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HomeMy WebLinkAbout15887 (22) CITY OF DIAMOND BAA \ � J DEPARTMENT OF COMMITNITY&DEVELOPMENT SERVICES �''�•"--••� 21660 E.Copley Drive Suite 190 (909)860-3195 Fax(909)861-3117 PRESS '�'�A�^� BUILDING PERMIT APPLICATION FIRMLY _ .. . , „ . _ ,... . �� JOBSITE '^ � APPLICATION � � - l 3!�UMB R `5��� #IC `.J'r��I� ADDRESS' e ` DATE c� ISSUE TYPE OCC APN LOT TRACT DATE CONST. GROUP p OWNER p ADDRESS Gf C �v� 'f ,$' � ZONING SETBACKS � CITY�j-�,cqyl" ��t" Z s� +�"� TEL. rlS� —� FRONT RW ❑ APPLICANT TEL. REAR ❑ SIDE/SIDE S7REET RW ❑ � CONTRACTOR SIDE ❑ ¢ ADDRESS `��� �� PROPOSED USE ��L'�. c 4�- �L�L(i� "'� LI'LCIG1 i V�.- o CITY 1 c�YLIPrI� TEL. �, �^��` �` wo ARCFUENG/ � DESIGNER — N0.DWEL. NO. NO. ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. y DESCRIPTION SQ.FT. FACTpR PSF ADJ.AREANALUATION cn Q OWNER-BUILDER DECIARATION SFWADD/REM O I HEREBY AFRRM UNDER PENALTY OF PEFiNRV THA7 I AM ExEMPT FROM THE CONTRAC70RS L4 G8fflg0/Cd(POfI S CENSELAWFOR7HEFOLLOWINGREASON(SEC.7031.5BUSMESSAN�PROFESSIONSCODE:ANVCITYOR (n � COUNT`/WHICHREWIRE&APERMITTOCONSTRUCLAL7EH.IMPROVE,DEMOLISH.ORRE7AIRANY57AUC- `W Pati0/DBdc IURE.PHIOR TO ITS ISSUANCE,ALSD REOUIRES 7HE APPUCANT FOR SUCH PEFMIT TO F�LE A SIGNED S7ATEMENT THAT HE OR SHE IS IICENSED PURSUANT TO THE PROVISIONS OF THE CANTRAC70RS U- � CENSELAW(CNAPTER9(COMMENCIN�WITHSEC71ON7000)OF�IVISION30FTHEBUSINESSANDPRD- U' PODI/SPd FESSIONSCODE�ORTHATNEORSHEISIXEMPT7HEREFROMAN�THE6ASISFORTHEALIEpE�EXEMP- (� 710N.ANVVIOI.ATIONOFSECTION7031.59YM1YAPPlICANTF�FIAPERMITSUBJECTSTNEAPPLICANTTO z Re-Roof � ACIVI�PENALTY OF NOT MORE THAN FIVE HUNDREO DOLLARS(f5o0).): � ❑I,ASOWNEROFTHEPROPERTY,ORMYEMPLOVEESWIhiWAGESASTHEIR50LECOMPENSATION, 0 Commercial WILL D�THE WORK,ANp THE STRUCTURE IS NOT IN7ENDED OR OFFERED FON SA�E(5EC.7od4,BUSI- J NESS AN�DfpFE5510NS CODE:THE CANTMC7ai5 UCENSE LAW�OES NOTAPPIY TO AN OWNER OF � PROPERTYWFqBUILDSORMPROVESTHEPEON,ANDWHO00ESSUCHWOFKHiMSELFORHER6ELFOR � � THROU�HHISORHEROWNEMPLOYEES,PROYIDE�THAT5UCMIMPROVEMENTSARENOTINTEN�EOOfl m Q ,OFFEpEDFOH5KEIF,NOWEYEFLTiEBUiLdNGOli1MPROYEMENTISSOtDWITHINONEVEAROFCOMVLE- Z TION,THE OWNER-Bl11lDER WILL HAVE THE BUR�EN OF PROVING TMAi HE OR SHE DID NOT BUILD OR = IMPROYE FOq THE PURPOSE OF bALE�. O 1,AS OWNEfl OF 7NE PROPERTV,AM E%CLUSIVELY CANTRACTINfi WITH LICENSED CONTRAGTORS � TO CONSTRUCT THE PROJEC7�SEC,7aM,BUSWESS AND PROFESSIONS CApE:THE CONTiiACTORS�I- V81118�ion ` ADJ.AREA CENSE U1W OOES NOTAPPLY TO AN OYMER OF A PflOFERTY WNO BUILDS Oft IMPROVES THEREON,ANO WI�IOCONTRACTSFORSUCNPROJECTSWYfHACONTRACTOF(S�UCENSEDPURSUANTTOTHECONTRAG pUANTITY DESCRIPTI N FEE � TOqS�ICENSE i.AW.). ❑I AM EXEMPT UNDER SEC. 8.8 P.C.FOR THIS REASON Q 3 � L u' OATE _OWNER U Z W Q UCENSED CONTRACTORS PECLhRATION -� � W I HEREBYAPFIRM Uf1DER PENALT'OF PEFUUilY TMAT 1 AM LIGENSED UN�ER PROVI310N5 OF CHAPTEq � � 9{COMMENCINOWITHSECTION7000)OFDIVISION30F7HE8USINESSANDPROFESSIONSCODE,AND Z MY LICENSE IS M FU L F E AND EFFECT. �- m � LICEN3E CLASS��� LIC.NO. � � � j V DATE ��'���} CONTRACTOR �+� - a W � WORKERS'COMPENSATION DECLARATIDN Q � I HEREBYAFFIqM UNDER PENALiY OF PF.RJURYONEOFTNE FOLLOWING DECLARA71oN5: � � Z Q � IH1�ANDWILLMAIN7AINACERTIFICATEOFCONSENTTOSE4F-INSUREFORWORKERS' 2 � �JMPENSATION,AS PROYIDED 8Y SECTION 370o Of THE UROR CODE,FOR THE PERFORMANCE �U /OF TFIE WORN FOR WNICN 7HiS PERMIT IS ISSUED. � W i�IHAYEANOWILL.MAIMMNWORKERS'COMPENSATIONINSUflANCE,ASPE9UIREPBYSECTION Q 37000FT1iELA80RCO0E,F RTHEPE RMFNCEOFTHEWORKFOqWHICHTHiSFERM1T15 0 ISSUEO.MY RS' NS0.TION UHANCECARRIERANDPoUCYNUMBERAFiE: CONSTRUCTION ? CARRIER � � PLAN REVIEW �0 � 2 PouCYNUMeER_� C�r���� ELECTRIC � I�> >..�0 Q o fnussEc.navr�r�rvoTeEa.�n�t�fmoFn+E�r�rrsr�aveHuraaeJ�inr�sR�wloa�ess} PLUMBING w I CERTIFY 7NAT IN THE PERFORMANCE OF 7HE WORK FOR WNICH 7HIS PERMIT IS ISSUE0.1 MECHAN�CAL Z � SHALL NOT EM?LOY ANV PERSON IN ANY MANNER SO AS TO BECOME SUBJECTTOTHE �y WOPKERS COlAOENSATION LAWS OF CAI.IFORMA,AND AGREE THl1T IF I SF10l11O BECOME INSPECTION FEE � SUBJEGT TO THE WORKERS'COMPENSATION PqOV5104 SECTION 470o OF THE LABOR � v = CODE,I SHALLFORTHWITHCOMPLV WITHTHOSE PROVI NS. �SSUANCE o � � �p� `�'�"�'� ...✓ SMIP �r���,���n���_��— p DATE:/�.,.�i_�_w""��-1_ APPLICANT:'-�J/u.': .� y W � � ENERGY PIC -�`J�.n�����h�A � �ncr J WAflNINGFAILURETOSECUREWORICEHS'COMPENSATIONCOVERAGEISUNUWFVL,ANDSHALLBE � SUBJECTANEMPLOYERTOCRIMPJALPENALTIESFJVOCIVILFINESUPTOONEHUNDRE�THOUSAND ENEFGYPERMIT DOLLARS(5100.000).IN R�DITON TO THE COSTOf COMPENSA'f�ON,DAMAGES AS PflOYIDEO FOR IN y'"�g ¢ SECTION 3'7080F THE IABOR CO�E,INTEREST.AN�ATfORNEV'S FEES. 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