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HomeMy WebLinkAbout15782 (23) �' e�^� �'._ �� CITY OF DIAMOND BAI2 E��� O /D j DEPARTMENT OF COMMUNITY dt DEVELOPMENT SERVICES '� G 21660 E.Copley Drive 5uite 190 2�%Ci'" w (909)860-3195 Fax(909)861-3117 PRESS ��"����� BUILDING PERMIT APPLICA'1'ION FIRMtY �9X^ o� JOBSITE l�"tpQ , .. �1� �• SSUE ATIO ' ' � TYPE IT ,-�PlCO ., . .. ,.,_ ADDRESS DATE� NUMBER # � CC APN LOT TRACT DATE CONST. GROUP p OWNER 3MtiL'S LA1�1 p ADpR,�SS.�i.'�-� ZONING SETBACKS � CITY��'+�'� �1- ZIP 7EL. FRONT RW ❑ APPLICANT TEL. REAR ❑ � SIDE/SIDE STREE7 RW ❑ � CONTRACTOR �=�-�s���-�-P SIDE ❑ p� ADDRESS � 3 . � CITY �iJ�►�-�41177t�0 ZIP C��Z- TEL. �i� PROPOSED USE o ARCWENG/ � �ESIGNER NO.DWEL. NO. NO. ADDAESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.FT: FACTOR PSF ADJ.AREANALUATION � Q OWNER-BUILDER DECLARATfON S�R/ADD/REM O � 1 HEHEBV/.FFIRAI UJDER PENAL7Y OF PERtt1RY THAT I AM E%EMPT FROM THE CONTRACTORS LI- � Garage/Carport W GENSEUWf-0RTHEFOILOVYINOREASON(SEC.7037.5BUSINESSANOPROFESSIONSCODE:ANVCITVOR �..7 COUNT/WHICHREdUIRESAPERMITTOCONSTRUCT.ALTER.IMPROVE.PEMOLISH,OfiREPA1RANY5TRUC- W Pdt10/DOCk WiLRE,PRIOR TO ITS ISSUANCE,ALSD REQUIRES 7HE APPUCIWT FOR SUCH PERMIT TO FI�E A SIONED W � STATEMENT THAT HE OR SHE IS LICENSEO PUHSUANT TO 7HE PROVISIONS OF THE CONTRAC70RS LI- � CENSE tAW(CNACTER B(COMMENCINO WITH SECTION�WO)OF DIVISION 3 OF THE BUSINESS AND PRO- V' POOUSp2 FESSqNSCOOEIORTHATHEORSHEISEXEIAPTTMEREfROMANDTHEB0.515fORTHEALIEQEDEXEMP- (� TqN.ANYVIOIATlONOFSECTION7o31.68YANYAPPLICAMFORAPER��TSU&IECTSTHEAPVUCANTTO Z Re-Foot � ACIVILPENALT(OFNOTMORETHANFIVEHUNOREDDOLUIRS(35oaJ.�: � ❑I,ASOVMEROFTHEPROPERTV.ORMVEAIV�OVEESWRHWAGESASTHEIiiSOLECOMPENSATION, O Commercial � Wtt1 DO THE WORK,AND THE STRUC7URE iS NOT INTENDE�OR OiGEREO FOR SALE(SEC.7oA,,BU51- J NESS AN�PqOFESSION3 COOE:THE CONTPACTORS LICENSE LAW DOES NOT APPLV TO AN OWNER OF � PROPEH7YYVFIOBUILASORIMPROVESTHEREON,ANDWHODDESSUCHWORKHIMSELFORHERSELFOR = � THRd1GH HIS OR HER OWN EMVLOYEES,PROVIOED THATSUpi IMPROVEMENTS ARE NOT INTENDED OR m QOFFENEDFORSALEIf,HOWEVER�NEBUIIDINGORIMPROVEMEMISSCIDWITHINONEYEAROFCOMPLE Z TION,iHE OWNER-BUIlOEfl WILL MAVE THE BURDEN OF PROVINO THAT HE OR SHE DID NOT BUILD OR = IMPROVE FOR THE PUPPOSE OF SN.E). W OI,ASOWNEROPTHEPROPERTY,AME%CLUSIYELYCONTRACTINGWITHUCENSEDOONTMCTORS TO CONSTRUCT THE PROJECT(SEC.70{l,BUSINESS AN�PROFESSIONS CODE:THE CONTRqCTORS U- ValUatiOfl ADJ.AREA W GEN9EUWDOESNOTAPPIVTOANOWNEROFAPROPERTYWHOBUIL�SORIMPROVESTHEREON,AND — � NMOCOMMCTSFORSUCHVROJECTSWITMACON7RACTOR(S)LICENSEOPURSUMR70THECONTfUC- QUANTITY �ESCRIPTION FEE � TORSUCENSELAW.). J �I M1 E%EMPT UNDER SEC. B.8 P C.FOR Th15 REASON � 3 � �j" OATE OWNER �' Z W � UCENSED CONTRACTORS DECIARATION -� � W I HEREBYAFFIRM UNOEF PENALTV OF PERJURV THAT 1 PM LICENSED UNDER PflOVI510N50F CHAPTER � �� � � 9(COI�IMENCINOWITHSECTION7aao)OFDIVISION30FTHEBUSINESSANDPFlOFESSIONSCO�E.AN� Z X MY IICENSE�S IN FUII FORCE AND EFFECT. m LlJ � LICENSE CLASS e"�� LIC.NO._� � � � J V DATE_�� CONTRACTOR_. a W � WORKERS'COMPENSA710N DECLARATION -� � a � U � I HEREBV AFfIRM UNDER PENALTV OF PERIURY ONE OF THE FOLLOWING DECIARATIONS; Z Q 0 �IHAVEANDWILLMAINTNNACERTIFICATEOFCONSENiTOSELF-INSUREFORWOHKEFS' 2 � COMPENSAT�ON,AS PROVIOEO BV SECTION 370o OF THE LABOR CODE,FOR THE PERFORMANCE W OFTHE WORK FOR WHICN THIS VERMIT IS ISSUED. � � !i HAVE ANO WILL MAINTNN WORKER3'COMPENSATION INSURANCE,AS REOUIRED BY SECTI04 Q 370oOFTHELABORCADEFORTHEPERFORMANCEDFTHEWORKFORWMICHTHISPERMIi15 ISSUED.MYNIORK MPENSATIONINSURANC A�R�RIECR�AN�DPOL:CYNUMBERARE: CONSTRUCTION � CARRIER ���"�-�2�,�-��.,C'�ti'^'y��L"� - PLANREVIEW Z va.icrrNMeEFl �����Dl�'Z7� ELECTRIC �___. .� . � � (THISSECfqNNE�NOTBECO�.BLEfEDOF7i-EPE�UMISFnROn1EHUMHEDD�I.IARS(S1m)ORLE55} PLUMBING E. n rbQ9 1-� --�y w MECHANICAL g`�� '� � Z i CERTIFY THAT IN THE PERFORMPNCE OF THE N�ORK FOR WHICX THIS P'cRMIT IS ISSUED,I y� (} SHALLNOTEMPLOYANYPERSONINANYMANNERSOR5708ECOMESUBJECTTOTHE - A � WORKERS'COMPENSATIONLAWSOFCAUFORNIA.AN�AGREETHATIFISHOULDBECOME INSPECTIONFEE � �7`}a(��y%�N�t'a � SUBJECTTOTHEWORKERS'CAMPENSATIONGROVISIONSOFSECTION37ooOFTHELABOR y" "�� . �� CAOE,I SHALL FORTHWITH CDMPLY WI Y ISSUANCE 'a��3 T�a���`}��:��Jl�'j �� � DATE:"�`� AP%.ICANT. T ��--�--- SMIP � � ENERGY P/C WIIRNING FAILURE TO SECVRE WORKERS'COMVENSATION COVEHAGE�5 UNIAWFIJ�AND SHALL BE � SU&IECT AN EMPLOYER TO CRIMP7RL PENALTIES ANO CI�IL FINES UP TO ONE HUNDREO THOUSAN� ENERGY PEFMIT DOLIJ�RS(5100,000),IN ADDITION TO THE COSTOF CqMPENSATIMI,DAMAGES AS PROVIDED F�R IN � SECTION 3708 OF'iHE LABOfl GODE,INTEflEST,AND ATTORNE'!'S FEES. RETENTI ON FEE: a CONSTRUGTION IENDING AGENCY PRE-A�T FEE: O � IHEPE9YAFFIRMUNDERPENALTYOFPERJURYTHAThIEREISACONSTRUCTION4ENDINGAGENCY FOR iHE PERFOflMANCE OFTHE WORK FOR WHICH THIS GERM'�.T IS ISSUEO(SEC.3097,CIV C.), Z W - � LENDER'S NAF1E I— LENDEFYSADDRESS WI CERT�FV THAT I MAVE READ TMS APPLICAT�ON AND STPTE THATTHE ABOVE INFORMATION IS CORRECT. TOTAL FE ES • � 1 AGREE TO COMPIY N7TN ALL CITV MID COUNTY ORDINANCES AN�STATE LAWS RELATMG TO 6UILDING CONSTRUCTION,AND HEREBY AUTHOpIZE REPFESENTATIYE9 OF hilS COUNTV TO ENTER UPON THE ZABOVE-MENTIONEDPROPERTYf-0RINSPEC710NPURPOSES. 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