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HomeMy WebLinkAbout15723 ., CITY OF DIAMOND BAB � ---�� DEPARTMENT OF COIVIMUNITY 8c DEVELOPMENT SERVICES , � . 21660 E.Copley Drive Sirite]90 (909)860-3195 Fax(909)861-3117 PRE$S ��'9�' BUILDING PERMIT APPLICATION FIRMLY __ o� JOBSITE j� • f�J I 1��7 APPLICATION i l.� �j� NUMBEFi���� #/C ADDRESS �`" � . _ i` . DATE �� �/ $ ISSUE TYPE OCC APN lOF TRACT DATE CONST. GROUP pOWNER— "� r_ . "' ADDRESS L�G'� �%,,,�3�%� __ � �� ZONING SEfBACKS Z CITY �"' !� -] ZIP ' TEL REART AW p g APPLICANT TEL. SIDE/SIDE STREEf RW ❑ � CONTRAC �% i �' .", ,- ,��JG SIDE ❑ ADDRES t. � � .�. � � O fr = � 7 j� ti PROPOSED USE�< ���"�. ,.c 's' CIN ZIP t _"G TEL.�'� � f� �` , � w ARC ENG/ ~ -�� - �� z DESIGNER s N0.DWEL. O. NO. � � CDDRESS Z�P TEL. UNITS STORIES BEDROOMS � u� DESCRIPTION SQ.FC FACTOR PSF ADJ.AREANALUATION Q OWNER-BUIIDER DECLARATION SFR/ADD/REM O p I HEREBV AFFlAM UNDEfl PENALTY OF PE0.tt1RY THAT I AM E%EMPT G'ROM THE CONTRACTORS LI- G8t2J0/C2tp01'I W CENSELAWPOHiHEFIXLOWIN6REA50N(SEC.7031.5BUSINESSANDPPOFESSIONSCODE:ANYCITYOR (� � COUNiV NMICH PE�l11HESAPERAl1TT0 CONST{M1CT,ALTEF,INPROVE,�EAAOLISH,OR REPAIR ANV SiRUC- TUHE,PRIOR TO ITS ISSUM'CE.ALSO REWIRES THE APPLICANT FOR SUCH PEqMIT TO FILE A SIGNED W PfltIO/DBCk � STATEMENT THAT HE OH SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CIX�ITRACTORS LI- a• � CENSEUW(CNAPTEH9(COMMENCINGN77HSECTION7oo0)OFDIVISION30FTHEBUSINESSnN�PqO- u' POOUSpB iES5pN5 C6DE)OR THAT HE Oq SHE IS EXEMPTTHEHEFqOM AND THE 6A515 FOR THEALLEGED EXEMP- TION.ANYVIOLATIONOFSECTION7o31.58YANVAPPLICANTFORAPERMIiSU&IECTShIEAPPiiCANTTO Z Re-Raof �� r ACML PENALTY OF NOT MOflE THAN FIVE HUNDPED�OLLARS(8500)J: . � ❑I,ASOWNEROFTHEPROPERTV,ORMYEMPIAYEESWITHWAGESASTHEIRSOLECOMPENSATION, � CO(71fI18fC13I- - . .. - VALL UOTHE WORIC,AND THE STflUCTLRE IS NOT INTENDEO OR OFFERED FOR SALE(SEC.7044,Bu51- �j �- NE55 AND PtiOFESSIONS COOE:7HE CONTMCTOPS LICENSE LAW OOES NOT APPLY TO AN OWNER OF � Pl�PERTV VhIOBUiLOSOR IIAPNOVES THERFAN,AND YhiO DOES SUCH WORK HIAiSEIf OR HERSELF OR - �- THROUGHHISO(iHEROWNEMPLOYEES,PROVIDEDTHATSUCHIMPROVEMENTSARENOTINTEN�E00R m _L�7; OFFEREDFOR$ALEIF,NOWEVERIMEBUNDINOORIMPflOVEMENTI550LDWITHINONEYEAftOFCOMPLE- _ u TION.THE OWNER�BUILDER WILL HAVE THE 6URbEN OF PitOVINO THAT HE OR SHE�IO NOi 9UIlD OR � IMPROYE GOR THE PoIRPOSE OF SAL�. ' - . (�J ❑I,AS OY/NEROF THE PflOPERTV,AM EXCLUSIVELYCANTflACTINO WITH LICENSED CONTRACTORS q -¢ i0 CONSTRIICTTHE PROJEC7(SEC.70u,Bl1SWESS AND PflOfESS10NS CODE:THE CONTRACTOR3l4 V8IU81f0(1 �l e ADJ.AREA W-- CENSEUWDOESNOTAPPIYTOANONMEROFAPpOPEflTVWHOBUIiASOqiMPROVESTHEflEON,ANO � _� WHOCONTMCTSFORSUpiPRQIECTSW1tHqCONTqACTOR(5)LICENSEDPURSU/WTTOTHECONTRAF - QUANTITY DESCRIPTION FEE . .� TOHSIJCENSEUW.i. �. ❑IAME7(EMP7UNDERSEC. B.BP.C.FORTHISREASON Q � U LL � DATE OWNEfi U Z W -.�- UCENSED CONTRACTORS DECLARATION W --�-_ IHER�YAFFIRMUNDEflPENAITYOGPERIURYTHATIAMLiCENSE�UNOERPflOVI510N50FCHAPTER � - -_p�: s(COAIMENCINGWITHSEC710N7000)OFDIVIS10N30FTHE8USINESSIYDPROFESSIONSCO�E,AND Z _3S-:. MY UGENSE IS IN hlRL FORCE AND EFFECT. w �'�� �y� �qq `� CD �- LICENSE CLASS�UC.NO. ' —J �- j J �'j' oaTE �� � �"� �'• CONTRACTOR "� o- W. s � �-�` - WORKERS'COMPENSATION DECLARATION� L - -+ - - - Q :�-- I HEREBY AFFIRM UNDEN PENALTY OF PFq,1UHY 04E OF TNE FOl40WING OECIARATIONS: -_ Z =0-�"_IHAVE1IYDWIILMAIN7AINACERi1FIGATEOFUhYSeNTTOSEIr-IN3UPEFOftWOflKERS' - y ._� COMPENSATION,ASPROVI�EDBVSEC710N3'IaDOFTHEIAB�PCOOE,FOPTHEPEPFORMANCF 'U Of THE WORK FOR WHICH THIS PERMIT IS ISSUED. � o' �W-� _I HAYEAND WILL MNMAIN WORKERS'COMPENSATION INSURANCE,AS REQWRE�BV SECTION Q-- 37600FTHELABORCODE.f-0RTHEPERFORMANCEOFiHEWONKWftWHICHTHISPERMITIS -��- ISSUED.MVWO i�EFlS',� P.E TIONINSUR ECARFIERAN POIICYNUMBENAPE: CONSTRUCTION � �� �� �- �j�: caaaiER � ti� Y R- PLAN REVIEW _ `�` POLICYNUMBEfl I L�. �� ELECTRIC __0: .(IHSSECTpNNE�wieEa�.4�EfID�n-�PFaMIlsFaialEtRx+OFlED00ttaRS(S�aqoaLEss} PLUMBING ��-�9�� W; • :�z-. ICEHTIFVTHATIhhIEPERFORMANCEOFTHEWORKFOflWHICH7HISPERMITI5ISSUEO.I MECHANICAL "(S? SHALLNOTEMPIQYANYPERSONINANVlAANNERSOASTOBECOMESU&IECTTOTHE - -_�.(A� WORKEflS'COMPENSAiIONLAW50FCFLIFORNIA,ANDAGHEETMATiFISHOULOBECOME WSPECTIONFEE � SUBJECT TO THE WORKERS'COMPENSATION PROV�SIONS OF SECTION 37000P THE LABOR ° � �� - -_s',_ CA�E,ISNALLFOFlTMMTHCOMPLYWITHTHOSEPROVISIONS. ISSUANCE �� • ;`p": �ATE: APPLICANT. SM�P `�.�. ' i ^ a d.i T' -�< ENERGYP/C B�.ST a�.� �r +e x,�^�s-�w.�r -,J. WARNING�FAILURE TO SECIIFE WORKERS'CAMPENSATION COVEHAGE IS UNLAWfUL.AND SHALL BE t�-�e A��i�' 'LL= SU&IECTANEMPLOYEftTOCRIMINALPENALTIESANDCNILFINESUPTOq4EHUNDREOTNOUSAND ENERGYPERMIT DOLURS(51a0,o0�).IN A�DIiION TO THE COST OF COMPENSA710N,DAMAGES AS PiiOVIDED FOfl IN .J� SECTIDN37080FTNELABONCO�E,MTEREST,ANDATTORNEI"SFEES. -�_ RETENTION FEE: ;d; CONSTRUCTION LENDING AGENCY PRE-ALT FEE: =O:: ��- I HEREBYAFFIRM UN�ER PENAITY OF PERJURY THAT THERE IS ACONSTRUCTION LENDING AGENCY _ - - FOR 7HE PE{iFORMANCE OFTHE WORK WFt WHICH THIS PERAIIT IS ISSUED(SEC.3097.CIV.C.7. . r Z; `-Wz �' LENDER'S NAME ;t=-; LENDEflSADDRE33 . . �+�/� j@ --�� ICERTIFYTHATIHAVEREADTHISAPPLICATIONANDSTATETHATTHEABOVEINFORMATIONISCORRECT. TOTAL FEES ( �//� (� '�W IAGREETDCAMPLYWITHALlC1iYANDCOUNTYORUINANCESANDSTNTELAWSREIATINGTO8NL01NG - i G-t _�,_ CONSTRUCTION,ANPHERE6VAUTHORREREPRESENTATIVESOFTHISCOUNTVTOENTERUPONTHE � _Z, ABOVE-MENTpNED PROPERTY FOq INSPEC710N PURPOSES. COMMENTS - O`: � �>. �¢: PE 1T1"E�NNAE(PRINT) � �j . :Cn- �� 'w �.�%s �.��, OF PERMI�EE OATE :_: � � RECPT.NO. PAID BY VALIDATION -~ WHI7E—De aRmant Co YELLOW�inance Co PINK—Assessor Co GOLDENROQ�-File Co GREEN— . P pY, PY� PY� PY. ApPlicant's CoPY � �, �� ;�+ -� "� _ i E� _ _ ,�:w ��� � `� `�� ' -�r �� ,� `�,z °�-- Ye t i . 3` .L 1 k j hR�'�r�`�r���� �£g� � � i . '� _ � � '4 � � � � � � ��s� ��` �, ! � cr � _ ��-� ���.�,� ��� �'-��� � € - ' � �� i � : ' �.�..�'. �.. � � � ^�^a 3 � i . c � � � 4:� ���.�'a � �7 � J j 1 , �' ���' _.� � �� �' __� � '€�€� ��� � - � _ - _ i ' �' �. �'�. ea- a��`� . � I = i � � � � � � � � � �` +; � i ; �^ x-�` ���' � . �� � i � - > ; � : "` �v"����z� '�:�€��-��� P ' i . �. � .� j a I -': �' ;^ ��� s �.s rq�.,� �." ^��^��� ' ( ; - � I F i a. � �� - € ����N __ ��� �°��zi°._ , : �_ E - -Fr �"j -, ���� � � � � � i ( � ' ! � j � 4 . i � _ a � +J( i � i � i i � � . i : . i : '' i _+ i 's -' -� i � � � � � � , _ ' _ _ J l _ � � _ � _ � � e ` ; ' i ' _ � ' . 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