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HomeMy WebLinkAbout11155 • -- -�---- CITY OF DIA;VIONb BAR I I I � ! COMMUNITY DEVELOP\�IENT DEPARTMEtiT E ql6 .�=-w 21660 E.�opley Drivc Suire 190 �............: (909)860-3195 Fax(909)8C1-3117 PRESS �:""' BliILDING PERMIT APPLiCATION FIRMLY y JOBSITE ,/�� f� // �('JG, APPLICATI PERMIT � I� p/C o ADDRESS�`"�-� �/���M✓�/ °�� DATE_��_ NUMBER S� # . °-° APN LOT TRACT ISSUE TYPE OCC � �� �� DATE _CONST. GROUP p OWNER _SoI✓J[�' K6i w�;iC�'7_ o ADDRESS_ ?i�- D�%a-s�i�w n_���� ��]/� ZONING SETBACKS oCITY �w l� �tfLIP�',�-rGs'TEL-�.�t� � FRONT RW C: o APPLICANT �, TEL. REAR z I I SIDE/SIDE STREET R�n/ �_; Q CONTRACTOR �J SIDE �__ � ADDRESS � CITY ZIP TEL. PROPOSED USE oARCH/ENG/ � z DESIGNER � ADDRESS NO.DWEL. VO. NO. � CITY ZIP TEL. UNITS 3TORIES BEDROOMS cn - � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-BI:ILDER DECLARATION p � SFR/AD0/REM p I HEREBY AFFIRM UNDER?cNALiY OF PEFJURY THAT I AM E%Eh'PT FROM THE CO\TRACTORS LI- G0�flJ0/C8f(J011 W CeNSELAWFORTHEFOL�OWIVGR'cA50N�SEC.'03!.SBUS'NESSA�DPROFESS�ONSCO�E:ANI'CITYOR (/� z COUN?YWHICHR'cQUIR'cSAPERb'IT�OCONSTRUCLALTcR.lA1PROVE,DEh!OL'SH,ORRE?AIR�AK�YSTRUG TURE.PRIOR TO ITg ISSUANCE.A�SO R'cQUIRES THE A7PLCA\T FOR SL'CH PER".91T TO FILG A S'GNED W Patio/Deck W STATEMEN'i HA7 HE OP.SHE�S LICENSE�?URSUANT TO TH=PROVISIONS OF THE CONTRACTOPS�_1-�� W �� CENSELAW�CHAPTEf79(CAMM'cNCINGWITHSECTIC!;7C��)OFDIViSION30FTHEBUSINESSAND?FiO- � P001/$pe FcSSIONSCOJE;09THATHEORSHEISE%EMPTTHEREFROIAA.�CTH'cBA51SFORhieA:.LEGEDE%E`dP- � V TION.ANVVIOLA'IOYO�SECTION�03t.56YANYAPPLICA!�'TFORAPERMI'S�9.:EC'fSTHEA?PLICANTTO Z Re-Root � AC:VILPE:\ALTYOFKOTMORETHANFIVEHUN�REDDOLLA95('.SOCj.): 0 t�I.ASOWNEROFTHE?ROPEfliY,OR1.IVEMP_OYEESWI'HWAGESASTHEIRSOI.ECOMPENSA'ION, O CCrtIrtlBfCiel Z WILL DO THE WOAK,AND THE STRUCTURE IS NO?LtiTcXDED On OPFER'cD FOR SRLE(SEC.7Caa.BUSb _1 � YE55 AND PROFESSIORS COD'e:THE CON:RACTORS LICENie'LAW DOES NOT APPLY TO AN OWN"eR OF ? P.aOPER i Y Y�40 BUILDS OR IMPROVES'HEFEON,ANO WHO DOES SUCH WORK HIMSELFOR HERSELF OR � THROUGHH'SORHEROW�ESIPLOVEES,PROVIDED'HATSUCHI!APROVEMENTSAREM1'OTINT'cNDEDOR m Q OF�ER'e�FORShE.��,HOWEVER,THEBUILDiNGORIMPROV'eMEKTiSSOLDWITHlNONFVEAqOFCONPLE� Z TION,THE OWNEa�BUIL�ER W;L'_HAVE Th,�BJROEN OF PROVI.\'G T::AT HE Oa SHE DIJ NOT BUILD Oq � I`APROVE FOR THE PURPOSE OF SAIEj. w ::]I.ASOWNEROFTHE?riOPERTY,AKEXCLUSNEIYCONTRACTINGWI?HL!CENSECCONTRACTORS Q TO CON57riUC7 THE?ROJECi(SEC.7a44,9USIKESS AND PROFESS�CNS CO�E:THE CONTRACTORS L4 , V21Uation _ADJ.AREA W CENS`eLAWDOESNOTAPPLYTOANOW9"eROFA?P.OPE�TYWHOBUILDSORIMPROVESYHEREON,ANO --- = VlHOCONTRACTSFORSL'CHPROJECTSWITHACONTR4C?ORIS)LiCENSEDPL'HSUA4TTO7HECONTRAG FEE ~ TORSLICctiSE�AW.). QUANTITY DESCRIPTIOtJ � C"I AM EXEMPTUNDER SEC.___ _ B.&?.C.FORTHIS REASON Q G M r�'P�j �—'�'� I /,.S V _ " S/� � �y � � I� __ ON:NER y I�-��� � i.�7 '" DA'E � Z U � LICENSED CONTRACTORS DECLARATION W ¢ I � I NEREBV AFF:PA!UN�ER PE4ALTV OF�'cR�URY THAT I AM LICEN6ED UtiDER PaOVISIONS OF CriAPTER � 9(COMM.ENC�NG VlIT�SECTION 7oco;OF DIVISION 3 OF THE BUSIKESSAND PROFESS!ONS CODE,AND' �X MY LICENS'c:S IN FULL FORC=A�rD EFFECT. 0 LIC'eNSE CLASS__ _ LIC.NO. _____ U DATE_____ CON7R4CTOR W � WORKERS'COMPENSATION DECLARATION � � � i H`r.RE9Y AFFIRM U�DER PENALTY OF PERJURY OYE OF TH'e FOLLOWiNG DECLARATIONS: z _!HAVE A\D WILL MAINTAIN A CERTIFlCATE OF CONSEM1T'O ScLF-INSURE FOR WORKERS' ¢ CAMPENSATION.ASPROVIDEOBYSECT'ON370oOFTHE.A80RC0]E,FOR'HcPERFORMANCE . OFTME WORK FOR WHICH Tn15 PeR1AIT IS�SSUED. 0 W I YAVEAN�WILL�IAIVTA!N WORNERS'COMPFNSATIDN:NSUFANC'e,AS REQUIHED 9V SEC?ION Q 37COOFTHE:A60RCODE,FOHTHcPERFORMANCEO.='HEWORKFORWHICHTHISPERMITIS ISSUE.J.1dYYIORKERSCOMPENSA'IOYIY9URANC'cCARRIERANDPOLICYNUMBERARE: CONSTRUCTION J j cnaa;Ea_ _ _ PLAN REVIEW Z POLICYN�4BER__ __, _ ELECTRIC �9 �,O Q — — � (iHISSECl10NNEFDWTBEOJl!PLEfEDO=TH`c�EFdJfrIS:ORONEMU\��R=DDOLUWS(S!Oo)O:�LESS). PLUV!BING ll.! Z ICEFiI"rYTHA7I.YTHc`PERFOR'.AANGEOFT-EWORKFOri'NHICHTHISPERNIT155SU=D.1 MECHANICAL C.`S SMAL'10TEM.PI.OYA:�'YPERSON'.KA!�'V.4.ANNE.a50ASTOB:COh1E5UB.;EC"TOTHE (/) YJORKERS'COMPEYSATIONLAWSOFCALIFORNIA.AYDAGREETHAT'F�SHO!.'LDRECOME INSPECTIONFEE ? SUfi:ECTTOTHEWORK'eRS'COMPENSA?IONPROViSION50FSECTION3�COO:TN=LA30a COJE,ISHALIFORTHWITHCOA!PLYWITHTHOSEPqOVi510N5. ISSUANCE �{�U'� 6 p �� 1"'N p DATE:__ APPLICANT: SMIP �•.� w ___' ___ — _i� �'� �1", � WARNING:FAILURE TO SECJRE WORKERS'COMPENSA'ION COVERAGE IS U��LAWN_,AND SHALL BE ENERGY P/C ___ �–'�i`�''�:-��.�� � Sl1BJECTANEMP'_OVERTOCR'MINALPENALTIESA\�C:VI;F'�M1ESU?TOONEHI;NDREDTY.OL'SAND ENERGYPERMIT y DOLLARS(E100.00-0),14 A�7ITION TO 74E COST OF COMP'cNSATION,OAMAGES AS PFOVIDED FOR IN ._�1 SECTtON37oeO�TFELABORCOD'c,l\TEREST,ANDATTORNEV'SFEES. �� oc RETENTION FEE: O CONSTqUCTION LENDINGAGENCY I i ___ _ '�'� PRE-ALT FEE: Q,. � I HERcBV A�FIRh!VNOER PENAL'V OF P'cr7JURY T::AT7HERE ISACOYS'RUCTION LENDING AGENCY I FORTHE PERFCRMR�CE OFTHE WORX FCR WHICH THIS P:RM�T IS ISSUED(SEC,3097,C:V G.). " — – Z w __ ? LENDER"SNA.UE_ '" _ _. --"—'-------'-- � F— LcNJER'SA7DRE55 . . ......�.:..................: � ICERTIFYTHAT'�,HAV'eREADTHISA?PLICATIONANJSTATETHATTHEA90VEINFORMA�IONISCORRECT. TOTAL ��ES �� . �Q w IAGREE?0001.1?�_VWITr{q�LCITVANDCOU�'TVCRD:NA�C[SnNOSTATEiA'h'SRELAI'INGTOB�Ii.CIM1G � CONSTFUCT!ON,ANOHEREBYAUiHORIZEF_PRESENT�T!VESOFTHISCOUtiT1'TDENTERIi?ONT'rE � ABOVe-MENTIOtiED PROPERTY FOR INSPECTION PURPOSES. Z �/�/ 1 COMMENTS � -��1—�.L�. L'�'-L)CL�% -- - ------ m P=RMnIT?�EE N/ph_E/(Pg1qT) Cn �AQl�vY �/ ¢^7 � „.' '_ ___._ � �NA'UREOFPERMITTEE pp�'E��� ' "1 - � � _ RECP NT O_�_��__ PAIDBY r�l�� VALIDATION � WHITE—Departmem Copy,YELLOW--Finance Copy,PINK—Assessor Copy,GOLDENROD—File Ccpy,GREEN—Appli6anPs Copy r.�,,�: . ..: �,�..,:,...v.ep.e4. � � ,. . � . .. �.�,. .:. . .� .v.y... ..s�: ......:. ".n..'� .�J . .:,r.v.a.W.. .., 4 ..:.�`.."5,&4 ,. .ri -�.i41�.i,'�L' �- ..`�.F . .. � i :J�:k. ... 1t..0 . . . .,� 1 �.:i ' J' 7:.`s:- t-' .:... .--.'; . ��s`� �. -. .. ,. „�. .�_ � � .. . ... . . "„jI � ���� �N� ,..d�a' ��;�€f Eg.i'� 0.� &'..:.�:. 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