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HomeMy WebLinkAbout15713 (23) _ . _ _----- - - ___ ,��.. _� . ,,,1.___ �_ _. _ CITY OF DIAMOND BAIt - -�� - DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES _ w , 21660 E.Copley Ihive Suite 190 � � (909)860-3195 Fax(909)861-3117 PRESS �"�", � BUII,DINGPERMITAPPY,ICATION ` FIRMLY � JOBSI7E / Q O ����/- �� J �n� J�j o ADDRESS, �y 4 DATE CATION�� �� � NUMB R 4✓ � #/C���� � APN LOT_� TRACT ISSUE TYPE OCC DATE CONST. GROUP p OWNE�/'►'1 LD2uQCo.oyv��.�f � ADDRESS ZONING SETBACKS 0 � GITY ZIP TEL. REART RW p APPLICANT TEL9�`h_L�'C�/'�.2 /�C SIDE/51DESTREET RW ❑ � CONTRACTOR ��I ' ��� , SIDE ❑ O CDDRESS` Z�P TEL��'�� PROPQSED USE `� -s C. �� ARCH/ENG/ J� y! DESIGNEH �"JCD� !".rh 1 h C��"/A�, NO.DWEL. NO. NO. ADDRESS �t�J YV- �t. I� UNITS STORIES BEDROOMS � CITY i�r. l,�l'i� ZIP��}�, TEL� cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION Q OWNER-BUILDER DECLAFATION SFWADDlREM � 1 HEREBY AFFlRM UNDER PENALTY OF PERRIRV THAT I AM EXEMPT FROM THE CONTRACTORS LI- G2f890/C3fP01� W CENSEUWFORTHEFOLLOWINCvREASON(SEC.7031.5BUSINESSANOPROFESSIONSCOOE:ANYCINOfl (n �..� COUNTYWHICHHEOUIRESAPEFMITTOCONSTRUCT,ALTEfi.IMPROVE,OEMOUSM,ORREPAIRANYSTRUC- W NRE.GRI01i TO ITS ISSUANCE,Q50 REQUIRES 71iE APPIICAN7 FOR SUCH PERMIT TO PIIE A SICNED W PatiO/D6Ck STATEMENT THAT HE OR SHE IS LICENSED PURSUANT M THE PROYISIONS OF THE CONTRACTORS ll- � CENSE UW I��ER 0(COMMENCINO WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PHO- � POOUSpB ,yZ` FESSIONSCOOE�ORTHATHEORSHEISEXEAIPTTHEREFROMAND'HEBASISFOPTHEALlEOE�E%EMP- C7 TqN.ANVVIOLATIONOFSECT10N7o31.6BVANVMPLICANTFOHAGERMITSUBJECTSTHEAPPUCANTTO z Re-Root � ACIVIL PENALTV OF NOT MOHE'THAN FNE HUNDREO DOLLARS(SSao).): � ❑I,ASOWNEROFTHEPROPEPTY,ORMYEMPLAYEESWITHWAGLSASTHEIRSOLECAMPENSATION, � COII1f118fC181 -- WILA.DO THE WORK,AND THE STNUCTURE IS NOT INTEND60 OR OFFEREO f-0R SALE�SEC.7oM,BU51- J � NE55 AND PROFE550N5 OOOE:THE CANTRACTORS LICENSE lAW DOES NOT APPLY TO AN OWNER OF � PROPEHTY YMO BUIL.DS OR IMPROVES THEflEON,MID WHO UOES SUCH WORK HIMSELF OR HERSELF OR " [Z THROUI3H HIS OR HEFiONM EMPLOYEES,PROVIDED THAT SUCH IAIPROVEMEN75 ARE NOT INTENDm OR m � 0 ,OFFEREDFORSN.EIF,HUWEVER,THE8UIl01NOORMPROVEMENTIS50LOWITHNONEYEAROFCOMPLE- Z TION.THE OWNER-BUIIDER WILL HAVE THE BUPDEN OF PROVING THA7 HE OR SHE DIO NOT BUILD OR � IMPRDVE FOR THE PU RP0.5E OF SALE�. W ❑I,0.50WNEROFTHEPROFER'T1;AME%CIUSIVELVCONTRAC7INOWITNLICENSEOCONTRACTORS � TO CONSTRUCT TNE PROJECT(SEC.7014,6USINESS AND OROFESSIONS CODE:THE CONTRACTORS LI- VdIUdIlO71 ADJ.AREA W CENSEUIWOOESNOTAPPLYTOANOWNEROFAPROPERTYWHOBUtLDSOFINPROVESTHER[ON,AND , � WFIOCONTFlACTSFOR3UCHPROJECT3WITHACONTRACTOA�S)LICENSEDPUFlSUAN770THECONTRAG- QUANTITY DESCRIPTION FEE �, � TORS LICENSE Uw.). p �IAM EXEMP7 UNDER SEC. B.8 P.C.FOR THIS REASON y � ¢ i9 I � i"t(, � DATE OWNER �" �i[ UCENSED CONTRACTORS DECLARATION W V�vt p� J 2 I HEREBY AFFIRM UNDER PENAI.TY OF PERJURYTHAT I AM UCENSED UNDER PROVISIONS OF CHAPTER � . � Y�COMMENCINOWITMSECTION7o00�OFDIV1510N30FTME8USINE55ANDPROF'c5510N5CODE,AN� Z MY UCENSE IS IN FUII FORCE AND EFFECT. _ y � �r�-� � Q UCENSE CLASS "� LIC.NO. �I �! � ]� / ~ DATE CONTRACTOR d � � � I'I�Cy/' ' N� �rI ( �' w - � - r Gu - L. � v � � WORKERS'COMPENSATION DECLARATION � ' "� I HEREBV AFFIRM UNOER PENALTY C'�PERJUflY ONE OF THE FOLLOWING UECL0.RATION5: Z ,� r �/�%� ���J G� _lNAVEANDWILLMAINTAINACEATIFICATEOF/'ANSENTTOSELF-INSl1REFORWORKERS' _ Q COAIPENSA710N,Aa"PROVIDED BY SECTION 37000F THE LABOP CODE,FOR TNE PERFORMANCE W OF hIE WORK FOR WHICH 7HI9 PERMIT IS ISSUEO. � O ],/' '�?i HAVEAND'NILI.MAINTAIN WORKEPS'WAAPENSATION INSURANCE,AS REdUIRE�BY SECTION � � 370aOFTHElA80RCO0E,FORTHEPERFORMANCEOFTHEWOPNFORWHICHTNISPERM1T15 � ISSUED.MV WORKERS'COMPENSATION INSUFANCE cARHIER AN�POLICY NUM6ER ARE: CONSTRUCTION _ � CARRtEA��I PLANREVIEW � POLICV NUMBER_ � ELECTRIC Q � (PHISSECfIONNE�NOTBEODMPlEfF00FT1�EPERAMI'ISPDFONEIi�JhDREDDOIUAS;S100)ORIESSF P�UMBING Wi�+ � I CERTIFV THAT INTHE PEtiFOqMANCE OF THE WqRK FOR WHICH THIS PERMIT IS ISSUED,I MECHANICAL -t L7 SHALL NOT EMPLOV ANY VERSON IN ANY MANNER SOAS TO BECOME SUAJECT TO TNE 5/� WORKERS'COMPENSATION UWS OF CAUFORNIA,AN�AGREE THA'IF I SHOULD BECOME INSPECTION FEE SUBIECTTO THE WbRKERS'COMPENSATION PROVISIONSpOJlF SECTiON 3'!0o OF THE UBOR - CAOE.ISHALLFORTHWITHCOMPLYWITHT} 5 VI'pJl� ISSUANCE p DATE: APPLICANT: N�yx�� SMIP �'�7� p�7�}y'{y�gg�p9 I.C�/� � WARNINGFA�LURETOSECUREWORKERS'COMPENSATIONCAVERAGEISUNLAWFUL,AN� ENERGYP/C ���• +� �����.AA'YiVl�@LaUfAHl. �� J y}j p � SUBJECTANEMPLOYERTOCRIMMALPENALTIESANOCIVILFINESUPTOONEHUNDREDTHOI/SANO ENERGYPERM�T�.J DOUARS(f100.000),IN ADDRION TO THE COST Of COMPENSATIIXJ,DAMAGES AS PROYIDED FOR IN � � SECTION97080FTHELABORCODE,INTEflEST,ANDATTORNEY'SFEES. RETENTIONFEE: o OCONSTRUCTION LENDING AGENCY PRE-ALT FEE: � IHEREBYAFFIfiMUNOERPENALTYOFPERJURYTNATTHEREISACONSTRUCTIONLENDINGAGENCV FOfi TME PERFORMANCE OFTHE WORK FOft WHICH THIS PERMIT IS ISSUE�(SEC.309],CIV.C.). Z W �Z LENDER'SNAME_ � a F-- LENDER'SADOFESS W� TOTAL FEES -��- ��, �� � � I CERTIFV THAT I HAVE READ THISAPPLICATION AN�STATE THAT THE ABOVE INFORMATION IS CORRECL �"') � I AGftEE TO COMPLY WITH ALL CIT'NIO COUNTV ORDINANCES MIO STATE LAWS REUTING TO BUILDING � � CONSTRUCTION,AN�HEREBYAUTHORI'LE REPRESENTATNES OF THIS COIJNTV TO ENTER VPON THE z ABOVE•MENf NEDPqOPERTYFORINSPECTIONPVFPOSES. C ENTS � `l��e�-f �e ,�L�/c�r � ` — m r� ��ry � PE N ad ��1i l,/ ���A f�� (?'� _ ' . = RECPT.NO. �"G� PAIDBV VALIDATION ~ WHITE—Deparlment Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOL�ENROD—File Copy.GREEN—Applicant's Copy - ���, ,�.�� �1� �j ' �'L�i`j� � C� ..ir ... , ... . •.'.,..:'. .:,h. � .�' . .-',,.�':.�- .x�. _ . . ....., -. ' . . -. �_ . .d t� N#+....t ..�1 . 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