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HomeMy WebLinkAbout15171 (19) ! t,,.�' ,>._ _�` CITY OF DIAMOND BAB DEPARTMENT OF COMMIJNITY 8�DEVELOPMENT SERVICES � a 21660 E.Copley Drive Suite 190 (909)8b0-3195 Fax(909)861-3117 PRE`SS �''A�'� � BUILDIlVG PERNIIT APPLICATION FIRMLY � JOBSITE APPLICATION "`L� PERMIT � P/C o ADDRESS � DATE NUMBER # $ ISSUE TYPE OCC APN LOT TRACT DATE CONST. GROUP p OWNEA - C. o, ADDRESS ZONING SETBACKS Z GTY � ZIP 2L�TEL. � FRONT RW ❑ APPLICANT TEL. REAR ❑ � SIDE/SIDE STREET RW ❑ � CONTRACTQ � Ts SIDE ❑ � ;ADDRES � PgOPO�USE o CITY��}��Z�,�_ ZIP TEL. �u ; w ARCHlENG/ ���,� z OESIGNER a ADDRESS NO.DWEL. NO. NO. � CITY ZIP TEL. UNITS STORIES BEDROOMS m �n DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNEH-BUILDER DECLARATION . SFR/AD�/REM O I HEpEBY AFFlRM UNDER PENPL7V OF PEqJURY THAT i AA1 E%EA1PT FROM THE CONTRACTORS ll- Gflf2 J@/C3�Oft -W- CENSEUW WflTHEFOILOWINaREA50N(SEC.7031.5BUSINE93ANDPpOFE9310NSCODE:ANYCItYOfl (n _C�� �UUNTYWHICHREW{RESAPEflMflTOCONSTRUCT,ALTEN,IMPftOVE,OEASOtJSH,ORflEPAIflANVSTRUC- W Pdl10ID8CK L. TI/RE,ORIOR TO ITS ISSU/WCE,AL50 RE�UIRES TNE APPLICANT FOR SUCH PERMIT TO FILE A 516NED W � STATEMENT 7HAT HE OR SHE IS LJCENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTOH9 LI� � CENSELAW(CHAPTERB{COMMENCINGWITMSECTION7000�OF�IVISION30FTHE9USINESSANDPRO- POOUSPd : FESSIONSCOOE)ORTMAtNEORSHEiSE%EMPT7HEREFROMAND7HEBASISFORTHEALIEGEDEXEMP- -(� ; TION.ANYVIOLATIONOFSECTION70.91.50YANY/PPLICANTFORAPEflMITSU&IECTSTHEAPPLICANTTO -Z Re-Raof : AGIVILPENAITYOFNOTMOflETMANFIVc'Hl1NDREDD�iLARS(i500).): - �~- ❑I,ASOWNEHOFTHEPROPEYdTl,ORMYEMPLOVEESWITHWA6ESASTHEIRSOLEC�MPENSATION, _❑ - - - _Z: Commercial - -� - VHILL 00 THE WORIC,AND 7HE STiA1CTURE IS NOT INTENOm OR OFGERED FOR SALE(SEC.'/04d,BUSI- J �'= NESSAND PROFESSfONS CODE:TiE CONTRACTORS LICENSE UW�OES NOTAPPLY TO AN OWNEROF � : PROPERNY�IiiOBUIIDSORIMPROVESTHEREON,ANDVMODOESSUCHWORKHIMSELFORHERSELFOR .--[[_ THPOl1GHNISORHEROWNEMPLOYEE3,PROVIDEDTHATS11qiIMPROVEMEMSAHENOTINTENDEDOR m _.SL1, 9FFEREDFORSALEIF,HOWEVERTMEBUILDPl�ORIMPROYEMENTISSOL�WRHiNONEYFAROFCOMPLE `'0�= --TKIN,THE OWNERAUILDER WILL HAVE THE BUHDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR - -- -- ,�-€ IMPROVEFOPTHEPURPOSEOFSAIE). ' �jj O I,A90WNEfl OF THE PflOPEFiTY,Mi EXCLU51VElY CONTMCTIN�W17H UCENSED CONTRACTORS ��-.¢� TO CONSTAUCT hiE PROJECT(SEC.7D1{,BUSINE55 AND PROFESSIONS CODE:THE CONTRACTOflS LI- VaIUBIlOf1 ADJ.AREA .W� CENSEUWDOESNOTAPPLYTOANOWNEROFAPFOPERTYWMOBUILDSORIMPROVESiHEREON,pND �� NfiOCONTMCTSFORSUCHPROJECTSWITHACONTRACTOR(5)LICENSEOPURSUANTTO�}iECONTRqC QUANTITY DESCRIPTION FEE _- TOfl3 UCENSE LAW.). _0�_-_ ❑1 AM EXEMPT UN�EFi S�Q B.S P.C.FOR THIS REASON � Q �: U LL_. � - UF7E OWNER U z:. W ;�' LICENSED CONTRACTORS OECIRRATION W .--�; IHEREBY/�FIRAIUNDERPENPLTYOFPEiUURYTNATiAMLICeNSEDUN�EftPflDVISIONSOFCHAPTER V, ._d= 9(COMIAENCINOWITiSECTqN)000)OFOIVISION30FTHEBUSINESSANOPHOFESSKKJSfADE.AND _ Z - ,X;. MYLICENSEISINFULLFOflCEANOEFFECT. '��_ LICENSEC S ` LIC.NO._r_�S,��__ . j V' onrE corrrrucror�tl,n/�idF's.2etl�rid a w- � '��=- WORKERS'COMPENSATIONDECLARATION � � - - z� Q '�� 1 HEREBY qFfIRM UNDEH PENAI.TYOF PER1UflYONE OF7HE FOLLON7NG DECLARATIONS: � t/� Z -��- _IHAVEAN�VALLMAINTkiNACEflT�FICATEOFCONSENTTOSELF-INSUREFOFWORKEftS' z '�_-. COMPENSATIOld,ASPROVIDEDBYSECTIIXd37000FTHELA90FCIX7E,FOfiTHEPERFOftMANCE 'U - OFTlIE WORK FOR WHICHTNIS PERMIT IS ISSUED. � �_ _IHAVEANOWILLMAINTAINWORKEHS'COMPENSATIONINSURAhCE,ASREQUIREDBYSECTION � L , //\ %_Q�- 37000GTHELABOflCOOE,iORTHEPEflFORMANCEOFTHEWORKFORWHICHTHISPERMITIS [�/I ISSUED.IAY WORKERS'COMPENSATION INSl1RANCE CARNIERAN�POL�CY NIJMBERARE: CONSTRUCTION /`� ;�j_ '`�O�'� _ PLAN REVIEW � CARRIER — `�- POI.ICYNUMBER � � ELECTRIC .Z �¢: (iF�sEcil0.vt�NoieECOh1PLEiFDOFhEPEFA4TiSF0{toNE�iI�TDFiEooauJis(StaoloalEss� PLUMBING . ._ . . .. _�_ . ... .. . . . . .._ _ . . _ _ . . . . . . . _ .. -- . . . =Z%- ICERTIfYiIiNTINTHEPEflFORMANCEOF7HEN`ORKFOflWHICH7HI5PEHMITISI5SUE0,1 MECHANICAL . � `(�'- - SHAIINOTEMPLOVANYPERSOMINANVMANNERSOASTOBECOMESU&IECTTOTHE- - - - - - f_�-. WOPo(ERS'COMPENSA710NUWSOFCFLIFORNIh�oACREE7HATIfISHOULDBECOME INSPECTIONFEE ;�-; SU&IECTI'OTHEWOPo(Efla"CAMPENSATIONPAOVISIONSOFSECTION37o00FTMElABOP - __�- CO�E, SHALL RTHN'�THCOMPLVWIh1THO5EPROVISIONS. �SSUANCE __ � _ '�� � -SMIP �� -DAT@ APPLICANT. �-W-- WARNING: AILURE OSECURE'NOHKEHS'COMPENSATIONCAVERAGEISUNLAWFUL,ANDSNPLLBE ENERGYP/C E zJ,, - ;�-.: SUBJECTANEMPIOYERTOCRIlAINPLPENALTIESANOCIVILFMESUPTOONEHl1N�REDTHOUSAND ENERGYPERMIT `.'}';_ DOLLAfl3({100,000),INADOITIIXiTOTHECOSTO�COMPENSATION,DAMAGESASPROVIOEDFORIN -: SECTION37080F'fHELABORCODE,IN7EHE5T,AN�ATfORNEY'SFEES. RETENTIONPEE: ;�= "W" CONSTRUCTIONLENDINGAGENCY . PRE-ALTFEE: <d= — ;:0; -'��' IMEflEBVAFFIflMUNDEHPENALTYOFPERIUflYTHATTMEREI3ACONSTqUCTIONLENDINQAGENCY 'n^= FORTHE PERFORMANCE OFTHE WORK WN WHICH THIS PERMIT IS ISSUE�(SEC.3097,qV.G.). .� ���� LENDER'S NAME A - :1=-- LEN�ER'SAUGHESS ����/_��( �/�ry�` -- . �w- ICEpTIFYTHATIHAVEREA�TIISAP(4.ICATIONANDSTATETHATTHEABOVEMfORMATIONIS�CORRECT. TOTAL FEES -��� / � �:d; I AGpEE TO CAMPLY WITH ALL CITY ANO CDUNTY OROINANCES FND 3TATE LAWS FELA71N0 TO BUILDIN6 �' ,_�- CONSTRUCTION,ANOHEREBYAUTHORIZEREPHESENTATNESOFTHISCOUNTYTOENTERUPONTHE - . :.--_Z; ABOVE-MENTIONED P O Rtt FOF INSPECTION P aoses. COMMENTS - x�'` P� - -- -- �: 'm� PERMITTEE N E(P M) - ¢� {.�: '-_�• SIGNATUfiEO ERMI E DATE _ - - - - ___; RECPT.NO. PAID BY ALIDATION -'~- WHITE-0epertment Copy,YELLOW--Pinance Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—ApplicanPs Copy � ..�.I ,.��-:. k . _. � t_ �' � �i � -I ➢ t y)E � . ,'�^�� ..o-. �.,�,�"�a^'� � � . S ���������.-�s t'� �� ;`�_ r �� ( i � r ' "� ' ' t '' r � i�`.r � .,..; ",` � � � � ��"� r 2� I � j �� . � 4. P 45�� "'E° 't t . : i� `t �; `"j f C: 7 5 s�`g�'�F �#t�°�; �'. �.' ' � i- . 1 � � �: _ i _( i ; ` � . i ������������ � € � . I p � � i .� �` � �.� � �� ' '� �f�� � �v . € .�� '� � =� F ' � � ,I [ � . 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