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HomeMy WebLinkAbout15278 (19) 1� CITY OF DIAMOND BAx � DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES : � . 21660 E.Copley Drive Suitc 190 (909)860-3195 Fax(909)861-3117 PRESS °�" BUQ.DING PERMIT APPLICATION FIRMLY N JOBSITE �' ' >- .l J. � . APPLICATION PERMIT ��j �J 'P!C d ADDRESS � /� �_/ . .- �� f � � # o DATE NUMBER t�,d � 04, ISSUE � TYPE OCC APN LOT TRA T DATE �� CONST, GROUP p OWNER = LL' ADDRESS" J /;�. ONING SETBACKS 0 �W CITY ZIP LL EL. FRONT RW ❑ APPLICANT� TEL. REAR ❑ � SIDFJSIQE STREET RW O CONTRACTOR SIDE p � ADDRESS � C�T1' ZIP TEL. PROPOSED USE � ARCHIENG/ z DESIGNER a ADDRESS NO.DWEL. NO. NO. � UNITS STORIES BEDROOMS � CI7Y ZIP TEL. N DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION ¢ OWNER-BUILDER DECLARATION SFWADDlREM � 1 HEREBY AFFlRM UNOER PENAITV OG PEPJURV THAT I AM EXEMPT FROM THE CONTflAC70R5 Li� G8(6QB/C8lPOfl W CENSELAWFOHTHEi'OLIOWINqREA90N(SEC.7031.sBU51NE55ANDPROFE55iONSCODE:ANYCITYOH (/� �� COUMYWNICHREqUIRESAPEHMITTOCON5TRl1CLAf.TERJMGROVE,DEMOLISH,ORREPAIRANVSTRUG pai10/DBCk �� TUFlE,PRIQR TO IT3 ISSUANCE,AL50 RE�UIRES THE APPLICANT FOR SUCN PEqMIT TO FILEA SIGNEO W 3TATEAIENT THAT HE OR SNE 13 LICENSED PURSUANT TO7HE PROVISIONS OF THE CONTRACTORS LI� � CENSE UW(CMAPTEH e(COMMENCINQ WITM SECTION 7000)OF DNISION 3 OF THE BUSMESSAND PRO� � POOUSp2 FESSION3COUE)ORTNATHEORSHEISEXEMPTTHEREFFiOMANDTHEeASISFOR7HEALlEGEDEXEMP- (� TION.ANYVpIATIONOFSECTION7037.5BYANYAPPUCANTFORAPEHMiTSU&IECTSTHEAPPUCANTTO Z Re-Raof � AGMLPENALTYOFNOTMORETHANFNEHUNDREADOLLARSSE5001J: ❑I.ASOWNEROFTHEPROPERTY,DRMVEMPLOYEESWITNWAGFSASTNEIRSOLECOMPENSATION, COI11Ri8fC18I � WILL 00 THE WORK,AND THE 6TRUCTURE IS NOT�NTENDED OH OFfERE�FOR SAIE(SEC.7044,BU51� � � NE33 AND PR6FESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES NO7 pPPLY TO AN OWNEH OF = PflOPERTY VhiO BUNDS OR IMPROVES THEREON,ANO WHO OOES SUCH WORKHIMSELF Op HERSELF OR � 1HROU(iHHI30RHEROWNEMPl.OYEES,PROVIDEDTHATBUCHIMPROVEMENTSARENOTINTENDE00R m Q ,OFFEREDPofl3ALEIf,HOWEyEp,7ryE&11LDINGORIMPFOVEMENTISSOIOWITNINONEYEAHOFCOMPLE Z TION,THE OWNEP•BUILDER WILL HAVE THE Bl1RDEN Of PROYM�TNAT HE OR SHE OID NOT BUIID OP � IMPROVEFOR7HEPURPOSEOfSALE). � W ❑I.ASOWltEHOFTHEPROPERfY,AMEXCLU5IYELYCONTRACTINGWITHLICENSEDCONiRACTOqS Q- TO CONSTRUCTTHE PFiOJEC7�SEC.tW4,BIISME55 AND PROPESSIONS CODE:THE CONTqACTORS U� YalUatiOn ADJ.AREA LLI CENSELAWDOESNOTAPPLYTOANOWNEROFAPROPERTVWHOBUILDSORIMPROVESTHEREON,AND � WHOCONTMCTSFOFSUCHPR0.1ECT3M7THACONTMCTOR(S)LIGENSEDPURSUANTTOTHECONTHAC� QUANTITY DESCRIP7ION FEE - HA Y TORsucervseuw.�. � O IAM EXEMPTUNDER S�C. &d P.C.F HIS qEA50N � � �P . A LL DATE � �� —__._ '" � - OWNE Z __ _ � UCENSED CONTRACTORS D 10 W � � Il1EREBYAFFIRMUNDERPENALNOPPERJt1HYTiATIAMIICEN5E0UNDERPROVISIONSOFCHAPTEP � p. 9(COMMENCINCiWiTHSECTION7000)OfDIVIS10N30FTHEBU51NES5ANDPROFESSiONSCODE,PN� z }C MY UCENSE IS IN iULI FORGEAND EFFECT. � Ll,i 0 UCENSE CLASS Lla NO. ________ � V DATE CONTRACTOR OJ. W � WORKERS'COMPENSATION DECLARATION a � IHEREB7AFFIRMUNDERPENALTYOFPERJURYONEOFTHEf-0LLOWING�ECLARATIONS: Z 0 _IHAVEANDWILLMAINTAINACEFiTIFICATEOFCON9ENTTOSELF-INSUflEFORWORKEflS' ¢ �t COMPENSATION,AS PROVIDED BY SECTION 3700 OF THE LABOR CODE,FOH THE PERFOPMANCE W a OF THE WoflK FOfl WHICH THIS PERMIT IS ISSUED. � '— F `I HAVEAND WILLMAINiAIN WOPoCERS'WMPENSAT�IJ INSURANCE,AS FEQUIRED BY SECTION Q37ooOFTHELA80RO00E,FORTHEPERFORMANCEOFTHEWORKWRWHICHTHISPEPMI7i5 � ISSUED.MY WORKEfiS'COMPENSATION INSURANCE CARRIER AND POLICV Nl1MBEfl ARE: CONSTRUCTION � CflqHtER PLAN REVIEW ___ Z PaICYNUhreER__ ___..___ ELECTRIC �� Q � ri (nassECTaNNEmMoieEaX�LFtEooF'n�aEfaMASi�RavewhuoaE000unAsg�ro7oa�Ess� PLUMBING Z ICEHTIFY7HATPITHEPEflFORMANGEOFTMEWONKFORWMiCHTHISPERMITI51S5UE0.1 MECHANICAL � CrJ SNAILNOTEMPLOYANYPERSONINANYMANNEpSOAS70BECOMESUBJECTTOTHE (/� WORXEFS'COMPENSATIONLAWSOFCALIFOftNIA,ANDAOflEETHATIFI3HOULDBECOME INSPECTIONFEE SUBJECTTOTHEWORKEflS'COMPENSATIONPflOVISION50F5ECTION3T000FTHELABOFi � � = CODE,ISHALI„FORTHWITHCOMPLYWITHTHOSEPROVISbNS. ISSUANCE o- _ - p �ATE: - APPLICANT. SMIP ."�V.}a____ m n � ENERGY P/C ��� A WAANING FAILURE TO SECUHE WOFKERS'COMPEfiSATION COVERAGE IS UNLAWFII�,AND SHALL BE LL SUBJECTANEMPLOYERTOCRIMINALPENAL7IESANOCIVILFINESUPTODNEHUN�REOTNOUSAND .. .�7-{�� '� DOLURS(5700,000),IN AD�IiION 70 THE COST OF COMPENSATION,DAMAQES AS PROVIDED FOR M ENERGY PERMIT T A 1R1 f.!� J SECTION37080FTHELAB�ftCOOE,WTER[ST,ANDATTORNEY5FEE5, RETENTIONFEE: � --�a OCONSTRUCTION LENDING AGENCY PRE-ALT FEE: � IHEflEB7AFFIFMUNDERPENALTYOFPERJURYTHATTMEREISACONSTflUCTIONLENDINGAGENCY � � FOR THE PERWflMANCE OF THE WORK F'Ofl WHICH THIS PERMIT IS ISSUED(SEC.3097,CIV.CJ. . Z W � LENDER'SNAME_ " ' � i— LENDER'SADORE55 w ICEflTIFVTHATIHAVEREADTHISAPPLICATIONANDSTATETHATTHEABOVEINfORMATIONISCARRECT, TOTAL FEES � ��� � IAGflEETOGOMPLVWITHALICITYANDCOUNTYOfl01NANCE5ANO5TATElAWSREIATINRTOBUILDING � � WNSTRUCTIIXJ,ANDHEREBVAUTHORIZEREPRESENTATIVESOF7HISCOUNTVTOENTEftUPoNTHE ' . ' z ABOV6MENilONED PNOPERTY f-0p INSPECTION PURPOSES, COMMENTS - - - ' ' 4 ; � �� �— � m �EQ FMITTEE N PRllin ' Q `� .{�., ���� � � SIONAT REOFPERMITfEE, DATE = RECPT ND. PAID BY VALIDATION- ~ W E—De artment Co YELLOW—Finance Co PINK—Assessor Co GOLDENpOD�—File Co GR N— IicanYs Co p pY. 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