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HomeMy WebLinkAbout15533 (22) � �� ,� .-� �,� CITY OF DIAMOND BAx � DEPARTMENT OF COMMUMTY&DEVELOPMENT SERVICES � 21660 E.Copley Drive Suite 190 ;,� (909)860-3195 Fax{909)861-3117 PR�`S$ 9M. BUILDING PERMTT APPLICATION FIRMLY JOBSITE "" � APPLICATIO P� PERMIT f '�2�J, P!C o ADDRESS DATE NUMBER� l� # ISSUE � TYPE OCC �' APN LOT TRAC7 DATE CONST. GROUP p:. OWNER �' ADDR SS s ZONING SETBACKS �"' CITY ZIP TEL.S'f�i�_�fiZ REART RW O : APPUCANT 7EL. SIDE/SIdESTREET RW ❑ � CONTRACTOR yt.- SIDE ❑ � � ADDRESS S �- CITY ° ZIP TEL ��2�S�) PROPOSED USE % Pii�' ARCH/E G/ �` DESiGNER ADDRESS NO.DWEL. NO. NO. �j=; UNITS STOaIES BEDROOMS �� CITY ZIP TEL. <�is, DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION -�k OWNER•BUIIDER DECLARATION SFR/ADD/REM Os p I HEREBV AFFlMI UN�ER PENALN OF PEfLtt1RY THA7 I AM EXEMPT FROM THE CONTRACTOflS LI- G0fdg8lCBfPO(I �W` CENSELAWFOHTHEFOLLOWINOREA:AN(SEC.7031.5BUSINESSAN�PROFESSIONSCODE:ANVCINOR �(n , �� COUNTYWHICHREQUIFiESAPEflMIT7000NSTRUCT,ALTER,iMPROVE,DEMOLISH,ORREPAIRANVSTRUG W Pytio/DeCk - r. NRE,PRIOR TO ITS ISSUANCE.A150 REa11RE5 THE APPLICl�NT FOR SUCH PEHMIT TO FlLE A SIGNEU - W. STATEMENT iH�T HE Ofi SNE IS LICENSED PUR5l1PNT TO7HE PROVISIONS OF THE COMRACTORS L�• ��'� CENSELAW(CHAVTERH(COMMENCINOWITHSECTION7000)OFDIVISWN30FTHEBUSINESSANOPRO• '� PooUSpa ��� FE9310NSCODE)ORTHATHEORSHE�3ESEMiTTHEflEfROMANDTHEeA51SFORTHEAILEIiEDEXEMP- � ; TION.ANYVIOUTIONOiSECiIONTrt31.58VANYAPPLICANTFORAPERMITSUBJEGTSTHEAPPUCANT70 'Z pe-Roof �_; ACIVILPfiNALTYOF NOTMORE THAN fIVE HUNDRED DOLURS(SbOoJ.J: . �I,ASOWNEROfTHEPqOPERTV,ORAIVEMPLOYEE3WITHWAGESASTHEIRSOLECOMPEN5A710N, �-� Gommercial -' ��.�` WILI DD'fFIE WORK,AND THE STRUCTUflE 13 NOT INTENOEOOR OFFEREO FOfl 5ALE�SEC.7044,0L151- �:_I - NESS ANO PqOFE3310NS CO�E:THE CON7RAC70RS LICENSE LAW DOES NOTAPPLY TO AN OWNER OF ��: PROPERTYMTpBU1lDSORIMPROVESTMEREON.M1DMhfOD0E5SUCMWORKHIMSELFORHEfl3ElFOq � m .�^ THHOUCHHISOHHEROYMEMPLOYEES,VROVIDE�711ATSUCHIMPHOVEMENTSARENOTIN7EN�EOOH OFFEREDPoR SALE�fi NOWEVER'ME BUILOING OR IMPROVEMENY IS SOLD WITHIN ONE VEIROFCOMPLE- ��, TION,THE OWNER-BUIIDER WILL HAVE THE BURDEN OF PROVMO THAT HE OR SHE DIU NOT eUIID OR w,, IMPROVEWRTHEPURPOSEOFSAIE). ❑I,ASOVMEflOFT1E PROPERTY,AM E%CLUSIVELY WMRAGTINO YlITH LICENSED CONTMCTORS (C'; TO CONSTflUGT TME PRO.IECT(SEC.70{4,BUSINESSAND PROFESSIONS CODE:THE CONTRACTOflS LI- Va�uation � ADJ.AREA �W-- CENSEUWDUE9NOTAPPLYTOANOWNEAOFAPROPERiYWHOBUILDSOqIMPNOVES7HGREDN,AND - �_ WFfO00NTMCTSFORSUCHPRQIEC76WITHACONiRACTOR(5)UCENSEDPUHSUANi70THECONTMF QUANT DESCRIPTION FEE � TORS UCENSE UW.j. �-�- ❑IAMDCEAIPTUNDERS�C. 8.8P.C.FORTHISREASON �. v ' �: � LL'; OATE OWNER V !— W LICENSED CONTRACTORS DECLARATION �j �, IHEHEBYAFPIRMUNOERPENAL7YOFPERJl1RY1HATiAMLiCENSEDUNDERPROVISION50FCHAPTER � . -d�. 9(CDAIMENqNOWITHSECTION�ouo)OFOIVf510N30FTHEeUSINESSANDPfiOFESS10N5CO0E,AND Z AIY LICENSE IS IN FULL FORCE AND EFFECi. m � �0-��� LICENSE CLA LIC.NO. � -� . J _�j�� DATE CONTRAC70R+ a W � 1 �'! WORKERS'COMPENSA710N C RATION � �^ � � ..c.,[, � y- 1 HEREBYAFFlRM UNDER PENrLLTV OF PERJURY ONEOi THE FOLLOWING DECIARATIONS:� Z �- ,IFUYEANDWILLMAINTAINACER71FlCA7EOFCONSENTTOSELF�iNSl1REFONWORNERS' - ^T�d.- CAMPENSATION,ASPROVIDEDBYSECTION370oOFTHEIABOflCWE,FOFTHEPERFO E W OF,jHE WORK FOR WHICH THMS GERMR IS ISSUE�. � W ,: �HAVEANO WILL MAINTAIN WORICERS'COMPENSATION INSURANCE,AS RE D BYSECTIO ��n ///��� /'` Q- 37000F7HEI.A80HCODE,FOPTIIEPERWRMANCEOFTHEWORKFOfl ICHTHI3PEflM1Tl — — ��1� ISSUED.MYWOflKER CO &NSAT INSURANC CARRIERANDPO YNUM9ER RE: C TRUCTION . —a J � CMRIER 6rLy NREVIEVJ � POLICYNUMBEfl `IO.�. ,..- �S�'�i `1J _._ _._ LECTRIC A s h,. Q (fFBSSECfl,^.NNE�NOTBEOOMPlFfm0F71-EI'EPo�TrISFORadE4rtNiMiE� i�+ao)-ori�E'ssA.. J PLUMBWG =� � Z i CERiIfV THAT IN THE PEFf-0RMANCE OFTHE WORN FOR WHICN THIS PERMIT I5IS5UE�,i MECHANICAL .-� �• �''3'�� (� SHALINOTEMPLOYANYPEH50NINANYMANNEFSOASTOeECOMESUBJECTTOTHE � Wpql(EpS'CpMPENSATIONLAWSOFCALIFORNIA.ANDAGflEETHATIFISHWLDBECOME INSPECTIONFEE .. SUBJECTTOT WORKEflS'COMPENSATIO PflOYI510NSOFSECTION37000FTNELABOp ������ pCOUE, HALL RTHWITH COMPLY WITH OSE PROVISIONS. �° �SSUANCE _���, �� ' .--�"� DATE: � APPLICANT: .c� -SMIP .._.. `�9}^"� r �g P !�_ ..� .. .a W . .c� . �-y.„`�&A-+'.��K�'�"`..?�- . -J WqqNINO:FAILIIflETOSECUflEWORKERS'GO PENS NCOVERAOEIS NUWFUL,ANOSHRLLBE ENERGYP/C 3���°' Q F � �. ��4 �,_ ���' � SU&IECTANEMPLOYER70CRIMINALPENAL S CIVILFINESUPTOONEHUNDPEDTH0U5AND � u. ENERGY PERMIT 's'��P"�s�-a r���''`'� OOLUflS(f100,OD0),INADDITIONTOTHEC TO MPENSATION,OAMAGESASPROViDEDFORIN �-�-�-g�,� � SECTION3JOBOFTNELABORCODE,INTE ST,ANDATiORNEY'SFEES. � RETENTIONFEE: __ _ a CONSTRUCTION LENDING AGENCY PRE-AlT FEE: � IHEREBYAFFIFMUNDERPENALTVOFPERJURYTHATTHEREISACONSTRUCTIONLENDMGAGENCY � FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PEHA��T IS ISSUE�(SEC.3aW,CIV.G.�. . Z W � LENDER'SNAME --- - F- LENDER'SAUDRESS C - � � � . � ICERTIFYTHATIHAYEREADTHISAPPLICATIONANDSTATETHATTHEPBOVEINfORMATIONISCORFECT. TOTALIELS � ' � IAGREETOCAMPLVWITHALLCITYANOCOUNTYOROINANCESANDSTATELAWSFiEtATMGTOBu1L�IN0 , . CONSTRUCTION,ANDHERE9VAUTHONREREPRESENTATNESDiTHISCOUNTYT(]ENTERUPONTHE � . . ZA80VE•MEHrIONED PROPERTY FOR INSPECTION PURPOSES. COMMENTS - - � 7 � � m PERMI E N (PRINTj �� 4 N � SIO UqEOF EE AT - = RECPT.NO. 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