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HomeMy WebLinkAbout15182 (17) r .� �`�( {z.��p CITY OF DIAMOND BAbt ��� � '" �--��— DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES �� W . 21660 E.Copley I?rive Suite 190 (909)860-3195 F�(909)861-3117 PRES$ ��'��'� BUII,DING PERMIT APPLICATION __ FIRMLY _ .. . .. � JOBSITE �Z�S G.���/'L / ,�,�" o ADDRESS i0� APPLICATION , PERMIT P/C DATE_ NUMBER ✓ # OCC � APN LOT TRACT DATE CONST. GROUP p OWNER Li:tJ'�A !1L/� p ADDRE�S–��2` ZONING SETBACKS "� CITY 1��' r� ' ZIP � TEL. SlF2I" t,�5 FRONT RW ❑ � APPLICANT TEL. REAR n � SIDEJSIDESTREET RW ❑ CONTRACTOR Kls �'�QS' SIDE p ADDR SS ?c�` '3 � CITY " ZIP /Z. TEL. � S'�L7 PROPOSED USE o ARCWENG/ � DESIGNER NO.DWEL. NO. Np, � ADDRESS UNITS STORIES BEDROOMS = CITY ZIP TEL. � � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-BUILDER DECLARATION � SFPoADD/REM p I HEREBY AFFIPM UNDER PENALN OF PERJURY THAT i AM E%EMPT FflOM iHE CONTHACTORS LI� GafBgB/CBtPOfI W CENSEUWFORTHEFOLLOWINaREASON(SEC.7037.56USINE33AN�PflOFESSIONSCODE:ANYq7YOR (n COUNTlWHICHHEWIRESAPERMITTOCONSTRUCT,AL7ER.IMPROVE,DEMOLISH,ORREPAIRANYSTRUC- W pgtl0/DBCk w 7URE.PRpR TO ITS ISSUANCE,ALSO RE�UIRES THE APPLICAN7 FOR SUCH PERMIT TO FILE A S�GNED W � S7ATEMENT THAT HE OR SHE IS LICENSED PURSUAN7 TO THE PROVISIONS Of THE CANTRACTORS U- � CENSE LAW fCHAPTER 91COMMENCINO WITH SECTION 7000)OF DIVISION 30F THE BUSINESS ANO PRO- POOVSp2 iESS10NSC00E1�THATHEORSHEISEXEMPTTHEREFROMANDh1EeASISFORTHEALI.EGEDEXEMP- (� TKKJ.ANYVIOI.ATIONOFSECTION7031.66VANYAPPLICANTFOHAGERAIITSUBJECTSTHEAPPIICANTTO Z Re-Roof � ACML PENAL7V OF NOT AIORE THAN FIVE HUNOREO DOLLARS(t500).): � ❑I,ASOWNEROFTHEPROPEFTY,ORMVEMPLOYEESWITHWAGFSASTHEIRSOLECAMPENSATION, COfllfflBfCidl - WRL DD THE WOi#(,MID THE STRUCTURE IS NOT INTENDED OF OFFEREO FOR SALE�SEC.7oda,BU51- � � NESS AND PROFESSIONS CO�E:THE CONTRACTORS I.ICENSE LAW OOES NOT APP�Y TO AN OWNER OF = PqOPERTY YVFp BUILDS OR IMPROVES THEREON,AND Nh1000E5 SUCH WORK HIMSELF OR HERSELF OR � h1ROUGHHISORHEROWNEMPLOYEES,PROVIDEOTHATSUpi1MPRDVEMENTSAflENOTINTENDWOR m OFFERED fOR SALE IF,HOWEVER,TNE BUILOINGOR IMPROVEMENT IS SOLD WITMN ONE YEAR OF CAMPLE- � 710N,TME OWNER�9U0..DER WILL HAVE THE 6URDEN OF PROVINO THAT HE OR SHE DID NOT BUILD OR � IMPROVEFORTHEPURPOSEOFSALE�. W ❑I,AS ONRdER DF THE PROPERTY,�A1 EXCWSIVEIY CONTflACTING WITN IJCENSE�CANTRACTORS � TO CONSTflUCT THE PRQIECT(SEC.7WA,BUSINESS AND PROFESSIONS(:nDE:THE CONTRACTORS LI- V8�U3t10� ADJ.AREA W CENSEUWDOESNOTMPLY70ANOWNEROFAPROPERTVWHOBUIL�SORIMPRDVESTHEREON,AND � WI�OCONTRACTSFORSUCHPRQIECTSWITHACCNTRACTOR�S)LICENSEDPURSUANTTOTHECONTRAG QUANTITY DESCRIPTION TORS UCENSE LAW.). FEE O ❑I AM EXEMPT UNDER S�C. B.&P,C.FOR THIS REASON Q .Z U LL � DATE OWNER V— Z — U 4 UCENSED CONTRACTQRS DECLARATION W O[ 1 HEREBV AFFIR/I UNDER PENALTY OF PERJURY THAY 1 AM LICENSEO UNDFR PROVISIONS OF CHAPTER � C1 �'2�.. '+rt� p„ B(COMMENCINQ WITH SECTION 7000)OF DNISION 3 OF THE BUSINESS AND PROFESSIONS CODE,ANO Z 3.J -�-"�� x MY LICENSE IS IN FUIL FORCEAND EFFECT. �'r� `� LICENSE CU/S�S^��Cj J(G LIC.NO. rI� � V DATE_fP"`L7"� _ CONTRACTOH /'��'"� � d W � WORKERS'COMPENSATION DECLARAl10N ¢ � I FIEREBY AFFIRM UNDER PENALTV OF PEflJURY ONE�F THE FOLLOWING DECLAflATIONS: Z � _tHAVEAN�WILLMAINTAINACEHTIFICA7EOFCONSENTTOSELF-INSUREFORWORKERS' _ COMPENSATION,ASRfiOVIDEDBVSECTON37ooOFTHELABOqCOOE,FORTHEPF_RFORMANCE U Q OFTHE WOPK F4P WHICH THIS PERMIT IS ISSUED. � F _IH0.YEAN�WIIIMAMTAINWORKERS'GOMPENSATIONINSURANCE,ASREQl/1A.E�8YSEGTIDN Q 37000F 7HE LABOR CODE,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.MYNJOR 5COMPENSATIIXJINSU CECARRIERANDP�LICYNlJMBERARE� CONSTRUCTION j CARRIER ��� L��'���-� PLAN REVIEW Z POLICY NUMBER _ �� ._— ELECTRIC __ Q � (fFiiSSECfqNNEIDNOTBE�MP�ETEDOFTiEPEG�.IffISFORONEHUI�DPEDDOltARS(EIOo)ORLESS} PLUMBING "' Z I CERTIFV THAT INTHE PERFORMAhCE OFTHE WORK FOR WHICHTHIS PERMIT IS ISSUED.1 MECHANICAL �— CJ� SHALL NOT EMPLOYANV PERSON IN ANV MANNER SOAE TO BEC06AE Sl1BJECT TO THE � WORKERS'COA4PENSATIONLAWSOFCALIFORNIA,MIOAGREETHATIFISFi0ULD0ECOME INSPECTIONFEE SUBJECT TO THE WOFERS'COMPENSATION P SIONS OF SECTION 37oG OFTHE LABOR S CQOE ALL.FORTHWITH COMPIY OSE PROV� ISSUANCE � �L� p DATE:�� � APPLIC�ti � SMIP J WARNINCa:FAILURETOSECUREWORKERS'COMPENSATIONCOVEAAGEISUNLAWFUL,ANOSHA�LBE ENERGYP/C _��� �� �y SU&IECTANEMPLOVERTOCRIA7INALPENALTIESANDCIVILFINESU7TOONEHUNOREDTHOUSAND ENERCaYPERMiT OOLLARS(f100,0o0),IN ADDITION TOTHE COST Of COMPENSATION,DAMAGES AS PROVIDED FOR IN � SECTION 3708 OF TiE LABOR CAOE,INTER[ST,ANDATTORNEV'S FEES. RETENTION FEE: T�TT OCONSTRUCTiON LENOlNG AGENCY PRE-ALT FEE: �LJ u+D � I HEREBY AFFIRM UNOER PENALTY OF PERJUNV THAT THFRF_IS A CONSTRUCTION LENOING AGENCY _ FOFTHE PEPFORMANCE OFTHE WORK FOR WHICH THIS PERE,II71S ISSUED(SEC.3oW,dV.C.). Z W � LENDER'S NAME F— LENDERSA�DRESS /� W 1 CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INf-0RMATION IS CARPECT. TOTAL FE ES " /)�� "�% // � IAGREETOCAMPLVWITHALLCITVANDCOUNTVORDINANCESANDSTATELAWSRELATINGTOBUIL�ING 4/ / // � CONSTRUCTION,ANDHEREBVAUTHOR2EPEPRESENTATNESOFTHISCOUNTVTOENTERUPONTHE < « Z ABOVE-MEN EO PROPERTY FOR INSPECTION PURPOSES. COMMENTS � �-,�' ��`��i�.I� j QPERMITTEE NAI�Zrnin i) �_T"� � �a ` � `^�`�'�.�.__. 1 L�"'��� � SIGNATURE OF PERMITTEE �� �ATE = RECPT.NO. _ PAID BY VALIDATION ~ WHITE--Department Copy,YELLOW—Finence Copy,PINK—Assessw Copy,GOLAENROD—File Copy,GFlEEN—ApplicanPs Copy �...„�",,. ,...- .:'�4�.,w �;,�. �r' . ..,..,, ., ... .�.. , r .,. . . y ' . ' � , � . 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