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HomeMy WebLinkAbout11991 __�a CITY OF DIAMOND BA� C �%'/ DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES -� #. � . 21660 E.Copley Drive Suite 190 (909)860-3195 Fax(909)861-3117 PRESS .:`;�'"\' 'BUILDING PERMIT APPLICATION -__ FIRMLY a DDRESS �Q;� �3 ��€'� �iT1 f ! (�C� DATE CATION � � NUMB R #/C $ ISSUE NPE OCC APN LOT TRACT DATE CONST. GROUP p OWNER � % "� .` o ADDRESS • .� /L� : /��-�ti� JS f ��? ZONING SETBACKS Z CITY ZIP TEL. ��"' ��� FRONT RyW ❑ S APPLICANT / @ L` �/}1R%C e�l�.. TEL + Y ��7 REAR ❑ zd SIDElSIQESTREET RW ❑ � CONTRACTOR g�l t - ' ' d��' SIDE ❑ Q ADORESS C-�. J1� �� i �►�, , � o CITY �+ EJ ' ZIP£4�� TEL. PROPOSED USE 'C�� �� _ 4'ttf� �. (��" w ARCH/ENG/ • � � DESIGNER NO.DWEL. NO.' NO. y a ADDRESS � CITY ZIP TEL. UNITS STORIES BEDROOMS � N DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER DECLARATION SFR/ADD/REM O p 1 HEREBV�FFIRM UN�ER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI- G3rdge/Cdrport W CENSEUWFOR7HEFOlLOWIN6REASON(SEC.7o31.58t1SWESSMDPNOfES510NSCODE:ANYCITYOH (n C�: COUNfYWHICHREWJIRESAPERMITTOCONSTAUCT,AITER,IMPROVE.DEMOLISH,OflREPA1RANY5TflUG �J,J PgIlO/DBCk Z NpE.PHIOH TO ITS ISSUANCE,AL50 REQUIRES THE APPLICANT FOH 5UCH PERMIT TO FILE A SIGNE� - W STATEMENT'fHAT HE OR SHE IS UCENSED DURSl1ANT TO THE PROVISIONS OF THE CONTRACTORS LI- W �. CENSEIAW(CHAPTERO(COMMENCINOWITHSECTION7000)OfO1VI510N90FTHEBU91NE33ANDPRO- -u"' POOUSPB PESSpNSCOD�ORIHATHEOR5HEi8EXEMPTTHEREFftOMAN�7HEBA5ISFOFlTHEALIEGEDEXEMP- (� - TION.ANYVIOLATIONOFSECTION7a37.56YANYAPVLICANTFORAPERM�TSUBJECTSTHEAPPLICANTTO Z Re-Raof -�-- ACIVILPENAITYOfNOTMORETFiANFIVEHUNDREDDOLLAflS(5500).J: � ❑I,ASOYVNEROFiHEPf10PERT/,OFiMYEMPLOYEE5Y.ITHWAGE5A57HEIR50LECOMPENSATION, ❑ COtt11178fCial � _ WILL DO 7HE WORK,ANO THE STRl1CTl1qE IS NOT INTENOED OR OFFEflED FON SALE(SEC.7046,BUSI- J �- NES$AND PRDFESSIONS OODE:THE CONTRACTORS LICENSE LAW DOES NOT APPLV TO AN.OWNER OF � PqOPEflTY WF10 BUILDS OR IMPflOVES TNEflEON,AND WHO DOES SUCH WORN MIMSEIFOR HERSELF OH - CC.- 7HROUfiHHISORMEROWNEMPLOVEES,PROVIDEDTHATSUCHIMPROVEMEM3AREhOT1YTEN�E00q � m - Q .OFFEREDWRSp1E1FHOWEVERTNEBIHIDINGORiMPROV9dENTi3SOtDWfTHINONEYEAROFCOMPLE- - - Z_- -TION,THE OWNEH-BIIILDER WILL HAVE THE BURDEN 6F PROVING THAT HE OR SHE DID NOT BUILD OR . � IMPROVEWRSHEPURPOSEOFS/LLE). - . ❑I.ASOWNEHOFTHEPROPERfY,AMEXCLUSNELYCONTRACTIhGWITHLICENSEDWNTRACTORS � TO CONSTRUCT THE PflOJECT(SEC.7aa,BUSINESS AND PROFESSIONS CODE:THE CONTflAGTOfl3 LI- � V2IU8SIOf1 ' ' ADJ.AREA W: CENSELAWOOESNOTAPPLYTDIWOWNEROFAPfl�PEflTYNM09U0.D50FIMPROVESTHEHEON.AND � - VY/IOCOMiiACTSWHSUCHPflOJECTSWITHACONTRACTOq(S)LICENSEDPUPSUANTTOTHECONTqAC QUANTITY DESCRIPTION FEE Y roasuc�sEuw.�. 0--, ❑1 AM EXERIPT IINOEH SEC. B.&P.C:FOR THIS REASON Q - � - - ?r' U � � - DATE OWNER � . - 0: W � LICENSED CO'JTRACTORS DECLARATION W �� I HEREBY�FFIRM UNDER PENALN OF PERJURY THAT IAM UCENSEO UNOER PFOVISIINJS OF CHAPTER � ._�- 0(WAiMENCINO WRH SECTiON 7000�OF O1VI510N 30F 7ME OIISINE55iWD PROFESSIONS CODE.AND. Z MV LICENSE IS IN FUi.L F-0RCE AND EFFECT. � �q � �� IICENSECUSS- � � LiC.NO.� � ��� J� - - - _V DATE � CONTRACTOR � ' � . W -� WORKERS'CAMPENSATION DECLARATION f���— ��_: IHEqEBYAFfIqMUNDERPENALTVOF0E0.NRVONEOFTHEFOLIOWINGDECLA{7ATIONS: - Z - _� Y I NAVE AND WILL A/AINTAM A CERTIFICATE OF CONSENT TO SEI FMSURE FOR WORKEHS' i CAMPENSATION,ASPROVIOEDBYSECTION3i000FTHElABOFiCODE,FORTHEPERFORMANCE U� e . Q OFTHE WORK GOR WHICH TMIS PEflMIT IS ISSUED. � W _IHAVEANOWILLMAINTAINWOHKEflS'COMPENSATIONMSUflAIrCE,ASRE�UIREDBYSECTION _ Q 87000F 7HE LA90R CODE;FOR TiE PERWqMMlCE OF THE WORK FOR WHICH THIS PEHMIT IS D - ISSUED.MYWOftKEAS'COlAPENSATKKJMSURANCECARRIERMIDPOLICYNUMBERARE: CONSTRUCTION Z jCARRIER ��-- c� PLAN REVIEW � -�� L'? .�� { . _�- POLICVNUMBER_�� ELECTRIC !=- - . � (I}USSEG710NNE�MDTBE�LE7mOF7HEPERMTi3FORIXJENUrDfiED� s�5iao���� } PLUMBING Z I CERTIFY THAT IN hIE PERFORMANCE OF TNE WORK FOR WHICH THIS PERMIT IS ISSUED,1 MECHANICAL C!T SHqLLNOTEMPLOYANYPERSONINANYMANNERSOASTOBECAMESUBIECTTOTHE - - -•�- WORKERS'CAMPEN5ATKKdLAWSOFCALItORN10.M:0AGREETHAT�FISHOULOBECOME iNSPECTiQNFEE - - ��- SUBJECTTOTHE WORKERS'COMPENSATION PFIOVISIONSOF SECTION 37000F THE LABOfl- COOE,1 SHALL FORT}iWITH COMPLY WITH iHOSE PROVISIONS. ISSUANCE ✓ � .p- OATE: APPLICANT: SMIP . ` G _ J: WAWJING:FAILUR[TO SECUHE WORKERS'COMPENSATION CAVERA6E IS UNLAWFUL.AND SHFLIBE ENERGY P!C -LL- SUBJECTMlEMPLOYEflTOCRIMINPLPENALTIESANDCIVIIFINESU7TOONEHl1NDREDTHOUSAND ENERGYPERMIT ' DOLLARS(f100.000),INA�OITIONTOTHECOSTOFCOMPENSATION.�AMAGESASPROVIDF.DFOqIN - -� 9ECTION37080FTHELABORCOUE,MTEAGST,ANDATTORNEY'SFEES. 9 RETENTION FEE: �_�� - �O CONSTRUCTION IENDING AGENCY PRE-AlS FEE: - _. �. IHERE6VAFFlRMUNDERPENALTYOFPERJURYTHATTHENEISACONSTRUCTIONLENOWGAOENCY � �� � '� : FOR THE PERFORMANCEOFTHE WORK f-0R WIiICH THIS PERMIT IS ISSUED(SEC.:097,CIV.C.�. �� . Z- W �- LENDEH'S NAME . -F-� LENOEH'SADDRE55 W ICERTIFYTHATIHAVEflEADiHISAPPLICATIONANUSTATETHATTHEABOYEINFOflMATIONISCOPRECT. TOTAL FEES . - � � IAGREETO�MPLYWITHALLCITVANOCOUNTVORDINANCESANDSTATELAWSRELATINaTOBUILDING - -��-. CONSTRUCifON,ANDMEflEBYAUTHORIZEREPRESENTATIVESOFTMISCOUNtt70ENTERUPONTHE - - - Z ABOVE�.IENTIONE�PROPERTY FOH INSPECTION PUFIPOSES. COMMENTS �" :tr�L. 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