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HomeMy WebLinkAbout16302 (23) ._ ����rE� !� CITY OF DIAMOND BA� �/�3a��/I � DEPARTMENT OF CONIMiJNITY&DEVELOPIvIENT SERVICES �`'(/ � 21660 B.Copley I7rive Suite 190 ��~"W BUII,DING PERMTT AP�LICATION , ,. . FIRESS � JOBSITE �-y� ��. APPLICATION �JI� PERMIT �j P/ ' o ADDRESS ����� ���'�� DATE NUMBER J' � ISSUE TYPE OCC APN LOT TRACT pATE CONST. GROUP p OWNER ��L����'�"�'� o ADDRESS a3��`�Fv � �7G� �� ZONING SETBACKS �W CITY �L�/�B ZI� TEL.. �r I� rL. REART RW p APPIICANT TEL. SIDElSIDE STREET RW O � CONTRACTO � �. SIDE ❑ � ADDRESS �"`� ' PROPOSED USE WT � � CITY,/� e ZIP��.f� TEL. w� ARCWENG/ W DESIGNER NO.DWEL. NO. NO. n. ADDRESS UNITS STORIE5 BEDROOMS � CITY ZIP_ TEL. _ � DESCRIPTION SQ.Ft: FACTOR PSF ADJ.AREANALUATION � m OWNER-BUILDER DECLARATION SFR/ADD/REM � (] I HEREBY AFFlRM UNDEF PENALTY OF PERJUqY THAT I AM EXEMPT FRO�THE CONTRACTORS LI- � GaragelCarport � CEMSELAWFORIMEFOLLQ4'lINCREASON(SEC.7031.5BUSINESSANDPROFESS�ON3CODE:ANVCITYOfl CWNttWHICHAEOUIRESAPEFMITTOCONSTRUCT,AL7ER.IMPfiOVE,DEMOUSH,OpREPAIRANVSTRUC- W pg410/DeCk W NRE,�RIOR TO I75 ISSUANCE,ALSO RE�UIRES THE APPLICANT FOR SUCH PERMIT TO KILE A SIGNED � STATEMENT THAT HE OR SHE IS LICENSED PURSUANT T�THE PPOVISIONS OF THE CONTRACTORS LI- � CENSE UW(CMAP7'Efl e(COMMENCINO WITH SECTION 70ao)OF DIYISION 3 O(THE BUSWESS AND PPO- � POOVSP3 FE5510NS CODE)OR THAT HE 6R SHF IS EXEMPT 7HERF.FflOM AND THE 6A515 FOR THEALLEGED E%EMP- TION.ANYVIOLATIONOFSECTION7031.56VANVAPPUCANTFORAPFFMITSU&/ECTSI'HEAPPUCANTTO Z Re-Rooi � A CML PENALT'OF NOT A/OftE THAN FNE HUPI�REO OOLlARS(5500).1: � OI,ASONMEROFhiEPROPER7Y,OFMVEMPLOYEESWITHWAGESA57H61RSOLECOMPENSATION, � CommOfCiel ' WILL�O TNE WORK,AND THE STRUCTURE IS NOT INTENpED OR OFFERED FOR SALE(SEC.7oM,8U51- J � NESS AN�PROFES510NS CODE�THE CONTRACTORS I.ICENSe lAW DOES NOT APPLY TO AN OWNER OF = PROPEflTY VIliO BUILDS OR IMPROVC-5 iMEREON,AND WHO DOES SUCH WOftK HIMSEIF OR HERSELF OP Q 1HRd16H HIS OR HEF OWN EAIPLOYEES,PAOVIOE�7NAT SUCH IFAPROVF.MENiS ARE NOT INTENDED OR m � OFFEREDiOFlSAIEIF,HOWEVERh1EBUILDINGORIMPROVEMENTIS50LDWITHINONCYEAROFCpMPLE- _ Z TION,THE OWNER�BUILDER WILL FUVE THE BUROEN OF PAOVING 7HAT HE OR SHE DID NOT BUILD OR � IMPROVE FOR7HE PUHPOSE OF SAlE} ❑l AS OWNER OF THE PROPERTV,M1 EKIXAISIVFL7 CONTRACTING WITH LICENSEO CONTRAC fORS � TO CONSTftUCT THE GRQIECT(SEC.7ol�e.BUSW ESS AND PROFESSIONS COCE THE CONTRACTORS U- V01u8�IW1 _ ADJ.AREA W CENSELAWDOESNOiAPPLYTOANONMEROFAPROPERTY`AMOBU!LDSOR�MPROYES?HEPEON,AND � INfOCdNTRACTSFORSUCHPR0.1EC7SNATHA00NiflACTOR�S)LICENSEOPURSUANTTOTHECONTRAF QUANTITY DESCRIPTION FEE � TOFSIICENSEl,AW.j. — — O!AM EXEMPT UNDER SEC. B.&P.C.FOR THIS qFASON Q 3 - --- � � LL DATE _,__ON7dER_ C� ? W Y LICENSED CONTRACTORS DECLARATION � � u� IHEREBVAFFIPMUNDERPENPLYYOFPEbUUMTHATIAMLICENSFDUNDERPROVISION50FCHAPTER � I ���� �. �ry d 9(COMMENCINCi WITM SECTIOfJ 7000)OF OiVISION 3 4F THE 9USMESS AN�PRO!'ESSIDNS CO�[,ANO z « X YV LICENSE IS IN NLL FORCE AND FFECT q � LLJ '7 7.�I�'� �� � UGENSE GLAySS C...�'� LiC.NO. J �'j DATE__�{,�,.�_� CON7RACTOR �� a 6il � WORKERS'COMPENSATION DECIARATiON Q � U � IHfREBYAFFIRMUNDERPENN.T'OFPEAJUP.YONEOFTHEFOLLOWINGOECLARATIONu: Z Q � �IMAVERNDYYILLMAINTNNAa.ERTIFICpTEOFCANSENTTOSE�F-INSUPEFORWORKERS' _ � COMpENSATI ,AS PROVIDEO 9�SECTION 370o OF THE LABOR CODE.FOR THE PERFORMANCE �U UF TH 1(FOA WNICH TH:S PERMIT IS ISSUEO. � W ;HAVE MIO WILLMA�NTAIN WORKERS'COMPENSATION INSURANCE,AS REGUIPE�BY SECTi0�4 Q � 370oOFTMELAB DE,FORTNEPFRFOiiMAMCEOF E �KFORWHI^NTHISPERMITIS 0 155UED.MYWq K S'C�M7EN5ATIONINS E 'DPCLIC Ill�7f9EflAflE CONSTRUCTION > CpqRIEA `��.__. PLAN REVIEW —� z �oucrwurnee� ��.y��(„d�`_.�.�� � � ELECTNIC �� ¢ ____2 r Q fIHt55EGIkXJNcEDMOT9E(S7h1PLEtEDOFTHEPEWMlS ar+e oa IE+co)oatEss�. PLUMBING _. W I CERTIFYTHAT INTHE PER=05MANCE Of THE YdURK F WHICH PE IT IS ISSUED,1 MECHANICAL Z — � SHA,LLNOTFMPIQYANVPERSONMMIVIAANNERSO ECTTOTHE � WORKERS'COMPEN.�iATION LhVd3 OF CALIF fiEE A OUW BECAME INSPECT�ON FEE SUBJECTTOTNE6YORKEFS'CCM7PENSAT S ION a00FTHEU60R � CADE,I SHAti FORTHWiTH COMPIY WiT H VI O . " ISSUANCE Q SMIP p DATE:� . APPLICAN"C _. . . � ENERGY P/C _._._____ _ � WppNINGFAILURETOSECUREWORKF.RS'COMPEN ION VERA WFUL,ANDSHALLBE � SU&IECTANEMPLOYERTOCRIMINALPENI.LTIESANDC FWESUPTOONEHUNDREDTHOUSAND ENERGYPERMIT pGN.LARS(f 100,0001.:N ADDITION TO TNE C057 OF COMPENSATION,DAMAGES AS PROYIDED FOR IN � 5[GTION37oBOFT'rIELA90RCODE,INTEHEET,ANDAT'lORNEV'SFEES. FIETENTIONFEE: d CONSTRUCTION LENDING AGENCY PRE-ALT FEE: � IHERE6YAF�IRMUNDERPENAITYOFPERJURYTMATTHEREISACONS7PUCTIONLENDINGAGENCV FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PEFMIT IS ISSUED(SEC.3os�,CIY.C.). Z W � I.ENDER'SNAME_____ -- _ F_— LENDER'SADDRESS_�__. ---- � ICERTIFYTHA7IHAVEREADTHISAPPLIG ON NDSTATETHATTHEABOVEINFORMATqNISCARRECT. 70TAL FEES � � 0. I A3FEE?O CAMPLY WITH ALL CI7Y AND UNT ORDINANCES ANO STATE IANlS REUTING TO BUIIDING , , CONSTRUCTION,ANDHER[6YAUTHO REO ESENTATIVESOFTNISCOUNTYTOENTERl/PON7HE ZABOVE�MENTIONED PPOPERTV FO 5 ECT{ runPases. COMMENTS � � m PEflMITTEE �� � / . 4 1 N ! � SIGNATURE PERMI DATE ' "'� = RECPT.NO. PAID BY � VAL�DATION_ _ ~ WHITE—Department Copy,YELLOW—Finarxa Copy,PINK—Assessar Copy,GOIDENR04—File Copy,GREEN—ApplicanYs Copy „,,. ; , ,. .. . , , ..� ; .., ,M. - ..: , ,: ., � ,,. ,. . ..:�:.. �, . . ..,., . ,- � ,�,.�_, ;�-„ �,.. ,,f . , ., �.,,. ��""�� �� �� k���� �� , . .. ����������� _ _����� - 6. . n. . 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