DATE �}.." I� ^ p� CONTRACTOh C/"�T�'" — . . ��.��i�� � n+-�'y\ . ' . . . v✓i` J ���� MPEN ATI4N DECLARATION . WORKERS'CO S � . � � ¢ . . . �� U . u ,. �i' � � IHEREBYAFFIHMUNDERPENALTYOFP6LIURYONEOFTHEf-0LLOWINGUECLAflATIONS: _ z � ' Q � IHAVEANOWILLMAINTAINACERTIFICATEOFCANSEhTTO6ELFINSUREFORWORKERS' _ � ��� COMPENSATpN.AS PF80VIDED BY SECTIbN 37000F THE LABOP.CODE,FOfl THE PERFORMANCE ' W OFTHE WORK FOR WHICH THIS PERMIT IS ISSUED. � � 'W' S'COMP ATION IN&URANCE�AS RECUIFEO BY SECTION ' � ' I F, �IHAVEANDWILLMhINTAiNWORKER ENS � ^� , Q 37000FTHELABOflCOOE,FORTHEPERFORMANCEOFTHEWORKFOflWHICHTHISPEflMIT15 , ( 0� ggg a l,� 0 ISSUED.MYWORKEAS'CbMPEN5ATl0@IN5URANCECARRIEP.ANDPOLICYNUMBERAiiE: CONSTRUCTION �� � � i Q �„ cnaaiEa PLAN REVIEW . �,Z,;, , POLICYNUMBER .. ELECTRIC �"' Q IN �J .(fHISSECfpNPE�NOT8E0CMM.EIIDOFTF�PEFANrISFnRONEHUf�DHED�OLLARS(S1W)OAL.ESS} PLUMB G ,Z'�'� 1 CERTIFV THAT IN THE PERFORMANCE OF7HE WORK FOR WHICH TY.IS PEFIMIT IS ISSLIED,I MECHANICAL Lf°'�: SHALLNOT EMPLOYANY PERSON IN ANV MANNER SOAS TO BECOME SUBJECT TC THE � ga- , ���I WOPo(ERS'COMPENSATION LAWS OF CAIIFORN�A,ANDAGREE THAT IF I SHOULD BECOME INSPECTION FEE � :, _ Gn,.. �.�,, - $U&:ECTTOTHEWOFE(ERS'COMPEN3ATIONPROVI910NSOFSECTION370oOFTHEL4BOA � , _� COUE,ISHALLFOFTHWITHCOMPLYWITHTHOSEPRAOVI_SIONS. ISSUANCE q'�py7a�q y [�g� .. "pW':,' DATE:^L L O O�d APPLICANT L(�rt/�'L..— . 5MIP -� � �����6���B1-k�� t�a 4J'l.d . . . , ENERGY P/C ���� " �� J' . �. WARNING.FAILURE TO SECURE WOHKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHA�L BE J':, ",���", SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FMES UPTO ONE HUNDRED THOUSAND ENERG �� DOLLAFiS(S1o0.�00).INADDITION TO THE COSTOF COMPENSqTION,�AMAGES AS Pf10VIDED FOR IN ��„ SEC710N 37a80F hiE LABOR CODE,INiEREST.AND ATTORNEI"S FEES. � R TION FEE: y O�„�, CONSTRUCTlON LENDING AGENCY EqR�,T FE E• �-^�'" � O ( � /�/� � �� � � L � �..Q-�� IHEREBVAFFIRMUN�ERPENALTYOFPERJURYTHATTHEREISACONSTRUCTIONLEN�INGAGENCY 5„z4:'t;�l_.R� � 'n- FORTHE PEflFORMANCE DFTHE WORK WflYYHICH THIS PEHMR I5155UED(SEC.3097,CIV.C.). . ' Y Z L[J .._�..�,. . � . . LEN�ER'S NAME � � iI F--. LENDER5A�DRE55 W,.' ICEWTIFVTHATIHAVEREADTHISAPPUCATIONANOSTATETHATTHEABOVEINFORMATIONISCARRECT TOTAL FEES- � � i y � . .� ' ` � �.,.,, I AGREETO COMPLV WITH ALL CITY AND COUNTY ORDINANCESAND STATE L4WS FELATNG TO BUILOMG -- � ' � CONSTRUC710N,ANDHEREBYAUTHOFREFEPRESENTATiVESOFTHISCOUNTYTOENTERUPONTHE ,� {III II ,�I. 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