HomeMy WebLinkAbout17483 I� -
CITY OF DIAMOND BAA ��/�;�.�
-�' -- DEPARTMENT OF COMMLJNITY&DEVELOPMENT SERVICES / � �- �
� � a 21660 E.Copley Drive S�rite 190 `� { �
(909)86Q-3195 Fax(909)861-3117 � PRESS
'���9��� BUII.DING PERMPr APPLICATION FIRnALY
� JOBSITE �1 �j APPLICATION � PERMfT �P/C
o ADDRESS��a`` ��`���`�` �'���� � DATE � � � ��� I NUMBER �����j#- ��'
� APN LOT �� TRACT � �G��(�� �SSUE TYPE OCC
� ^ , •
DATE CONST. GROUP
OWNER �
p ADDRES '� -� r ZONING SETBACKS
Z CITY 4•T":.,e.��--�-��::) ZIP q�Yb�E . �3- �,�. � FRONT RW ❑
g APPtICANT��''.% .��L-"�L- TEI� - ��,�' REAR O
SIDFJSIDE STREEf RW O
� CONTRACTOR �k,=pC�"3 G-�.{1;i,�� ��r..)C�. SIDE O
� ADDRESS ' '� I�
I
� CITY S�� F(i�, ZIP��-TE� "� PROPOSED USE �
w ARCH/ENG/
z DESIGNER NO.DWEL. NO. � NO. �
� ADDRESS UNITS STORIES BEDROOMS
� CITY ZIP TEL.
N DESCRIPTION Q.Fi. FACTOR PSF ADJ.AREANALUATION
Q OWNER-BUILDER DECl1�RATION SFR/ADD/REM � • � � � O
0 I HEREBY AFFlFtlA UNDER PFNALTY OF PEfLIURY TNAT I AM EXEMPT FROM THE CONTRAC70R5 L4 GHfa90IC8fpOR ' ; J 3.
W CEHSEUWFORTiEFOIL�WINGREA50N(SEC.70.71.59USINESSANDPROFESSIONSCODEANYCITVOH (n , '
U COUHTYWHICHREWIHESAPERMRIDCONSTFiUCT,A�TER��PROVE,DEMOLISH.ORREPAIRANYSTAUG W Pd�lO/DOGk ' 1 (� n
Z TUR�PRpR TO RS ISSUANCE,ALSO REOUIRES h1E MPLICANT FOR SUCH PERMIT TO FILE A SIGNED W , I C� `�;�'�1 ��� ( . �
w STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO T1E PROVISIONS OF THE CONTRACTORS ll
� CENSE UW(GUPTER 9(COMMENCINO WffH SECTION 7000)OF DIVISION�OF THE BUSINESS AND PRO � Pool/Spa "��
� FESSqHS OODE)OR h1AT HE OR SHE IS IXEMPT THEREFROM AND THE BA515 FOR THE ALLEGED E%El1P• .
U T10N.ANY VIIXATION OF SECTION 70.11.5 BYAHV APPLICANT FORA PERMIT SU&lELTS THE APPLICAM TO Z Re-Roof
� A CML PENALiY OF NOT MORE THAN FIVE INNDRED DOLLARS(TSoo).): ,
O ❑I,ASOWNEROFTHEPROPEHTY.ORMYEMPLOYEESWITHWAGESASTHEIRSOLECOMPENSATION, � Commercial � �
Z WILL DO THE WOHI(,M1D 1HE STRUCTURE IS NOT INTENDED OR OfFERED FOR SALE(SEC.70�1,BU54 J
NESS AND 7ROFESSIONS CODE THE CONTRACTORS UCENSE UW DOES NOT APPLY TO AN OWNER OF '
� PROPEHiY VrtiO BUILDS OR RAPROVES THERE-0N,AND VAiO DOES SUCH WOFiK HIMSELF OR HERSEIF OR m
CC 7HROUGH HIS OR HER ONM EAIPLOYEES,PROVI�ED THAT SU01 IMPROVEMENfS ARE NOT P17ENDFA OR
W OFFERmFOHSALEIF,HOWEVERhIE8U0.DP1GORIMPROVEIAFM�S50LDWRHINONEYEAROFCOMPLE-
0 TION.THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVWG THAT HE OR SHE DIO No7 BUILD OR
Z WPROVE FOR 7TiE PURP0.5E OF S�LE�.
w ❑I,ASONMEROFT1EPROPERf?:AMEXCLUSIVELYCOhTRACTINGWfTHUCENSEDCOMFUCTORS � �
(= TO CONSTRUCT T}/E PROJECT(SEC.7oM,BUSINESS IJiD PROFESSIONS CODE:THE COMFACTORS U- VeIUB[IOfI ADJ.AREA
W CENSE UW DDES NOTMPLY TO AN OWNER OF A PROPERTY WHO BULLDS OR IMPROVES TiEREON,PND
F WFqCONTRACTSFORSU(]iPROJECTSWITHACONTRACTOR(S�LICENSEDPURSUANTTOTiECOPffRAG QUANTITY DESCRIPTION FEE
Y TORS UCQ15E UW.).
� J
O O I AM EXEM7T UNOEfi SEC. 8.6 P.C.FOR 7HI5 REASON Q
3 Q r G�..t-1� " ' '� -i-�.�!'
LL' DATE �WNER �
V � � � � �:�� � .3
W /�
� LICENSED CONTRACTORS DECIARATION W � S�LI •=�� !C,O��-
CL I HEREBY AFFIRM UNDER 7ENALTY OF PERIURY THA7 I AM LICENSED UNDER PROV�SIONS OF CHAPTER
p_, � Y(LOMMENCPIO WITH SECTION TDDO)OF DNISION]OF THE BUSINESS AND PROFESSICNS CODE,AND Z �� L' '�
X MV LICENSE LS IN FULL FORCE AND EFFECT. , ,^
LL1 ^ `' m C
,� � j �
� UCENSE CUSS�'' �7 l�C.NO.�YT��� � /' ;�l.
��w �J /
VDATE �' 1 � ' f`).,�_ CONTRACTOR ``�'LL'��� s' �.��'V�� t.
;1, �' r 1 Y !-�P. � �J`1�s L ��i��'.�
� WORKERS'COMPENSATION DECLARATIGN Q � (L �`�� 4!�)"-
� I HEREBY AFFIRM UI:DER PENALTY OF PERNRY ONE OF THE FOLIOWING DECLARA7tON5: �
Cl) z
� 1 HAVE AND WILL MAINTAIN A CERT1flCATE OF CONSENT TO SELF-INSURE FOR WORKERS' _ '
� COMPENSATION,AS FROVIDED BY SECTION]700 OF 77iE IABOR CODE,FOR THE PERFORMANC'c 'U
OF TAE WORK FOH wHICH iH15 PERMIT IS ISSUEO. . � .
�
w I HAVE AND WILL SMINTARI WORKEFS'COMPENSATION INSURANCE.AS REOUIRED BY SEC7ION I I,/�1
Q 7700 CF iHE 1M80R CODE FOR TIE PERFORM/�NCE OF THE WORK FOR WHICH THIS PERAirt IS 1.� I '1 ��' �
lSSUED.MY YlOPJCEflS COMPENSATION INSURANCE CARRIEFl.WD POLICY NUMBER ARE: CONSTRUCTION 4 � � �
J
� CARRIER PL4N REVIEW
Z 90LICY NUMBER ELECTRIC ��� `
¢ ;L�•� �. �.J
o �n�ssEcror+r�rroraEca.a�FrIDOFnfrrEroar�waa+EFnac�o�unssg+aoloa�Ess7 PLUMBING
W MECHANICAL � ` - � J (
Z 1 CFATIFV iHAT W THE PERFORMANLE OF WORK FOR WMICii 1}1I5 PERMI7 U'ISSUED,I
(} SHALL NOT EMPLOY ANY PERSON W ANY M ER SD AS TO BECOME SU�ECT TO NE � r�'\ �� /
� WORKEq5 COMPENSATION UWS OF CH.1 IA�ND AGREE THAT IF I SHOULD BECOME INSPECTION FEE �
SU&IECT TO THE WORKERS'CQMPENSATIO ROVISh�NS OF SECTICN]�oo OF?He LABOR .�
� CODE,I SHALL FORT}INATi COMPLY WIT1 1�'rp ROVI - 5—��.�., ISSUANCE
p DATE: Y��_1?� aPPLICANT: C V �7��r SMIP �
w � ENERGY P/C
J WARNING:FAILURE TO SECURE WORKERS'COMPENSATION CAVERAGE IS UNUwFUI,AND SHALL BE �
� SU&IEGT AN EMPLOYER TO CRIMINAL PENALTIES MD CIVIL fINES UP TOONE HUNDRED TiWSAND ENERGY PERMIT _
DOLURS(f�00.00a).IN A601T10N TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN . fl1 �
� SECTION]70e Of h1E LABOR CODE,INTERESL M70 ATfORNEPS FEES. , RETEN7ION FEE: �p I �I I I U•�L
a CONSTRUCTION LENDING AGENCY PRE-ALT FEE: ��ll � I � � —
O
� I HEREBY AFFIRM UNOER PENALTY OF PERIURY THAT THERE IS A CONSTRUCTION LENDMG AGENCY . �
FOR THE PERFORMANCE OF THE WORK WR WH1p17HIS PERMIT IS ISSUED(SEC.30Y7,CIV.C.�. `
Z l 1
W �-1rT—�—�r'
S LENDERSNNAE � � �
�
F— LENDER'SADDRESS n
� I CERTIFY THA7 1 FUVE REA01-IIS AP?LICATION AND S7ATE THAT iHE A80�E�NFORMATION I5 CARRECL TOTAL FEES �� � I I f•
w I AGREE TO COMPLY WITH ALL CfTY AND COUNiY ORDINANCES AND STATE L4W5 REL171NG TO BUILDING � �
� CD1tSTRUCTION.AND HEREBY AUTHOHIZE REPRESENTATIVES OF THIS COUNiV TO EMER U70N THE
ZABOVE�MENTIONED PFOPERTY FOR INSPECTION PURPOSES. � COMMENTS
� � � �
m PERMITTEE NAME(PRIIJn �
, c4_n � /i L'
� SIGNANFE OF PERMIiTEE DA7E �
RECPT.NO. PAID BY VALJDA710N
2
~ - WHITE—Department Copy.YELLOW--Finan�Copy,PINK—Assessor Copy,GOLDENFOD--file Copy,GFlEEN—Appliwnt's Copy