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Home My WebLink About14392 (19) _ � CITY OF DIAMOND BAB i DEPARTMENT OF COMMiJNITY&DEVELOPMENT SERVICES _ a � 21660 E.Copley Drive Suite 190 (909)860-3195 Fax(909)861-3117 PRESS '�'��°�� BUILDING PERMIT APPLICATION FIRMLY o ADDRESS ��-' �(� DATECATION%�:i'7—�� NUMBER�( �� #/C �� ! �� -� � � APN LOT TRACT DATE CONST. GROUP ¢ OWNER ��cn�r�t.�o�o O Q ADDRESS ��`- ZONING SE1'BACKS Z CITY - ZIP TEL.�O��O 1.'�� REART RW � � APPUCANT s TEL. SIDE/SIDE STREET RW ❑ � CONTRACTOR��' ' 76. R`_ �r'. � ;a' r V . SIDE ❑ � ADDN 1`3�P''3 i S� ,_,_��. uo� CA.7��.�._ it� CITY ' ZIP_�� TE �'_ �� PROPOSEDUSE � ARCHlENG/ DESIGNER NO.DWEL. NO. NO. ADDRESS UNITS STORIES BEDRODMS � CIIY —� ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � � OWNER-Bl11LDER DECLARATtON SFR/ADD/REM op l HEREBY AFFIflRI UNDEfl PENPL7Y OF PERRIRY THAT I AM EXEMPT FROM THE' RACTORS LI- G8f8J8/COfPOf[ W CENSEUWFORTHEFOI.LOWINGREASON�SEC.7037.5BUSINESSANOPROFESSIONSCODE:ANVCITYOR (n , U COUNTYWHICHRE�UIRESAPERNITTOCONSTHUCT.W.7ER,IMPROYE,DEMOLISH,ORREPAIRANYSTRUC- W P8110/DBCk WTURE,PHIOR TO IT5 ISSUANCE.ALSO RE�UIHES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNE� W � STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI- CENSEIAW(CHAPTERB(COMMENCNOWITHSECTION7000)OFDNISION30FTHEBUSINESSANDPRO- � POOUSPB fESSIONS CODEJ OR7HAT HE OR SHE IS E%EMP7TWEREFROM AND THE BASIS FOR iHEALLEGED EXEMP- V TKKi.ANYVIOLATIONOFSECTIOti'7039.58YANYAPPLICANTFORAPERMITSU&IECTSTHEMPLICANTTO Z Re-Root � ACIVILPENAL7VOFNOTMOHEh1ANFIVEHUNDflEDDOLIARS(35oo).): � ❑I,ASOWNEROF7HEPFOPERTY,ORMYEMPLOYEESWITHWAGESASTHEIRSOLECOMPENSATION, � �mmercial . � Y(ILL 00 THE WORK AND TF�STRUCTURE IS NOT INTEN�ED OR OFFERED FOR SALE(SEC.70M,BUSI- J NE55 M1D PROFES510NS CODE:THE CONTRACTORS IICENSE UW DOES NOTAPPLY TO AN OWNEfl OF � PROPERTYNMOBWLDSONIMPROVES7HEREON,ANDWHODOESSUCHWORKHIMSELFORHERSELFOR = � THq0Uf3HHISOHHERONMEMPIAYEES,PROVIUEDTHATSUCHIMPROVEMENTSARENOTMTENDEDOR � QOFFEREDFORSALEIF,HOWEVERI'NEBUILDPIGORIMPROVEMENfISSOLDWITHINONEVEAROFCOMPLE- � �TION,7HE OWNER�BUILDER WILL HAVE THE BURDEN OF PROViNG THAT HE OR SHE DID NOT BUILD OR IMPROVE FOFi 7HE PUHPOSE UF SALE} ❑1,AS OYMER OF THE PROPEHTY,AM IXCLUSNELY CONTMGTINO WITH LICENSED CONTRACTOR3 d Ttl CONSTRUCT THE PRQIECT(SEC.7W4,OUSINE55 AND PROFESSIONS CODE:THE CONTRACTORS LI- VaIt18I1011 ADJ.AREA W CENSEUWDOESNOTAPPLYTOANOWNEROFAPROPERNY/H06UIL�SOHIMPROYE57HEREON,AND � V/FIOCOMRACTSWRSUCHPA0.IECTSWtfHACONTRRCTdq(5)LICENSEDPURSUANTTOTHECONTRAG QUANTI7Y DESCRIPTION FEE Y TOp51JCENSEUW.J. ¢ J ^ ❑I AA1 EXEMPT UNDER SEC. B.&P.C.FOR THIS REASON U S � u' DATE OWNER_ V W Qe{ UCENSED CONTFACTORS DECL4RATIGN � IL I HEREBYAFFIFW UNDER PENAN OF PERNRV THAT IAM LICENSED UNDER PROVISIONS OF CHAPTER +'�,�'" a, Y(COMMENCINCi WIiH SECTION 7000)OF DIViSION 3 OF THE BUSINESSAND PROfESSIONS CODE,AN ,. ,,. Z X MY UCENSE IS IN FULL FORCEAND EFFECT. (�� " 0 LICENSE CLASS �� LIC.NO. � V �' m y��„ , ! ~ �ATE_ �i . � CONTRACTOR 11rr F� �W ae� ` WORKERS'COMPENSATION DECLARATION ¢ ' � � iNEREBYAFF�RMUNDERPENALTVOFPERJURYONEOFTHEFOLLOWINGDECLARATION: � t 0 _IHAVEANDWILLMAINTAINACEHTIFICATEOFWNSENTTOSELFINSUREFOA HKERS' - � � COMPENSATION,AS PpOVIDED BY SECTON 370o OFTHE IABOp COOE,GOR PEflFOR/�ANCE `U OFTHE WORK FOfl WHICH THIS PERMIT IS ISSUER s'" -- 0 � � W ,i HAVEAND WILL MAINPRIN N/ORKERS'COMPENSATION INSUflANCE,AS REqU1RED B7 SECTIOf�w"`�N � Q 37ooOFTHEtABORCb6FFORTNEPERFORMANCEOFTHEWORKWAWHICHTHISPER,pq1PIS iSSUED.MY WOPO(EAS'ClOMPENSATION INSURANCE CARFIERAND POLICV NUMBEF � O�NyS-�TR�U ION ___ .____ jcnacuEn - �'f / ��C�!�'� �/ � PK9ft�YR�VIE � POLICYNUMBEH �' � E ECTRIC � � ((ttlSSECf10NNE�N0T8E�LETmOFhIEPERlN'I'lSFDRONEF0.N�DRED (51ao)ORL PLU - � I CERTIFYTHAT IN7HE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSU , MECHANICAL � �" �f � SHALL NOT EMPLOY ANY PEF4SON IN ANY AAAtJNEft SO AS TO BECOME SUBJECT TO THE `fj WORKERS'COMPEN5AT10NLAWSOFCALIFORNIA,ANDAQREETHATIFISHOULDBECOME INSPECTIONFEE SUBJECTTO T.HE WOflI(ERS'COMPENSATION PROVISIONS OF SEGTION 37DOOF THE LABOR ��J� 1-= ISSUANCE n�r � � 9q_ . CODE,I SHA ORTHWITH COMPIY WIiH TMoSE PROYISIONS. � p DATE:{�':��1� APPLICANT: � �`_ SMIP p�� ENEflGY P/C�$�3 J WARNING:FAILURE TO SEWRE WORKERS'COMPENSATION GOVEFAGE IS UNLAWFUL,AND SHALLBE 7y � SU&IECTANEMPIOYERTOCRIMINALPENAL7IE5ANOCMLFWESUPTOONEHl/N�REDTHOUSAND ENERGYPE��dB'[y�7!v �SAlll£!Aa-var...._ D�LIARS(S1UO.00oI,IN ADDITION TO THE COST OF COMPENSATION,�AMAGES AS PHOVIDED W R IN �V�Yz� � SEC71oN a�oe OFTHE LABOR CODE INTERESi AND ATTORNEI"S FEES. RETENTION FEE: 2 d CONSTRUCTION LENDING AGENCY PRE-ALT FEE: O � 1 HERWYAFFlF�1 UNDER PENALTV OF PERJURV THATTHERE IS ACONSTRUCTION LENOING AGENCY Z FOR THE PERFOPMANCE OFTHE WORK fOR WHICH THIS PERMIT IS ISSUED(SEC.3097,CIV.C.). �� I.LI � LENDER'S NAME F— LENDER°SADDHESS � ICERTIFYTHATIHAVEHEADTHISAPPLICATIONAN�S7ATETHATTHEABOVEINFORMATIONISCORREC7 TOTAL FEES w I AGREE TO CAMPLY WITH ALL CITYAND COUNTV ORDINANCES RND STATE LAWS REl.A71NG TO BUILDING � CONSTRUCTION.ANOHEREBYAUTHORIZeREPRESENTATIVE50FTHI5COUNTVTOEMTEHUPONTHE � ZABOVE�MENTIONED GROPERN FOR INSPECTION PURPOSES. COMMENTS - n ��J�i/t s�,9 /'� � ��`,' ,�,.�,R,r.e QPERMITTEE NMIE(PHI� ' � °��`� ;sr�� SIGNA7UREOFPERMITTEE DATE _ � AECPT.N�. 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