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HomeMy WebLinkAbout15302 (19) „v,� > CITY OF DIAMOND BAI� '������ � ^--��-- DEPARTIvIENT OF COMMUNITY&D�VELOPMENT SERVICES � � � �C� �' f � 21660 E.Copley Drive Suite 190 (909)860-3195 Faz(909)851-3117 PRESS ""''",, FIRM�Y - __.. TION -- .DIN „ APPLICA � . ._ ,., ,,.� � .'dNUMBER::I �.:;�. , .,;�:. ��.�, JOBSITE �� I /'�/)1-A1s1 r �^ DATE CATION��� PERMIT � Q P/C M1, , � ADDRESS I,�r•-t��� � APN LOT T T �SSUE TYPE OCC � DATE CONST. GROUP g OWNER � ADDRESS ZONING SETBACKS w � CITY ,�i�,�'!✓LC�.N� �Y �TEL. FRONT RW ❑ APPLICANT TEL. REAR � � SIDE/SIDE STREET Ryy p CONTRACT SIDE � � ADDRESS P� ,,,� � CITY_�-�.L ZIP TEL. ) PROPOSED USE o ARCH/ENG/ � DESIGNER NO.DWEL. NO. � CDDRESS Z�P TEL. UNITS STORIES B DROOMS � DESCRIPTION SQ.Ff. FACTOR PSF ADJ.AREANALl1ATION p� OWNER-BUILDER DECLARATION p SFR/ADD/REM p 1 NEREBV AFFlPoA UNDEP PENALTV OF PERJURV THAT I MI EXEMM FROM THE CON7RACTORS U- Gd�3gB/C8 fI W CENSELAWFORTHEFOILOWINGqE4SON(SEC.7031.6&JSINESSANDPROFESSIONSCOOE:ANVCITVOR (n � C� COUNTYWHIqiRE0U1REgAPERMITTOCONSTRUCT,ALTER,IMPROYE,DEMOL'EH,ORREPAIRANY57RUG W pa(i0/DeCk � TUHE.PRIOR TO RS ISSUANCE.QSO REUUIRES THE MPLICANT FOR SUCH PERMIT TO FILE A SIONED � STATEMENT TFihT HE OR 3HE IS LICENSEO PURSUANT TO THE PROVISIONS OF THE CONTRACTORS U� � CENSE LAW(CHAPTER e(COMMENCINO WITH SECTION 7WO)OF piVISION 3 0F THE BU51NE55 AND PqO� � PooUSpa FESSpNSCODE�OR7HATHEORSF1E15EXEMPTTHEFEFROMqNOTHEBASISfORTHEALLEOEDb(EMP• (� TION.ANYVIOLATqNOFSECTION7031.5BYANYAPPLICANTFORAPERMITSl1BJECTSTHEAPPUCANT70 Z pe_q�} � A CML VENALTY OF NOT MOqE THAN FNE HUNDRED OOLUqS(5500�.J: O ��.ASOMMEROFTHEPHOPERTY.ORMVEMPLOYEESWITHWADESASTHEIRSOLECAMPENSATION, Comm9fCi81 . Z WILL DO THE WORK.AND THE STRUCTURE IS NOT INTENDED OR OFFEHEO FOR SALE(SEC.70ta,BU&I� O � NESS AND PROFESSIONS CODE:THE CONTRACTOqS LICENSE LAW DOES NOT APPLY TO AN OWNER OF ? PROPERTY VNW BU0.DS OR INPROVES TFIEREON,AND Vh10 DOES SUCH WORK HIMSELF OR HERBELF OH � TMROUGH HIS OR HEH ONRJ EMPCOVEES,P{1OV10EDTHAT SUCH IMPROVEMENTS ARE NO7INTENDED OR m � ,OFFEREDFORSALEIF,HOWEVER7NE0UIlDIN00HIMPHOVEMENTI550lDWRHINONEVEAROFCOMPLE• Z 710N,THE OWNER�UiLDER WILL NAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT 6UIL0 OR � IMPtbVE PDH THE PURPOSE OF SALE). W ❑I,ASOWNEROF7HEPROPERfY,AMEXCLU5IVELYCONTRACTINGWfIFIUCENSEDCONTRACTORS � TO CONSTRUCT THE PHQIECT(SEC.7os4,BUSINESS AND PROFESSIONS CO�E:THE COMRACTORS LI� ValufltlOrl ADJ.AREA W CENSEUWDOESNOTAPPI.VTOMlOWNEROFAPPOPERTYWFIOBUILDSORIMPROVESTHEHEON,ANO � WFqCOMRACTSWRSUCHPROJEC7SWITHACONTRqCTOR(S)LICENSEDPURSUANTTOTHECONTpAG QUANTITY DESCRIPTION rops uc�sE uw.�. FEE 0 ❑I AM E%EA1PT UNDER SEC. 8.8 P.C.FOR THIS REASON Q ?,�, U � DATE OWNER !— � U LICENSED CONTRACTORS DECLARATION W � I HEREBYAfFIRM UNDER PENAL7V OF PERJURY 7HAT IAM LICENSED UNOER PpOVISIONs OF CHAPTER �, Q � O(C01A1AENCINO WITH SECTION 7000)OF DNISION 3 0F THE BUSINESS AND PROFESSIONS CODE,AND z �X� MY IICENSE IS IN FULL L'ORCE AND FFECL _�p� /� m ' � ' ,`. `� �1 ! �� � � 11 � UCENSECLASS LIC.NO. � V DATE � CONTRACTOR d W � WORKERS'GOMPENSATION DECLARATION Q � IHEREBVAFFlRMUNDERPENALNOFPERIURYONEOFTHEFOLLOWMCDECLARATIONS: Z � IHAVEANOWiLLMAINTqINACERfiFICATEOFCONSENTTOSELF-INSUREFORWORKERS' 2 Q C�APENSATION.ASPROVIDEDBYSECTION37000FTHELABORCODE,FOFTHEPERFORNANCE W Q �CTHE WORK FOR WHICH THIS PERMIT IS ISSUED. � � _I HAVE AND WILL MAINTIIIN WORKERS'COMPENSATION INSURANCE,AS REOUIRED 8Y SECTION � 370o OF7HE LABOR CO�E,f-0R TME PERFORMANCE OF THE WORK FOq WHICH THIS PERMIT IS ISSUE�,MYVIOq ER5COM SATIONII��SUPANC CAqRIE ANDPOLICY BlKAqE: CONSTAUCTION /� I � CARRIEH C.�'° � �� - PLAN REVIEW � aouCYNUMBER � � ” _ � ELECTRIC � (Ri�sSecnotaN�raoTeE��ooFn�ErEantt'�swqaaEFurnAeo �SlooiotiLEss} PLUMBING f Z ICERTIFYTHATINTHEPERFORMANCEOFTHEWORKFORWHICHIHISPERMITISISSUED.1 MECHANICAL �t— SHALL NOT EIAPIOY Y PERSON IN ANV MANNER SO AS TO BECOME SUBJECT TO THE (/� WORKERS'COMPE SATIONLAWSOFCALIF OAGREETHA7IFISHOULDBECOME INSPECTIONFEE S SUBJE TO THE RKERS'COMPENSATI PROVIS OF SECTION 370o OF 7HE LAB ...-"- �r CADE, SHALLF LJjHITHCOMPIV WITH ose ovis Ns. ISSUANCE r T� .a —L�. � O fe�l p OATE: r�ti APPLICANL W � WARNING:F�LURETOSEIXIREWORKERS'COMPENSA710NCOVERAGEISUNLAWFUL,ANDSHALLeE ENERGYP/C �� �y SU&IECT�INEMPI.OVERTOCRIAfINALPENALTIESANDCIVILFINESUPTOONEHUNDREDTHOUSANO ENERGYPERMIT OOLLARS(f100.00oJ.IN AODITIdJ TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN J SECTION 3�oe OF THE L480R CADE,IN7EREST,ANDATTORNEV'S FEES, OC RETENTION FEE: T+Mr v-� n.r,r'�wm ri�� O � CONSTRUCTIONLENDINGAGENCY PRE-ALTFEE: ��_�r����` � 1 HEREBV AFFlRM UNDER PENALTV OF PERJURV THAT THERE IS ACONSTqUCTION LENDINd AGENCV ' FOF THE PERFOPMANCE OF THE WORI(FOR WHICH THIS PERAIIT IS ISSUED(SEC.309�,CIV.C.). Z W � LENDER'SNAME_ F— LENDER'SADDRESS W ICERTIFYTHA7IHAVEREADiHISAPPLICqTIONANDSTATETHATTHEA80VEINFORMAT10N15CORREC7. TOTAL FEES ^-�, JS d 1AGREETOCOMPLVWITHALLCIT/AN�COUNTVORDINANCESANO ATEIAWSRELATINGTO9UILDING +/' "" , � CONSTRl1CT AN�HEREBVAUTHORIZEREPRESENTATIVESOFT ISCOUNTYTOENTERUPONTHE �� Z AeOVE-M TION FOPER'TYFORINSPECTIONPV OSES. COMMENTS � _! / .,,�.,,�,.►. ,s�'^y —` _ m PERMITTEE NT) - ... Q N � SqNATUREO RMITTEE ATE , - � RECPT.N0. 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