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HomeMy WebLinkAbout14758 (19) �P��'� __��_ CITY OF DIAMOND BA� DEPARTLRENT OF COMMiJNITY&DEVELOPMENT SERVICES G6�,'�d�U/ """ W 21660 E.Copley Drive Suite 190 � (909)860-3195 Fax(909)861-3117 PRESS �'��'� � BUII.DING PERMIT APPLICATION ____ FIRMLY o� JOBSITE��/�(� ��.)��� ' � O�_ ��� APPLICATION � ' �PERMIT J �� !C ADDRES •�� r� a DATE NUMBER � # � ISSUE TYPE OCC APN LOT �RACT DATE CONST. GROUP p OWNER p ADDRESS G �' ZONING SETBACKS � APPLICANT �,?�'�A�a nl �,�3TEL. RE�ART RW O SIDE/SIQE STREET RW ❑ � CONTRACTOR �-�-�Q_�, SIDE ❑ o AD�RESS ` � � PROPOSED USE � CITY� pc1Y1C��' ZIP TEL. o ARCH/ENG/ z� DESIGNER NO.DWEL. NO. NO. a ADDRESS UNITS STORIES BEDROOMS � CITY 21P TEL. y y DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-BUILDER DECLARATION SFR/ADD/REM O 0 I HEREBY AFFlRM UNDER PENRLTY OF PERJURY THAT I AM EXEMPT FHOM THE CONTRACTORS LI- GBfdjB/C2�OfI W CENSEL4WFORTHEFOLLOWINOREASON(SEC.7D31.58USINESSANDPROFESSIONSCADE:ANYCITVOR (n COUNTYMMIGHREOUIRESAPERMITTOCONSTRUCT,ALTER,IMPROVE,DEMOLISH,ORREPMRANVSTRUG W patio/Deck W TURE,PRIOR TO IT9 ISSUANCE,ALSO REWIRES THE APPLICANT FOR SUCH PERMIT To FILE A SIGNED W S7ATEMEM THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTONS LI- � CENSE LAW(CHAPTER B(COMMENCINQ N'ITtI SECTION 7000)OF DIVISION 3 OF 7'HE BUS�NESS AND PRO- V' POOUSpB FESSpNS CODE�DR THAT HE OR SHE IS IXEMPT hiEREFROM PN�THE BA515 FOR THE RLLE�ED EXEMP- TION.ANVVIDLATIONOFSECTION7031.6BYANYAPPLICJWTFORAPERMITSUBJECTSTHEAPPL�CANTTO Z RB-R001 � ACMLPENNSVOFNOTAIORETHANFIVEHl1NDREDDOLLARS(f50U).): � ❑I,ASOWNEROFTHEPROPERTY,ORMVEM7LOYEESWITHWAGESASTHEIRSOLECAAIDENSATION, O Commarcial - WILL DO THE WORK,M1D 7HE S7RUCNRE IS NOT INTENDED OFl OFFERED FOR SALE(SEC.7ou,BUSI- J NESS ANO PROFESSIONS CODE:TiE CONTRACTOPS LICENSE LAW DOES NOT APPLV TO AN OWNER OF � PROPERTYW1108ULD30RIMPROYEShiEREON,ANDWHO00ESSUCHWORKHIMSELFORHERSELFOR � Q THMUOFIHISORHEflONMEMPLOYEES,PROVIOEDTiATSUCHIMPROVEMENTSARENOTINTENDEDOR m Q ,OFFEREDPORSALEIFFIOWEYER7MEBUILDINGORIMPROVEIA6JTISSOLDWITMINONEYEAqOFCOMPLE Z TION.7HE OWNER�UILDER 1M�LL HAVE THE BUHDEN aF PAOVIN6 7HAT HE OR SHE OID NOT 8UIL0 OR � pdPRQVEFORTHEWRPOSEOFS/U.E). w ❑I.ASONMEROFTHEPROPERTV.AMEXCLUSIVELYCONTMCTINOWITHLICENSEDCONTRACTORS � 70 CONSTRUCiTHE PROJECT(SEC.7W4,BUSINE55 AND PROFE5510N5 CODE:THE CONTRAC70RS LI- Valuation ADJ.AREA W CENSEUW�OESNOTAPPLVTOANOWNEROFAPROPERTYWNOBUILDSORIMIPROVESTHEREON,AND Z WVqCONTRACTSFORSUq/PROJECTSWITHACONTRACTOR(5)LICENSEDPURSUANTTOTHECONTqAG QUANTITY DESCRIPTION FEE �" �s ucErase uw.�. � ❑IAM EXEMPT UNDER S�C. B.8 P,G FOR TMIS qEASON J � U � � LL' DATE OWNER � � Z w � LICENSED CONTRACTOHS DECLARATION W � I HEREBYAFFqAI UN�ER FENAITV OF PERAIRV THAT I MI LICENSED UNDER PROVISIONS OF CHAPTER � p� 9(COMMENCINONAhISECTIOPJ700DJOF�NIS10N30FTHEBUSINESSANDPROFES510NSCAOE,AND Z X MY LICENSE IS IN FUII FORCEAND�EFFECT. m � LICENSE SS r ' LIC.N4 ��� � � J V DATE CONTRACTOR a W � WORKERS'COMPENSATION DECLARATION Q = U � I HEREBV FFFlRM UNDER PENALN OF PERJURY ONE OF THE FOLLOWING OECLARATIONS: Z � _IHAVEM10WiLlMAiNTAINACEfTIFICATEOFCONSENT70SELF-INSUREFORWORKERS' 2 COMPENSA710N,AS PROVIDED BV SECTION 3700 OF THE LABOR CODE,F�R THE PERFORMANCE C� �� 'JFhIEWORNFORWHICHTHISPEqM1TISISSUED. � 0 � _IHAVEANDWILLMAIMAINWORKERS'COMPENSATIONIf�URANCE,A5RE0UIREDBYSECTION Q 37000FTHE V1BOR CQDE,FOR THE PEAFORMANCE OF THE WORK FOR WHICH THIS PERMIT 15 iSSUED.MY WORKERS'COMP TION U'IRAN��^°E CARRIER AND POLICV NUMBER ARE: CONSTRUCTION jCARRIER ��� (� PLAN REVIEW Z vaICYNUMBER_ _��, � ELECTRIC ¢ � (?HISSEGTIONNE�NOTBEOOMPLETEDOF7HEPERMT6FnHONEHUN�FiEDDq1PRS(51oo)OFiLESS� PLUMBING Z I CERTIFV THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUEO,I MECHANICRL (� SHALL NOT EMPLOY ANY PERSON IN ANV MANNER SO AS TO BECOME SUBJECT TO THE �� � N WOqKERS'COMPENSATIONUWSOFCALIFORNIAANDAGREETHATIFISHOULOBECOME INSPECTION FEE 5 SUBJECT TO THE WdRKEHS'COMPENSATION PROVISIONS OF SECTION 3�a0 DG THE LABOA CODE,I SHALL F RTHWIhICOMPLY WI THOSE PFOVISIONS. ISSUANCE p �ATE:_���APPIICANT. � �, i" • l NL(J1/L�-k�.� SMIP �- � J WARNIN6:FAIWqETO SECURE WORKERS'COMPENSATION COVERAGE IS UNUWFUI.AND SHAIL BE ENERGY P/C j�+��/�y� �y SU&IECTPNEMPLOYERTOCRIAIINILLPENAITIESANDCIVILFINESUPTOONEHl1NOREDTHOUSAN� ENERGYPERMIT �II llt"IilA����Ab OOI.LARS(f100,000).IN AODITIONTO THE COSTOF COMPENSATION,DAMAGES AS PROVIDE�fOR IN T �p� J SECTION37oBOFTNEU160RCODE,INTEREST,ANDATTORNEV'SFEES. RETENTIONFEE: 17IJ(�.T)TI�T � aW.. CONSTRUCTI�N LENDING AGENCY PRE-ALT FEE: O � 1 HEREBV AFFIRM UNDER PENAITY OF PERJURY THAT THERE IS A CONSTFUCTION LEN�ING AGENCY FOR THE PERFORMANCE OF 1HE WORK FOR WHICH THIS PERIAIT IS ISSUED(SEC.309�,CIV.C.). Z W � LENOER'S NAME 1� LEN�ER'3ADDHE53 /'� � ICER�IFYTHATIHAVEREADTHISAPPUCATIONIWDSTATETHATTHEABOVEINFORMATIONISCARRECT. TOTAL FEES �� _/ � � IAGREETOCAMPLYWITHALICIT'ANOCOUNTVOROINANCESANOSTATELAWSRELATINGTOBUILDING � � CONSTRUCTION,ANO HEREBV AUTHORIZE REPRESENTATNES OF THIS COl1NTY TO ENTER IJPON THE Z ABOVE-MElf�IONED PROFERTV FOR INSPECTION PURPPSES. COMMENTS � ��,�1�I� {�'�L'l� C�l (�C�t !� � m P MITTEE NAME(PHIN� - ¢ �f � 4 t �� a � � ���1� � � I M�1P.E OF R I ATE ' � RECPT.NO. PAID 8Y VALIDATION WHITE—Department Gopy,YELLOW—Finen�Copy,PINK—Assessor Copy,GOIAENROD—File Copy,GREEN—ApplicanYs Copy . ..�. �. n:. - �.�„�.e �. ,.��:i. . . �.i .. ..�� . .i. . ... ... ��.. '+'•'e �:a' � 1 �h�. F �['��M ... ......i .,e ...�t .� .� , �.� ..��y �.;� '���. -.. .. ':�.". �.. .. -..�...... ' , .. .. ..a .':, �, '': :";;.. .. . ..... . � . , . , �. . , �,"a� .. . 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