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HomeMy WebLinkAbout17562 (10) CITY OF DIAM�JJND BAR /� ^---��—� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES `� 21825 E.Copley I7rive '� (409)860-3195 Fax(909)861-3117 PRESS `''-v��� BiJILDING PERMiT APPI.ICATION FIRMLY � JOBSITE ��j/_'' �"'� ��� APPLICATION PERMIT i ,,.+��P/C o ADDRESS « �C�" � DATE ��" NUMBER � ,�f�7 # o� ISSUE 7YPE OCC APN RAC, DRTE CONST. GROUP p OWNER _ " ADDRESS f"� t.ii//� ZONING SETBACKS z CITY ZIP TEL. _ FRONT RW ❑ � APPLICANT TEL REAR ❑ � SIDE/SIDE STREET RW ❑ ¢ CONTRACTO} ��?' SIDE ❑ O ADDRES ` ' � PROPOSED USE � �' � '� CITY :� ZIP TEl. w ARCH/ENG/ ,�'7� ��Cf - �z DESIGNER `� � NO.DWEL. NO. NO. a ADDRESS UNITS STORIES BEDROOMS , � CITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION cq OOWNER•BUlLDER DECLARATION SFR/AD�/REM � Q 1 HEREBY AFFlflM UNDEft PENALTY OF PERJURY THAT I AM EXEMPT FflOM THE CONiRACTORS LI- G8fH92(C2f�Jaf[ I W CEN5ELAWFORTHEFOLLOWINGR'eA50N(SEC.7037.SBUSINESSANDPROFESSIDNSCO�E:ANVCITVOR (/� ' U COUNiYWHICHREQUIRESAPEFMITTOCONSTRUCT,ALTER,IMPROVE,OEMOLISN,ORREPAIRANVSTRUC- W PetIOIDECk � TURE.PRIOR TO ITS ISSUANCE,qL50 REQIlIflES THE APPLICANT FOR Sl1CH PERMIT TO FILE A SIC.NED W STATEMENT THAT HE OR SHE IS LICENSE�P�flSUANT TO iHE PflOVI510N5 OF THE CONTRACTOR5�I- W .�cc GENSE LNW(CHAPiER 9(LOMMENqNG WITH SECiI�N 7000)OF DIVISION 3 OFTHE 9USINESSAND Pq0- u" POOUSPd 0 FESSIONSCODt�ORTHATHEORSHEISEXEMPTiHc.9EFROMAN�iHE0A51SFORTHEALLEOEDEXEMP- V TION,ANYVIOLAiIONOFSECilON7o31.5BYANVAPPLICANTFOHAPERMITSUBJECiSTHEAPPLICANTTO Z Re-Roof A qVll PENALTY OF NOT NOR6 THAN FNE HUN�RED DOLLARS�SSoo).�: o ❑I,ASOWNEROFTHEPROPERTY,ORMVEMPLOVEESWITHJNAGESASTHEIFSOLECOMPENSATICN, CJ C�t1llR0fC131 � - Z WILL DO THE WORK,ANO THE 57RUCiURE IS NOT INTEN�ED OR OFFERE�FOR SALE(SEC.70da,9U5:- J NE55 AN�PRQFESSIIXJS CO�E:TNE CONTRACTORS LICENSE I.AW OOES NOiAPPLY TO AN OWNER DF � ' PflOPERTYWHOBU1LO50RIMPROVESTHEflEON,ANOWHODOE55lJCHWORKHIMSELFORHERSELFOfl = � THfiOUGHHI50RHEflOWNEMPLOYEES,PROVIDEOiHATSUCHIMPROVFaAENTSARENOTINTENDEDOR m W OFFEREDFORSALE�F,HOWEVEP,THEBUILDIN�ORIMPpOVEMENi1550LDWITHINONEYEAROFCOAdPLE- � .TION,THE OWNER-BUIL�EF WILL HAVE THE BURDEN OF PqOVING THAT HE OF SHE DID NOT BUILD OR Z IMPROVEFORTHEPUPPOSEOFSALE). _ ❑I,ASOWNEROfTHEPROPERTV,AMEXCLU5IVELYCONiRACTWGWITYIICENSE�CONTRACTOpS W � �TO CONSTRUGT TNE PROJECT(SEC.1044,81151NESS ANO PflOFE5510N5 CODE:THE CDNTRACTORS LI- VHIUd(IOII R"�' ADJ.AREA W CEtJSELAW00E5NO7APPLYTOANOWNEROFAPflOPERTYWFpBUILD50FIMPROVESTHEREON.AND � WHOLOMRACTSfORSUCHPROJECTSWITHACONiRACTOR(5)LICENSEDPUR9UANTTOTHECONTRAG QUANTITY DESCRIPTION FEE Y TOHSLICENSELAW.�. � J O p IAM EXEMPT 11N�ER SEC. B.&P.C.FOR THIS REASON U � � LL DATE OWNER t' � W p LICENSED CONTRACTORS OECLARATION W Q � �HEREBYAFFIRM UNDER PENALTV OF PERJURYTHAT I AM LICENSED UNDEfl PROVISIONS OFCHAPTER � . p: 9(COMMENCING WITH SECTION�000)OF DIVISION 30F THE BUSINESS AN�PROFESSIONS COOE,ANO z X MY LICENSE IS IN FULL FORCEAN�EFFECT. � LICENSE CLA S� � � ���� � � LIC.NO, � � J� �t J V ' �ATE �f L� CONTRACTOR _ d W � - WORI�RS'COMPENSA?ION DECLARATION Q = U �' IHfiREBVAFFIRMUNDEflPENALTYOFPERJUFflONEOFTHEFaLLOWiNGDECLARATI�NS: C!J Q C1 IHAV l"lILLMAINTAINACERTIFlCA7EOFCONSENTTOSELF-INSUREFORWoftKERS' _ CO ENSA710N.ASPROVI�EDBYSECTION37o00F'MELABORCODE,FORTHEPERFORMANCE U ¢ 7HE WORK FOR WHICH THIS PERMfi IS ISSUED. � � O � _IHAVEANDWILLMAINTAINYlO.RI�RS'COMPENSA NINSURANCE,ASREQUIREDBYSEC710N � Q 37000FTHElP80R DE FORTHEP , ORM EOFTHEWORKFORWHICHTHISPERMITIS �� ISSUED.MV�K�C EN "INSU CECARRIERANDPOLICYNUMBERARE: CONSTRUCTION Q � CARRIER PLAN REVIEW Z POUCVNUMBER � ELECTRIC 4 � (i}iISSECTANNEmNOTBECQNPLkTE�OFhIEPEWv1fI'ISi-0RONEHUhDREDDd1AFl5(§10o)ORIESS). PLUM8ING Z ICERTIFYTF;ATINTHEPERFORMANCEOFTHEWOPKFOPWHICHTHISPERMITISISSUED,1 MECHANICAI � ����- " �� �-� � �J SHALLNOiEMPLOYANY?ERSONIN�INVMANNEflSOASTOBECOMESUBJECTTOTHE � � � � ' .., . � WORKERS'COMPENSATION LAWS OF CALIFORNIA,AYDAGREE 7HAT IF I SHOULO BECOME 9NSPEC7fO1J FEE � � ��� SUB.'ECTTOTHEWORKERS'COMPENSAiIONPROVI510N50F5ECT�0 3]O�OFTHEL49aR � RV � CO� SHALL RTHWITHCOMPLV WITHTHOSEPRO�IONS. � ISSUANCE � B fR�a�F d F °)(Y(�FD ' �_= O ,y� 4, i �.�— _,__� p �ATE:/ � � APPLICANT: SMIP . w � - ENERGY P!C ' J WARNI :FAILURETOSECURENlORKERS'COMPENSATION VEPAG Fl/L,ANOSHALLBE J. �' ''.^,'„ � � SUBJECTAN EMPLOYER70 CRIMINAL PENALTIES AN�CIVIL FINES UP TO ONE HUN�PED THOUSAND ENERGY PERMIT ' . OOLLARS(S i�4W�.IN AD�ITION TO iHe GOST OF COMPENSA710N.�AMAGES AS PFOVIOED FOfl IN /� J SECTION3�oBOFTHELABOflCODE,INTERE57ANDATTORNEY'SFEES RETENTIONFEE: • °� �' d CONS7RUCTION LENDING AGENCY PRE-ALT FEE: O � IHEftE6YAFFIPMUNPEFPENALTVOFPEHJl1qYTHATTHEflEISACONSTflUCTIONLENDINGAGENCY WR 7HE PERFORMANCE OF THE WOFK FOR WHICH THIS PERMI715ISSUED(SEG.3D97,CIV C.). Z W —' � LENDER'S NAME i'_ 4ENDER'SADDRESS /t� � ICERTIFYTHATIHAVEREAOTHISAPPLICATIDNANDSTAiETHATTHEABOVEINFORMAiIONISCOFRECT. TOTAL FEES w �LO�d�a � 1 AGflEE TO COMPLY WITH ALL dTY MI�C 'NTY O INANCES ANO STATE LAWS RELATING TO 9UILDING � CONSiRUCTION,ANDHEREBVAUTHOfl2E EPRES TATIVE�FTN�SCWM1TYTOENTERUPONTHE ZABOVE-M ONED PFOPERTVPoR INSPE TION RPOSES. 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