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HomeMy WebLinkAbout12056 � CITY OF DIAMOND BAt� � J�—� DEPAIiTMENT OF COMMUNITY&DEVELOPMENT 5ERVICES �� 21660 E.Copley Drive Suitc 190 (909)860-3195 Fax(909)861-3117 PRESS � "��'� BUILDING PERMIT APPLICATION FIRMI.Y o AODDRIESS�SS I� CO�/d�'fl SYR���C9 S �r`- � DATECATION O__�__G� NUMB R �� #fC L � ISSUE q TYPE OCC j APN LOT TRACT DATE �"��^ L� CONST. GROUP p OWNE�AIV w tC,N-T "' ADDR�S `.� C��EOTh. •.� ( A� ,, ZONING SETBACKS u' CITY �` ZIP�T�� TEL.35�o^ G FRONT RW f_l_, � APPLICANT fJ uQt� TEL. $—!�!?� REAR �]�_ i � SIDE/SIDE STREET RW C]_ � CONTRACTOR ��fL � 1�C� SIDE �7, � p� ADDRE I 95'3 L !Z-h. �CJ L^� �P�E�USE U S�Al�.+� I'V�"i�A-►-� ��G�X �l �vrw � o CITY ZIP IZ TEL. �� Z ,S -�-f+-. hl_T �C G o ARCHIENG/ —��_ ��.�,� � � �, z DESIGNER W NO.DWEL. NO. ( NO. a ADDRESS � CITY ZIP TEL. UNITS STORIES _____,_BEDROOMS � = DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION - � � OWNER-BUILDER DECLARATION SFR/ADDIREM � I HEFFBY AFFIRM UNUER PENAL7Y OF PERNRY THAT I PM EXEMP7 FftOM THE CONTRACTORS LI- � GBfOJB/C8(POfS � W CENSELAWFORiHEFOILOWINGREASON(SEC.7037.58USINESSANOPFWFESSIONSCODE:ANYCINOR (� C.7 CIXIMYWMCHNEWIRESAVERIAITTOCONSTRl1CT,ALTER,IMPROVE,OEMOUSH,ORREPAIRANVSTRUC� (J,J pyI10/DBCk Z TURE,PNIOR TO ITS ISSUMICE,AL50 REW IflES THE APPIICANf FOR SUCH PEpMIT TO FILE A SIONED � W STATEMENT THAT ME OH SHE IS LICENSED PURSt1ANT TO THE PROVISIONS OF THE CONTRACTORS L6 W � CENSELAW(CHhPTEfl B(CAMMENCINa WITH SECTION 7000)OF DIVISION J OF THE BUSINESS AND PRO� u' PooVSpa FESSIDNS CDDE)OR 7HAT HE OR SHE IS EXEMPT THEPEFf70M ANO THE BASIS FOq 7HEALLEGED EXEMP- U TION.ANYVKK.ATIONOFSECTION7o31.5BYANYAPPLICANTFORAPEHMITSUBJECTSTHEAPPLICANTTO Z Re•Roof ! ACMLPENALTY DF NOT MORE THAN FIVE HUNDREO OOLLARS(E500).j: ( Q ❑I,ASOWNEflOFh1EPROPEqT/,ORMYEMPLOYEESNATHWAGESASTHEIP,SOLECOMPENSATION, 0 COfI1R1BfC17i Z ,WILL DD THE WORK,AND THE STRUCTURE IS NOT INTENDED OH OFFERED FOfi SAIE(SEC.70a4,6USI- _J j N., NE55 PN�PROFE9SION5 GODE:THE CONI'HlCTORS LICEI:SE LAW COES NOT APPLY TO RN OWNEfl OF = � PAOPERTYWFiOBUIlD50RIMPROVESTHEREON,ANDWFIODOE55UCHWOHKHIMSELFORHERSELFOR ' ` � THRIXIGHHI30RHEflOWNEMPLOYEES.PHOVI�EDTHATSUCH�MPROVEMENTSpqENOTINTEN�EDOR m i QOFFEREDFORSALE.IF,FIOYlEVERTMEBUILOINGORIMPROVEMENTISSOLDWITHINONEYEAROFCOMPLE'- z TION,hIE OWNETi�BUILDER WILL HRVE THE BURDEN OF PROVING THAT HE OF SHE DID NOT 9UILD OR � � IMPROVEFOHTHEPURPOSEOFSALE). j W ❑I,ASOWNENOFTHEPROPEHfY,AME%CWSIVELYCANTRACTINGNATHLICENSEOCANTflACTOHS c� E ¢ TO CONSTRUCT THE PflOJEC7(SEC.7041,BU9INESS AND PHOFESSIONS fADE:7HE CONTRACTORS U- �IgIU8l10I1 ._____�CJ.� ADJ.AREA lll CENSELAWDOESNOTAPPLYTOANOWNEROFAPROPERiVWH06U1LDSORIMPROVESTHEREON,AND --`— ' F NTIOWNTMCTSFOflSUCHPRQIECTSVfITHAGONTRACTOR�3�UCENSEDPURSUANTTOTHECONTRAC- QUANTIN DESCRIPTION FEE � Y TOqS LICENSE U�WJ. � fIIAMEXEMPTUNDERSEC. _B.$P.GFORTHISREASON � "� � ---_ V i� LL � � OATE_ OWNER__ __'""...'_ U ii Z � �� � LICENSED CONTRACTORS DECLARATION W `� QIHEREBYAFFIRMUNDERPENALTYOFPERJUflYTHf.TIMILICLNSFDUNDERPROVISIDN50FCHppTER � d B�COIAMFNCINO WffH SECTqN 7om)OF DIVISION 3 OF THE O1151NE5S AND PflOFESSI�NS CO�E,ANO Z � X MYLICENSE IS IN Ft0.L FOflCEAND EFFECT. ': � LICENSE CLAS ��� LIC.NO._�y I�� 7 � i' �- �-R�- --- ----- _ � V DATE CONTPACTOR _,__ �1- � W � WORKERS'COMPENSATION DECLARATION Q � � U } � I HEREBY AFfIRM UNOER PENALTY OF PENl1RY ONE OF THE FOLLOWING DECLPMTION5: Z i � _IHAVEANDWILLIAAINTAINACEfiTIFIC4.TEOFCON5ENTTOSELf�INSl1REFOFWORKERS' 2 � COMPENSATION,ASPROVIDEDBYSECTION37000FTHELABORCADE,FOfiTXEPERFORMMICE U � OF THE WORK FOR WHICH THIS PF.RMIT I615SUED. W ' Q � i � __IHAVEIWDWILLMAINTAINWORKERS'CAMPENSATIOYINSURANCE,FSREOUIREDBYSECTION � � Q 37000FTHElABOflCODE,FOflTHEPERFOflMANCEOFTHEWORKFORWHICHTHISPERMITIS �/J �� C �` � ISSUED.MY WORK�EHS'COMPENSAT �NSURANCE CARRIER AND VULICV NUMBER O.RE. CONSTRUCTION G- v �` _'"''_-_'__""'"' — a CARRIER ���-'c. _VND ----'—-- PLAN REVIEW _.. . .------..----.. ....—_...—__ t > (LL d.� _ ZPOUCY NUMdEF__. � I ._ _.,_'__' ELEGTRIC "___"_"' '_'_' '...__'____'_' Q ? � (fF14SSEC7pNNE�NDTBEO�Ir4iEiEDOF7}�EPF.R"MISFORONEMh`ARED�OLIA[1S(S�W)OtiLESS�. PLUMBING ____'_"..—___�___'____ ` _,_..._"__'— 6 w Z ICERTIFYTHATINTHEPERFORMMCEDFTNEWOIiKFORWHICHTHISPERMITISISSl1ED,1 MECHANICAL ___._.____.____.___ .._______ � () SHRIL NOI'EMPLOY ANV PF.PSON IN ANYlAANN[R SOAS TO 9ECAME SU0.IECT TO iHE � WORKERS'COMPENSATIONLAWSOFCALIFORNIA,ANDACflEETHPTIFISHOULDBECOME INSPECTIONFFE __.__,___ ' SUBJECTTO THE W�RKERS'COMPENSATION PROVISIO OF SE///C���TION 37000F THE LPBOR �,�y � � COOE,1 SHpli FO THWIiH COMPLY WITMI'ITIpSE PRO N� ISSUANCE _.._.— ���.(�' '_'_'_'—'' O /yI�( �` .l 1 � p �ATE:Y �`L APPLICANT: _V�CT --- SMIP --------..---"---- -- i W ENEFiGY P/C � J WARNING:FAILUfi[TO 5ECURE WOqKEflS'COMPENSATION COVERAGF.IS UNLAWFUL,AND SHALIBE _-"""_'__—_ ""'_ "'___'_--' � SU0.IECTFNEMPLOVERTOCRIMINALPENALTIESpNOCIVILFINESUPTOONEHUN�RE�THOUSAND ENERGYPERMIT � OOLLARS(f100.OW),INADDITIONTOTHECOSTOFCOMPENSATION,DAMAOESASPHOVID[�FORIN ---'-'-- -'-- -- � J SECTION37oeDFTHELABORCODE,INTEREST,ANDATTORNEY'SFEES. RETENTIONFEE: � � I � CONSTRUCTION LENDING AGENCY ppE-ALT FEE: _..__ _.___�,,..___ _ � � IHEREBVAFFIRMUNDERPENALTYOFPERJURYTHATTHEREISACONSTFIUCTIONIEN�INGAG[NCY _ __ ______ ___ ,_ � FOFi THE PERFORMANCE OF THE WORK FOR WHICH Ti15 PERMIT IS ISSUED(SEC.30W,CIV C.�. w .. _.. ._ -- � � LENDER'SNAME_._. ."_'_"- ___'_ ____ '.._.._" _—_'"__ + F- LFNDER'SAODRE55 ,__._ -__- I � � w iCERTIFYTMATIHAVEREADTHISAPPLICA710NANUSTATETHATTHEABOVEINFOHMATIDNISCORRECT. TOTAL FEES � � � IAGflEETOCOMPLVWITHALLCITVANDCOUNTYOF�INANCESANOSTATELAWSRELATINGTO�ULL.01NG ; GONSTRUCTION.ANDHEREBYAUTHOflIZERLPRESENTATIVESOF7HI5COUNTYTOENTEFUPONTHE � � ZABOVE-MENTIONEDPROPERTYFORINSPECTIONPURPOS[S. COMMENTS � � I� � i O � ('\ �� "_ ' _�- I .nS C � PF.RMITT E AME(P � -_- ����V —_ ___-— -- � N � SIGNATUREOFPEPMITTEE DATE = RECPT.NO. PAID BY VALIDATION_ � ~ WHITE--0epertment Copy,YELLOW--Finance Copy,PINK—Assessor Copy,GOLDENRO�File Copy,GREEN—Appiicanfs Copy �� ,_.�.�.�. . _.Irt ...-- ...{.. ....._. 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