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HomeMy WebLinkAbout12122 (13) _!� CITY OF DIAMOND BA12 '� �� tt DEPARTll�IENT OF COMMUNITY&DEVELOPMENT SERVICES � . 21660 E.Copley Drive Suite 190 ,l (909)860-3195 Fax(909)861-3117 PRE`SS ����'. BiJILDING PERMIT APPLICATION FIRMLY o' DDR'ESS �� � - � \ APPLICATION PERMIT a/a..� P/C �" DATE NUMBER �-# c� ISSUE NPE OCC ` AP� OT TRAC DATE CONST. GROUP � OWNER " ADDRESS � ZONING SETBACKS �W CITY ZI TEL. Suec6��b``� ; REART RW � APPUCANT TEL. SIDE/SIQE STREET RW ❑ m�; CONTRACTOR ! ' --7 \ SI�E ❑ p�.. :AODR S ` ��� . - - �' CITY ���`'�.�.��S��Z_ ZIP`A," �"1� TEL.'�3"13��1,�`Z PROPOSEDUSE � w' ARCH/ENG/ z DESIGNER NO.DWEL. NO. NO. a ADDRESS UNITS- STORIES. BEDROOMS � CITY ZIP TEL. y DESCRIPTION SQ.FT. FACTOR P5F ADJ.AREANALUATION - �- OWNER-BUILDER DECLARATION SFR/AODlREM O p � I HEflEBY AFFlPoA UN�ER PENALTY OF PER.A/HY THAT 1 AM EXEMPT FROM THE CAN7MCTORS LI- � G2f8gBIC2�pOlt W CENSELAWPDRTl1EFOLLOWINGflE0.40N(SEC.703f.5BU51NESSANOPftOFE5510N5CODE:ANYCITYOR �, C�- OOUNTVWHICHREqUiRESAPBRAIRTO(bNSTRUCT,ALTER,IMVROVE,DEIAOLISH,ORREDAiRANY5ttil1G � W Pdf10/DeCk � `NHE,PRIOR TO RS{SSUANCE,AlSO REW IRE6 THE APPUCAM FOR SUCH PERMIT TO FlLE A SIGNEP - � STATEMENT THAT HE OP SHE IS LICENSED PURSUANT TO-THE PROVISIONS OF THE CONTRACTORS�L4 ' w �: - CENSELAW(CHAG7ERB(COMMENCINOWITHSECTION7aoa)OfDIVISION30PTHE8U$INESSANDPRO- ' LL POOUSpB FE6SION&CODEJORTHATHEORSHEISIXEMPTTHEREFROMANDTHEBlSISFOHiHENLEOEDEXEMP- � TION,ANYVIOUiIONOFSECTION7IXS7.5BVfJVYAPPLICANTFOqAPERMITSU&IECTSTHEAPPLICANTTO � Z Re-Roof � ACML PENALiY OF NOT�RE TtiAN FNE HUNORED OIX.LAFiS(5600).}: , , � ❑I,ASOWNEROFTHEPROPERTY,OFMYEMPLOYEESWITHWAGESASTHEIRSOLECOMPENSATION, . 0 COR1f11B(CIBI - -- WILL�O THE WORK,AND TNE STRUCTURE IS NOT INTENDED OR OFFERED POR 3ALE(SEC.7044,BU91- J � . � NESS,WD PHOFESSIONS OODE:T}IE CONiRACTORS LICENSE LAW DOES NOT APPLY 70 AN OYJNER OF - � PiWPERT/WlIOBUILDSOflIMPpOVESTHEREON,ANDVhiODOESSUCHWORKHIMSELFORHERSELFOR ! y CC'- 7HROUONH190HHEROWNEMPIOYEES,PR6VIDFOTHATSUCHIMPROYEMENTSANENOiWTENDEDOR - m • O ,OFFEAEAFORSKEIFHOWEVEi�iHE6UIiDINGORIMPROVEMENTI550LOWfTNINONEVFAROFCOM%.E• Z 'TION,THE OWNEH�BUIIDER WILL HAVE iHE&1RDEN OF PROYING THAT HE OR SHE DID NOT BUIID OR . �� IMPRDVEPoRTH=PUflPOSEOFSAIE). O 1,AS OWNER OF THE PFW PERIY,AM EXCLUSIVELY CONTfUCTIN�WITH LICENSED CANTRACTORS - �- TO CONSTRUCT THE PqOJF.CT(SEC.�a41,BUSINESSAND PROPESSION9 CODE:THE CONTRACTORS LI- � ValUe�iOn ADJ.AREA W CENSEtAWDOESNOTAPPLYTOANONRJEROFAPROPERTYWHOBUILDSORIMPROVESTHEfiEON,AN� . � ��. VhpCONTMCTSFOR6UCHPRQIECTSriITHACONTRACTOR�S�UCENSEDPURSUANTTOTHECONTFAG . QUANTITY DESCRIPTION FEE � TOASLICENSELAW.). . . O ❑IAMEXEMPTUNDERSEC. B.eP.C.,FORTHISPElSON - � #� � � LL' OATE OWNER U , ' - QW � LICENSED CONTRACTORS DECIARATION � IHEREBYAFFIqMUNDERPENALTVOFPEfL1URVhIAT1AMLICENSEDUNOEHPflOVISIDN50FCHAP P z �'� - � �.9(COMMENCINOWITlISECTION7COo)OFDIVISION30FTHEBUSINESSANDPROFESSIONSCOOE, MYIICENSE IS IN fUpLI FOflCEAND EFFECT. m \�, � �o � UCENS�E,pCLA`SS �"^�`� LIC.NO. � + `l -- --- - e � V .�ATE '6""��'•�� CONTMCTOR� � � III � � WORKERS'COMPENSATION OEGLARATION Q � -IHEREBYAFPIBMUNDEflPENALTYOFPERJUHYONEOFTMEFOLIOWING�ECLARATIONS: V � a r '� � � .�IHAVEANDWILLMAWTAINACERTIfICATEOFCOFlSENYTOSELF-iNSUREFORWORKEflS' _ � COMPENSATION,ASPROVIDEDBVSEC710N37aoOFTNELABORCODE,FOHTNEPERFORMANCE � W OF THE WOflK FOR WHICH THIS PERMIT IS ISSUEO. � Q W _IHAVEANDN7LLMAIMAINWOW(EHS'COMPENSATIONINSURANCE,AS'HE�UIREDBYSECTION Q 370D THE LA80R(bDE.FORTHE PEFW ANCE OF THE WOflK FOfl WHICH THIS PERMITIS ( D ISSUE. RK S' �MPENSA7 INSU'�CE CARRIER AND POLICV NUAIBEN ARE: CONSTFUCTION +��. CARRIER �-^�' ,._ PLAN REVIEW Q� vo��cvuuMeEa�� "'� _ � ELECTRIC � Q Q (fHI55ECfI0NNEB�NOT8EO7MPLEfIDOFh�PER4gT6FORONEF0./PL%aED00l1MS(510010RLESSa PLUMBING _----------------- Z I CERTIF1'THAT INTHE PERFORMANCE OF THE WORK POR WH�CH THIS PEflMIT I5155UED,l � MECHANICAL � � — ('} SHALLNOTEMPLOYANYPEflSONINANVMP.NNERSOASTOBECAMESUBJECTTOTHE (/� NfOflKERS'COMPENSATIONLAWSOPCALIFOflN1A,Ml�AGflEETHATIFI3HOl1LOBECOME �NSPECTIONFEE F 'SU&IECTiOTHEWbRKEHS'COMPENSATIONPROVISIONS'OFSECTION37000F7HELABOH � cooE,isHAu.coRniwin+cor.+a�vwirNniosEaaowsioNs. ISSUANCE p: DATE: � APPLiCANT. SMIP ``�'^. r +' � J WARNINO:F/ULURE70SECUREWORKEAS•COMPENSATIONCAVERAGE�SUNtAWFUL,AN�SHRLLBE ENERGYP/C `'�--�" �� SUBJECTAIdEMPLOYERTOCRIMINAIPENALTIESANDCIVILFINESUPTOONEHUN�H�THOUSAND ENERGYPERMIT WILARS(5100.000),IN AOOITION TO THE COST OF COMPENSATION,DPMAGE9 AS PFiOVIDED FOfl IN � SECTIONa7ueOFTHELABORCODE,INTEREST,ANDATTORNEI"SFEES. RETENTIONFEE: --- "�"- "- � 2. _ — � CONSTRUCTION LEND�NG AGENCY � PRE-ALT FEE: - �_ O � �1 HEREBY AFFIflM UNDER PENALiY OF PEFJURY TFiNTTHEflE IS ACONSTRUCTION LENDMG AGENCY , FORTHE VERFORMANCE oFTHE WORK FOR WHICH THIS PEHMIT IS ISSUED(SEC.3097,CIV.C.�. Z 9 —_"__ J LENDEfl'S NAME � h=- LENDER'SMDRESS i W� ICERTIFYTHATIHAVEHEIIDTHISAPPUCATIONAND37A7E7HATTHEABOVEINFORMATIONISCARRECT. TOTAL FEES � - d IAGFEETOCOMPLYWITHALLCITYANDCOUNTYOROINANCESPN�STATELAWSREIATIN�TOBUILDING CON6TRUCTION,AND HEREBY AUf}/ORIZE REPRESENTATIVES OF THIS COl1NT'TO ENTER UPON THE - � . Z ABOVE•MENTIONEDPROPERTYFOHINSPECTIONPUftPO5E5. COMMENTS � , Q e....e�M��+. e�� � , . _ _"��4`��2;,�».� ��r��4!'n.,r' . m PE EE NAME(�RIN��, ' � �""���.,1�a�`�4��� �"`��'`� y 51(iNANPEOFPERMITTEE DA7E � ,_. RECPT.NO. PAI�BY VAUDATION ~ - WHITE-0epartment Copy,YELLOW--Financa Copy,PINK—Assessor Copy,GOLDENFOD--File Copy,GREEN—ApplicanYs Copy _...._. _ _ _. _�,..��..,,,�:. ,... ,,,., , � � � ��_.� ' ! 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