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HomeMy WebLinkAbout11886 (9) _� .. �� CITY OF DIAMOND BAht � DEPARTMENT OF COMMUNITY&DEVELOPMENT SEF.VICES � � 21660 E.Copley Drive 5uite 190 � (909)860-3195 Fax(909)561-3117 PRESS •�.�9N�'�' BUILDING PERMIT APPLICATION , FIRMLY - :,.:...: . :. ..:.:.. ... . . .. _.. .. .... .. N JOBSITE F > APPLiCATION � �~ PERMIT ! p/CR T.`�� � ADDRESS � ��'�' -r'� �6�n K'�1`1"�t��1C�11 �+'t�� ���'1i''�� DATE �� '� NUMBER � � # " � � c� ISSUE { / TYPE OCC APN_r LOT TRACT _,r____.. DATE � CONST. GROUP p OWNER '�'�.,a'i�+'r1(1c.'1��"'� 1��,Y l%�,`a �'�' ADDRESS-� r"' -� ' �d- ` ZONING SETBACKS � CITY . ' ZIP`` .,3' 1'E�� ' � FRONT RW C APPLICANT • TEL. 'i REAR ❑ Z SIDElSIQE STREET RW G � CONTRACTOR (V R 1 lC]N�Si�'+'1 � �'1��T�. SIDE C � ADDRESS �`'� � � o CITY����-• ZIP TEL.� f ROPOSED US�E e�� � 1 d�_ l� r � o � o ARCH/ENG/ J _��a �•- W DESIGNER NO.DWEL. ���NO. NO. a ADDRESS t1NITS _ STORIES BEDROOMS � CITY ZIP TEL. � DESCRIPTION F7. FACTOR PSF ADJ.AREANAIUATION cr� o OWNER-BUILDERD�CLAFiATION SFFVADD/REM �� /"� � i / p I HEREBY AFFlRM UNDER PENALTY OF PEfiJURY THAT I AM EXEMPT FpOM THE CONTRACTORS LI- G3f3CJ8/CBfPOh I� �� r 7�p W CENSELAWFORTHEFOLtAWINGqEASON(SEG7031.58USINESSAN�PROFESSIONSCOOE:Af�VCIiY�Ofl (n . U OOUNTYWHICMREOUIRESAPERMRTOCONSTpUCT,ALTER,IMPROVE,DEMOUSH,ORREPAIRANY5IAUG LLJ patio/Deck ' ' w 7URE,GRIOR TO ITS ISSUANCE,ALSO PEQUIRES THE APPLICANT FOR SUCH PEHMIT 7b FILE A SIGNE� w ' � STA7EMEM THNT ME OR SHE IS LICEN3ED PURSUANT TO'7HE PROVISIONS OF THE CONTMC70RS Lb ` � CENSE LAN�(C1IAPTER D(COMM6NCING WIiH SECTION 7000)OF�IVISION 9 0F THE BUSINESSAND PR0• � PoOVSp2 � i'i"�'i�" �f I FESSqNS CODE)OR THATHE OR SHE IS EXEMPTTHEREFROM AND THE BASIS FOH iHE ALLEaEO EXEFAP� TION.ANVVIOLATIONOFSECTION7o3t.5BVANYMPLICANTFORqPERMIT5U8JEC7STHEAPPLICANT70 Z Re-Rooi �,�(� �(� � ACIY6.PENKTYOFNOTMORETHIWFIVEM/NDREDDOLLAii5�55oo)J: � ^ � ❑I,ASOWNEROF7HEPHOPER7V,ORMVEMPLOVEFSWI7HWAGESAS7HEIRSOLECAMPENSATION, C, COfi111'IBfCi01 �(,',� +` • WILL 00 THE WORK AND THE STHUCTURE IS NOT INTENDEO OH OFFERED FOH SALE ISEG.7Ud1,BU51� J � NESSMO PROFESSIONS CODE:hiE CANTRACTORS LICENSE UW DOES NOTAPPLY TO AN OWNEii OF = PROPERTYWFIDBUILDSORILiPROVES717EREON,lWDWHOpOESSUCHWORKHIMSELFORHERSELFOR m � 1HROUCiHHISORHEHOWNELIPLOVEES.PR041�ED7HA76UCHIMPROVEMENTSARENOTINTEND�DOR WQ OFFEHEDFORSALEIF,HOWEVERh7EBUILOINGOflIMPFOVEMENTiSSOLDWITHIN�NEYEpROFCOMPLE _ Z TION.THE OWNER-BUILOER WILL HAVE THE BUROEN OF PROVING THAT HE OR SHE DID NOT BUILD OR � IMPROVEFORTNEPURPOSEOF5ALE). ❑I,ASOWNEROF THE PROPEHTY.AM EXCLUSIVELY CONTRACTING WI7H LICENSED CAN7RACTOHS � � TO CONSTRUCT THE PRQIECT(SEC.7o40,BOSINE95AND PROFESSIONS CO�E:TFiE CON7RACTORS"Ll� V21UatiOfl ,A �_ A�J.AREA W CENSELAWDOESNO7APPLYI'OANOWNEROFAPROPERTYWHOBUIIDSORIMPROVESTHEREON,AND " � MM1IOCONTRACTSFORSUCHVRQIECTSWITHACONTRACTOFi(5)LICENSEDPURSUAMTTOTHECONiRAG QUANTITY DESCRIPTICN FEE � TORS LICENSE UW.). J 0 ❑I AM EXEMPT UNDER SEC. B.e P.C.FOR THIS REASON U � � � OA7E �'NNEF � � LICENSED CONTRACTORS DECLARATION w � w 1 HEREBY FFFIRM UNDER PENPLTY OF PERJURV TNAT I AM LILENSED UM1DEF PROVISIONS OF CHAPTER � d 9�COMMENCINC3 WITH SEC710N 7006)OF DIVISION 3 OF THE BUSINE55 AND PROFESSIOYS CODE.AND�� Z X MY LICENSE IS IN FULL FORCE AND EFFECT. � m � LICENSECLASS � � LIC.NO. �`?•�6d�t✓ � � U �p�-�,�� � J DATE CONTRACTOR_J YsZ►�►__ W ,/ � . � � WORKERS'OOMPENSATION DECLARATION � Q � � U — � IHEREBVAFFIRMUNDEHPENALTVOF�Ei1JURYONEOFTHEFOLLOVCINGOECUMTIONS: z Q � _IMAVEANDWILLMAINTAINACEfR�FICATEOFCONSENTTOSELF-INSUREFOAWORKERS' _ � COMPENSATION,ASPflOVIDE0BY5ECT10N37ooOFTHELABORCODE,FOR7HEPEflFORMNNGE W OFTiE WORK FOR WHICM THI3 PERMIT IS ISSUED. - � � ' W _IHAVEANOWILLMAINrAINWaRKERS'COMPENSATIONINSURANCE,ASRE�UIREOBVSECTION �'�` Q 37000F THE LABOR CODE,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS 7 9.-�s--� ISSUED.MY WOP.KERS'COMGENSATION INSURANCE CARRIER AND POLICY NUMB�R ARE: CONSTflUCT�ON /"1� Y� j CARHIER � � � i� )� ���/���/�,�j] PLAN REVIEW �_ ' Z POLICYNUMBER � t�--�--t�-• ELECTRIC ¢ (iHISSECTpNNE�NOiBECORffLETEDOFTHEPERlMISFORONEuuAORWDOLLPRS(E:�)oRLESS� PLUMBING _ 0 � MECHANICAL Z I CERTIFY THAT IN THE PERFORMANCE OF THE WORH FOR WHICHTH!S PERMIT IS ISSUED,I (;j SHALL NOT EMPLOYANY PERSOM IN M1V MANNER SO AS TO BECOME SUBJECT TO THE � WORKEiiS'CCMPENSATIONLAWSOFCALIfORNIA,ANDAGREETHATIFISHOULDBECOME INSPECTIONFEE _ F SUBJECTTOTHEWORKERS'COAIPENSATIONPROVIS�ONSOFSECTiON3��00FTNELABOR ISSUANCE ' �D� � CADE,ISHALLFORTHWITHCOMPlYW17HTM PROVISIONS. -- 0 ����Lj ' " � p DATE:_���.`�APPLICANT � SMIP _ . 6�0 W ENERC:Y P/C _ � WAFNINO:FAILURE TO SECURE YlORKERS'COMPENSATION CAVERAGE IS UNLAWFU:.,AND SHALI BE � Sl1BJECTANEMPLDYERTOCRIMINALPENAITIESANOpYILFINESUPTOONENUNDREDTY.0U5AND ENERGYPERMIT DOLLAfl3(5700.000),IN ADDIilONTO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN c � SECTION37080F'fNELABORCODE,INTEREST,AN�ATfORNEY'SFEES. RETF_NTIONFEE: _ _ � ^' '�� OCONSTRUCTION LENDING AGENCY PkE-ALT FEE: �1S /. _ � IHEREBYAFFlRMUNDERPENALNOFPERJUHVTHATTHEHEISACONSTRUCTIONLENDINGAGENCV �� VU n- FOR THE PERFORMANCE OFTHE WORK FOR WHICHTMIS PEFMiT IS ISSUED�SEC.3oB7,CIV.CJ. � w ������-+� � LENDER'S NAME ' �yaae F= LENDER'S 1DDHE55 � ICERiIFVTHATIHAVEREADiHISAPPi1CAT10NANU5TAiE7NATTHEA60VEINFORMATqNISCORRECi TOTAL FEES ������ � IAGREETOCAMPLYWRHALICITYANDCOUNTYORDINANCESANOSTATELAWSRELATINGTOBUILDING CONSTRUCTION,AND HEREBY AU7FIORRE HEPRESENTATIYES OF THIS COUNTY TO EMER UPOY THE Z ABOVE�MENTIONE�PROPEflTYiORINSPECTIONPURPOSES. COMMENTS � � t�'- ��, - m PERMI AME(PRINT) � ,����.�� �.�.1 �� � � p� DATE = RECPT.N0. P?.ID BY �V 0 _VALIDATION ~ WHITE—Departmant Copy,YELLOW—Finance Copy.PINK—Assessor Copy,GOLDEN3?O�D—Flle C:opy,GREEN—Applicanl's Copy ��TM����� ��� ������a'���`��� �'��a.4"a � ;��'��'��;�������� �E��#���i�� . 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