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HomeMy WebLinkAbout13411 (16) _ -� ��;: CITY OF DIAMOND BAht � `' ���-- DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES i 21660 E.Copley Drive Suite l9D (909)860-3195 Fax(909)861-3117 PRESS � ��?��n� BUILDING PERMIT APPLICATION FIRMI.Y � JOBSITE ��"}J � 1 �� APPUCATION PERMIT � I P/C Q ADDRESS t'� �- DATE NUMBER "� � i # c� ISSUE a^�_. ��_�_�'�q i TYPE OCC APN L T .TRACT DATE I � CONST. GROUP p OWNER � �'• �Z-a�+. , " ADDR SS' �� •, � '`��'� ZONING SETBACKS W CITY + '' ZIP_ TEL�i•-�.,���•-���� FRONT RW Ll_ � APPLICANT r TEL.(�)-�a" It]�*9 REAR _ I_]_ SIDEfSIDE STREE7 RW"fl __ � CONTRACTfOR � J • . ��. - -� SIDE LJ g ADDRE 5 J .r' `'� CITY r ZIP � TE 4��i�j 1�°7i� PROPOSEDUSE g � ' ° � � ARCH/ENG! t �,,3. .,..�c ',r � DESIGNER NO.DWEL. NO. `� NO. ADDRESS UNITS � STORIES c7'` BEDROOMS� � CITY ZIP TEL. y DESCRIPTION 5Q.FT. FACTOR PSF ADJ.AREANALUATION N � OWNER•BUILDER DECLARATION SFR/ADD/REM O (] I HEREBV AFFlRM UN�ER PENAL7V OF PERtt1RY THAT i AM EXEMPi FROM THE COMMC70RS L6 � GaraqelCarport W CENSELAWFORTHEFOILOWiN(1flFA50N�5EL.7o3t.5BUSINE55ANDPROFES510NSCODE:ANYCITYOR � CIX1NiYWHICMNEIX11RE5APEHMITTOCON5TPl1CT,A�7ER,IMPROVE.DEMOLISH.ORREPAIRANYSTRUG w PetiO/OBCk NqE.PPIOR iOITS ISSUANCE,rLLSO REOUIRES'ME APPLILl�NT fOR SUGH PEHMIT TO FILE A SIONED � STATEMENT TMl1T ME OR 5NE IS UCENSED PUHSUMIT TO THE PNOVISIONS OF TNE CANTRACTORS LI� � CENSE LAW(CHA7TEfl 8(COMMENCINa W1T}I SECTION 7000)OF OIViSION 3 0F THE BIISINE55 AN�PRO� � POOVSpO — _ FESSIONSOO�E�ORTHATHEOqSHEiSEXEMP77HEflEFROMANOTHEBA5ISFORTHEALLEGEUEXEMP. (� TION.ANVVIOLATIONOFSECTION7o31.68YANYAPPLILANTFOHAPEq1AIT5VBJECTSTMEAPPLICANTTO Z flB-R001 �. " � �CIVIL PENALiYOF NOT MOflE THAN FNE HUNDqEO DOLLARS IfSDOJ.): � ❑I,ASOWNEROFTHEPflOPERTV,ORMYEMPLOYEFSWITHWACESASTHEIRSOLECUMPFNSATION, � COmI71BfGIBI �', W�LL W THE WOPK,AND THE STqUCNRE IS NOT INTENOED OR OFFEPED WN SALF(SEC.7o4L BUSI� J NE53 AND PROFE5SION5 CODE:iHE CONTMGTORS LICEN&E LAW DOES NOT APPLY YO AN OWNEH OF � PROPEWTYWFIOBUILDSORIMPROVESTHEREON,ANDWHOOOES6UCHWOflKH�MSELFORHERSELFOR � [C:� TMIqUGHHI50RHEflOWNEMPLO�EES,PHOVIDEDTHA75UGiIMCqOYEMENTSARENO7INTENDEDOR � L.U,, ,OFFEREDPoRSKEIF,HOWEVEfl.THEBUILDIN00RIMPROVEMENTI5501DW�THININJEYEAROFCOMPLC- �; '710N,THE OWNER�BUIL�ER WILL HAVE TFtE BURDEN OF PROVINO THAT HE OR SHE�IO�T BUIID OR � IMPqtlVE fOR iHE PUHPOSE OF SAIE�. uy� ❑I,/SOfM�EROFTHEPROPERiI:ANE%CWSNELYCONTMCTIN6WITHLICENSEDCONTRACTOR3 ``�-�, �. TO CONSTRUCT7NE PROJECT(SEC.�ou,BUSINE53 AND FROFESSION3 COUE:THE CONTRACTORS LI- V21u3�ion �__ADJ.AREA_ __ _ _ W. CENSELAWOOESNOTAPPLYTOANOWNEflOFAPflOPEXTYWHOBUK�50RIMVHOVESTHEREON.ANO �'. W/qCONTRACTSFORSUCNPp0.1ECT5WITMACONTfiACTOR(S�LICENSEDPURSUANTTOTHECONTRAG QUANTITY DESCRIPTION FEE . TOHSUCENSELAW.�. �� O 1 AM EXEAIPT UNDER SEC. — ,_„B.&P.C.FOfl THIS REASON Q U � LLZ OATE �OWNER_ _^_ '__ V O- .w.l � LICENSED CONTRACTORS DECLARATION W �. IHEREBYAFFIflMUNDERPENALTVOFPERJURYTNATIAMLICENSE�UNDERPROVISION&OFCHAPTER � q�� 9(COMMENCM10WIiHSECTKKJ7D00�OFDIVISI0N30FTME8U5MESSANDPfiOrESSIDNuCODE,AND Z x MY LICENSE IS IN FULL FORCE PNO EFFECT, m W. �'' �,`� � LICENSEGLASSry Z�_. LIC.NO. � C�-�J� � 7 V� DATE �7"' 7 CONTRACTOR t J ` � ��� a ��� �� W -�=��W �� WORKERS'COMPENSATION DECLARAl10N ¢ � U �� INEHEBYAiFIRMUNOERPENAITYOFPERJURYONEOFTHEFOLLOWINGDECIAF✓TIONS, � � Cl __IFNVEANDWILLIAAINTpINACERTIFICATEOFCONSENTTOSELFJNSUREFORW(]PKFflS' _ OOMPENSATqN,ASPROVIDED9YSECTON3�a00FTHElABOFGOOE.FORTHEPERFORMANGE U Q OF TNE WORK FOR WHICH THIS PEflMIT IS ISSUEO. � B __I HAVE AND WILLMAIMMN WOFKERS'COMPENSATION INSIIRANCE,AS REOUIPEO BY SECTION + ' d 37000FTHEUB�RCODE,FORTHEPERFORMANCEOFTHEWORKWHWHICHTHISPERM�T15 17 � � � <� .-�-� � �__.-----._ �__-_ _.t�1.._,��-- 0 ISSIIE�.MY WOH ERS'COMPENSATI�Of11N5URAN E CAHPoER AN�POLICY NUMBERAR�� CONSTRUCTIDN �� 4 ": � CAFRIER � 'fy P .�. PLAN REVIEW .�i7,.=.--.__.�..--..--..-.'----- --- Z� aoL�CYNUMBEH�IL-=__�__�_..— '- � ELECTRIC � _'_ _._... ______ __ - Q —� `., � (f1C55EC1qNNE�NOTBEWMLEfE00FThEPEiNMfIS�ORONEMI�CFiEDDOLIFA31E100)OR1E551. � PLUM9ING _.. •' . . '. . ._. .._._—..—_—__.__ Z ICERTIFYlHATINTHEPERFORMANCEOFTHEYlONKFORWHICHTHISPERMITISISSUE�,I MECHANICAL ��! � _ ' .___ _ ,. :;.'..'"' (J �. SH/iLINOTEMPLOYAMYPEflSONINAN\'MANNERSOA5T08EWMESUI3JECTTOiHE �'��'o �,��-' j� . y- WaFKEflS'COMPENSATIIXJfAWSOFCALIFpflN10.ANDAGREETHATIFISHOULD�ECOME INSPECTIONF�€ �_ �� ;'._ _ ___ 4 � SU&IECTTOTHEWORNEfl3'COMPENSATIONPROViSION50F6ECTION3�000FTHELABOR �� �, � � _ —^ T— j: CODE,ISHALLFORTHwITHCOMPLYWITHTMO3EPROVI510NS 1SSUANCE ��.c_.____—.- , �,�� S.;. O � s'; .. —���j\--- �.,:. p DATE: —� APPL�CANL• ._ „_ SMIP `;�y.~' -�.'___.'__ --_—'_' -_� `�-�' ..— ! W � c � WAFNING:FA�LUREYOSECUREWORKEfl3'COMPENS/TIONCOVEflAGEISUNLAWFUL,ANDSHALLBE ENERGYPlQ,��' _..__ _.__�.___..._. J .—.._ J \ �y SU&IECTANEMPLOYERTOCNIMWALPENALTIESANDCIVILFINESUPTOONEHUN�REOTHOIJSAND ENERGYPERMIT ��, � Y DOI.UNS(S1oa.000),INM�ITIONTOTHECOSTOFCOMPEN3ATION,DAMACESASPROVIDEDFORIN '--"-"--'-'---"'—'-'-- '--"— J SECTION 3708 OFTNEUIBOR CODE,INT[REST.AND ATfORNEY'S FEES. RETENTION FEE: . __ ._____._ .-__ f.: � w CONSTRUCTION LENDING AGENCY PRE•ALT FEE; I�� � � IHEREBVAFFIqMUNDEPPENAITroFPEAJUftYTHAT7'MEHEISAWNSTflUCTIONLEN�INGAGENCY �' (r'{1 I� . FOP THE PERWRMANCE OFTHE woRK FOR WHiGH TMIS PENMIT IS ISSl1ED(SEC.9o9],CIV.CJ. — '—�� �� -_---- �����'L _'�� w � LENDER'SNAME_ .— "' .^._.... _ '_'_"_' _„' F- LENDEq'SA�DflESS___,_ — -- -- - ' W ICERTIFYTHATIHAVEREPD'fMISAPVLICA1loNANDSiATETHATTHEABOVEINFOHMRTIONISCORRECT. TOTAL FEES . � I AGREETO COMPLY WITN ALL CITY nN0 COUNTV ORDINANCES ANO STATE LAWS qELATING TO BUILDIN6 CONSTflUCTION,AND HFREBY AUTHORIZE REPnESENTATIVES OF T1n5 COUNTY TO ENTER UPoN THE zpBOVE-MENTIONED PROPEFlTY F�N INSPEc7lON PURVOSEs. COMMENTS _, _-____ _ � ' J . ` ` _ _ � � m PE EENAME(P _— Q �.��;�.�.. .. _ -- - - ---�---�- � SI�TU O PEflMITT E DATE = RECPT.N0. ��PAI�BY_L ���b VALIDATION_ �,�_ ~ WHITE-0epartment Copy.YELLOW—Finance CoDY.PINK—Assessor Copy.GOLOENpOD--Fiie Copy,GREEN—Applicant's Capy . _. .,_ _ _, _ . , . - . . .. . _. , , � , , , ?, . -�' � � ��,ti - �.: � �, , : � ; „ � , ., � , �y � .: � � , i a: i ��€ ��� � � � , , � . „ , , � ` ! _ �_:. . , , . � . . I , t . . , i � � � � ' . _ ; i v� i i ^ � i ' � ' I -c ',� . , , , , , ; � � : , _ . , , _ _ ^ ; � � � , , '., �; � _ . ' .,' . .:. '.. ,. i �, i I- � � . � � ., , . � . ; , , , , . , � , t � , . ,. � � ; � : i �. � � � ; �,; , , : �� , , � , : � � � � �� , � `� �� � � - ', ' � � : � � ' ' { < < ' , , ' `` , � � � � � i � � � ' . r , � 1 . �. , ,.. , , 3 : , , , , , , � - - � , ; - _ , � - . . , ; � . 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