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HomeMy WebLinkAbout11604 _��_ CITY OF DIAMOND BA� DEPARTMENT OF COMMUNITY�&DEVELOPMEN ERVICES 21660 E.Copley Drive Suite 190 (909)860-3195 Fax(909)861-3117 ��� PRESS ��'°"" BUILDING PERMIT APPLICATION FIRMLY oa DDRIESS I/�p p� /� ' ,n l� � �����' ��' " `rJ� DATEICATION '� �� NUMBE I`f� � p/C � ISSUE TYPE OCC APN LOT TRACT DATE_ CONST. GROUP p OWNER d�Y'�! G:% p ADDRES$�' ,/ �-,% �..�/"� �' ZONING SETBACKS z CITY Q�:��aa:�Vl:J�r�-gt�IP�'��Tf�.7 � �� REART RW LI_ APPLICANT TEL. ��—__ � zQ SIDE/SIDE STREET RW n__ � CONTRACTOR�/I,1.°'�,�j���y�!='/'-�a3�`7- OB1�.!• SIDE _ p � ADDRESS� ' o CITY s,��/}..�r,.li ZIP Z T y� PROPOSED IJSE wo ARCH/ENG/ - W DESIGNER NO.DWEL. NO. NO. n. ADDRESS rn UNITS STORIES BEDROOMS � CITY ZIP TEL._ - N DESCRIPTION SO.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER DECLAFlA710N SFWADD/FEM O Q I HEREBY AFFIRM UNDER PENALTV OF PERJURY THAT I AM EXEMPT FROM THE CONTMCTORS LI� G2f99B/CflfPOfl W CENSEUWFORTHEFOLLOWINOFEASON(SEC.7o3i.5W51NE55ANDPROPE5510N5CODE:ANYCITYOR (n C� COUMYWHICNRC-0UIflESAVERMITTOCONSTRUC7.ALTER.IMPROVE.�EMOLISH,OIiREGA1PANY5TRUC� �jf pai10/DBCk W TUHE,PRIOR TO ITS ISSUMICE,ALSO REOUIPES THE APPUCANT FOfl SUCH PEHMIT TO FILE A SIGNED � W � STATEMENT THpT HE OR SHE IS LICENSE�PURSU/44T TO THE PROVI310N3 OF THE CANiRACTOFS LI- � � CENSE LAW(CNRPTER B(COMMENCINO WITH SECTION 7000)OF OIVISION 30F THE BUSINE55 AND PRO- PDOUSpB FESSIONS�E)ORTHATHEORSHEISE%EMPTTIIEREFqOMANDTHEBASISFORTHEALLEGEDEXEMP- � 710N.ANYVIOLATIONOFSECTIDN7031.5BYANYAPPLICANTFORAPEHMITSl1BJECTSTHEAPNUCqNTTO Z Re-Root F ACNIL PENN.TY OF NOT MORE MAN FIVE HUNDREO�OLtARS(5500).): ❑I.ASOVMEROFTHEPROPERTY,OqIdVEMPLOYEESWITHWAGESASTHEIRSOIECAMPENSATION, C� Commerclal g. WILL DO hIE WORK,AND THE STRUCTURE IS NOT INTENOED OR OFFEflED FOfl SALE(SEC.70G4,BU51� J N NE55AN0 VROFESSIONS CODE:IHE CONTPACTORS LICENSE lAW OOES NO7 APPLY 70 AN OWNER OF � PROPEflTY N'FIO BUILDS Ofl IAIVROVES THEREON,ANO WHO OOES SUCH WORK HIMSELF Oq HERSELF OR CC THROl1GHNISORHEROWNEMPIOYEES,PRDViDEDTHATSl1CHIMVROVEMENTSARENOTINTENDEDOR m Q. OFFEflED FOR$ALE I'r,NOWEVER 7NE BUIL�ING Oq IMPROVEMENT IS SOID WITHIN ONEYEAROFCOMPLE- Z TION,THE OWNER$WL�C-q WILL HAVE THE BUHDEN OF PROVING THAT HE OR SH[DI�NOT AUIID OR � IMPROVEFORTHEPURPOSEOFSALE), ' �,y� ❑I.ASOWNEflOFTHEPROPEHfY,AMEXCLU51VElYCANTflAGTINGWITHLICEfVSEDCOMflACTORS [C TO CONSTftUCT TME PHOJECT(SEC.70/4,B1151NE55 AND PROFESSIONS CODE:THE CONTRAC70H5 LI-. ValU84i0n , ___,___,._A�J,qREA__.__.___ -� [dI CENSEUWOOESNOTAPPLYiOANONRJEROFAPROPERTYWHO6UILDSORIA4PROVESTHEqEON,PND -- — M WHOCONTMCTSFORSUCHPROJECTSWITNACONTMCTOR(S)LICENSEDPURSUMITTOTHECANTRAP QUANTIN DESCRIPTION FEE Y mRsuce�sEuw.�. � ❑I AM EXEMPT UN�ER SEC.__________„____,_ B.8 P.C.FOR THIS REPSON a 3 � � — � � DATE_ OWAER ___ .. U — �s[ LlCENSED CONTRACTORS DECLARATION W ¢ IHEREBYAFFIFMUNDERPENALTYOPPERJURYTHATIAMLICENSEDl1NDE(iPROVI510N50FCHAPTEF � � 9(CWAMENCINO WITH SECTIilN 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESS!ONS CODF.,AND Z �X� MYUCENSE IS IN FULL FORCE AND EFFECL � llJ P� ['� e' o IICENSE CLASS L_.."��Cr�v _LIC,NO.__�S��G:.�{V j V DATE� ` " CONTRACTON.�s.tYt.a,'��1,s±,r-�1''�� a w • �ry� � � WORKERS'COMPENSATION DECLARATION �j�,����r�� U N V � IHEHEBYAFFlRMUNDEflPENP17VOFPERJURYONEOFTHEFOLLOWINGDECLARA710N5: Z � � IHAVEANDWILLMAINTAINACERTIFICAYEOFCONSEN7TOSF.IFINSUREFORWOPKENS' d �� � COMPENSATIO4.ASPROVIDEDBYSEC710i1J7000FTNELA60RCOUE,FOR7t1EPERFORMANCE W � O �F TTiE WORK FOR WHICH TNIS PERMIT IS ISSUED. � W I HAVEAND WILL MAINTAIN WORKERS'COA7PENSATION INSURAhCE,AS HEt]UIRF.D UY SECTION O 37000F THE IABOR CODE,FOR THE PERFOPMANCE OF TNE WORK FOR WHICH THIS PERMIT IS ISSUED.MY WOP.KERS'COMPENSATION INSURANCE CARRIER ANO POI.ICY NUMBEHAqE: CONSTRUCTION /���� "'—_ _'-"_ -'_""____ - � cnnnieA_!'L��_6..��ry�ry��.yG�e� . PLAN REVIEW __.....----,--- ---- ----- ,''. � PDLICYNUMBEF i:l:�.s i��r c� ` Z — ELEC,TRIC _ ___ _ ¢ 0 (n�SSEcnatah�IDraoreEoa.�ErmoFi�aEaa�ar�sr-naoniEFnln�ooatnas(Sioo)at�� PLUMBING l�..A97.1=��1`��::�'1�� �-rr�,�pr�/��- 1.� . � � I CEflTIFY 7HAT IN THE PERFORMANCE OF TNE WORK FOH WHICH THIS PERMIT IS ISSl1ED,I MECHANICAL � SHALLNOTEMPLOYANYPERSOhINANYMANNER50ASTOBECOMESUBJF.CTTOTHE � �� — ('n WOflKERS'COMPENSATION LAWS OF CALI'rORN1A,ANU AGREE THAT IF I HOUL�l3ELO1dE INSPECTION FEE _.__ � SU&IECTTOTHEWORKERS'COMPENSATIONPROVISIONS 6ECTI 7 O k'A9 �� � � � CADE.ISHALLFO�TNWITHCDMPLYWITHTHOS � NS ISSUANCE __ _ p "-_" `p DATE_�� �� APPLICANL � ._'.' SMIP _ . a f __...,.".'.___ . J WARNING:FAIlURE70 S[CURF.WORK[RS'COMPENSATION COVERAGC-ISUNtAWF SHALLBE ENERGY P/C _.,.._._. .._.__ __ � SU&IECiANEMP�0YER70CRIMINALPENAL71E5ANDCIVILFINESUPTOONEHUNDRED7HOl1SAND ENERGYPERMIT y DOLLAR9(E1ao,0007,INM�ITIONTOTHECOSTOFCOMPEN9ATION,DAMAGE3ASPROVIUEDFORIN �` _._.__ J� SECTION37oeOFTHELABORCOD[,INTEfiEST.ANDATTORNEI"SFEES. RETENTIONFEE: �-��__ � �� OCONSTRUCTIDN LENDING AGENCY PRE-ALT FEE: __. ____ ._____ _ � INEREBYAFFIRMUNDERP[NALTYOFPERJUFiYTMATTHEREISACON57'RUCTIONI.ENDINGAGENCV _ __ _ FOR THE P[RFORMANCEOF THE WORK fOR WHICH THIS PERMIT IS ISSUED ISEC.3097.CIV.C.�. --- Z . LLI ..__—.__ ____ _'__'.._._" �� LENDER'SNAME '—""'_- _'___ "" _'_' "' � LENDEH'SAD�RE55 __""_""_._.._"_""""_—'_—'_'__ � ICERTIFYTHATIHAVEHEADTHISAPPLICATIONANUSTATETHATTHEABOYEINFOPMATIONISCqRRECT. TOTAL FEES �)f � � I AGREE TO GOMPLY WITH ALl CITYAN�COUNiY OflDINANCES AN�STNTE LAWS REIATING i0 BUILDING ✓ � � CONSTRl1CTION,AN�HERE6YAUTHORIZEREPRESENTATIVF50FTf{�SCOUNTVTOENTERUPONTHE ABOVE�MENTIONE�PflOPERTY FOR INSPECTION PURPOSES. o COMMENTS _,_.___ _ _' _�_�.T'1,;�-�_�/��/�;_�.�c_��- � �,�.. Y�1 ---- QPEflMITTEENAME(PHIN'A.��. _'__ _' � �F 9 '�� � � / �� � SION H�E 0 /'//J//� "� x RECPT.NO.{�_`+�' W __PAID BY ;=?'—' VALIDATI '~ WHITE rtment Co YELLOW—Finance Co PINK—Assessor Co GOLDENROD�iie Co GREEN— PY, PY, PX PY. APPlicant's Copy € a.T � � . � ..,._ � � i � �t' ,a �� � � �( �zr�'"�k � ��� �' � � � d��. �—z z '� .e I � F �' x 4,r � r w � ; i t � � I f ; � ' '� �N 93 . ,, .� 5 �h, � ,. 1 I ' I� ! }^ � ',�! , `Y' ' a�y .s� d , . - , � I t- 1�t _ � - ' .,f � =,1 } ` �� s � y��+ i � ! " i:" � � ,� i 7 i i 1 s:� � ) i �� � ;k � .; �'� � i ; C i `' ': [� T I . 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