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HomeMy WebLinkAbout16330 r � '� ��,� � CITY OF DIAMOND BA� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES % w 216G0 E.Copley Drive Suite 190 � (909)860-3195 Fax(909)861-3117 PRESS �'"%9�''��' BUII.DING PERMIT APPL[CATION FIR � JOBSITE ��y ] �^ (� APPLICATION PERMIT d�i/d�, P/C � 0 ADDRESS ��V�� �t eih C}C � �� �/r DATE � � NUMBER ���� �� # c� ISSUE � TYPE OCC APN LOT TRACT DATE CONST. GROUP p OWNER 1d � ADD SS C[? ' ZONING SETBACKS w CITY� .�r ZIP � TE C ' FRONT qW IJ � APPLICANT TEL sjf�7�1i'i7zf� REAR ❑ SIDE/SIDE STREET RW ❑ � g ' SI�E ❑ CONTRAC70R Y1 f� c� ADDRESS rI =3= t lw c.'�� - o CITY C7CtYC�L'C7C➢ ZIP �'�7Z T L ��% J 1 a f PAOPOSED USE w. ARCWENG/ � DESIGNER ADDRESS NO.DWEL. NO. NO. �` C�TY ZIP TEL. UNITS__ STORlES BEDROOMS � cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUAT�ON - �__, OWNER-BUILDER DECLARATION . � SFR/ADDlREM ��QQ� I HEREBY AFFIRM UNDER PENPLTY OF PEHJURY THAi i AW EXEMPT FROM THE CONTPACTORS LI- � G8f0g0/C8fj70(1 .CENSELqWFOft7HEFOLIOWINGREA$ON(SEC.7o37.5BU51NES5ANOPROFES510N5CA�E:ANVCITYOR� {n . �:pOUNTYWHICHREWIPESAPEHMITTOCONSTRUC7,ALTER,0.IPROVE,DEMOLiSH,ORPEPA1fiANYSTRUC- �� W pyiiO/DBCk 'IURE,PPoOP TO ITS ISSUANCE,AlSO PE�t11RES THE APPLICANT FOR SUCH PFAMITTD FlLE A SIGNED 'STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTFiAC70RS LI- �- ?.CENSELAW{CHMTEfl9(COMMENCIN(IWITHSECTION7000JOFOIVISION3OFTHEBUSINES5ANOPRO- ' � PooUSpa �-� fES3fON500DE)ORTHATHEORSHEISEMEMPTTHEREFAOMANDTHE9ASISFOR7HEALLEG[DEXEMP- (� TION.ANVVIOLATIONOFSECTION7031.68YANYAPPLICANTFORAPEPMITSUBJECTSTHEAPPLICANTTO Z pe_q�} �. �ACIYILPENALTYOPN07MdRE711ANCNEHUNDREDDOLLARS(SSooJ.): � OI,ASOWNEROFTHEPROGERTV,ORMYEAIPLOYEESWITHWA6ESASTHEIRSOIEf,'OMPENSATION, � Commercial � - YIILL DO THE Y10AK,AND THE STflUCTURE IS NOT INTENOED OR OFFERED FOR 9ALE(SEG 7046,BU51- J - NE33 AND PROFESSIONS CODE:THE CANTFiAC70R5lICENSE UW DOEs NOT APPLv TO PN OWNER OF � PRDPER7YWtiOBUU.DSORIMPflOVE57MEREON,ANDWMODOESSUCHWOFKHIMSEtFORMERSELfDH � ��, 1Hi00UONHISORHEFlOXTIEAIPLOYEES,PROVIDEDTHATSUCHIMPROVEMENiSARENOTIN.TENDEDOR m Q.-,OFFEREpFORSALEiFHOWEVERIME8UILDINGOR6UPqOVEMENT155olAW1THINONEYEAROFCOMPLE- z, 'TqN.THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVMG tNAT HE OR SNE DID NOT BUIl6 OR �, IMYROVEFORTf1EPURPOSEOFSALEI. ❑I,AS OWNER OF THE PROPEKTY,AM EMCIUSIVEIY COMRACIIN�WITH UCENSED CONTHACTORS � TOCONSTRUCT THE PRQIECT(SEG.7044,OUSINESS ANO PflOFE5510N5 CODE:THE CONTRACTUR3 LI- VelU8ti0t1 ADJ.AREA � W. CENSEUWDOESNOYRPPlV70ANOWNEROFAPflOPERTYNJHOBU11D50RIMPROVE6THEflEON,AND - � WFfOCONTRACTSFORSUCHPR0.�ECT5WI7HACONTNACTOR(S�LICENSEDPlIflSUANTTDTHECONTflAG QUANTITY DESCRIPTION FEE . Y mns ucEnsE uw.�. d J o ❑I AM EXEMPT 11NDER S�C. B.&P.C.FOR THIS REASON Q � U � � DATE _OWNER V Q W �q LICENSED CONTRACTORS DECLARATION -� OC W �-IHEflEBYAF�IRMUNDERPENALTYOFPEFLURYTNATIAMLICENSEDUNDEflPflOVI510NSOFCHAPTER �i �-i-A SQ'} d �-�B(COMMENCItM3WITFISECTION)000)OF�IVISION30FTHE9USINESSANDPflOFESSIDNSCODE,AND Z I/y��� �+MV UCENSE IS IIJ FU ORCE ANO EFFECT. (� �j(,� C_� � 0 ,'LICENSE CIASS�o+�')r`�' UC.NO. ���4✓�� J .. ��j `,DATE ��� �"� ��,_(, CONTfiACTOR �- . W � � -. WORKERS'COMPENSATION DECLARA710N � � � � l a � ��.IHEpEBVAFFIR1.4lTlDERPENA:.TYOFPERIURYONE�FTHEFOLLOWING6ECLARA N5: U � z a L] _-�,iIHAVEANDWILLMAINTAINACEATIflCATEOFCON5ENT7'OSELFINSUREFORWORKERS' S - COMPENSdTKNJ,AS PPOVIDEO BV SECTION 37o00FTHE LA90Fi CO�E.FORTHE PEiiF-0RMANCE U Q OFTHE WORK FOR WH�GFITNIS PERMIT I5155UED. � 0 �i HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSUqANCE,AS PEOUIRE�AY SF.CTION Q � 37000FTHELABORCOOE.FOFiTNLPERWRMANCEOFTHEWORKFORWHICHTHISPERM1T15 , ISSUED.MYWOAK 5'COMPENSATIONT�_s UHANCECA RIERANDPOLICYNUMBERARE: CONSTRUCTION j : rar�RiER � � Y�►�I PLANREVIEW Z - Pa��cV MIMBER �a' ELECTRIC < t 0. - (ttass[cnnavrvE�n^o7ee�AArtETmoFn;EPEwr%r�wRaaEFaN�7m (S )oR�EssD PLUMBING '�""'--�--�-----.� W. :`.., . � - ICERTIFYTHA7INiHEFERFORMANCEOFTH[WORKFOflWHICHTHISPERM1715155'ED.i MECHANICAL ' "'� ���� -�-- ' ��..,. � � cJ SHALLNOTEMPLOYM'YPERSONINANVMANNERSOAS70�ECOMESUBJECTTOTHE - Uj WOAKERS'COMPENSAi'tONIAWSOFCALIFORNIA,AN�AGREETHATIFISHOUL�BECOME INSPECTIONF E � SUBlECTTOTMEWbRKERS'CAMPENSATIONPF041510NSOFSECTION37000FYHELAOOR CADE,I SHAII FORTHWITH CAMPI.Y WIT�;tTHO5E PPOVISIONS ISSUANCE ` � // f�- „ `q� .�iv�, ----------...__ .— � � �� df 'i , �� CV'f,�jjl V,�3 SMIP � DATE: �__�_ APPIICANT, ---- J ENERGY p/C R _. J WARNIN6:FAIIURE TO SECURE WORKERS'CAMPENSATIDN CUVEflAGE IS UNIAWFUL AND SHFIL BE +-��___ LL SU&IECTpNEMPLOYERTOCRIMINALPENALTIESANDCIVILFMESUPTOONEHUNDREDTHOUS�ND ENERGYPERMIT "�y""'""""'".""-"."---..,,_,„__,., � DOUARS(f1a0,00�),INADOITIQNTOTHECOSTOFCAMPENSATION.OAMAGESASPROVIDEDFORIN J SECTION 37oe Of hIE LABOFI LODE,MTEREST,ANDATfORNEY'S FEES. RETENTION FEE: Q W CONSTRUCTfON LENDING AGENCY PRE-ALT FEE: O � I HERFBY AFFIRM UNDER PENAIN OF PERJURY THAT THERE IS ACONSTRUCTION LENDING AGENCY n- FOR TNE PEFWRMANCE OF THE WOflK FOR WHIGH TMIS PEflMIT I5155UED(5EC.3a<lf,CIV.C.). � Z W � LENDER'SNAME . - F- LENOER'SMDRESS _ � ICERTIFYTHATIHAVEREADTHISAPPLICATIONANDSTATETMpTIHEABOVEINFORMATIONISCAflRECT. �OTAL FEES . b � IAQREEIOCAMPIYWITHALICIT/ANDfAUNTYOqDiNANCESANDSTATELAWSRELATINGTOBUiLDING CONSTRUCTION.AND MEREBY AUfHORIZE REPRESFNTATNES OF THIS CW N(Y TO ENTER UPON THE ZMENTIONE�Pq07EflN FOR INSPECTIDN PURPOSES. COMARENTS - � � ��1�e6"�,� � � PERMITTEE RIPf�I '_'__- � � y SIONATUHEO MITTEE �ATE .. . = FECPT NO. PAID BY VALIDATION f'" WHITE—Department Copy,YELLOW--Finance Copy.PINK—Assessor Copy,QOLDENROD—ile Copy,GREEN—ApplicanPs Copy i � _ _,,.._ __�I ,� _F—`—�i__..�� .�.�.„�w v._ � � _ .v�_. _ . �� � � � � � .� � � � ( _� � ._ �—, � f � , � ,��i � ,� �� � � _ ' ( , � � � �', ��� z �� � f �- � ,�� � - � � � �- � � � �- a ; -1 � � , � �� , i� a � ' , r�� � i � � � ��:.a � � ; � . � �-; � � jri � i : 1 ( I° 3 I 3} � � t E i! � i_ 1 � i s ( � 9 . � �. I � �_ . i.� �� � Ii � r : i 3 l � ���� ; {' -:i ` ; ' � .�.�. i 3 � { i ; �. � ; i 1' � � � � � 3 � f � j , ( � �';� j ! F i : i� � i� j I_ , ' I � �_ � ; � � � � t � , ��� � ' I �� j- . ! ( � � � � ; � ; , t- � ��.� � ' � � I � �� �� � � �� � i � � .� � + E' � � � �a , '�' { � �i �� '� � .. 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