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HomeMy WebLinkAbout13641 � �� � CITY OF DIAMOND BA� � DEPARTMENT OF COMMUNITY&DBVELOPMENT SERVICES � _ : _� 21660 E.Copley Drive Suite 190 (909)86(�3195 Fa�c(909)861-3117 PRESS � ��'9�°�f� BIJILDING PEI2MIT APPLICATION •.; _ FIRMLY � JOBSITE APPLICATION PERMIT P/C o ADDRESS ���a� ���+C� DATE L �4 NUMBER # � ISSUE TYPE OCC �- APN �OT�,�-�-- TRACT DATE CONST. GROUP p OWNER iCCYIt� �` ADDRESS ZONING SETBACKS z CITY ZIP TEL. Gl�� a FRONT RW ❑ � g APPUCANT� y TEL. REAR ❑ � SIDE/SIDE STREET RW ❑ t CONTRACTOR ' f SIDE ❑ ¢ ADDRE S i� I � h � CITY 21P TEL. PROPOSED USE o ARCH/E G/ - r Z DESIGNER W NO.DWEL. 1 N . NO. Q ADDRESS � y UNITS � ORIES � BEDROOMS N CITY ZIP TEL. � tn DESCRIPTION SO.Ff. FACTOR PSF ADJ.AREr1/1/ALUATION Q OWNER-BUIIDEfl DECLARATION SFR/ADD/REM � O ' p I HEREBY AFFlflM UNDER PENALiY OF PERIURY iHA7 I AM EXEMPT FpoM iHE CON7RAC70R5 LI- Ga�age/Ca�port W CBdSEL4WWii7HEFOLLOWW�REASON(SEC.7031.58USINESSANOPRO'.ESSIONSCADE:ANVCITVOP (/� U. COUNfYWHICHHEIXIIRESAPEflMITTOCONSTRUCT,ALTER,IMPROVE,DEA!OJSH,ORREPAIRANYSTflUC- W P31i0/DBCk W TURE,PRIOH TO ITS ISSUAFICE,ALSD REQUIRES THE APPIICPNT WH SUCH NEHMIT TO FILE A SIGNEO W STATE6IENT TNAT HE OR SHE IS LICENSED PURSUANT TO 7HE PROVISIONS OF THE CANTRACTOFS U� �- CENSE UW�CFiAPTER 9(COMMENCiNG WITH S[CTION 1aCo)OF DIVISIOY 3 OF THE BUSMLSSAND PRO- LL PooVSpa - FESSpNSCOOE)ORTHATHEORSHEISEXEMPTTNEREFROMANDTHEB/SISFORTHEALLEGEDEI(EtdP� � TION.ANYVIOLATbNOFSECTION7031.5BVANYAPPLICANTFORAPERMITSU&/ECTSTHEAPPLICANTTO Z- Re-Aoof � � A GNL OENALT'OF NOT MORE TNAN FNE HUNDRED DOLLAFS(S5oo).): �_ ❑I,ASOWNEROFiHEPROPERTV,OflMYEMPLOVEESWITNWAGE5A5THEIRSOLECAMPENSATION, � Commercial � NIILL DD THE WORK,A.N�TNE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC.7044,BIJSI� J � NESS AND PROFESSIONS CODE:YHE CANTRACTORS LICENSE LAW DDES NOTAPPLV TO AN OWNER OF ? PiOPEflTY V/FIO BUILDS OR IMPii0YE5 THERC-0N,AND WHO DOES SUCH WORK HIMSEIF OR ifER5ELF OA � THROUGFIHI50RHER0\4NEMPLOYEES,PROVIDEDT}IATSUCNIMPROVEMENT5ARENOTINTENDE�Ofi m .�� OEFERW WRSAlE1F,HOWEVE0.7ME8UILDINGORIMPROVEMENTiSSOLOWfTHINONEVFAHOFCOUPLE Z- -TION,THE OWNER$UILDER WILL HAVE TriE BUFiDEN OF PROVIN6 TF1AT HE OR SHE DID NOT BUIID OFi _- IMPROYEWRTHEPURPOSEOPS/LLE). - W_ ❑I,ASOV.TIEROFTHEPfiOFERTY,AMEXCLUSIVELYCANTRACTINGWITHIICENSEDC�NTRACTORS -� TO WASTRUCT iHE?HOJECT iSEC.704a,BUSINE55 ANO PflOFE5510NS CODE:THE CONTRACTORS U� V21U8Ii0lt ADJ.RREA W: CENSEUWWESR'DTAPPLVTOANOLVNEROFAPHOPEflNWti96U�LDSORLiSPflOVESTHeREON,AN� ��. NM1pCONTRACTSFORSUCHPROJECTSWIlHACONTRACTOR(S)JCENSEOFURSUANTTOTHECO4TRAG � QUANTI DESCRIP710N FEE - ._�_ TOflS 110ENSE LAW.). . . . . J ❑1 AM EXEMPT UNDER SEC. B_&P.G FOR THIS R.EASON . Q � i- V � � — � OATE OWNER � � W ��_ - LICENSED COiVTRACTORS DECLARATION �� I- -�:- I tiEREBY AFFIRM UN�ER PENALTY Cf PEft.:URY THAT I R!.1 UC��SEC U4�[f?PIlO:".5!OtlS Of CN.AF?E(1 ' � j �d. 9(COA!MENGNG WITH SECTION 700J)O�DIVISION 3 OG TME 6USMESShND PFUFE5510Y5(:ODE.AND Z _X_.. 1AY LICENSE IS Ih'FULL FOp E AND EFFECT. _ m W � ;0 LICENSEC 5 °� UC.NO. . . . � ��� � :�.j J -} V.: DATE__ ��___—CONTRACTOR . d � W; -.�- WORKERS'COMPENSATION DECLARATIGN Q `�; (� `� U -��- IHEftEBYAFFlFIAUNOEHPE4AlTYOFPER.IURVONEOFT}iEWLlOWiNGDECL4RATIONS: 7�'�� �A. (i y :C>: IWlVEeVdbWILLMAMTNkACERTifICA7FQF�NSENTYOSELF-INSUREWRNlOHI(eR5' �� _ - .-�- COMPE1eSATION,ASPflOV1�FABY3EC1'tON3lo00FTHELA90RCOD[,FORTHcPEFlFORMANCE W - OF Tt1E WONK FOR WHICM THIS VERMIT IS ISSUE9. � W� �I HAVE AND WILL MhIMAIN WORKEHS'COMPENSATION INSURANCE,AS P.EQUIflEDBY SECTION //�� �/ � --Q 37000FTHElA80RCODE.FORTHEGERFOflMRIiCEOFTHEYJOAKFORWH:CHTHISPERMITlS � �/ J {� -�: ISSUED.MYWOFiKEFlS' MPEN ION�NSUARNCF.CARHIERANDPO:ICYNUMBE9AFE � . CONSTRUCTION `'� � �""� � / J' ; -�` cnaaisa .-/ ' PLAN REVIEW `�-__ POLICYNUMBEfl � EIECTRIC � �ss[t'na�r�fl�horee�EhoeFn¢aEta+ar�sroAavEFnx�ottEocounas� a�on�Essa PLUMBING - - �- W� I CERTIFYTHAT IN THE PERFtlRNM10EOF THE WORK FOR WHiCH THIS PERMIT IS ISSU'eD,l MECHANICAL �" - - - '�' '�, � SHALLNOtEMPLOYANYPEflSONINANY6IANNER50A5T08EGOMESU&IEGTTOTHE -. - - :Uj•_ WORNERS'COMPENSATIotJLAYlSOiCALItORN14,AN0AGREETHATIFISH0ULD8ECOME INSPECTIONFEE�a SU&IECTTOT EWORKERS'COMPENSATIO� P4iOVISfONSOF CTION3]ooOFTHELA80R �f« �-� � � - --5,_ COgE,ISH F flTHWITHCOMPlYW1THT�OV1510 �, -1 ISSUANCE L '�[- . /� rIR d. / . �p:_ DATE: `� � APPLIGANT: ✓��CiF�/ SMIP -�` - ENERGY P/C �--�'. WAflNING:FAILUflETO SECUFE WORKERS'COMPENSATION CA RAGE IS UNIAWFUL,AND SHALLBE ,_J'. - -=-�y,:" SU&IECTANEMPLOYEHTOCRIMINALPENAUIESANDqVIL SUPTOONEHUNDFEDTHOUSAND ENERGYPERMIT �: : DOLLARS(fi00.000j.INAODITIIXJTOTHECOSTOFCOMPENSATION.DAMAGESASPROVIDEDFORIN ;J:. SECTION3708OFTHELABORCODE,�NTEREST,ANDATTORNEY'SFEES. RETENTIONFEE: �' ;-��; CONSTRUCTION LENDING AGENCY PRE-ALT FEE: O: -'-��� IHEREBYAFFIPMUNDERPENALTYOFPERJURYTHATTHEPEISACONSTqUCT10NLEN�INGAGFNCV -- =�'- FOR THE PERFOflMANCE OF THE WOFiK FOR WHICH THIS PERMIT IS ISSUED(SEC.30W,CIV.C.). - Z- _:LLF —___—_________--___ Ts LENDER'S NAAIE __.. �—'_'---'---- :.S`_ �_F—" LENDEWSADDflESS _ ��-�:- ICERTIFYTHATIHAVEREADTHISAPPLICATIONANDSTATETHATTHEABOVEINFOflMATIONISCOPRECT. �OTAL FEES + �-W- IAGREETOCOMPLVWITNALLCITYANDCOUNTVORDINANCESANDSTATEL4WSRELATINGTOBUILDING - ��� GONSTRUCTIO4,AN EREBYAUTMORREREPRESENTATIVE�OFTHISCOUNTVTOENTERUPONTHE � .Z' PHO �ME 770NE PERTY fOR I SPECTION PURPO ES. COMMENTS O- � J. 7 I � -m PEflMITTEE NANE�PRINn / ' �' LG __.-�- SIGNATUREOFPERAIITTEE �A := RECPT.NO. PAID BY VALIDATION `~ WHITE—�epartment Copy.YELLOW—Finance Copy,PINK—Assessor Copy,GOLAENHOD—File Copy,GR N—ApplicanCs Cvpy � ' € ��� _ ._ ' _ i _. 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