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HomeMy WebLinkAbout14504 (20) � � CITY OF DIAMOND BAB DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES 21660 E.Copley Drive Suite 190 �;n (909)860-3195 Fa�c(909)861-3117 PRESS '� ��"�� BiJII:DING PERNIIT APPLICATION. ____ __ FIRMLY `} � - - -------- � o� JOBSITE ��/ �S"l��������� DATEICATION �,, � �i� NUMB R I � #/C ADDRESS (er d� $ ISSUE TYPE OCC APN LOT TRACT DATE CONST. GROUP °C OWNER �D i .� o ADDRE T `�r^ ✓�y� ZONING SETBACKS W CITY / ZIP ` �'� TEL. FRONT RW ❑ � � -APPLICANT "� TEL. REAR ❑ � SIDEISIDE STREET RW ❑ CONTRACTOR SIDE ❑ � � ADDRESS PROPOSED USE o CITY ZIP TEL._ _ o ARCH/ENG! Z DES�GNER NO.DWEL. NO. NO. �` ADDRESS UNITS STORIES BEDROOMS �; CITY ZIP TEL. �` DESCRIPTION SQ.Ff. FACTOR PSF ADJ.AREA/VALUATION �° � _-O--_ OWNER•BUILDERDECLARATION SFR/ADD/REM 'p-, I HEREBY AFFlflM UNDER PENALN OF PERJURY iHAT I AA1 E%EMPT FROM THE CONTflACTORS LI- G8f8QB/Caf(Mrt W--- CENSELAWFORTMFf-0LLOM/INGNE440N(SEG�0.91.58USINESSANDPROFESSIONSCODEANYCITVOR ._ (n � - -U- COUNiYWHIGHREIXIIRESAPERMITTOCONSTRUCT,PITER,IMPftOVE,�EMOIISH.ORREPNRANVSTRUG � W Patio/Dack - a -Z-. TiJflE.PflIOR TO IT3133UANCE,/LL50 REQUIRES TME APPLIGANT FOfl SUCH PERMIT TO FlLE A SIGNED ; W � _�� STATEMENT THAT HE OR 3HE i3 LICENSEO PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI- � � CENSELAW(CHAPTE98(COMMENCINOWRHSECTION7000jOFDIVISION30FTHEBU51NES5ANOPRO- ' LL PooUSpa _�` FESSq1�5OODE)OR 7HAT FIE OR SHE IS FJ(EMPT7MEREFHOM ANO7HE BASIS FOR THEALLEGED EXEMP• 710N.ANYVIOLATiONOFSECT10N7031.58YANVAPPLICANTFORAPERM1T5U81ECT5THEAPPLICANTTO �- Z Re-Roof ;�_ At�V16PENALNOFNOTMORE7FWIFNEHUNDREDOOt6ARS(55ao).): . :j ;�: ❑1,/4SOWNEROFTHEPflOPERTY,ORMYEMPLOYEESWITHWAGE5A5TMEIR50LECAMPEN5AT10N, �0- COtil(IIBfCIdI ' . ' -..Z�_ WILL DO THE WOPo(PND THE STRUCTllRE IS NOT INTENDED OH OFFERED FOR SALE(SEC.7044.BUSI- :1 NESS MY1 PflOFESS10N3 CODE:THE CQNTMCTORS UCENSE LAW�OES NOT APPLY TO AN OWNER OF � �'. .PROPEflTTYMOBU1LO50RIMPflOVESh1EflEON.ANDVMO00E55UCHWOflKMIMSELFOflHERSELfOR -m . �-�_ TFtliOUGHHISORHEBONMEMPLOYfES.VROVIOEDTHATSUCHIMPROVEMENTSARENOTIMENDE00R -W� OFFEqEpFpq5ALE1FHOWEVEiliHEBUILDMQORIMPROVEMENTISSOLDWf�HINONEVEAROFCAMPLE �'�- -T10N,THE OYYNER-BUIfAEfl V/ILL HAVE THE BUflDEN OF PHOVINO THAT HE Oq SHE DID NOT BUIID OP - . _j IAIPqOYEWRTHEPURPOSEOFSALE). - � - - ❑1,AS OWNEROF TME PROPEHfY,AM IXCLUSIVELV COMNACTING WITH L�CENSEn CONTRACTORS :_�y _TO CONS7RUGTTHE PHOJECT(SEC.7oat,BUSINESS AND PROFESSIONS CODE:THE CAMRACTORS U � VdIU8fI0f1 ADJ.AREA 'W -CENSEIAWDOEBNOTAPPLYTOANOWNEflOFAPROPER7YWHOBUILD50HIMPROVESiMEREON,AN� . i�F twacoKrancrswasucHcaaEcrswm�nconraacToa�s�ucEus[oauasu,wrroniEcatrat�c QUANTITY DESCRIPTION FEE ' roRs uc�se uw.�. s ❑ItJA IXBdPT UNDER SEC. 8.&P.Q FOR7HIS HEASON °- U � f ��`�� � ^ - .�,� : ' . Q � � �. !/f -Z _DATE.,.!^' )�"�D('7/�� OWNER �., W ' . - . r-� .y t �Q� LICENSED CONTRACTORS DECLARATION � - �f'": ' tu �' ;�•. I NEflEBY AFFIRM UNDER PENALTY OF PERJURY TH�T I AM LICENSED UNDER PftOVISIONS OF CHRPTER � . . :(L- 9�COAIMENCINOWfIHSECTION7000)OFDMSION30FTHEBUS�NESSANDPROFESSIONSCODE,AND ',l�;:_ MY LICENSE IS M FlR.L WRCE AND EFFECT. _m W ;� x •� � ,:�y UCENSE CUSS —LIC.NO. '.J __ ��j'.-- DATE CONTflACTOF - n. W -�--- '_�; WORKERS'COMPENSATION DECLARATIQN ` � �. U, . . . �. '�`. I HEREBY AFFlRM UNDER PENALTY OF PENUPY ONEOF THE f-0LIOWING DECLARATIONS y' Z y � Q � 0- __lHAVE.VAVJILLAL4!NT/UNACERI'IFlCATEOFCONSEMTOSELF-0NSUREFORWOHK'cflS' _ �,� - COMPEHSATION,ASPROVIDEOBYSECTION37000FTHElA60RCOUE,FORTHEPEHWftMANCE ,- `U . OFhiEWORKFORWHICHTHISPERMITi51S5UED. � g W� _ _I HAVE AND WILL MAIMAIN WOIi11Efl5'GOMPENSATION INSU�ANCE,AS RE�UIRED BY SEGTION i_O€ 37aoOFTHELABORWDE,WH7MEPERFORMANCEOFTHEWORKWRNRiICHTHISPERMInS ""�� � - ISSUED.MY WORKERS'COMPENSATKKJ MSURANCE CARRIER AND POIICY NUMBEHAFE: CONSTRUCTION � <>�. c�qp�Ep PLAN REVIEW , -0• POLICYNUMBER ELECTRIC �_._�Fy ..�. > (�}{��(,'ipNt�pp7gEaAPLETmpF'(HEpEpAffISFORONEF0.h�DREDDOLLMS(5100)ORLE55�. PLUMBING >�a' 0_ �-W� - ICERTIFY7HATINTHEPERFOflMANCEOFTHEWORKFOHWHICHTHISPERMITI5155UEP.l MECHANICAL Y :Z :(!S:` SHALL NOT EMPLOY ANY PERSON W ANY MANNER 50 AS TO BE�ME SUB.IECT TO THE - , --�_ N'ORKERS'COMPENSATION LAWS OF CALIFoflNl0./1ND AGREE THAT If ISNOULD eECOME INSPECTION FEE S'. `- 9U&IECTTO THE WORKERS'COMPENSATION PFIOVISIONS OF SECTION 370a OF THE LABOR '�'i�° � -� 1 ,-_s,_ �COOE.ISHALL.FOflTNWITHCOMPLYWITHTHOSEPROYISIONS ISSUANCE ,�^ � -.�^. . . .SMIP �,s����i. � - - -p.- OATE: APPLICANT: - �W` - ENERGYP/C �E,3�5 '�� - J-� WAHNINO:iA1LUHETOSEC�REWOPJ(ERS'COMPENSATIONCOVERAGEISUNLAWFUI,ANDSHALLBE J�� 91&IECTANEMPIOYERTOCPIMINALPENALTIESANDCMLFINESUPTOONEFIUNDREOTHOU3MlD Y�-��` OOLLAflS(51oo,00o),INADDITIONTOTHECASTOFCOMPENSATION.DAMAGESASPHOVIDEDFORIN ENERGYPERMIT -Ji SECTION 37oe OF hIE LABOH GODE,INTEREST,AND ATTOflNE'I'S FEES. - RETENTION FEE: a.�_ '`W� CONSTRUCTION LENDINGAGENCY PRE-ALT FEE: 'e n.= ;+',O'. �-Q: IHEREBVAFFIflMUNDERPENALTYOfPER/URYTHATTHEfiEISACONSTPUC710NLEN0INGAGENCY ____ '-n-: f-0HiHEPEflFORMANCEOFTHEWORKFOFWH�CNTHISPERMITI&ISSUE�(SEC.309'l,CIV.G). - `Z` W� Ts IENDER'S NM1E — }, �-.t-< LEN�ER'SA�ORESS "�¢' ICEflTIFVTHAT�HAVEREADTHI5A07LICATIONANDSTATETHATTHEA60VEINFORMATKKJISCARfiECL � TOTAL FEES - 1 AGREE i0 COMPLY N1TH Pll CITI AND COUNTY ORDINANCES AND STATE LAWS RELATWG TO BW LDMG � CONSTRUCTION,PN�HEREBVAUh10flIZEREPRESEMATNESOFTHISCOUNNTOENTERUPONTHE � ABbVE-MENTIONE�VFOPERNPoRINSPECTWNPURP0.SES. 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