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HomeMy WebLinkAbout12965 (11) ,, y` �.� ,�.._.�� � CITY OF DIAMOND BAI� ^--��— DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES = ��'� �-'�r W , 21660 E.Capley Drive Suite 190 (909)860-3195 Fax(909)861-3117 PRESS � ���'A�'� � BUII.DING PERMIT APPLICATION FIRMLY o� JOBSITE 1 APPLICATION �3/� PERMIT P/C ADDRESS ��020 �L�RODI� �� DATE. '��I �'"!-1 NUMBER����� # � ISSUE TYPE OCC APN LOT TRACT DATE CONST. GROUP p OWNER �� o ADDRESS �Z9Dk- ZONING SETBACKS W CITY�.[�,y�pi�,) �cw ZIP TEL. � -Lq FRONT RW ❑ APPUCANT /��r/T�_ REAR ❑ � S�.J TEL. Sf �l LLh7� SIDE/SIQE STREET RW ❑ � CONTRACTOR � SIDE ❑ ADDRESS .�I � � CITY ZIP TEL. PROPOSED USE L Grv '' o ARC ENG/ gb� � - � '` DESIGNER NO.DWEL. NO. • o�., ADDRESS . >. � � CITY ZIP TEL. - UNITS - 570RI�S BEDROOMS - tn_ v� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION Q _ OWNER-BUIL�ER DECLARATION � SFRlADD/REM - O p I HEPEBY AFFIRM UNDER PENALN OF PERltIRV THAT 1 AM EXEMPT FpOM THE COMHACTORS L4 ;� Gafa98/Cafport � - W CHiSELAWFORTHEFOLLOWINGPEA50iJ�5EC.7031.68U51NE5SANDPROPESSpNSCODE:ANYCITYOR U. 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PpOPERTYWH08UILD30R�MPROVE8THEpEON,ANDWFiODOESSIICHWORKHIMSELFORHERSELFOR � THRIXIGHHISORHEROWNEMGLOYEES,PROVIDEOTHATSUCHIMPROVEM[NTSARENOTiNTENDEDOR' m " � �� Q OFFEREDPoRSALEIF,MOWEVER,THEBUILDINOORIMPROVEMFNTISSOLDWfi}i1NONEVEAHOFCOMPIE- � -Y�- Z �TION,THE OWNEfLBWLDER WILL HAVE THE BUFDEN OP PROVING THAT HE OR SHE DID NOT BUILD OR - , � IMPHOVE FOR TNE PUPPOSE Of SN.E). - - ❑1,AS ONTJEHOFTHE PROPERTY,AM EXCLUSIVELY CONTfiAC71NG WITH LICENSED CONTRFCTONS� , �� TO CONSTRUCT 7HE PHOJECT(SEC.7044,BUSWESS AND PROfE3SIONS COOEc THE COMRACTORS LI� V81118ti0n � ADJ.AREA � W CENSELAWDOESNOTAPPLYTOANOWNEROFAPROPERTYWHOBUILDSOFIMPROVE57HEflEON.AND - - � -NTiOCONTRACT5fOR5UqiPHOJECiSWITHACONTRACTOR(5}LICENSEDPURSUAN7TOTHECONTflAG QUANTITY DESCRIPTION ' �E Y TORSUCENSELAWJ. . � ��AM EXEMPT�NDER B�C. B.8 P.4 FORTHIS RERSON Q � - 3 0 LL � DATE 01NNER _ V Z W � LICENSED CONTRACTORS DECLARATION W , IHEREBYAFFIRMUN�ERPENALTYOFPERIURYhiATiAMLICENSEDUNDERPROVI510NSOFCHAPTER � � � , d :9(COMMENCIN(3WITHSECTION�OOD)OFDN�SION30FhiEBUSWESSANDPROFESSIONSCADE,AND Z ' - X :MY UCENSE IS IN FULL FOFCE AND EFFEGT. ' ��'Jy�� m ' Lll (�+� � LICENSE CtA55 "C �G LIQ NO. � �J J�-� � j - V DATE�,�",�_ CONTRACTOR `�d�,� n. . W a� WORKERS'COMPENSATION DECLARATION Q Ni HEPEBYAFFIRM UN6ER PENALTY OF PERJURY ONEOFTHE FOLLOWMG DECLARATIONS: Z ' � �IHAVEANDWILIMAINTAINAGERTIFlCATEOFCONSENTiOSELF-INSUREFORWOflKEPS' y COMPEN5A710N,ASPROVIDEDBYSECTION37000FTHELABORCADE,FORTHEPEflFORMANCE ' W OFTHE WORH FOR WHICH THIS PF.flMiT IS ISSUEO. � 0 W _IHAVEANDWILLMAIMAINWORKERS'COMPENSATIONINSURANCE,ASPEWIRE�BVSECTION - Q ' 37000FTME LABOR CO�E,FOR 7HE PERWRMMlCE OF THE WORK FOR WHICH TMIS PERMIT IS � �/ �/'1 ISSUED.MY WOfiKERS'COMPENSATION INSURANCE CARHIER AN�PDLICV NUMBER ARE: CONSTRUCTION LJ j cnaaiea - L �ts� PLAN REVIEW - � POLICYNUMBER .�I_� 'L ELECTRIC � � (IN4SS[CIIUJNE�NOTBE�tEfEDOF'f1�PEPARTISFORONEF0.A9RED00LL1RS(5100)ORLESSa PLUMBING Z. I CERTIFYTHAT IN THE PEflFORMANCEOF THE WORR FOR WHICH THIS PEPMIT IS ISSUED,I MECHANICA� (!f SHPLLNOTEMPLOYANYPERSONINANVMANNERSOASTOBECAMESU&IECTTOTHE � WORNERS'COMPENSATION LAWS OF CALIFORNIA,ANO AGREE THAT IF i SHOULO BECOME �NSPECTION FEE - � SUBJECTTOTHEWORKERS'COMPENSATIONPROVISIONSOFSECTION37aoOFTHELABOR ' - � CADE,1 SHALL fOFTHWITH COMPLV WITH THOSE PROVISIONS ISSUANCE o ?�.►--�- ��/ p DATE: � � APPLICANL SMIP W ENERGY P!C r� �. WAFNING:PAILURETOSECUflEWORKER3'COMPENSATIONCOVEPAGEISUNIAWFUL,ANUSHalL6E � SU&IECTANEMPLOVERTOCRRAINALPENALTIESPNDCIVILFMFSUPTOONEHUN�REDTHOUSANO ENERGYPERMIT � DOLIARS($t00,0a0),INADDITIINJTOTHECOSTOFCAMPENSATION,DAMAGESASPROVIDEDFORIN �_ SECTION37080FTHELABORCO�E.IN7ERES7,ANDATTORNEY'SFEES. RETENTIONFEE: � d CDNSTRUCTION LENDING AGENCY PRE•ALT FEE: 47�, O � � I HEREBYAPfIRM UN�EFi PENALTY DF PEFJURY THAT THERE IS ACONSTRUCTION IENDING AGENCY - FOR THE PERWRMAtJCE OFTHE WOFK FOR WHICH THIS PERMIT IS ISSUED�SEC.3aW,CIV.C.�. . . _ Z W � IENDER'SNAME s i h—- LENDER'SADDRESS , � ICERTIfVTHATIHAVEREADTHISAPPLICATIONANDSTATETNATTHEABOVEINFORMATIONISCORRECT. TO�AL FEES - ' w- IAQREETOCAMPLVWITHALICIT'ANDCOUNTYOPDINANCESANDS7ATELAWSRELATINQTOBUILDINO � ' � CONSTRUCTION,ANDHEFEBYAUTHORIZEFEPAESENTATIVESOFTHISCOUNNTOEMERUPONTHE ' - ' Z FBOVE-MENTIONEO PflOPERN FOfl INSPECTION WRGOSES. ' -' . _ Q � �� � COMMENTS S �.{� m PERMITTEENA nin�/ cQ�n .—�� � /I� �J r 1/�� _, � ai�rc��nEOFPE I DATE - , = FECPT.NO. PAID BY VALIDAl10 � ~ - WHITE—Department Copy,VELLOW—Finance Copy,PINK—Assessor Copy,GOLDENROD--File Copy,GREEN—ApplicaM's Gopy � ! ' i ! 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