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HomeMy WebLinkAbout12626 (11) � '� CITY OF DIAIVIOND BA& ��� I --��� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES � 21660 E.Copley Drive Suite 190 �, (909)860-3195 Fax(909)861-3117 PRESS ( °�° BUII.DING PE1dMPr APPLICATION _ FIRM�,Y ± d D�RiESS �� L� � ����� � APPLICATION PERMIT i PIC p DATE �� '�'��� NUMBER I��� # ����� � APN LOT TRACT �SSUE t TYPE . OCC � �����D�,� DATE 1� ��'-9� CONST. GROUP p OWNER ; " ADDR S Ti S .�.� E�O.� ZONING SETBACKS z CITY /R�p✓� ��.G-f TEL. ^ OS FRONT pW ❑ � g APPLICAN7 L� ��</�►"' TEL � ^ T' REAR � 3 � SIDE/SIDE STREET RW C] c� CON7RACTOR �� ���/�I �� vG77 SIDE ❑ �u ADDRESS G �' ��• j � CITY �I-� �ll��- ZIP /'T TEL.� � y PROPOSED USE ��'� - � TO�.j`1'-/_ �t w- ARCHlENG/ � � f( / o;Gdl _ nvc,asi z DESIGNER W` ADDRESS — NO.DWEL NO. NO. �; CITY ZIP TEL. UNITS STORIES BEDROOMS �;; ur DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION ;:Qt. OWNER-BUILDERDECLARATION SF �� M '3 , � 0 - 1 HEREBY AFFlRM UNDER PENALT'/Of PEqIJRY hIAT I AA7 EXEMPT FROM hIE COMflACTORS LI GaragelCarport �� `W- COVSELAWWRTFIEf-0IIOWINGREASQI(SEC.7037.58USMESSANDPROFESSIONSCOOEANYCITYOR �(f� -� „-�,. CIXINTYWHICFIflEIX1IRESAPEflMRTOCON3TRUCT,AITEP,IMPROVE,�EMOLI5H2ORfiEPAIRANYSTNUC ::.�j,J Pa110�8Ck - TURE.PFiIOR TO It5155U1WCE,AL50 REWIftES THE APPLICMIT FOR Sl1LH PERMIT TO FILE A SIGNED ��W-`- $TATEMENT TiAT HE OR SME IS LICENbED PURSURNT TO THE PROVIS�ONS OF THE COMRACNq5 U- � -" � `-�� CENSE UW(CFIAPTER 9(COMMENCINQ WI7H SECTION 7000)OF�IVISION 90FTHE BUSINESS AN�PRO- `� PooVSpa � - - � ,�- FES810NSCODE)OATHATHEOqSHE1SEXEMPTTNEREFflOMAlJDiHEBASISFORTHEALLE6EDEXEMP _ TION.ANVYIOLATIONOFSECTION7a31.5BYANYAPPLICANTFOqAPEHMITSU&IECTSTHEAPPLICANTTO Re-Roof ,L?Q -Q'� `'} ,_�; ACML PENALN OF NOT MORE TNAN FNE NUt�RED OOLLAHS(S5W).): - t ❑I,AS OWNEFOFTHE PROPERTY,OR MY EMPLOY�ES WITH WAGESAS TNEIq50LE CAMPEN5ATION - ---j . Y/ILL DO THE V10FlN,MID THE STRUCTURE IS NOT INTEf�AED OP OFFEPED FOR SALE(SEG]aaa,Bt1Sl �-�� Commercial - ::�; A � �, NE33 AND PROFESSIONS COOE iHE COMTMCTOflS UCENSE tAW DOES NOT APPLY TO qN OWNEfl OF - q �� - VROPEqTYW110BUILD80RiMPROVES7HEflEON,ANDWHO�OESSl1CHWOHKHIMSELFOflHERSELFOR � � ��J V�.C�P� ap �� `�.�� -THROUGHHISOflHEROWNEMPIOYEES,-PROVIUEDTHATSUCHIMPROVEMENTSARENOTINTENUEDOR k CO c:Qx ;.OFFEHEDFORSPLEIF,HOWEVER,IHEBUIL0INGORIMPROVEMENTI5501,DWffH!NONEVEAflOFCOMPLE ._Zi `TION,THE OWNER�BURDER W1LL HAVE lHE BURDEN OF VROVWG TNAT HE OR SHE DID NOT BULLD OR� <- - . . . . . . _ . _� :IMPf�YE FORTME PUflPOSE OF SPLE). }; ❑I,AS OWNEROF TME PHOPEFTfY,M1 EXCLUSIVELYCONTRACTIN6 WITH LICENSEO CONTflACTORS '-�� �-TOCONSTflUCT THE PR0.JECT(3EC.t048,BU91MES5 AN�PROFESSIONS CODE:THE CONTflACTOqS LI -= VaW2ti0� ADJ.AREA �--Wt -_CENSELAWOOESNOTAPPLYTOMlOVMEROFAPflOPERTYWHOBU1LbSORIMPROVESTHEPEONAND -- �-_, �NM1tOCONTRACTSFORSUCHPRQIEC7SWITHACONTpACTOR(S�LICENSEOPURSUANTTOiHECONTRAG � QUANTITY DESCRIPTION FEE ~ "TORSUCENSELAN.j. c.- __� -�OY �.- 0111MIXEMPTUNDERSEC. 8.6PC.FORTHISREA50N �. Q ✓�� L�d •��� 3. ,' " � �.S' C� •� � � :` _�v OATE OWNER _w vj�'I ���`� V i �� -,���. LICENSED CONTRACTORS DECLARATION - W - ��`- !HEflEBYAFFlRM UNDER PENAI.TYOF PERIURY THAT I0.M IICENSE�Ut�DER PROVISIONS OF CHdPTER R_ � _p„_� 8(COMIAENCINOWITtiSECTION70ao)OFDIYISION30FTHEBUSINESSANDPROFESSIONSCADE,AND k._ Z -:� �4 MYLICENSEISMNLLFORCEANDEFFECT. y -:�-. LICENSE CLASS- � �4��� ` � LIC.NO. �: �- i "w5 oarE ��"0 —`I8 CONTRACTOfi�' l.�fCGN�/� m• a .� :�-� WORKERS'COMPENSATION DECLARA710N - Q � � '-�N�_ -IHEREBYAFFIHMUNDERPENA6TYOFPERIURVONEOFTHEFOLLOWINGDECLARATIONS: Z _j , i�. `IHAVEANDWIIIMAINTAIMACERT�FlCATEOFCONSENTTOSELF-INSURFFOHWORKEFS' _ � �`�-_ COMPErySATION,0.5PqOV�EDBY9ECT10N970oOFiHELABORCOD[.FORTHEPERFORMANCE W OF TME WORK(-0R WNICHTHIS PERMIT IS ISSUED. � � � : �HAVE AND WILL MAINTAIN WOflKERS'COMPENSATION INSURANCE.d5 REQUIRE�BY SEC710N - 'Q, 37000FTNElABORCODE.fORhIEPERFORMANCEOFTHEWOHK'rORWHICHTHiSPERM17�5 - ��/s��—��9 � - '� ''��' ISSUED.MY WOry\2��1 JS'C_'�OMPENSA'�TION-INSUF3AMC6CARRIER/Ml�O POLICY NUMBEflAAE: NSTRUCTION Jy r « �-}T� CARRIEH " + ' _ ����I NREVIEW�, �^' � /�y y ; -�� POLICY NUMBER I I-'�' TRIC � /-�L,J _�_� �4�� , _—_- !, :a (iHi3sECnONNE�NDTBE00AYLETEDOFh�PEfih9TISFORONE DOl1AH5(5��)ORLESSa PIUMBING .vW . . � Z- ICERTIFYRiATINTHEPEflFOPMMICEOFTHFWORKFOfl CHTHISPEHMITISISSUED.I MECHANICAI � C� - �:SHALLNOTEMPLOYANYPERSIXJMIANYSAMINERSOAS BECOIJE3U&IECTTOTNE � WORKERS'CDMPENSATIONLAWSOFCALIFORNIA,AN SHOIILDBECOME INSP NFEE SU&IECTTOTHEWORKEFS'COMPENSATIONPRO SOFSECTION OOOFTHELA80N i� /f$/oq ' � __ � =O- CODE,I SHALL/FyRtTNW�TH COMPIv WITiTHQS VI5 NS. ISSUANCE CS 6tc� � � --I :-p'. DATE:`�y�� ��APPI;ICAM: . �SMIP __ a } i f �J--WARNING FAILURETO SECUqE WORKERS'COMPENS f COVERAGE ISUNIAWFUL,AND SHALLBE ERGY P/C ' �- � � .-�y -SU&IECTANEMPLOYERTOCRqA1NALPENALTIES ILFINESUPTOONEHUN�flEOTHOUSAND ' ,/� (�q� ��� �a) ,. - DOLL4RS�S700,000),INAD�ITIONTOTHECO3T0 PENSATION,DAMNCESpSPFWIOE�FORIN ENE V l'-- � �"'"�q -�J- SECTION 3]oe OFTHE LABOq WDE,1NTEREST, ATTORNEV'5 FF.ES. ION FEE A*� AU �t'�Cf �.�. pW._� CONSTRUCTION LENDING AGENCY pRE- • F DIC11viOND BAl\ �" B►,�[„DIlVG AND SAFETY --- -- � -_•.�t. IHEREBYAFFIRMUNDEAPENALTlOfPERJUqVTHATTHEREISACONSTRUCTIONLEN�MGAOENCY FOF7NE PEqFOPMANCE OF 7HE WONK FOR WHICN TMIS PERMIT IS ISSUED(SEC.3097,qV.C.). �. -:_-�- LENOER'SNAME � � � F-- LENDER'SADDRESS �'�� ICERTIFYTHATINAVEflEADTHISMP ATIONAN�STAT ATTHEABOVEINFORMqTKKJISCORRECT. � TOTAL FEES �� � �- � � �� I �- IAGREETOCOMPLYWITHALLC NDCOUNTYOR01 CESANOSTATEL4WSRELATINGTOBUILOING �- WNSiRUCTION, HEREB hbR2ERED ES IVESOFTHI5COUNTYTOENTEHUPONTHE . 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