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HomeMy WebLinkAbout12819 , __`� CITY OF DIAMOND BAI� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES _ 21660 E.Copley Drive Suite 190 - (909)860-3195 Fax(909)861-3117 PRESS ^%�°��ry BUII.DING PERMIT APPLICATION `��I � FIRM�Y p DDR'ESS ���� ��� `��'+'�-�--'� ` DATE CATION�,q�,����UMBER �" -� #/C Z � issuE ,/�_ rrPe occ APN OT TRACT DATE [ I � CONST. GROIJP p OWNER �-�'�- " ADDRE ��6J �' � ZONING SETBACKS z CITY , ZIR- TEL. FRONT RW . ❑ g APPIICANi" � TEL. REAR ❑ Z SIDE/SIDE STREET RW ❑ � CONTRACTOR :`>'R� �` �• SIDE ❑ � ADDRESS �' �: � � ` � CITY --J'�L ZIP :1C3�� TEL. `�.�C.7C?� PROPOSED USE �1 � ., . � � � ' w ARCH/ENG! W DESIGNER NO.DWEL. NO. NO. d ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREA/VALUATION � Q OWNER-BUILDER DECLARATION SFR/ADDIREM O � p I HEREBY AFFIRM UN�ER PENALTY OF PERIURY 7HAT I AN EXEMFT FROA1 THE CONTRACTORS LI- � Gef9yB/Ce�pOR W CENSEUWFORTHEFOLLOWIN6REA90N(3EC.7091.SBUSINESSANDPqOFESSIONSCODEANVCI7VOR ZCOIINTYWHICHNEOIIIRESAPERMITTOCONSTHUCT,ALTER.IMPROVE.DEMOLISH,ORREPAIHANYSTRUG W patio/➢eck W TUflE,PRIOH TO ITS ISSUMICE,RLSO REW IRE&THE APPI�CANT FOR SUCH PERMR TO FILE A SIGNED W � STATEMENT 7HAT FIE OR SHE IS LICENSEO PURSl1MIT TO iHE PROVISIONS OF THE CONTRACTORS LI- c CENSELAW(qiAPTERe(COMMENCINGWITHSECTION7000�OFDN�SION30FTHEBUSINESSANDPH0. V' � q VFESSIONSWDE)OIiTHATHEORSHEISEXEMP77HEREFROMANDTMEBA515FORTHEALLEGEDEKEMP- -� V TION.ANYVIOLATIONOFSECTION7037.6BVANYAPPLICANTFORAPERMITSU&IECTSTHEAPPLICAMTO REROOf-� � ACMLPENALTYOFNO7MOFETHRNFNEHUNDfiEDDOLURS(55oo).): � ❑I,ASOWNEROFTHEPROPERTV,ORMVEFAPLOVEESWITHWAGESASTHEIRSOLECAMPENSATION. �y� . WILL DO 7HE WOAK AN�THE S7RI1CTUqE IS NOT INTENDED OR OFFEf1E0 FOR SALE�SEC.7044,BUSI- J NESSAND PROFESSIONS CODE:THE CONTRACTORS LICENSE U1W DOES NOTAPPLY TO AN OWNEfl�F � PpOPERTYN710BUROSORIMPROVESTHEREON,JWDWHODOESSl1CHWORKHIMSEIFORHERSELFOH � + Q THRIXIOHHISORH6iOWNEMPLOYEES.PROYIDEUTHATSUCHIMPROVEMENTSAqENOTINTENDEDOR m ' 0 ,OFFEAEDWR6ALEIF,FIOWEVER.THEBUILDINGOfiIMPROVEMHJTI550LDWITHiNONEYEAROFCOMPLE- - Z 'TION,THE OWNER-BU�DER WILL HAYE 7HE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILU OR � IMPROVEFORTHEPUHPOSEOFSALE). � ❑I,AS ONMER OF THE PHOPEflTV,AM EXCLUSNELY CONTRACTING WITH LICEN3ED CONTRACTORS � TO CONSTRUCT THE PRQIECT(SEC.i0�6,BUSMESS AND PRDFESSIONS CODE:THE CONTRACTbRS LI- V81UHflOf1 ADJAREA � W CEN9ELAWDOE9NOTAPPIYTOANONRJEROFAPROPERTYWHOBUILDSORIMPpOVESTHEREON,AND F WIiOCONTRACTSFORSUCHPflQIECTSWITHACONTRACTOR(S)LICENSEDPURSUANTIDTHECONTAAG QUANTITY DESCRIPTION FEE - Y rons ucerse uw.>. O � ❑IAM IXEMPTUNDEFl SEC. &&P.C.FOR THIS HEASON U 3 � LL' DATE OWNER � z W �q LICENSED CONTRACTOR$DEGLARATION �j [� 1 HEPEBYAFFIfiM UN�ER PENALTY OF PERIURV THAT IAM LICENSEO UNOER PROVISIONS OF CHAPTER � . p� 9(COMMENCIN(i W17H SECTION 7000)OFOIVISION 3 0F TNE�151NESS AND PR�FES=pNS CADE,AND Z ��� MY LICENSE IS IN RCE AND EFFECT. � � UCENSE CLASS � � LIC.NO. ` � H V ppTE �� CONTRACTOR d td WORKERS'COMPENSATION DECLAHATION a � U N I HEREBV AFFRlA UNOER PENAL7V OF PERIURY ONEOFTHE FOLLOWING OECLARATIONS: C/� a � _IHAVEANDWILLMAMTAINACERTIfICATEOFCONSENTTOSELF-INSUREf-0RWORKERS' _ � COMPENSATION.ASPROVIDED9YSECTION37000FTHElABOPCODE,FORTHEPERFORMANCE W OFTHE WOflK FOR WHICH THIS PERMIT IS ISSUE�. � "' _I HAVE AND WILL M,41NYAfN WORKER3'COMPENSATION IN3URANGE,AS RC-0UIRED BY SEC710N jpp' ` Q 37000FTHELABORCO OflTHEPERWRMANCEOFTHEWORKFORWHICHTHISPERMITIS � J 31 � � ISSUEO.MY WORKEflS' PENSATION INSURANp�e,/�'q°}�R�IER AgND POLICY NUM6Efl ARE: CONSTFUCTION � � CARRIER '�`'�'��d'l '$�c.-"'�6! PLAN REVIEW Z aoucvNUMeEa , ELECTRIC ¢ � (R155ECilONNE�I�ATBECCM'LEfEOOF'fHE pYSFo EHUwRmDavAslStao)ORLESS� PLUMBING �W �CERTIFY THAT IN TiE PEAFORMANCE OF THE qK FO WHICH T 5 P MIT IS ISSUE�,I MECHANICAL SHALLNOiEMPLOVANYPEFSON�NANYMANNE $OA OBECO S ECTT07HE � WORKERS'COMPEPJSATIONLAWSOFCAUFOflNI,AN� REETH FIS OULOBECOME INSPE FEE � SU&IECTTOTHEWdRKERS'COMPENSATIONP VI510 OFSEGI' N9700FTHELABOR �SSUANCE � � ��� � COD,I F hl COMPLY WITH THOS PRO ONS. � - o t DATE: � APPIICANT: �P � �� W � J WARNING FAILURE TO SEGURE M�RKERS'COMPENSATION COVERAGE IS NLAWFUL,AND SHALL BE ENERGY P/C � SUBlECTANEMPLOVERTOCHIMINALPENALTIESAN�CIVILFINESUPTOONEHUN�REDTHOUSAND ENERGYPERMIT DOLLARS(S10D.000).IN ADDITION TO THE COSTOF COMPENSATION,DAMAGES AS PROVIDE�FOR IN J SECTION 37oe Of THE LABOR CODE,WTEREST,AND ATTORNEV'S FEES. flETENTION FEE: 7 T A'h.t(lATT1 TZ � CrT���rrri.viarr�n�'' oCONSTRUCTIONLENDINGAGENCY PRE-ALTFEE: BT.�.�..�.�,r. �;£mTv� � IHEREBYAFFIflMUNUER NALTVOFPERJURYTHATTHEREISACONSTRUC710NLENDINGAGENCV � FOR THE PERFORMANC OFTHE WORK FOR WHICH THIS PERMI715155UED(SEC.30s7,CIV.C.). W ' � LENDER'S NAME - ' I— LENDEflSADORESS - . � ICEHTIFYTHATIN EREADTH APVLICA7KKJ�� DSTATETHA HEABOVEINFORMATIONISCORRECT. TOTAL FEES �++���►►//''jj .�q : Q IAGREETOCAMP WITHALL ANDCOUN ORDINANCE AN�STATELAWSRELATINGTOBUILDING ��� �� CONSTRUCTION, DHEREBY UTiORIZERE SENTATNE OFTHISCOUNiYTOENTERUPONTHE Z A60VE-MENTION PROPEH FOFIINSPECT PURP0.SE. COMMENTS - � f � . . �- , m PERMITTEE NAME' ) . �. . � � �� ��t _ ��S � SIGNATURE OF PEflMI DATE 2 . � RECPT.NO. 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