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HomeMy WebLinkAbout12994 (13) i, s � CITY OF DIAMOND BAI� `� I �� ' — DEPARTMENT OF COMMU1vITY&DEVELOPMENT SERVICES -%'� , i I 21660 E.Copley Drive Suite 190 � / � (909)860-3195 Fas(909)861-3117 �l,� PRESS '9K'�r BUILDING PERNIIT APPLICATION FIRMLY � 0 ADDRESS ��4a ��r I�S �1�� - DATEICATION`2- `�-�� NUMB R �`� #/C � o� ISSUE 7YPE OCC APN lOT TRACT DATE CONST. GROUP °C OWNER � � p ADDRESS ` ZONING SETBACKS Z CITY ZIP TEL. � FRONT RW ❑ � �, APPLICANT • TEL S DAE/SIQE STREET RW ❑ � CONTRACTOR C � /r f1 � SIDE ❑ a �- ADDRESS PROPOSED USE�___ ' � CfTY.Sd. /t"C. /7�10lrt�IP E . ` � � o ARCN/ENG/ � z DESIGiVER � a AD�RESS NO.DWEL NO. NO. ( � ' UNITS STORIES BEDROOMS � CITY 21P TEL. � �' DESCRiPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION ' � ._O; OWNER-BUILDER DECLARATION .. . SFR/ADD/REM - _ 1 HEREBY AFRRM UN�Efl PENALTV OF CE0.IURY THA7I AM E%F.MPT FROM THE CONTRACTORS LI- Gafa98lCatpOrt � -W;' CEN9EUWFOR7HEWLLOWINOREA90N(5EG7W7.5BUSME39ANOPROFESSIONSCO�E:ANYCINOP _(/� j U; COUNfVWHICHRE�l11RE5APERMITTOCONSTRUCT,ALTER,IMPROVE,OENOIJSH,ORREPAiRANYSTHUC- . W PdlIOI(�BCk � ���_: TURE.PflKKi TO ITS I&4UANCE,AL50 REQUIRES THE APPLICANT FON SUCM PENMIT TO FILE A SIGNED _� STATEMEN7 THAT HE OR SHE IS IiCENSED PURSUANT TO THE PROVISIONS OF THE CONTPACTOflS l4 ���� CENSE lAW(CHFPTEA e(COMMENGNG WITt15ECT10N 7000)OF DIVISION 3 OF THE BUSIN:SS PND PRO- � U' PooUSpa ; �--�` FESSpNSCODEJORiIiATHEORSHEISE%EMPTTHEREFROMPNDTHEBASISFORTHEALLEGEDEXEMP- , (� . � . TKKJ.MIYVIOLATIONOFSECTIIXi7a91.5BYANYpPPUCANTfORAPERMI7SU&lECTSTHEAPP�ICANTTD Re-Roof -.�; A CIVIL PENALTY OF NOT MORE THPN flVE HUNDRE�DOLLARS(55W).): � Z - I� ❑I,ASOWNEROfTHEPROPERTY,ORMYEAIPLOVEESWITHWAGE5A5THEIR50LECOMOFNSATION COmnl0fCi31 - - - VALL 00 THE WORI�AND THE STRUCTURE IS NOT INTENDE�OR OFFERED FOR SALE(SEC.7094 BU51 'n -.�� -�-�x' NE55 M1D PROFESSIONS OODE:THE CONTHACTOAS LICENSE lAW DOES NOT APPLY TO AN OWI.ER OF -µ� : PROPEflTYWHO@UILb50RIMPROVESTHEREON,ANDWHO�0E55UCNWOHKHIMSELFORHERSELFOF j m -�<�- TMiWGHHISORHEROWNEMPLOYEES,PHOVIDEDTHATSUCHIMPROYEMEMSARENOTINTENDEDOR- -.�; OFFENEOFORSRLEIF,HOWEVEi�TNEBUI�OINGONIMPROVEMB�1T15501_OWITHINONEYEAROFCOMPLE- BI7 - -_.�- YION,TNE OWNEREUILDEfl WILL HAVE THE OUR�EN OF PqOVINO THAT HE OR SHE D:D NOT BUIID OR - . - ,�:, IMPHOVEFORTHEPURPOSEOF3A�E). __�-. ❑I.ASOWNEROFTHEPFOPERTY.AMEXCLUSIVELVCONTRACTINOWRHLICENSEDCONTR0.CTORS ��-' TO WNSTRUCT THE PROJECT(SEC.7044,BUSINESSAND PqOFE3310NS CODE:THE CONTqACTORS LI-- VeI1/3t10� ADJ.AREA -:W,- GENSELAWDOE3NOTAPPLYTOANONTdEflOFAPROPERTYWHOBUiLDSORIMPROVESTHEREON.PND -�- �.Vh1OCONiMCT6FOflSUCHPRQIECTSWITMACONTRACTOR�S)LICENSEDPUflSUANTTOTNECONTRAF pUANTITY -DESCRIPTION FEE -�� -TOHS IJCENSE UWJ. /� � � ❑1 AM IXEMPT UNDER SEC. �'� B-h P.G FOR THIS REASON -; Q N HQ F� - ;.�_ - . .` C� . .� ; -[C /N �� - ��UATE OVNER -_ U 'Z_ � .. � . .. .j-o. LICENSEDCONTAACTORSDECLARATION - s` � - � .-� -�� i HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I A.0 LICENSEO UNDER PROVISION3 OF CHAPTEfl - � _ ,-(L-.. 9(COAIMENCINOWITHSECT�ON7000)OFDIVIS!ON30Fh1EBUSINESSANDPPOFES510NSCADE,Ah� - Z -}�- R1Y UGENSE IS IN FULL FOflCEAND EFFECT. /. � �4 ��!- - m_ . . . _. ���- LICENS.E�CLJgSS O`ZO' UC.NO.- � U. x � - DATE�[ cONTRACTOFI- � : a- W- A - ��- - WORKERS'COMPENSATIONDECLARATION ���E'l - Q . � �� � �� � _-��- IHEREBYAFFIRMUNDERPENALTYOFPER&JRVONEOF7HEWLLOYJING�ECiARATIO��f �-' Z /} � u � ` '/ C� .� .O-_ v IN�VEANDN9LLMA�NTAIfiAGERTIFICRTEOFCONSENTTOSEIf-INSUREFORti�ORKERS' - _ .� '`-_� COMPENSATION,ASPROVIDEOBYSECTION37000FTHElABDHCODE,FORTHEPERFORMANCE _ W OFTHEWOPKFORWHICHTHISPEFltAITiSISSUED. ; � � � "-W _IHAVEANDWILLMAWTAINWORKER3'COR!PENSATIONINSURANCE,ASHEQUIREOBYSECTIO`7 � _Q 37000FTHELpBORCODE,FOflTHEGERFORMANCECFTHEWORi(fORWHICNTHISPERM1T15 � ISSUED.MY ER5'C9 TION INSUflANCE CARRIER f�YD POLICY NUMBERA E: CONSTRUCTION ¢ � ���' 2'n.rU�.e�n C� C� . �_-�� caaaiEa PLAN REVIEW -0- PIX.IGYNUMBER ^' ELECTRIC 1 - �;. __0;_ (f}iISSECf10NHE�tJ�iBECUJFLfTEDOFINEPERMfTISFOaIXJEMNARED�aW1S(ftt� } PLUMBING :Z� ICERTIFYTNATINiHEPEFFORMANCEOFTNEWORKFORWHIGHTH15PERMITI515SUED.I MECHANICAL :-C�'- SHALLkOTEMPLOYANYPEftSONINANYMANNERSOASTOBECOME5U9JECiTOTkiE �'� -� .:'�� WOHKERS'CAMPENSATIONLAWSOfCALIFOflNIq,pNDAGREETMATIf�SHOULDBECAME INSPECTIONFEE `�- Sl1BJECTTOTHEWORKEflS'COMPENSAiIONPROVISIONSOF5ECT10N3looOFTHEIABOR - :�_ CODE,ij`'HALLFORTHWITHCOAIPLYWITHT V ION �l/ ISSUANCE __.__ `O' ,�) /t��qG' �GG�ri+�---^� SMIP "Ip- DATE: � APPLICANT: �._-J_. WAflNING�FAILUFETOSECIJREWORKEHS'COMPENSATIONCOVERAGEISl/NIAWFUL,ANDSHALLBE ENERGVP/C -��--�- -SU&fECTANEMPLOYEflTOCRIMINALPENAI.TIESANDCIVILFMESUPTO04EHlJNDRE�THOUSAND ENERGYPERM DOLL4HS(5100,Wo).IN AI7DITION TO iHE COST OF COMPENSATION.DAMAGES AS PROVIDE�FOR IN �--� --J�- SEC710N37000FTHELABOHCODE,INTEflEST,AN�ATTORNEYSFEE3. RETENTIONFE�Y7 �< ' t �.W-� lJ - v �_.;r`•:3 r,,., • .�. CONSTRUCTION LENDING AGENCY PRE-ALT FEE: _:I_ -:::0- — ----- -- - ._:�-_ IHEREBYAFFlRMUNDERPENALTYOFPERJURYTHATTHEREISACANSTRUCTIONLENDINGAGENCY FONTHE PERWRMANCE OFiHE WORK FOq WHICH THIS VERMIT IS ISSl1ED(5EC.3097.CIV.C.�. .:�__.W� /�`"�— _-`� LENDER'S NAME - '.�g- LENOERSADDRE55_ / J� '�-`�� �CEPTIFVTHATIHAVEPEADTHISAPPLICATIONANDSTATEThIATTHEABOVEINFOPMA�ION�SCOPRECT. TOTALFEES a • V -`W IAGREETOCAMPLVN7THALLCITVAN�COUNTVORDINANCESAN�STATELAWSRELATINOTOBUILOING q CONSTRUCTION,PNDHEREBYAUTHORREqEPRESENTATNESOFTHISCOUNTYTOENTEPUPONTHE - _�Z ABOVE-�IONE PROPERTYFORINS�jPURPOSES. 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