HomeMy WebLinkAbout15164 CITY OF DIAMOND BAIt "
�1� DEPART?�IENT OF COMMUNITY&DEVELOPMENT SERVICE5
,� - F.�
w 21660 E.Copley Drive Suite 190
. ;,, (909)8fi0-3195 Fax(909)851-3117 PRESS
�•��' BiJILDING PERMIT,APPI.ICATIC�N „ , .__,_ FIRMLY
� JOBSITE y�� f � ' ; APPUCATION , PERMIT C P/C
o ADDRESS �O��� G G"K-� •S 1 �� DATE �� � NUMBER �' #
� ISSUE ,r/�� TYPE OCC
APN LO7 TRACT DATE �r CONST. GROUP
¢ OWNER r- ' 1 l d
O '
ADDRESS .�--- 2- A�.� .�Y�r� Z% ZUNING SETBACKS
z CITY ��� ZI�P -j-� � TEL.�-��,�-�n FRONT RW Q
g APPLICANT G t TE REAR p
SIDFJSIDE STREET RW ❑
� CONTRACTOR �t,,� SIDE ❑
ADDRESS PROPOSED USE � L/� �
� CITY �/I� ZIP TEL. �y�-
o ARCH/ENG/ —
z� DESIGNER N�.DWEL. NO. NO.
a ADDR�55 UNITS STORIES BEDROOMS
� CITY ZIP TEL. -
� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION
v>
Q OWNER-BUILDER DECLARATION SFR/ADD/REM
O
Q 1 HEREBY AFFlqM UNDER PENALTY OF PEflJURV THAT I AM E%EMPT FROM 7HE CAMTRACTORS LI- � Garage/Carport
W CENSEUWFOi1THEF'OLLOWINGREASON(SFC.7o31.58USINESSANDPROFES510N5CODE:ANYCITYOR
� COUNTYWHICHREWIRESAPERMITTOCON3TRUC7,ALTER,IMPROVE,DEMOLISH,OHREPAIRANYSTRUP W Patio/Dedc
7URE,PRIOR TO ITS ISS4ANCE,ALS�RE�UIRES THE APPLICANT FOR SUCH PEPMIT TO FILE A SIGNED W
� STATEMENT h1AT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE COMRACIORS LI-
� CENSE UW f�PTER 9(COMMENCINO WITH SECTION 70oD)OF DIY�SpN 30F 7HE BUSINESS AN�PRO- � POOVSPB
FESSIONS CODE)OR TFUT HE OR SHE IS EXEMPT THEREFqOM AND hIE BA515 FOR THEALLEDED EXEMP-
TqN,MryV101.ATIONOFSECTION7031.56YANYAPPLICANTFOPAPERMIT&U&IECTSTHEAPPLICANTTO Z qe-Root
� A GYIL PENALTY OF NDT AAORE THAN FNE HUNDREO�OLUAS(SSao).):
� ❑I,l4SOWNEROFTHEPROPERTV,ORMVEMPLOYEESWI7HWAGESASTFIEIRSOLECOMPENSATION, � CORITBlCIBI �
MfILL DO THE WORK,FND 7HE STRUCTURE IS NO7INTENDEU OR OFFEFlED FOR SALE(SEC.704�,BUSI- J
� NESS AND PROFE590NS CODE:THE CONTRACiOqS LICENSE LNW DOES NOTAPPLV TO RN 9WNER OF �
PROPERNWHOBU0.ASORIMPROVESiHEREON,ANqWHODOESSUCHWORKHIMSELFORHERSELFOR ,
� TMRIX1f3HHISORHENOWNEMPIOYEES,PHOVIOEDTHATSUCHIMPROVEMENTSARENOTINTENDED'Oq m
� OFFEREOFORSALE.IF,HOWEVERIHEBUILDMGORIMPROVEMENTISSOLDWffHINONEYEAROFGOMPLE•
Z TION,THE OMMER-BUItDER WILL HAVE 7HE BURDEN OF PROVINQ THI1T HE OR SHE DID NOT BUILD OR
= IMPf�YE FOR THE PURPOSE OF bAL�.
W OI,AS�WNEROF7HEPROPERTV./WEXCWSNELVCONTRACTINGWITFILICENSEDCONTRIICTORS
� TO CONSTRUC7 THE PROJECT(SEC.7oat,BUSINESS AND PROFESSIONS CO�E:THE CONTRACTORS ll- V31U31io0 � ' ADJ.AREA
CENSE UW DOES N07MPLYTOAN OWNERaFA PROPERTY WHO BUIL�S OR IMPHOVES THEREON,AND
� NM1bCpNYRACiSFORSUCHPROJECTSWITHACONTRACTOR(S�LICENSEDPIIRSUAN7TOTHECONTFAC. QUANTI DESCRIPTION FEE
� TORS LIGENSE UW.).
Q ❑1 AM EXEMPT UNDER S�C. B.8 P.C.FOR THIS REASON �
� �
� OATE 01YNER V
� LICENSED CONTRACTORS DECLARATION W
J
� W
I NEHEBYAFFlRY UNOER PENALT'OF DEFWIIRY THAT I AM LICENSED UNOER PROVISIONS OF CHAP7EH �
4 i(OCIMMENCINO YYITH SECTKKJ 7a00�OF DIVISION 30F THE BUSINESS AND PROFESSIONS CADE,AND Z
X MY UCENSE IS IN FULI f-0HCE AND EFFECL '7 m
0 LICENSE S ` �� LIC.NO. (�� 7� � j
� J
WDATE � Z� CONTRACTOR_a���.�/.I`"� �-
� WORKERS'COMPENSATION DECLARATION ¢
� U
� 1 HEREBV AFFIRM UNOER PENALTV OF PERIURY ONE OFTHE FOLLOWING OECLARATIONS: ,
C!) Z
Q
0 _IHAVEANDWIILMAINTAINACERTIF�CNTEOFCONSENYTbSELF.�NSUREKONWORKERS•- 2
� COMPENSA710N,ASPNOVI�EDBYSECTION370oOFiHELABORCOOE,FbWiF1�`�PE'RFORF+IANCE �U
Oi TME WORN FOR WHIGH THIS PEF,MIT IS ISSUED, �
0
_I HAVE/WD WILIMAIMAIN WORKEFlS'COMDENSATION INSURANCE,AS REWIflE�BV SEGTION /�,
O s700 DF THE 4ABOR COOE,FOR 111E PERFORMANCE OF THE WORK FOR WHiCN THIS PEflMIT IS . . ���/ 'r
ISSUED.MYWORKERS'COyIAyPENSA�7,to,y�.IN-S�U�RANCECA'�RRIERANDPOL7CYNUMBERARE�- CONSTRUCTION � �
jCARRIER Ir'� /'� � I�/< !�� � PLAN FEVIEW
� POLICYNUMBER P,+� D , 0 ELECTRIC
� (iHsSCciaMNE�Noi6EN6pLEIEDOFh�PERMfitSfORONEwWHED00tt.aRs(Stoo)oRLEss} PWMHING
W g
Z I CERTIFV THAT IN h1E PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSllEO,I MECHANICAI �Il�
C7� SHAILNOTEMPLOYANYPER50NINANYMANNERSaASTOBECOM[SU&IECTTOTHE
� WORKERS'COMPENSATIONLAWSOFCPLIFOPNIA,ANDAGFEE7HATIFISHOULOBECOME INSPECTIONFEE
S SUBJECTTOTNEWORKERS'COMPENSATIONPROVI5101JSOFSECTION37000FTHELABOR ISSUANCE �
CO E,I SHALLF RTW�lfIHCOMPLY WITHTHOSE PROVI510N5.
�.!/➢ ����1 r°
o �nre: � �V�APPLICANT. �� G��� SMIP __,,�.y�' �
J ENERGY P/C
WARNINO:FA0.UPE SECURE WORKERS'COMPENSATION fAVERA E IS UNLAWFUL,AND SHALL BE
�y SU&IECTPNEMPLOYER70CRIMINALPENALTIESANDCIVILFINESIJPTOONEHUNDflEU7HOU5RN0 ENERGYPERMIT
DOLLARS(5700,000),IN AOORION TO THE COST OF COMPENSATION,DAMAGES AS PROVI�EO FOR�N
� SECTION 37080FTHE LA60R CODE,INTEREST,ANO ATTOHNEY'S FEES. RETENTION FEE:
d CONSTRUCTION LENDING AGENCY PRE-ALT FEE:
� IHEREBV�AFFIFiMUNOEflPENALTYOFPERJURYTHATTHEREISACONSTRUCTIONLENDINGAGEMCY
FOR THE PERi'ORMANCE�FTHE WORK FOR WHICH THIS PEflM1T IS ISSUED{SEC.30W.qV.C.�.
Z
W
� LENDER'S NAME
1_ LEN�ER'S NDaRE55
� ICERTIFY'fHATIHAVEREADTHISAPPUCATIONANDSTATETiATTHEABOVEINFOPMATKKJ�SCORRECT. TOTAL FEES � �`�
W I AGREE TO CAMVLY WITH ALLCRY ANO CAUNTY OR�INANCES AND STATE lAWS REUTING TO BUILDING
� CONSTRUCTION,ANDHEHEBVAUTIiOR12EAEPflESENTATNE&OFTHISCOUNTVTOENTERUPoNTHE
� PBOVE�MEN�IONEDPROPERTVFORINSPECTIONPUHPOSES. COMMENTS
� �.�-�l r� C���
�
m PERMITTEE NAME�N�'''`+� ��� �I. � j� .
N (�i�<-'� � �
� S16NATUREOF ERI E —�I� DATE
= RECPT.N0. PAID BV VALIDATION
~ WHITE—Department Copy,YELLOW—Fnarx�s Copy,PINK—Asaessor Copy,GOLDENROD—File Copy,GREEN—Applicant's Copy