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HomeMy WebLinkAbout16468 .,,,w-, ;�, , �� CITY OF DIAMOND BAI� � � • . ��� - DEPARTMENT OF COMMUNITY&,DEVELOPMENT SERVICES � � . : � 21660 E.Copley Drive Suite 190 � (909)86a3195 Fax(909)861-3117 PRESS ��'��°� BUILDING PERMIT APPLICATION FIRMLY o ADDRIESS Zf3 n� C.�') ' 6�E`�0.� �N = DATECATION J J} /j� ,/1� NUMBER U;?� �y #1C —��L � ISSUE 7YPE OCC � APN L�OT TRACT __ DATE_ CONST. GROUP p OWNER �°7'/4N __,e�/N _ " ADDRF�SS��+�f• ZONING SETBACKS � CITY rJ�/AdyOsjL_�_fslT_ ZIP��TEL.�,��"`S�� FRONT RW LJ AFPLICANT TEL. REAR fl � SIDE/SIDE STREET RW [:]_. — CONTRACTOR Al�' ��?�i j'�/N �id�� .f:�C SIDE __ ❑ p� ADDRESS�[�_S f�i7��E ��tt: 5�+/� T p � PROPOSED USE _ CITY�M1�/!t� ZIP 9'i"7t.;f TEL.��_ oARCH/ENG/ — z DESIGNER — — � ADDRESS � — NO.DWEL. NO. NO. � CIN ZIP TEL. UNITS __ STORIES _BEDROOMS___ � es� DESCHIPTION SQ.Fl: FACTOR PSF ADJ.AREANALUATION Q OWNEF-BUILDER DECLARATION SFR/ADD/REM O - � 1 HEflEBV AFFIRM UNDER PENALiV OF PERNRV THAT I AM EXF.MPT FftOM TH[CAMfiACTOflS LI- � GalOJE/CdlpOff � W CENSEIAWFORTHEFOUAWINGREA50N�5EC.7031.59U51NL55ANDPROFE5510N5CODE:ANVCITVOR (n !S' COUNNY7HICHREWIRESAPERMITTOCONSTRUCT,ALTER,IMPROVE,DLMOLISH,ORREPAIRANYSTfiUG W PatiO/DBCk W 7UflE,PRIOR TO ITS ISSUANCE,AL50 REOUIflES THE APFLICANT FOR SUCH Pf.RM17 TO FILE A SIGNED W � STATEMENT THAT HE OR SHE I5 LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS U� � � CENSE UW(CHAPTER 9(COMMENCING WITN SECTION lWo)OF DIVISION 3 OG THE BUSINESS AND PRO- � P001/S(I8 p�' ���� FESSIONSIXN7E)OPTHATMEoft5HEI5EXEMPT7HEREFROMANDTHE9A5I5rORTHEALLECEDEXEMP� (� F, TION.ANYVIOLkTIONOFSECTION70.91.5BVANVAPPLICANTFORAPERMITSUBJECTSTHEAPPLICANTTO � Z Re-Roof �� � ACIVIL PENAITV OI�NbT MORE THAN FIVE HUNDRED OOILARS(55oa).): - fC��� � ❑I,ASOWNEflOFTHEPROPEHTY,ORMYEMPLOYEF.SWITHWAGE5A5THEIR50LF.COMPFNSATION, L1 COfnmE+fCi�l _ •? YNLL�O 7HE WOIU(AND THE STi!UCiIJ�[IS NOi INiEN�ED OR OFFERF�FOR SAI.F.(S[C.70Aa,B1156 J— Y}}' � NESS RN�PROFESSIONS CODE:TFIE CONTRACTDAS I.ICENfiE LAW OOFS NOT A?PLY i0 AN OWNER OF . � � Pi�PERTY NRiO BUILDS OR IMPROVES THEFEON,AND NhiO W ES 5UCH WORK HIMSELFOR HERSELP OR � iHROUGHHISORHEROWNEtAPLOVEES.PROVI�EOTHATSUCHIMPROVEAIENTSARENOTINTENDE�OR � Q ,OFFENED�OPSALE.IF,HOWEVER,THEBUIIDINGOHIMPFOVEMENTI550lDWITHINONEYEAROFCOMPLE- Z TpN,THE OWNEN-BUILDER WILL HAVE THE BUflDEN OF PHDYING T}7AT HE Ofl SHE DID NOT BUILD Ofi IMPflOVE FOR THE PURPOSE OF SAlE). � �g=j GI,ASONMEROFTHEPROPERYY,AMEX(:LUSIVELYCONYRACTINGW!THIICEN&EOCO�TRACTOFS ' �. TO CONSTRUCT THE PRQIECT(SEC.7011,BUSINESS AND PflOFESS1045 COD£:THE CON'RACTORS LI- � V81118f1On ADJ.AREA W CENSEUWDOESNOTAPPIVTOANOWNEHOFAVROPEATYWHOdUIlD50HIMVR4VE5THEflEON,AN� � � - �- --���--- --- 1 WFIOCONfRACTSFOflSUCHPH4IEC'SWITS1ACOdJTRACTOR(S)LICEI:SEOPl1R5UANTTOTHECONTRAC- �UANTITY DFSCRIP710N FEE � TORSLICENSEIAW.j. _ /'' �/y,, o ❑I AM E%EMGT 11NDER SEC. B.&P.C.FOR?HIS REASCN � Q � d�`�//P/LV_ICce !,3�G^'��• � ------�--....----- -- OC � .. �'f' _ � . U � DATE OVINEFl_'__"'__"_'_' F' "'_""__..._..__._....._"'__ [,) ' Z W � LICENSEO CONTRACTORS DECIARATION � � IHEREBVAPFIflAIUNDERPENALTYOFPEFUUqYTHATIAMLICENSF.�UN�ERPROVI510NSUFCHAPT[4i � d D(COEiMENCINO WIfH SECTION 7aao)OF UIYISION 3 OF TME BUSINESS AND PROFESSIONS CODE.AND Z X MY UCENSE i5 M NLl FORCEANC EFFECI'. - �.._ UCENSECLASS .� A 9 ^� ' j ' O � G..� LIC.NO. ���.__—._..__*..__... ; . ~ DAT �j GONTRACTOR_��r /�qn a _— _-- W -- E� `�-`"��`�s+�"---- � �� ll�.-�-WOfiKER.i COMPENSATIUN DECLARA��~��"�� � ,i z _ ''' U F � IHEREBVAFFlRMUNDERPENALTVOFPEFi1UFVONEOFTNF.FOLLOYJING�ECLARATIONS: Cf� ¢ � _._,_I HAVE AND WILL MAINTAIN A CFRTIFlCATE OF CANSFNT TO SELF-INSURE FOR WORKERS' _ — f:OMPENSATION,ASPflOVI�EDBYSECTION3�oaOr���ELA90RCODE,FORTHEPF.RFORMANCE �U OFTiE WORK FORK'HICH TH�S PF.RMIT IS ISSUEQ. � � ' _-_ u, __I HAVE AND WILL MAIMAIN WORKERS'COMPEYSATI04 INSUFlANCE,AS flEOUIREO BV SECTION � -__. 3l0o OF THE LPBOR CODE,FOR THE PEHFORMAKCE GF TfIE YiORK FOR WHICH TN!S PEPMIT IS _ ISSllEO.MYWORKERS'C�MPENS TIOM1INSURANCECARRIERANGFOLIGYNUMBERARE: CONSTRUCTION � ..._._............__'—_.__,.__.._,........_-..._ � f:ARRIER_--_�'/�` �^{ � .�' ---------- PLANFEVIEW ------- .- � .. ...."__'_'_-'_'—'__-"_"_""_-_-__' 7 POLICYNUMBER�y�_46J � ��� ���y �—.-(,f —�—�p- ELECTRIC 4 --------------------�--------- � (IHISSEC(IONNEEDNOTCiEWN3'lE7mOFiF'.EPERV.TI51'ORONEMNAH[UIXiLIARS(Stao)(MLC-SS). PLUMBING _.___ ___._____'.__..______'.________ �, w � i ERTIFY 7HA71N THE PERFOPMANCE OF THE WORK FOH WHICH TH!5 PERMIT IS ISSUE�,I MECHANICAL Z -- _.__.._......_..�`J.,�_ �� ' NOTEMPLOYANYVEFlSOPlIN.WYMANNERSOASTODECAMESV0.;EGTTOinF. /" 1"'%'•'^'ii;=.�`�e � C!J �����.-..... - � ORKEHS'C01+1PENSAi ION LAWS OF CALIFOSINIA,ANb AGREF.THA71F I SHOUL�BECOME INSPECTION FEE •. � - --�_„A_'_____�____ '' j ;`i�}� 1 TTOTHEV7CRKERS'CGMPENSATIONPROVIGION�f: 3 �UfTHELA80R , ; ,�-y'` - � �� � ,I HALLFO MWITHCAMPLYWI7HThiDS[�R ISSUANCE r s./ti�� P� A _ a ,.: p DATE:� � _Q� APPLICAN7: • . SMIP ...._.......���_ .�. �J I����f i '_..__ ...._. ._. ."._.'._ , W ENEFGY P/C � J. WARNING:FMLURE'fO3ECl1REWORKERS'CO - ONCOVLRAGEISUNLAWFUL,ANDSHP.LLBE � '�'-'-'----�"""'--- -'----------------�-----?--------�----�---�--- yy 9UBJECTAN EMPLOYER TO CFIMINAL V[N S AND CIVIL FINES 11P TO ONE MUNURF.D TNOUSqND ENERGY PERMIT Y ( � _. DOLLARS(f1al,000),INADDITIONTOTHE STOFCOMPENSATION,DAMAGESASPNOVIDEUFORIN "--'-- - :- - � � - ----------�------ - ----�--------'......__ 4 J SECTION 37oe OF hiE Ll�BOH CO�E,INTL'ftEST,ANDATTORNEY'S FEES. �^ �� � � � RETENTION FEE: _ -�--�--- --�-:..'--��----....._._�----;. oCONSTRUCTION LENDING AGENCY PRE-ALT F[E: J � � I HEREBV AF�IqM UNDEfi P[NALP!OF PERJl113V?HATTHERE IS A CONSTRUCTI04 LENOING AGENCY � s� � FOflTHEPERI-0RMANCEOFTHF.WORKFOftWHICHTHI&PERMITISISSUED(SEC.30W,CIY.C.). �---- Z W __ -._-_____—_._._..____.___.__.-._._ __-____ � LENOER'S NAME'__....___...... __ — I _-__"—'___'""__ —___--'"'__ '_'- F- LEN[7EH'SA[]�RESS -_ .--- � � I CERTIFY TNAT 1 HAVE RF.A�THIS NPALICATION ANU STA1 f:TFIAT TVIE ABOVE INFOf7MATION IS CORRECT. TOTAL FEES �^� \ � � I AGFEE TO CAIAPLV WITH ALLCI'fY AND COUNTY ORDINANCES AND STATE LAWS RELATING'f0 dUILDING � C(NlSTRUCTION,AND HEFiEBYAUTHORI7.E HEPfl[S�NTATIVES OF'fHIS COUNTV TD ENTER UPON THE � ABOVEMENTIONEOPROVERTYFORINSPECTIONPUHPOSES. COMMENTS Q /` _-----_- '___"' � 1"L�''fL�F�I*-±C,_ �'.1.�9 f�.�2srC3 -----__....__...............------ ---- --- - m GERMITTEE NAMF.(Pfll • / ' "_" "___� ¢ � �/� �� '_-__'__-___"'._._._.._...""_"' � " "'/'___'-_'____'- -'__'_'_'_'_' ' � ' � � SIGNATUHE 'PER . - DATE � = RECPT.N0.__.._ PAID BY I VALIDATION_., _ ~ WFIITE—Department Copy,YELLOW—Finenc�Copy.PINK--�+ssessor Copy,GOLDENROD—File Copy,GREEN—Applicant's Copy �` .__. .._. . .. ... ,.._ .____ � - - -..... , ._ ._ _..._. � ._. . . . _... ,. i . . , I , i � � , . ,,�< � i ' ; I ' i �I., . . � i� i I.� f� � �'. �. t � I I � . � � � ( � � � � � ' � i_ .. ' ; ' . � I ` k � ;' � � _ i j ( ' '; ; �, � ' i , ; ; ; � . , j , � ,:i � . , , � : ; ; _�__ i _ _. , _ � � _ .� , , r , � i i I � � _ { ' � I i � i ' F ' � , I � , , , 4 � _- ; � � I : � � . i ` � . , , i. , i � i ..... _._ . _. . '.,__. _ . ; � � I � � f . � �� ( ' ' ; , I � � �.. S I I i � I • � ', ', �' . � - � ; �, . 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