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HomeMy WebLinkAbout11862 CITY OF DIAMOND BAI+i ----1�� DEPARTMENT OF GOMMUNITY Bc DEVELOPMENT RVICES � 21660 E.Copley Drive 5uite 190 , ;,� (909)860-3195 Fax(909)861-3117 PRESS ���' � BUII.DING PERMIT APPLICATION � � � FIRMLY �— __ -- / . — ; r_ p� JOBSITE .*`)J► I /1 � �QC�r� �� , APPLICATION ' j �/ PERMIT `�� ADDRESS���T �-� DATE a NUMBER # c� ISSUE TYPE OCC APN LOT TRACT , DATE CONST. GROUP °C OWNER � ��t_I ILl�s�'`Yl�(�-V�P Q� � ADDRESS�� �SLCJD�Ciffl ZONING SETBACKS W CITY - ZIP�(7(��i TEL. FRONT RW ❑ � APPUCANT �? , S c�Z,��_ TEL.��Z.C�� REAR ❑ SIDElSIQE STREET RW ❑ � CONTRACT R SIDE ❑ ¢ ADDRE, - 4 1 � CITY � k C G. ZIP `�t' L'�r3 TEL. ` � PROPOSED USE oARCHlENG! z DESIGNER N0.DWEL. NO. NO. a ADDRESS �`�, � CIN ZIP TEL. UNITS STORIES BEDROOMS c�i�' DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREA/VALUATION �_ OWNER-BUILDER DECLARATION - SFR7ADD/FIEM O :0_ 1 HEREBV AFAPM UNDER PENALTY OF PERJUHY iHAT i AM EXEMPT FROM THE CONiRACTORS Li- GfffflgO/CBIpOf[ - W. CENSEUWFOHiHEiOLLOWMGHF.ASON(SEG7o31.5611SMJESSANODROFESSbNSCOOE:ANYCITYOR (n _ .U- COUNT'(WHICNpEQUIRESAPEflMITTOCONSTRUC7,ALTER.IMPqOVE,O[IAOLISH,ORREPAIRANYSTRUC- : �jJ patio/Dack -_W: IUP.E.PflIOR TO ITS�SSUANCE,ALSO AE-0UIHES THE APPLICANT FOfl SUCH PEfiMIT TO FILE A SIGNED � W . - STATEMENT TNAT HE OR SHE IS LICENSE�PI1HSl1ANT TO iHE PROYISIONS OF THE CONTPACTOR3 L4 -�- CENSE LAW(CHAPTEP 9(COMMENCINO\NTH SECTION 7000)OF�IVISION 30FTHE BUSINESS ANO PR0 `� PooUSpa .�. PESSpNSCODE)OATh1ATNEOH5NEI5EXEMPTTHEHEPHOMANDTMEBASISFORTHEALIEGEDEXEMP• . _ TION.ANYVKKATIONOFSEC710N7037.5BVANYAPPLICANTfDNAPERMITSUBJECTSTHEAPPLICANTTO �--Z R8-ROOT - _ -F__ ACM6PENALTVOFNOTMOREiHANFNEHUNDREDDOLLARS(SS00).): - ❑I,�150WNEROFTHEPR�EPTV,ORMYEMPLOYEESWITMWAGESASTHEIflSOLECOMPENSATION,-- �� � COfI1fI1BlCI8I � - _�_ WILL00 7HE WORK AND THE STRUCiURE IS NOT INTENDEO OR OFfERED FOp SALE(SEC.7044.BU51- _J NESS AND PHOFESSIONS OD�E:iHE CONTRACTORS LICENSE LAW DOES NOT APPLY TO Ml OWNER OF -�- PROPEflTYY/F10BUM1D50RIMPROVE3TNEREON,ANOWF40DOE33UCHWORKHIMSEIFORHERSELFOR -�� - - ��' -THROUGHHI50flNEROWNEMPLOYEES.PROVI�EDTHRTSUCNIMPROVEMENTSARENOTIN7ENOE�OR- '-m- - - . _Q' ,OFGEHEDFORSALEIFFiOWEVER11iEBUIl01NGORIMPROVEMEMISSOLDWITHINONEYEAROFCOMPLE- :Z._ '=iION,-lHE OWNEfl�BUILDER Will HAVE THE BURDEN OF-PROVING TNAi HE DR SHE O�D NOT-8111L0 OR � �-_. IMPROYEWHTHEPURPOSEOFSALE). . - ❑I,AS OWNEROF THE PROPEflTV,AM EXIX.USIVEIYCOMRACTING WI7H LiCENSED OONTRpCTOF3- . �_�� :-TOCONSTRUCTTHE PRDJECT(SEC.7oN,BU5INE55 AND PFOFESSIONS CODE:TNE CONTRACTOHS ll- � VdlUdtlOn ADJ.AflEA - - -1i1-= -GENSELAWOOESNOTAPPLYTOANONRJEROFAPftOPEftT'MMOBUILDSORIMPROVESTHEREON,AN� -�:=- --NM1IOCOHTMCTSFORSIkNPqoJECTSWI7HACONTRACTOR(S)LICENSEDPURSUAMTOTHECONTRAG QUANTITY DESCRIPTION FEE -. TORSIJCENSEUW.�. . ���-- ❑i AM IXEMPT 11NDER SEC. 8.&P.C.FOR THIS REASON - Q O> V �'- �-�:-. DATE OWNER Z ' w _ -_��- _ _ LICENSEDCONTRACTORSDECLARATION �. WI I :.�� IHEflEOYAFFIRMUNDEflPENALTYOFPEfiRIf1VTHATIAMLICENSEDUNDERPROVI510k50FCHAPTER _-. � � •l�e BjCOMMENCINQWITHSECTICN�aao)OFOIVISION30FTHE8USMESSANDPflOFE5510N5CODE,N:D Z _� _X_ IAY I.iCENSE IS fN GULL FORCE AND EFFECT. ' m L1J �j� � • � ( ,��� LICENSECLASS ��`�-� IIC.NO. i' J . - . ;� "�V_ DATE CONTRACTOH - a : W ��� ` :.1- -�� - - - - - WORKERS'COMPEN5ATION DECLARATION .j�:�t�_ __ Q . . . .. . .. . .. . .. . . . ... . .. �= U �-�� IHEHEBYAFfIRMUNOEHPENALTVOFVERIUHYONEOFTHEWLIOWINGDECLAfUT10��J - C�- ZQ =.L]= 14AYEANDWiLLMAMTAINACERTIFICA7EOFCONSENTiOSELF-MSUREFORWORiCcqS' 2 :�` COMPENSATION,ASPROVIDEDBYSECTION37COOFTHELABDRCO�E,FORTHEPEPWRMANCE . W O iHE W�HK FOR WHICH 7HI3 PERMIT IS I55UE0. � W' - IHAYEPflDWILLMAINTAINWORKERS'WMPENSATIONINSURANCE,ASREWIREDBYSECTION -Q'. el00OFTHELA90RCODE,FORTHEDERWRMANCEOFTHEWOflKWRWHICHTHISPERMITIS - ��l: ISSUED.MY WORKERS'COM 3AT10N INSURANCE CARRI AND POLICYNltMBER A j CONSTRUCTION ::¢` - ��`� .��. PLANREVIEW .-�. CARRIER O. POLICYNUM9Efl . - " N ' /�� EL� . ���- (THISSECfIONNE�NOTBE�+9LETEDaFTHEPEPDM6FOi10�dEFiLY�REU00ltl3t5(5100)Og LF�G PCUMBING 0 //� W� ME�CAL -_z; ICERTIFYTHATINTHEPERFORMANCEOFTH6WORKFORWHICHTHISPERMITISISSUE j� S . . ��:[f_ SHALLNOTEMPLOYAMYPERSONINANYMr1NNER50A5TOBECOMESIJ&IECTTOTHE - - : '.�. WORKERS'COMPENSATIONLAWSOFC0.LIFORNIA,ANDAGREETHATIFISHOULOBE E 1NSPECTIONFEE `- SU&IECTTO THE WORKERS'COMPENSATION PROVISIONS OF SECTI��N 370o i H F . - - �.�j�- CAOE,ISHALLFORTHWITMCOMPIYWITHiHO . VISIONS. ISSUANCE A, "Ok SMIP JUIY l. v-��; - -:'p;- DATE: APPLICANP . . ENERGY P/C r�r. T,�T R R��} .-J> WAflNWGFAILURETOSECUREWORKEflS'COMPENSATIONCOVERAGEISUNLAWfUL,ANDSHALLBE . �'7�I+�SR���9f�" - - -�y;: SU&IECTlWEMPLOYER70CRIMINALPENALTIESANDGVILFINESUPTOONEXUNDREDTHOU3AND ENERGYPERMIT :t��T!'� AT�SAT'GTV � . :,_}� OOLLAqB(Si00,000J,INAD�iTIONTOTHECOSTOFCOMPENSATION.DAMAGESASPROVI�EDFORIN �<�ji+Lu�Q-�sl :.:-.J: SECTION97oeOFTHElA80RCODE,INTEREST,ANDATTORNEY'SFEES. - RETENTIONFEE: _.::��_ . __'_ ;a: CONSTRUCTION LENDING AGENCY PRE-ALT FEE: i 0` �.-�;�;- IHEPEBVAFFlFMUNDERPENALTVOFPERJURYTHATTHEREISACONSTRUCTIONLEN�INGAGENCV -�-�-�- FOR THE PEflFORMANCE OF THE WORK FOF WHICH THIS PERMIT IS ISSUED(SEC.30W,CIV.C.i. - Z=. 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