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HomeMy WebLinkAbout15813 (20) CITY OF DIAMOND BAI� � i ^---�� DEPARTMENT UF COIVIMUNITY&DEVELOPMENT SERVICES � , 21660 E.Copley Drive Suite 190 (909)66a3195 Fas(909)861-3117 PRESS � •�°,l BUILDING PERMIT APPLICATION FIRMLY �7 JOBSITE -j �s !� �/� �� '. qpPLICATION PERMIT P/C o ADDRESS JC 'c1 � �r�� C�IK�"�� DATE NUMBER ����# ` ISSUE TYPE OCC �i APN LOT TRACT oATE CONST. GROUP p;= OWNER � p` ADDRESS ��j ��° ..r—!� � ZONING SEfBACKS w; FRONT RW ❑ � CITY��[�����ZIP TEL.�CC3S'�3'�'� REAR ❑ .' APPLICANT TEL. SIDE/SIDE STREET RW ❑ �; CONTRACTOR f �rj � SIDE ❑ Q- ADDRESS � PROPOSED USE � -c�-o t�� �LPT� �L�i�!� C���!� CITY ZIF�� TEL f �j`. _ ' 'v'�w �Jv1 w: ARCH/ENG! xs c C �.+ti ��ss � DESIGNER ADDRESS NO.DWEL. O. NO. UNITS STORIES BEDROOMS � �` CITY ZIP TEL. � � � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-BUILDER DECLARATION SFR/ADDlFEM , p I HEflEBY AFFlRM UNOER PENALTY OP PERJURY THAT I AM EXEMPT FROM THE CONfflAGTORSII• G8f&QB/CdfPOft W �CENSEIAWFORTHEFOLLOWINGREA50N(SEC.70.71.5BUSINESSANOPROFESSIONSCODE:ANYCITVOH (n _ �� �COUNTVWH(CHRC-0UIRESAPERMITTOCONSTRUCT,ALTER,IMPROVE,UEMOIISµoRR6PAIRANYSTPUC �W patio/DecK- ; NRE,PHIOR TO 1T8 ISSUANCE,ALSO REQUIfiE9 THE APPLICANT FOR SUCH PEHMIT TO FILE A SIGNED W STATEMEN!THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIDN5 OF THE CANTRACTORS ll� �' -,CENSE LAW(CHRPTEH 9(COMMENCINO WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESSAND PRO�. - � POOUSpfl � - FESSION3CODE)OflTHATHEOR3HEI3EXEMPTTHEREFROMANDTHEBA5ISFORTHEALLE�E�IXEMP- � (� �` TION.ANYYIOtATIONOFSECTIONT037.58YANYAPPLICANTFORAPERMITSU&IECTSTHEAPPLICAMTO Z Re-Roof F, ACMLPENALiYOFNOTMORETHANFIVEHUNDHED�OLLARS(S5a0�.)� - , ❑I,ASOWNEROFTHEPROPERiV,ORMVEMPLOYEESWITHWAGESASTHEIR50LECOMPENSATION, � CORiff18fC18I " � WILL OD7HE WOFiK AN�THE STRUCTUflE IS NOT IN7ENOEU OR OFFERED fOP SALE(SECJa44,BUSb J NESS AND PROiESSiON3 CODE:THE CONTRACTORS LI(:ENSE LAW DOES NOT APPLV TO AN OWNER OF �- PHOPERTYWFiOBU1LD50RIMPROVESTHEREON,ANDNMODOESSUCNWORKHIA1SElFORHEHSELFOR � � - iHfi0U0HHiS�iHEflOWNEMPLOYEES,PROVIDEOTHATSUCHIMPROYEMENTSARENOTINTENOEDOfl m ' 1�-.. OFFERED FORS►LE.IF,HOWEVER7NE B�ILDINGORIMPROVEMENT IS SOLO WITMNONEYEAROF COMPLE• �TION,THE OWNEfl-BUItAER WILL HAVE hIE BUfmEN OF PROVING THR7 HE OR SHE DID NOT BUIID OR __ IMPflOVEWRTHEPURPOSEOFSAL�. ❑1,AS OYMIER OF THE PROPERiY.AM EXClt1SIVEl.Y CONiRACTINO WITH LICENSED CONTRACTORS � �� TO CONSTRUCT THE PROJECT(SEC.70u,BUSWESS AND PROFESSIONS CO�E:THE COMRACTORS LI• VflIU8Ii011 '— ADJ.AREA W. CENSEIAWDOE5NOTAPPLYNANOWNEROFAPflOPERTYYhiOBUILDSORIMPROVESTHEflEON,AND - T�_ 1NpCONiMCTSiONSUCHVHOlECTSWITHACAMRACTOR(S)LICENSEDPURSUpNTTO7HECON7RAG QUANTITY oEscaiaTioN FEE � �'. TORS LICENSE UW.). J O ❑IAM EJ(EAIPT UNDEfl SEC. B.6 P.C.fOR THIS REASON � � � LL' DATE OWNER F' U � LICENSED CONTRACTORS DECLARATION W � IHEREBYAFFIRMUNOERPENAI.TYOFPERJURYTHATIAA/LICENSEOUNDERPROVISIONSOFCHAPTER � ` � d Y(COMMENCINUWITHSECTION7000�OFDIVISION30FTHEBUSWESSANDPFOFESSION9CODE,AND Z � X AIY UCENSE IS IN FULL FORCEAND EFFECL � LLI �� jj�' m � � LICENSE CLASS LIQ NO. � j . F _�; p �__S.� �2�.�� 6. V DATE �4y�?._ CONTRACTOR W �� WORKERS'COMPENSA710N DECLARATION � � U N IHEqEBYAFFIRMUNDEHVENALTYOFDERIURVONEOFTHEWLLOWINGDECLARATbNS: � Z C ,� _IHAVEANDWILLMAMTlilNACERTIFiCATEOFCONSEMTOSELF-INSUftEFOHWOFKEflS' _ COMPENSpT10N.ASPROVIDEDBY6ECTION37D00FTHEL480RCODE,FORTHEPERFORMANCE 'U Of THE WORK iOR WHICH THIS PFAMIi IS ISSUEO. � W' _I HAVE NVD WILL MA�NTNN MiORKERS'COMPENSATION INSURANCE,AS flEQI11RE�BY SECTION Q - 37000FiHElPBORCODE.WNTNEPERFORMANCEOFTHEWORKFORWHIqiTHISPERMITIS B .. ISSUE�.MY WOpKERS'COMPEN TION INSURANCECARP�EiIAND POUCY Nl1MBERARE: CONSTRUCTION b � � CARRIER PLAN REVIEW � POLICVNUAIBER���f ���'� � ELECTRIC Q � (iiffi9ECIi0NNE�No7eEo0MREfIDociF�PEroMISFOna�laln'0{tEo�ctuas(Stco)ofiLEss�. PLUMBING .. �. --- 3,,';e��; x3 8. Z 1 CERTIFYTHAT IN THE PERFORMANCE OFTHE WORK FOR WHICHTHIS PERMIT IS iSSUED,i MECHANICAL �'�r�1'' ��-i�'= (� SMALLNOTEMPIOYANYPEfl50NINANYMANNERSOASTOBECAMESUBJECTTOTHE � WORKEHS'COMPENSATIONLAWSOFCALIFORNtA,ANDAGREETHATIFISHOU BECOME INSPECTIONFEE F SUBJE TTOTHEWORKERS'COMP NSA�ROVISIDN SECTION37000 ELABOR a� -�j CODE, SHALL ORTMWITHCOMP�V OSEPROVISION. (SSUANCE � ?;���i�a -� ��/�,���.�y ���� ��'��� �., p Dq7g:����" '/ APPLICANT: -SMIP 6 . W � l:�N T�"�l:v, '� WARNING:FAIWRETOSECUREWOFKEHSCOMPENSATIONCAVERAG 11NLAWFUL,ANDSHALLBE ENERGYP/C / _ �y, SU&IEGTANEMPIOYERTOCRIMINALPENALSIESANDCIVILfMESUPTOONEHUN�RE�THOUSAND ENERGYPERMIT ;�'�' DOLLARS(5100.0�0),INADDITION TOTHE COST OF CAMPENSATION,DAMAFiES AS PROVI�ED FOR IN : ,S '� >='�� � SECTION3708OF7HELABORCODE,MTEREST,ANDATTOflNEY'SFEES. RETENTIONFEE: W CONSTRUCTION LENDING AGENCY PRE-ALT FEE: O.. � IHEREBVAFFIRMUNDEFlPENALNOFPERJURVTHATTHEREISACONSTFUCTIONLENUINGAGENCY _ ____ FOR THE PERFORMANCE OFTHE WORK W R WNICH THIS PEPMIT IS ISSUE�(SEC.3097.CIV.CJ. Z W � LEN�ER'S NAME _ h=- LEN�ER'SAOORE55 . ' - - � ICEfiTIFYTHATIHAVEREAOTHISAPPLICATIONANOSTATETHATTHEA80VEMFORMATIONISCORFECT. TOTAL FEES � �1�1 �:D � IAGREETOCOMPLVWITHALLCI7YANOCDUNTYOROINANCESANOSTATELAN5REUUING70BUIlDING - � _ CONSTFiUCTION,AND HEREBY AUTHORIZE FEPRESENTATIVES OF 7HIS COUNN TO ENTER UPON THE . . ZAB EMENTIONED PFOPERTY FOR INSPEGTION PURPOSES. COMMENTS - _ �'`�.�� ;�,�-►�-s� 9��a,r�✓l-`3,��� A --- � VE ITTEE NAM - j . c¢_n o-..�—� 9!/;j S P.a� � SI6`�ATUREO�—FPER�T�� DRTE—�-�— = RECPT.NO. 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