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HomeMy WebLinkAbout17419 .� -----._1�..___. CITY OF 17IAMOND�AI2 �`' � DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES ° / 21825 E.Cop(ey 17rive ` (909)860-3195 Fax(909)861-3117 PRESS '�"�y���� BiIILDINGPERMTTAPPLICATION FIRMLY � JOBSITE �f APPLlCATION �j �� PERMIT P/C o ADDRESS_ ( � _,��� `- DATE !' "�� NUMBER � �? # o ISSUE TYPE OCC `T APN LO TRAC DATE CONST. GROUP p OWNER � ,� �91(i%�. " ADDRESS ,�, ZONING SETBACKS 0 z CITY ,ZIP TEL. FRONT RW ❑ � APPLICANT l�X 7EL. REAR ❑ � SIDElSIQE STREET RW ❑ z ¢ CONTRACT - SIDE ❑ p� ADDR S ` " PROPOSED USE r � (8 � � CITY?'. ZIP ' TEL. �-- r o ARCHIENG/ �� M� �'���°� � }' ,� z DE5IGNER NO.DW� NO. NO. a ADDRESS UNITS STORIES �!BEDROOMS � CITY ZIP TEL. � pESCRIP710N SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-BUILDER DECLAAATION SFR/A�D/REM O p I HERE6Y AFFIRM UNDEfi PENALTY OF PERJUflY THAT 1 AM EXEMPT FflOM THE CONTR4CTORS LI- G81890/C3fPOfk W CENSELAWFORTHEFOLLOWWGREASdN(SEC.7IXi1.SBUSWESSANDPROrESSIONSCO�E:ANYCIiVOR {n , U� COUNTYWHICHRE�UIRESAPERMITTOCONSTRUCT,ALTER,IM7ROVE,DEMOLISH,ORREPAIflANYSTRUG W pgt10/DBCk Z iURE.PfllOft TD ITS ISSUANCE.AL50 REWIRES�HE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED � STATEMENT THAT HE OR SHE IS LICENSEO PURSUANT TO iHE PPDVISIONS Or THE CON7RAC70ftS LI- � � CENSE LAW(CHAPTER e(COMMENCING WIiH SECiIIXJ 7aao)OF DIVISION 3 OF THE BUSINESS AN�PRO- LL PoaUSP2 FESSIONSCODE)DRTHATHEOFSHEISEXEMPTTHEflEFROMAN�iHEBA515FOfiTHEALLEGEOEXEMP- � �. TION.ANYVIOLATIONOFSECTION7031.5BYANYAPPLICANTFORAPEflMITSUBJECTSTHEAPPLiCANTiO Z Re-ROOT A CIVIL PENALiY OF NOT MORE THAN FIVE HUNDRED DOLLARS(5500)J: � ❑I,ASOWNEROFTHEPROPERTV,ORMYEMPLOVEF_SWITYIVAGESASTHEIFiSOLECOMPENSATION, C, Commercial �- WILI�O THE WOFK.ANO THE STRUCTUflE IS NOT INiENDED OR OFFERED FOR SALE(SEC.7044,BU51- J � NE35 AND PROFE3SION5 CADE:?HE CONTRACTORS I:ICENSE L4W DOES NOT APPLV TO AN OWNER OF = PROPEFITY WtiO BUILDS OR IMPROVES THEREON,AND WHOOOES SUCN WORK HIMSELF OR HERSELF OR � �THFlOUGHHISORHEAOWN£MPLOYEES.PFOVIDEDTHATSUCNIMPROVEMENTSARENOTINTENOE�OR m QOFFEREDFORSALE.IF,HOWEVER,iHEBUiLDWGORIMPROVEPAENTISSDLDWITHINONEYEAROFCOMPLE- Z. T�ON,THE OWNER-BUIL�ER WILL HAVE THE BURDEN OF PROVING TMAT HE OR SHE DID NO7 BUILD OR = IMPFOVEFORTHEPl1F2POSEOFSALE]. w, ❑I,ASOWNEROFhiEPROPERTY,AMEXCWSIVELYCONiRACTINOWITHLICENSEOCONTRACTORS � �' TO CONSTRUCT THE PROJECT(SEC.7094,BUSINESS RN�PROFESSIONS CODE:THE CONTRACTORS LI- VBIUailOff "�� � �� ADJ.AREA W� CENSELAW�OESNOiAPPLYTOANOWNEFOFAPROPERTVWHOBUILOSORIFAPROVESTHEREON.ANO � WHOCONTRAC75FORSUCHPROJECTSWITHACONTRACTOq(S)LICENSEDPURSUANTTOTNECONTRAG QUANTITY d DESCRIPTION FEE Y TORS LICENSE LAW.). � ❑I AM EXEMPT UNDER SEC. 3.&P.G FOqTH15 REASON U - � W � DATE OWNER � Z W � LICENSED CONTRACTORS DECLARATION W � I HEREBY AFFIqM UN�ER PENALTY OF PERJURV THAT IAM LICENSED UNDER PROVISIONS Of CHAPTER � � 9(COMMENCMG WITH SECTION 70e0)OF DIVISION 30F THE BUSINESS AN�PROFE551ONS CODE,AND Z X MY LICENSE IS IN FULL FOR ND EFFECT. m GLl ,�9 � 0 LICENSE C SS LIC.NO. �'1i' � F J V DATE CONTRACTOR d , . W � WORKERS'COMPENSATION DECLARATION Q � � U � I HER�YAFFIRM UNDER PENALTY OF PERJURY ONc OFTHE FOLLOWING DEGLARATIONS: Z � lIHAVEANDWILLMAINTAINACER7IFICAiEOFCONSBJTTOSELF-INSUREFORWORKERS' S CAMPENSATION,ASPROVI�E�BYSECTIIXJ31000FTHELAB�RCO�E,FOR7HEPEFFORMANCE U ¢ OFTHE WOflK FOR WHICH THIS PERMIT IS ISSUED. � 0 � �I HAVE AND WILLMAINTAIN WOFKERS'COMPENSATION INSURANCE,AS RE�UIRED BY SECTION _�,��,.j.^�f�- �"�vy o� QQ 37aoOFTHELABORCODE,FORTHEPERFORMANCEOFTHEWO FORWHICHTHISPEaMlT15 g�.. y*. / sr.�F.y ISSUED,lAVWORKEFS'COMP SATIO CECARRIER POLICYNUMBERARE: CONSTRUCTION � T f/ � j cnARi� PI.AN REVIEW �'� � aoucvNUMeEa ELECTRIC Z Q � (1H195ECTIDNNEmNOTBEDJMPLErEDOFhiEPERMfTISFORIXJEHUNDREDDO�INIS($1�0)ORLESSJ. PLUMBING ItJ Z I CERTIFYTHAT INTHE PERFORMANCEOFTHE WORK FOH WHICH THIS PERMIT IS ISSUED,I MECHANICAL '--- ` ' '-�"'-- - �--"=-�-"�'-" (J' SHALLNO�EMPLOYANYPERSONI�ANYMANNERSOASTOBECOMESUBJEGTTOTHE �� � WORKERS'COMPENSATION LAWS OF CALIFD AN AOREE iHAT IF I SHOUID BECOME INSPECTION FEE - ' ' � Sl1BJECTTOTHEWORICERS'COMPENSATIO P OVI NSOFSECi N37oaOFiHELABOR ' /� =J ag � � CO�,I SHALL FORTH H COMPLY WITH E P ISIONS. ISSUANCE a� ` p DATE: r <�PPLICANT: _ SMIP ' "� c �� J WARNINGFAILURETOSECUREWORKERS'COMPENSATIONCOVERAGEISIJNIAWFUL,AN S ALLBE ENERGYP/C - � SUBJECTANEMPIOVEflTOCRIMINALPENALTIESANDCIVILFINE5UP700NEHUN�RE�T SAND � " "' DOLLARS(5100.000�,INA��ITIONTO7HECOSTOFCOMPeNSATION,DAMAGE5A5PROVIDEDFORIN Eh1ERGYPERMIT "'__ __.__._.__—.._.. m�--- � SECTIDN37o80fTHELABOflCODE.INiEREST,ANDATNflNEY'SFEES. RETENTIONFEE: � a CONSTRUCTION LENDING AGENCY pRE-ALT FEE: O � I HEREBYAFFIRM UNDER PENAL7YOF PERJIIqVTHAT iHEHE IS!C�NSlFil1CTION LENDING AGENCY FOqTHE PERFORMANCE DFTHE WORK FOR WHICH THIS PERMI7151SSUE0(SEC.3o9'!,CIV.C.). �� . W � LEN�ER'S NAME JL��o C ./ F� LENDER'SADDHE55___._ - � � TOTAL FEES �� �� ~j-' _� � IGEfl71FYTHATIHAVEREADTHISAPPLICATIONANDSTATETHATTHEABOYEINFORMATIONISCORRECT. W IAGREETOCOMPLYWITHALLCITYANDCOUNTYORDWANCESANOSTATEL4WSRELP.TINGTOBUILDING - � ° � CONSTRl1CTION,AND HEREBV AUTHORIZE REPRESENTATIVES OF THIS COl1NiV i0 EN�ER IJPON THE �.�3 y � ABDVE-MENTIONEDPROPERTYFOflINSPECTIONPUFiPOSES. ��/ �� � GOMMENTS s � � ���� � PERMITTEE E(PRINT) - ^ �� /iy a � aV ` � SIGNATUREOFPE MITTEE DATE = RECPT.N0. ,�� PAID BY VALIDATION ~ WHiTE—De artment Co YELLOW—Finance Copy,PINK—Assessor Co GOL�ENROD—File Co GREEN—A IicanYs Co P PY� PX PY� PP PY , .. , � , '�' � �::', , i � '�' . , . ..w.�. � �i .. � :*�"�� �ar ff a t ���.x.� s"4-:� � �R� r .� "Y "�' � r � s ` � � � 4 § � '$-.. r � �� s �':„ t-a '+� ���; �p#b� �" k�.� p i ��. b� p i ". .� :.y, 3"' . §�N + p -: P ' 3 V'�"`e 1 m� ,� �`t r�Y � � � x:r �. �, � " E �:. a � . � � �.� � a i � x a ': x � [a�, a f,'.' # �8 f€�.€ � � � t �4� �€-;�#� :� '.� m� .d�s �.�` . �. . a n _�a� �' ._ '%. 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