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HomeMy WebLinkAbout15474 (32) G —`� '� J� CITY OF DIAMOI�D BAR �� DEPARTMENT OF COMMUNITY&D 21660 E.Copley Drive Suite 190 w (909)860-3195Fax(909)861-3117 PRESS � `ti�'�� BUILDING PERMIT APPLICATION FIRMLY oJOBSITE � APPLICATION � PERMIT J d'a� P/C ADDRESS ���Io �, i.�l.�i�ffi�:� �F� �'t..:;i:., DATE ' �"-�``-'_ NUMBER` �I # ���`� � ISSUE , APN LOT TRACT 'f NPE OCC °C OWNER � DATE _CONST GROUP O ���—�--� p ADDRESS ,��'^ ,ti;� ZONING SETBACKS � CITY �t s'�'i�t'�:�� f��.ZIP TEL.M� ^f,�."z;�t.� FRONT _ qW ❑ APPLICANT TEL._ REAR ❑ a SIDE SIDE STREE': RW ❑ � CONTRACTOR� _ _ � ,� ❑ o ADDRESS -��F��3� PROPOSED USE__���rJ.T? .�?� �':��'� CITY Ie0 TEL.��- w ARCHlENG/ -- f, F z DESlGNER •���f� �,�A+� �Y S13 ---- w • e , _ �- ',; NO.DWEL. IJO. NO. '"" � y ADDRESS � - ��.� ` '- UNITS O y CITY �,' '" ZIP ' ' TEL.� z3 ��" —� °�T�RIES BEDROOM�'s cn � • DESCRIPTION SQ.Ff. FACTOR PSF ADJ.AREANA�UATION p� OWlJER-BUILDEA DECLA ATION `� O �FRfhB6lA ;� f ��,.�'� ���`l'e�✓ I HEREBY AFFlHM UNDER PENALTY OF PERJURY 7HAT I AM EXEMM FROM THE CONTRACTORS LF Gef9 8/C8 ft W CENSEUWFORTHEFOLLOWINGREASON�SEC.7031.SBUSINESSANDPROFESSIONSCODE:ANVCIT/OR (n 9 � _ V COUNIVNMICNpEWIRESAPEHMITTOCONS7Rl1CT,AL7ER,IMPROVE,DEMOLISN,OqREVAIAANVS7qUG W PafiO/DBCk w iURE.PRIOq TO ITS ISSUANCE,ALSO REOUIRES THE APPLICANT WR SUCH PERMIT TO FILE A SIGNED w STATEMENi THAT HE OR SHE IS LICENSED PURSUAM TO THE PpOVISIONS OF THE CONTRACTORS LF �� CENSE LAW�CNAMER 9(COMMENCIN�WITi SECTION TODO)OF DIVISION 3 OF THE BUSINE55 AND PRO� � POOUSPB �'�' � FESSpNSCODE�ORTHATMEOflSFIEISE%EMP77HEHEFHOMAND7HEBASISFORIHEALLEGEDE%EMP- (� p V TKKJ.ANYYqUTKKVOFSECilON7031.59YANVAP7LICAN7FORAPERMIT5U8JECTSTHEAPPLICANTTO Z Re-ROOf � A CIVIL PENALTY OF NOT MORE THAN F�VE HUNDRED DOLLARS IS5ao).�: — � ❑I.ASOWNEROFTHEPROPERSV,ORMYEMCLOYEESWITHWAGESASTHEIRSOLECOMPENSRTION, � Commercial ;�.-r�•^�Y �j=��j�3�a`�+1^ WILL DO THE WORK,MID THE STRUCTURE IS NOT INTEN�ED OR OFFERED FOR SAL'e(SEC.7a4,BUSI- J � NESS AND PROFESSIONS CODE:h1E CONTRACTORS LICEN6E LAW DOES NDT APPLV TO AN OWNER OF ? '��'+i� , VROPERTV YhlO BUIW S OR IMPROVES i HEREON,AND VRiO DOES SUCH WOFK HINSELF OF MERSELF OR Q TFIROUGFIHISDRHEROWNEMPLOYEES,PROVIDEOTHATSUCNIMPROVETIENTSAFENOTINTENDEOOR m ' � ' W OFFEREDFORSl�lEIF,HOWEVEF�7MEBUILqNGORIMPROVEMENT1550!DWI'HINONFVEAROFCAMPLE Z TION,THE OWNEWBUL�ER WILL HAVE THE BURDEN OF PROVINO?HAT HE OR SHE DI�NOT BUILD OR = IMPROVE fOR iHE PUflPOSE Of SALEi. ❑I,AS ONMEA DF THE PROPERiV,AM EXCLUSNEL�CONTPACTING VFRk?LICENSEC CONTRAC70RS ` � To CANSTRUCT THE PR0.IECT(SEC.7o�A,BUSINESS AN�PROFESSIONS CA7E:THE CONTRAC'fORS ll- � ValU8ti0f1 ��� ADJ.AREA_�Z�C O LL1 CENSELAWDOESNOTTPPIYTOA*IOVVNEROFA7pOPERNWNOBUILDSOfl!MPROVESTiEREON,AND . 1 F WFIOCONTMCTSFOq3UCHPFiQIECTSWIT}IACONTRACTOH�S);.ICENSEDPURSUANY70THEGON'MG QUANTITY DESCRIPTIOtd FEE Y TORSIJCENSELRW.). 0 ❑I AM E%EMPT UNDER SEC. S.d P.C.FOR 7HI5 REASON Q � � U � � � DA7E _ OWN'H __ U � r 0 c — W WV F L!CENSED CONTRACTORS DECLARATION W � � 1 HEREBY AFFIRM UNDEA PENALTY OF PEa.IURV TMAT I AM iICENSED UNDER PROVISIONS OF CHAPTER � � /_ d 9(CD/AMENCINC WITFI SECTION 7000)OF DtVISION 30F THE BL'SIkESS RN�PROFe'SSIONS CODE.AND Z �(�y�„y�' �� X MY LICENSE IS IN FULL FOFCEAND EFFECi. / ��.c � LICENSE CLASS B � �.]�,LIC.NO._�,,_ n � V DATE � '� l7. CONTRACTOR.��lQ 1'�ri.. /�_ a- W c„a( ' ..z,n. � � WORKERS'COMPENSATiON DECLARATICN �� ' � �R _ r ,,,_� � I HEREBY AFFIRM UNDEH PENALTY OF PERJUflY qJE OF THE FOLLOWING DE� RATI � �� ' '� � _IHAH�ANDWiLLMAINiAINACERTIFICATEOFCANSENTTOSELF•Ih REFOR ERS a � CAMPENSATION.ASPROVIDEDBYSECTIIXJ37CAOFTHELA00ACO�ORT EPEP,FORMANCE OF TME WORK FOR WliIGH THIS PEFMIT IS ISSUED. a w � � �HAYEANUWILLMPJMAIHWORKERS'COMPENSA7'IONINSURANCE,ASRF.Ql1ipEDHV C p�--� ^ Q 3?o00F iHE U`SOR CODE,FOR THE PERFOHMANCE OF�HE Y/ORK FOR WHIC�+iH15 PFR.� IS �7 �! � 1�j ISSUED.MYWCRKERS'COMPE�SRTiONINSURWYCECARflIEAANDPO:ICYNU.N9ERAd�[: CONSTRUCTION �' v c�''�••� � �7 j caRaiEq ._ PWN REVIEW _�Z��G'G a L � zro��creuMeeP__ �—_—_. ELECTRIC _, ___ r/'�f•�� � �O � 4'' � 0 (?WSSECIqNIvErDNOTBEIXaNF.E�EDQ='tF.CPEFiAtlTISFLY70NEFiU4IXiED00L1AR5(Sf00)ORLESS� PLUMBING _____ � i ICERTIFYTHATPJTHEPERFORMANCEDFTHEWORKFORWHICHTHISPERMIi151SSUED,I MECHANICAL �J � SHALLNDTEMPLOYANYPERSONIYANYMANNERSOASTOBECAMESUBJECTTUTHE , (/] � WORKERS'COMPENSATIONLAWSOFCALIFORNIA,ANDAGREETHATIFISHOULJSECOME INSPECTiONFEE ___ � SUBJECTTOTHEWORKERS'COMPEN5ATqNPROVISIDN50FS'cCT.lON37000FTHELABOR ] � COOE.I SHN.1.FOHTN'NITH COMPLV WITH THOSt PROVISKNJS. ISSUANCE ___. J_�Y��-_ p OATE: $-Ig-� APPLICAN7: ��_1��1V�-` SMIP =� __ , C/ T—"�-'._,.--_-- J WARNING:FAILUflE TO SECUfiE WGRKERS'COMPENSA;:ON COVEFAGE IS UNLAWFU�,AND SHALL 9E ENERGY PJC _ � SU&IECTANEMPLOYEFTOCRIMINALPENALTIESANDCIVILFINESUPTOO4EHLINDREDTNOUSAND ENEHGYPERMIT DOLLARS(fi 00,000),IN ADDITION TO T4E COST Oi COMPENSATION,DAMAGES AS PROVIDED FOR IN ¢ SECTION 3708OF THE IhBOR WDE,INTEREST,AN�ATT.ORNEY'S FEES. RETENTION FEE: aW. CO�ISTRUCTION LENDINGAGENCY PqE-A�T EE:.�j��� O � I HERE9Y AFFIRM UNDER PENALTY OF PERJURV THATTH'cRE IS A CONSTRUCTION LENDING AGENCY �� p FORTHE PERFORMANCE OF THE WORK FOR WHICH TMIS PERMIT IS ISSU`c�(SEC.30H1,CIV.CJ. Z � W -- � .�Z LENOER'S NAME __ � F— LENDERSAD�RESS____ , W TOTAL FEES ���'��- �j � I CERTIFY iHAT I HAVE READ THIS APPLICATION AND STATE THAT lHE A90VE INFORMATION IS CARFECT. � I AGHEE TO COMPLV WITHALI CIN AND COUNIY ORDINANCES AN�STATE:AWS RELATING TO BUILDING � CONSiRUCTION,AND HEREBI'AUTHORIZE REPRESENTATIVES OF THIS COliNTY TO EMER 11PON iHE Z ABOVE-MENTIONFD PROPERTV FOR Ih'S7ECTION�VRPOSES. COMMENTS Q � _ m ___— Q PERMI EE (PAlf�f�) _ — �, I_.�,.�-` �:�� . �j SIGNA7 RE F PERMIITEE DATE RECPT.NO. 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