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HomeMy WebLinkAbout13887 (14) �� CITY OF DIAMOND BAB � DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES � 21660 E.Copley Drive Suite 190 �� � PRESS � ������ BUILDING PERMiT APPLICATION FIRMLY N JOBSITE APPLICATION y PERMIT l P/C o ADDRESS_z'� 2�'� ���''�� +a r� � DATE_ ��'"-� -- Gf �3� NUMBERr� # � ISSUE TYPE OCC APN LOT__ TRACT__ DATE_ CONST. GROUP � p OWNER ^��T'T Y� , — -- "" ADDRESS 7- � I ��VI��f S'(' ZONING SETBACKS w CITY 1�. (�'• ZIP�� I"��� TEL:�-Ss�IG-�' � °� FRON'i RW LJ � APPLICANT i/_k��1iil.i 1M.A7Fif TEL.�:j.e'.? .:'�7/�i!-. REAR __ r] � SIDE/SIDE STREET RW ❑ CONTRACTOR �F'�I�'' t "- �hl�'�1�� SIDE L:] � ADDRE.SS G`/�'r�''in r�•�� < V'�s -#��a'7 �-"'�'�'. '9F' �(5 'Vo.�..j vJuv� �y ti .t' , � CITY l�s-[r Mvni'f'F. ZIP�[.�_�1 TEL.E-:-"7�d--�"�4.Si PROPOSED US ( � ARCWENG/ '' IJ�f T e� .- 5 �r,y�� ,?9�l�SVCt � DESIGNER -- _____ NO.DWEL. NO. NO. ADDRESS .� UNITS � STORIES __� BEDROOMS � CITY_ LIP TEL. __ —_ y N �ESCRIPTION SQ.FT. FACTOR PSF ADJ.ARErWALUATION O. OWNER-�3UILDEH DECLARATION SFR/ADD/FEM ` '�i T '� ' ��. �- I H[REBV AFFRM UNDER PENALTY OF PERJIIhV THAT 1 M1 EXEMPT FROM THE CONTRACTOHS LI- G8f0$JBICflfpOR <: ' � CENSEUWFORTHEf-0LLOWIN6flEA50N(SEC.7P31�BUSMF:SS0.NDPftOFESSlO?15CODL:ANYCITYOfl , (� COUNTYNM1IICHRE�UIHESAPERWITTOCONF�TRUCT,ALTER.iMPROVE,OEMOLISH,ONREPAIRANYSfFil1C� ' �{,J patiolDeck ' W TUHE,GRIOR TO 1T9155UMlCE,AL50 RE�UIRES THE APPLICANT FDfl SUCH PEflM1T TO FILE A SIGNED . W � � S7ATEMENT THAT NE OR SHE IS LICENSED PURSUANT TO TME PROYI510N5 OF 7ME GONTRAC70PS U� - � CENSE LAW(CHAVTER 9(CAAIMENCING Y�ITH SECTION 70ao)CF�IVISION 30F THE OUSINESS AND PRO- � POOI/Sp3 FESSIOHSOODE)ORTHATHEOfl5HEi5EXEMPTThiEfl[FftOMANDTHEUASISFORTH�r.ALIEGEDE%EMP- ��: � p �V TION.ANYVKKATIONOFSECTION7031.SBYANVAPPLICANTFOPAPERMITSUBJECTSTNF:APPLICANTT9 , Z RB�ROOf y y" ACIUL PENALTY OF NOT MORE 7HAN FIVE HUHDRED DOLUIRS(f500).�: .I r~+,� I74ASOWNEflOFTHEPROPERYV.ORMYEMPI.OYEFSWITHWAGESASTHEIRSOI.fCOMDENSATION, ' ❑ CORIfilBfCi�I ' ; � WILL DO TME WORK,AND TME SiRUC7URE IS NOT INTFNDED OR OFFERED FOfi SALE�SCC.7044,BUSI� , J _ _ � NESSAND PiiOFESSIONS COOE�7HE CONTMCTORS UCENSE LAW UOES�'OT APPLY TO AN OWNER OF � � ��� ��"i�� PROPERIY WtiO BUILO6 OR IMPROVES THEfiEON,AND N'h10 OOES SIJCH WOHK HIMSELF OR HERSELF OR ' �� iHRC11GHHI50RHEROWNEMPWVEE5,9ROVIDEUTHATSUCHIMPflOVEMENTSAflENOTINTENOE�OR ' m1 , W� OFFEREDFORSALEIF,HOWEVERTMEBUILDINGORIMPROVEMENTISSOLDWITMINONEYEAHOFCOMPLE- Z TION.TH[OWNER-B110_DER WILL HAVE hiE BUHDEN OF PqOVING TlfAT HE OR SHE DIO NOl'B1111D OR � IMPROVEFORTMF.PUflPO5EOF3ALE). �� f.71,ASOWNEROFTHEPROPERiY.AMEXCLU5IV&LYCONTRdCTIN6WITHLICENS_DCONTRACTOHu � '� ,��' �TO CONSTRUCT TH[PRQIECT(SEG 70t<,BUSWESS ANO PROFE5510N5 CAU[:'fHF WMTRACTOflS LI- ' VdlUefiOn ,..,._._.___ ___ADJ.AREA ______ '� ��W:. CEN9EUh'DOESNOTAPPLYTOANOWNFROFAPROPERTYWHOBUILDSCRIAIPROVESTHLREON,AHD = --� �� WFqCONTMCTSFORSUCHFfiQ1FCT5WITHACONTRACTOR�S�UCENSE�?UflSUANT'fOTHECONTRAP QUANTITY DESCRIPTION FEE _Y TORS IICENSE UW.). I � J O CJIAMEXEMPTUNDERSEC. __,._._....____._.B.&P.C.WRTHISftEASON�. �; Q�_ � � . �. V . ... � ,.... . � - - -------- ._ ----- r a V"'.. DATE OWNER___'_.____ F� ---_� 'Z.� _-__'_-_ � ' W — _ ' �� LICEhSED CONTRACTORS UECIAFhTiON : u� F. �*, ,�-, 1 HER54iV AFFlRA!IINDER PENALTV PF PF.RIUI:Y THAT I AIA UCENSED UN�EP PROVISIONS OF CI�IAPTEH � �i I -- � .'p�,; 8(C06�MENCIN6 riITH SECTION 7a00)OF DIVISION 30F THC OliSMFES AND PROFESSIONS CO�E.h�D .� Z � .i?G�� MYLICENSE IS IN FULI�OflCEAND F.FFECT. �` m ( �.��. LICENSE CIASS__ �` ���__ LIC.N0.____��� .J' ! � � ' j . -- _- �..V� DATE !�i� ��� CONTRACTON�_��"�.�r�' r '. � .W. �'^� �_..__- �� -�_ --��1"� OFKERS'(:pMPEiVSA710N DECLRRA7IUN �v ' ,S - .�;,, � .. U� - Ny I�VAFFiRM PENALNOF7ERIURVONEOFTMEFOLLOW:NGCIEGLNflATKJNS: ..ff).i� � ]� '� Z _ � ��a�� _iHMEANDWILLMAINTA!NAGE�7T�FICATEOFCONSENTTOuELF-I(VS�REFOFlWORKEP^u' � --__ COMPENSATIOK.AS YFUVIOED BY SECTION 3700 OF THE LA6GR CO�E,(=0N THE PF.RFORMANCE , W � "�: OFTHEWOPKFORWHICMTHISPF.HMITISISSUED. — '.Q' � � ��"��„'-=r�'„ - _____ r F, _IHAVEANDWILLMAINPAINWORKCFlS'CAMPFNShTI0YiN5UiiANCF.,ASf?k:UUiFlEDHVS�CTION .&..,('..,,q�,j'� �:Q� 1]ooOFTHELA90RCODE,FOR7NEPERFORNANCEOFTHEWORKrORWNICHTHI,SP[FiNIT15 ,�, ISSUED.MY WOfl,,Ke�ERS'COMPENShTION INSU(iANCE CARRIER ANU PULICV NUMOEH ARE: .: CONSTRUCTION _____��.�_..��_._,_ '��' cAaAiea--_3�L�-��--��.�.r'4I � -- ---...... �� PLAN REVIEW . ��..; m — , a. - . 3' i�� . _. ..._. '�0• PouCYNUMeER_._.�_���_.�.'.--�--- " ELECTRIC , �"��4� �? ,..._. Z; ' �' f�'a!�a,.� " ... Q. � p � (nis navHGFvrao'rsEc�,wFrr:ocKn+ic+�w.�r'sra�eHetax�[�a�o0ouws�S+mloa�Ess�. � PLUMBING �--1if���` p--E�-(ii-k4 -_ ... w MGCHANICAL ����k� �+ �+� ..` •. r �. � Z I ERTIFY 7HA7IN THE oEF1FORMANCE OF THE WOR�C fOR WHICH THIS PEfiNI"f IS ISSU[0,I -..--�--wE�:;P.I�_ „r �T�--I,,�� --- .,, �r(_j' . ALLNOTEI�PLOVANVPERSONiNANYMAYNFRSOA5TOF3[CAMESUDJECTTOTHE ' �?(� RKERS'COMPENSATION LAWS OF ClLLIYORNIA,AND AGF'tE 7HAf IF I SMIOl/LL1 HECOMF. "' INSFFEC�ION FEE ___...__.._. _- _._._— - 5U&IECT TO 7HE WOLIKEHS'COMPENSATION PFOVISIONS OF SECTION 3700 OF THE.l A[30R . � �E� ~ �COO[,I SHAII.FOftiHWI1N COMPLY WiTN THOSE PROVISIONS. ISSUANGE ._....._..._ .__�._.__ :.p DAYE:�__�J APPLICpNT: _.._'.�,�,� � � �'�_.~� :� SMIP t�� w FNERGY P/C J WAflNING FAILUR['f0 SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWfUI.,AN�SHAIL BE ------"-"""' '-"-'---'---'"---'---""----"' `J ��LL SU&IECTANEMPLOYERTOCi11MINALPENALTIESAN�CIVILFINESUPTUONEHUNDHWTHOUSANU ,' ENERGYPERMIT DOLUf1S(fI0D.00f1),INAODITIONTOTHECOSTOFCOMPENSATION,DAMAGESASPROYID'cDFOAIN � ---'--"""-'-"""""-"'---'--"""---""""--"""'--"' '� SECTIONa7UBOF7HELABOFCO�E,INTEREST,ANOATTORNFYSFEES. RETENTIONFEE: -_ ___'..--._..."_"_._..... ___'_'_""" �-d CONSTRUCTION LENDING AGFNCY � PRF•ALT FEE� ---....-----------..____ _....------ - �Q1 HEREBV AFFIRAA UNDER PENALTY DF P[RJUfiV TMAT THEflE IS A CONSTRUCTION L[ND!NC AGENCY �` FON THf:V[RFORAAANCE OFTHE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.3097,CIV.C.�. ' - ��� � Z,,W _ __'....___.'_-- _"— _ �:�� LEN�ER'::NAME_._.._._._ ..._--"_ ___"__-- ,. ��1- LEN�EH'SADURESS_ "_-'_"' '_"-""_'__- � �CENTIIYTHATIHAVEflEAUTHISAPFLICATIONAND57A'fF.ThIATTHEABOVEINFORMATIONISCOR(7ECT. TOTAL F�ES W IAOREETOCOMVLYWITMALLCITYANDCOUNTYOPDNANCESANUSTATCLAWSRELATINGTOBUILDINO ;:5�=' ' � CONSTRUCTION,ANO HERF.BV AUTHORIZE RF.PfiESENTATIVES OF THIS COUNiV TO FNTER UPON THE ZAE30VE-MF.NTKKJEO PROPEHTY FOR INSPECTION PUflPO5E5. COMMF_NTS _._______.._.-._____ � . J _'_---'_""" _ _-'-'__ __"" '—'__- '......___"_— m PEiiMITTEENAME(PRINT) . ---".-..- - -�'-"--- d . - "-'- � -- � -----"- � �� �-� - ---- ----- - -- -- � SIGNANFEOFPEAMITTF.E DATE ' ' �- ' _ . s = RECPT.N0.- .---- PAID BY __._........_...---.-- ~ WHITE-Dapartment Copy.YELLOW-Finance Copy,PINK-Assessor Copy,GOL�ENROD--File Copy,GREEN-ApplicanYs Copy � . . ......a _....'.' f L j. - i � � i i `� r i t �-� R '� �sa � t �- � - ' i ' I J` q�. ; �� � a� x �'� t i . ; � � � �f� �y : . F� � + � , __ ... 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