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HomeMy WebLinkAbout16282 (22) ��c , Q� � - �� CITY OF DIAMOND BAI� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES f�� � C� � _ 21660 E.Copley Drive Suite 190 PRESS (909)860-3195 Fax(909)861-3117 �`'�;»�'+� ING PERMIT APPLICATION , , FIRM BUQ.D . _. .. ,. y JOBSITE � ��� �6 �^��4' � +..� pqTECATION� I/� �� NUMBER V' P'C o ADDRESS ��' '�}_y„_�___�' ISSUE TYPE OCC � APN LOT�--�c-- TRA T _ DATE_ CONST. GROUP � OWNER �l i"t� UE— ���! •rrJ � • .�S:i.� `L ADDRESS �.-i ��.� C-e!�(�'Y ZONING SETBACKS � FRONT RW ❑ �W CITY �Z�4t,3s�>a r3/�--ZIP TEL. REAR ❑ APPLICANT ''�� F���d�.t�'f TEL SIDFJSIDE STREET RW O � CONTRACTOR -1� ' RX-lC' C�J'^�4 ' �'l�h SIDE ❑ ADDRESS � � �{3c � ' PROPOSED USE a cirr("�i ,�s.z_�J?� ' ZIP�%�-fe TEL.G�Z4�' "�? w ARCH/ENG/ � OESIGNER NO.DWEL. NO. NO. ADDRESS UNITS STORI ES BEDROOMS � CITY ZIP TEL. `n DESCRIPTION SQ.FL FACTOR PSF ADJ.AREANALUATION � Q OWNER-BUILpER DECLARATION SFR/ADDIREM O p I HEREBY AFFIPod UNDER PENALTV OF PEFUURY THA7 I AM EXEMPT fROM THE CONTFtACTORS LI- GBfagB/CefpOfl W GENSEUWFORTHEFOLLpWMGPEASON(SEC.7031.5BUSINESSANDPROFESSIONSCAOE:ANYCIIYOR (n � WIINTYNRIICHREOUWESAPEflMiTTOCQN3TRUCT,ALTEF.IMPROVE,DEMOUSH,ORREPNfiANYSTRUG W P8ti0/DBCk TURE,PPoOR TO ITS ISSUANCE.ALSO REQUIRES TNE APPLICAN7 FOA SUCH PERMITTO FILE A SIGNEO W STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PqOVI510N5 OF TME CONTRACTOR3 U� t CENSE UW(CIiAPTER e�COMMENCINO WITH SECTION 7000)OF DIVISION 3 OF 1'NE BUSINESSAN�PRO- � PO�USpB SFESSIONSCODE)OR7HATHE4RSHEISEXEAIPTTXEREFROM/W�THEBASISFORTHEALLE(iEDE%EMP- V TION.ANYYIOLATIONOFSECTION7031.58YANYAPPLICANTFORAGEflMIT5U8JECTSTHEAPPLICANTTO Z Re•Roof F ACML PENQTV OF NOT MORE THAN FNE HUNORE�DOLIARS�f5oo).): � ❑4�OWNEflOFTHEPROPERiY.ORMVEMPIOYEESWITHWAGE5A5THEiRSOIEGOMPENSATION, � COfIV118YCiel WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OP OFFEREO FOA SALE(SEC.7044,BU51- J lESS MI�PROFESSIONS CODE:THE CONTRACTONS LICENSE LAW OOES NOT APPLV TO AN OWNER OF � PROPERTYWFIOBU�LUSORIMPROVESTHEFEON,ANDWHODDESSUCHN/ORKHIMSELFORHERSELFOq = � THROUCHHISORHEROWNEMPLAYEES,PROVIOEOTHATSIICHIMPROVEMENTSARENOTINTENDE�OR m QOFFEREDFORSALEIF,HOWEVER7HE6UILDINGORIMPROVEMENT1350LDWITMNONEYE'AROFCOMPLE- � TqN,THE OWNER-BUIIDER WILL HAVE THE @Ui1DEN OF PFOVING THAT HE OR SHE DD NOT BUIL�OR = IMP�VEFORTHEPURPOSEOFSALE). �y,� ❑I,ASOWNEROFTHEPflOPER7Y,AMEXCLUSIVELYCOMRACTWGWI4NLICENSEDCON7RACTORS (t TO CONSTHUCT THE DRQIF.CT(SEC.'IW4,BL151NE55 AND PHOFESSIONS CODE:THE WNTRACTORS LI- V81UdlIOfl ADJ.AREA W CENSEUWDOESNOTAPPLVTOANOWNEROFAPROPERTI'Vrt1OBUHDSORIMPROVESTHEREON.AND � Y/rqCOMRACTSFG�pSUCHPRQISCTSWITHACONTqACTOR(S)LICENSF.DPUpSUANTTOTHECONTRAC- QUANTITY DESCRIPTION FEE � TORSLICENSeUW.�. Q ❑I AM EXEMP'�UNDER SEC. B.d flC.FOFi THIS REASON � 3 � � DATE ONMER V w � LJCENSED CONTRACTORS DECLARATION �y � I HEREBYAFFIFM UN�ER PENALTV OF PERJURY TNAT 1 AM LICENSED UNDEP PROVISIONS OF CHAPTER �r �/i � G(COMMENCINOWITMSECTION7000)OFOIVISION30F7HE9USINESSANDP(iOFESSIONSCODE,AN� Z X MV UCENSE IS IN FULL FOPCE AND EFFECT. m �d t e n f W � D[�+C3 � LICENSE CLASS �rt LiC.NO.� � � y � V UATE �� _L�.Y_4— CONTRACTOR a W � WORKERS'COMPENSATION DECLA AT ON Q � IHEREBVAFFIRAI UN�ER PENALN QF PE0.IURV ONEOFTHE FOLLOWING DECLARATIONS: � � Z Q O _IHAVEANDW�LIMAINTAINACERTIFICATEOFCON5ENT70SELF-INSUFEFORWORNERS' _ � COAIPEN5AT19N,ASPRUVIDEDBVSECTION3�o00FTHEUBORCODE,FORTHEPERFORMANCE `U OF THE WORK FOfl WHiCN THIS PERM171S ISSUED, � W `� I HAVE ANO WILL MAINTFUN WOFKERS'COMPENSAiION INSUflANCE,AS HF�UIRED BY SECTION Q 3700 OF THE LABOR CODF,FOR THE PERF4flMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUEQ.MY WORKERS'COMPENSATION INSURANCE CARRIER AND POLICV NUMBERARE� CONSTRUCTION � CAFRIER �� ��� PLAN REVIEW _. / � POUCV NUMBER�2-�� ._--- ELECTRIC 1, � o ��ss[crpr�n�mr+oTeE�ErEvoFrr�veFr,ar�sroaaraerxx�tvoai.nras(s+ooioR�Ess�. PLUMBING � I CERTIFYTHAT IN hIE PERFOPMANCE OF THE WOHN FOH WHICH THIS OERMIT iS I55U D,I MECHANICAL � SHAIL NOT FMPLOV ANY PERSON IN ANV MANNEft SO AS TO BECOME SUOJECT TO THE � WORKER5 COMPENSA710N LAWS OF CM.IFORNIA N'��AGREE THAT IF I SHOULO BECOM INSPECTION FEE _ SU&IECT TO THE WORKERS'COMOENSATION PROVISIONS OF SECTION 3700 OF THE LABO � GOOE.ISHALLFORTMWITICOMPLYVATM FIOSEP VI 10�. ISSUANCE n � ��APPLIGANT.� � SMIP p DATE: _ J ENERGV P1C J WARNING:FAILURETOSEWflEWOFKERS'CO PENSA VERAGEI^uUNUWfUL,AN�SHALLBE LL SUBJECTANEMPI.OVERTOCRIMINALPENALTIESANDC 14FINESU7TODNEHUN�RFD7HOUSAN� ENERGYPERMIT OOLLAFlS(f700.0001.IN ADD1710N TO THE COST OF COMPENSATpN,DAMA�ES AS PROYICICD FOR IN � SECTWN3]aeOFTHEIABORCODE,INTEREST,ANDATTOR�uEY'SFEES. RE7�ENTIONFEE: W CONSTRUCT70N LENDING ACoENCY PRE-AL7 FEE: � -- � � I NEREBYAFFIRM UNOER PENALTV OF PERJURY THAT THERE IS ACONSTRUCTION LENOING AGENCY F�R THE PERFORMANCE OF THE WORK FOR WMICH THIS PERMIT IS ISSUED(SEC.3087,C�V.CJ. Z W � IENOER'S NAME .-___.._.. F- IENDER'SADDRESS � � ICEflTIFYTNATIHAVEREADTHISAPPL!CAiIONANDSTATET1iATTHEABOVEMFOHMATIONISCARRECT. T�TAL FEES � W I AGREE TO COMPLV WITH qLl CITY AND COUNTV ORDINANCES AND STATE LAWS FEUTING TO BUILOING � � �/.� ������jjj /��yy) � CANSTflUCTION,AN�HEREBYAU7HOF2EREPRESENTATIVE50FTHISCOUNNTOENTERUPONTHE �j��j �/ D�� y' ' � ABOVE-MENTIONEO PROPERTY FOR INSPECTION PUflPOSES. �✓ 1/ V 1 �� Z � COMMEN75 ■ � � � (✓� I -- � m PEPo.UTTEE E(PRI 1 ... 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