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HomeMy WebLinkAbout16634 �� � w � �� ^ 1� CITY OF DIAMOND BAIi DEPARTMENT OF COMMUNITY&DEVELUPMENT SERVICES 21660 E.Copley Drive Suite 190 (909)860-3195 Fa�(909)8613117 PRESS �'';��'�1' BiJII�DiNG PERMIT APPLICATION FIRI1��..�( ¢ ��REss 21865 Co I@ APPLIGATION ' PERMIF PICJ ,,,,� o i � � DO`� DATE � � NUMBER ' #_1��� � ISSUE TYPE OCC APN LOT TRACT DATE CONST. GROUP p OWNER AQMD�^ ADDRESS ZONING SETBACKS Z CITY D131110Y]C{ Baf ZIP TEL. FRONT RW ❑ g APPLICANT I TEL. REAR ❑ z, SIDE/SIC�E 3TREET RW ❑ � CONTRACT R '7 � �� P`!` SIDE ❑ � ADDRE S � �, PROPOSED USE � ' �+ Y ��! CITY � '�'t ZIP TEL.� °,I�y� w ARCH/ENG/ � W, DESIGNER I NO.DWEL. NO. NO. p: ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. y DESCRIPTION SQ.FL FACTOR PSF ADJ.AREANALUATION � � OWNER•9UILDER DECLARATION � SFRIADDlREM � O ��p" I NEREBY AfFIRM�UNDER P�NALTY OF PEFUUBY THA7I AM EXEMPT FFOM THE CONTRACTORS L4 �� Gal'296/C2fPOR ' W� .CENSELAWFORTH6FOLLOWMGIREASOfd(SEC.7031.58US�JESSANDPROFESSIONSCODEANYCINOR ' U�. COIINTYWHtC1iREtlUIRESAPERIJITTOCONSTRUC7,ALTER,IMPROVE,DEMOLISH,ORREPAIRANVSTRUG W POIIo/DBCk '�z� TUHE,PRIOP TO ITS ISSUANCE,lrLSO REY]UIRES THE APPLICANT FOR SUCH PERMITTO FILE A SIGNED � ' 'W '.�,STATEMENT THA7 NE OFi SH[IS ICENSE�PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI- W �" 'CENSE LAW(CHAPYEH B(CAMMEk(CtNG WITH 9ECTON 7ooa)OF DIVI910N S Of THE BUSINESS AND PRO� � POOUSP2 �� �FESSqNSCODEJORTNATHEOR$HEISEXEMPTTHEREFftON1ANDTHEBA515FORTHEALLEGE�IXEMP� '����:�TION.ANYVIOLATIO�JOFSECTION7031.58YANYAPPLICANTFOHAPERMITSU&lECTSTHEAPPLICANT70 Z RG-ROOf ��CML PENIJ.TY OF NQ7 MOFE TH/W FIVE HUNDRED DOLIARS(S500J.�: ❑I,ASOWNEROFTHEPROP RTV,ORIAVEMPLOYEESWITHWAGESASTHEIi1SOLECAMPENSATION, 0 CORIrtIBtC18i �" 'N7LL DO THE VJORK,AND THE STPUCTURE 15 NO71N7EN�ED OR OFFERED FOR SALE(5£C.7op4 BU51- J " �� �NESSAN�PROFESSIONS CODE: HE CANTRACTORS LICENSE LAW DOES NOT APPLYTO AN OWNER OF �. , � � �','�pROpERTYNhiOBU1LDSOflIMPR�VESTHEFIEON,ANDWHODOE5SUCHWq3KHIMSELFORHER9ELFOR , �'� ,'�.�.TNflOUGH MIS OR HER ONM EMPLOYEES,PROVIDED THATSUCM IMPRDVEMENTS AflE N4T IN7EN�ED OF m � 1L� �:OFFEREDWRSALEIFHOWEVERjiHEBVIIAINGORIMPROVEMENTI55IX.DWITHINONEYEAROFCOMPIE � � ��.; :TION,THE OWNER�BUILDER WILJ�i HAVE ThlE BURDEN OF PROVING THAP HE OR SHE DID NOT BUItD OR , 'IMPROVEFOR iHE PURPOSEOf$ALE).- , ��,,;',�; ❑I,�SOVVNEROFTHEPROPEFiTV,AME%CLl1SIVElYCANTRACTINGWRHLICENSE�WNTRACTORS , � � '��,� '�.;�TO CONSTRUCT 7NE PRQIECT(SEC.7044,9USINESS AND PROFE5510NS CDDE:THE CQNTRAC70RS LI- VdlUd�l011 ADJ.AREA � '� �,LLJ.' ���,'�CENSEtAWDOESNOTFPPLYTO�pFlOYMEflOFAPRO?EflTYWHOBUiLDSORlMPROVESTHEREON,AND � ���.,� �'�F�Vh�f7CONTHACT5FOR5UCHPROUECTSWITHACONTRACYOfi;S)IICENSE�PURSUANTTOTHECANTRAG QlJq�TiTY DESCRIPTION FEE � Y ��.TOHS LICENSE LAW.). ,' . ��� ❑i AM EXEMPT 11NOF,.R S�C; B.&P.C.fOA TH!S REASON ' U � i � . � :OATE '� ONTIER U � , ��.;�� LICEN6ED CON'FRACTORS DECL4RATION � r '���''�i,I HEAEBYAFFIRAI UNOER PENALT'OF PERJURY?HAT I AA1 LICENSEO UN6ER PAOV{SIONS OF CHAPTER � . . �,, ;��,�',e(COMMENCINfa WITH SECiIOIV 7i01w)QF t1NiSIpN 3 OFTHE BUSINESSAND PFOFESSYJNS CODE,ANO z lb �MV IICENSE IS IN FULL FORCE AND�FFECT. f� � ��,i ..LICENSECLASS ' �L�'� LIC.NO, - �✓��L-"d�p^ �j . V..�DATE �s� ��� ' �CONTRACTQR � �`� � /�4� d UJ �, WORK��iS°CAMPENSATION DECLARATION ' . Q _ ��' I HEREBVAFFIRM UNdERPENALYY OF 7E9JUR"ONEOF TNE FOLLOWING DECL4RATlONS: � � ��� �IHAVEAN�WtLLMAINTA4 ACERTIFiCATEOFC�P15EN7TOSELF-INSUREFORW�FKERS' z COMPEfVSATWN,ASPRO�IDED9YSECT10td37000FTHELABORCODE,FORTHEPEFFORMANCE 'U OFTNE WORK FOft WFiIC�i 4HI5 PERMIT I5 FSSUE�. . J� � i � e1HAVEAPI�W1{1MAINSRI bVOHKERS'COMPENSATiONIfdSURANCE,ASRE�UIRECBYSECTION � rya00FTHELABQRWYJ�,FORTHEPERFORMpACEOFTHEWORKFORWFIICNYHISPERMITIS - �. i55UE0.MY NJOi�(EfiS'CI�DAtPENSATfON INSURA CE CARRIER AND POLIC7 NUMBERARE: CONSTRUCTION + > ��qa�Ep 5 �r�-, � vl� _ __ ��uvRe��ew __3 hrs @ 85.= 255. {"\ � �� FOUCY NUMBER g' p �'� � ELEC7RIC � ��J l�� Q � (@i'SSECIMMJNE�NOTE�O:MMLEfEDOfTHEPEPDMbFORONEHUf�DAEDD:k.IAfiS(t1W)OFLESS} PLUMBING � �� 1 CEA71F/THAT IN hIE PEAFORAAlMCE Of?HE WOHH FOR WHICH THIS PERMfT IS ISSUED.I MECHANICAL __ ' (J SHAL�trOTEMPLOYANVIPERSONI�ANYMANNERSOA5T08ECAMES'JB,IECTTOTHE _ �y/y WORKER�COMPENSAi!�ti LAWS OF CALIFORNOA,AN AGREETHAT IF I SHOUL�BECOME INSPECTION FEE �!''� '�`����"'���'�� '� SU&IEC7TOTHEWOR0.^RS'C6MPENSA710N�VI kSOFS�ON37ooOFTHEU80F ./G � '�,� ' .� �F '=�-..z= � COD;IS ALLFOPTHV�c HCOM?LY WITMTH 5 OVISIONS. YSSUANCE � ' S C) ° p DATE: �PPLICAM: SMIP � ��.R � W � ENEAGY P/C � WARNINO:FAILURETOSECURE ORKERS'COMPENSATIONCOVERAGEISUNLAWFlIL,AN�SHALLBE -- --- ', � SU6JECTAN EMPIOYER TO CRI INqL PENALTIESAND CIVIL FINES UP TO ONE HUNDRED THOUSAND ENERGY PERMIT � DOLLAflS�5100,000),INAD01TI0 TO iHE COSTOF COMPENSATION,OAMAGES AS PROVIDEU FOR IN ' J SECTION37000FTHELABOR E.INTEREST,ANDATTORNEY'SFEES. � �° { �� � RETENTION FEE: ���.a _ ��_ — , � CQNSTRUCTION LENDING AGENCY PRE-ALT FEE � �� � ���. I HERE9YAFFIRM UNDER PENAL�OF PERJURY THATTHERE IS A WNSTRUCTION LENDING AGENCY - '- FORTNE PERFORFIANCE OFTH WORK FOR WiiICH THIS PEflM1T IS ISSUED(SEC.3097,CIV.G). . Z W �, T� LENDERS NAME � � , � � � - � I F_- LENDEFiSADDRESS �y � � ICERTIFYTHATIHAVEFEADTHISAPPUCAiIONANDSTATETHATTHEABOVEINFORMATIONiSCORRECT. TOTAL�EES�/ '^^�����' � ' ` ��1y,�lF ��� IAGREETO COMPIY WITN ALL C17Y AND CAUNTY OftDINANCESANO STATE LAWS RELATING TO BUILDING � . � CANSTRUCTION,ANDHERE6YAU7H6R2EREPRESENTATIVESOFTHISCOl1NTVTOENTEfll1PONTHE - ' , . � ' , Z ABOVE-MEdJTWME6 PROCERTY FOR INSPECTIOPI PURPOSES. COMMENTS � � � �,y�f /'�j��J a . .. . m 7ERMITT (PRINT) ��J i � . � � �l ;�, SIGNATO FPE EE '. DATE � � � � � - '�. � RECPT.NO. ^PAID BY " �VACIDATION ~ - ' WHITE—Depadment Copy,YELLOW—Finance Covy,PINK—Assessor Copy,GOLDENROD--File Copy,GREEN—ApplicanPs Copy � , .� . _ �.. . ,. �.. . ,.; ,.,. , . ,� , ,. � .. , . .- .,,.� ���� ��` ���������� �_����� ' ���� � �� �� �G, �fi'i ���������"��j�: � ;����:����� � ;. � �� �� � �. , �� ' �� ,�� ��'>�,��d���� �. .. � ?�:r��Np`r��r.g °� � "i. 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