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HomeMy WebLinkAbout12200 (13) CITY OF DIAMOND BAIi � ^--�- DEPARTMENT OF COMMUNITY&DEVELO S R _ � , 21660 E.Copley Drive Suite 190 (909)860-3195 Fax(909)861-3117 PRESS � ' 9N°�' BUII.DING PERMTl'APPLICATION FIRMLY �� JOBSITE ��/ �..,�/ �f�%�� APPLICATI N PERMIT �j��'y� P!C a ADDRESS I `y` �`�V L DATE NUMBER �`'"� # � APN LOT TRACT D TEE '¢�" CONST. GROUP p OWNER ��� i➢/tl"�i3��k'�` ADDRESS-�� ZONING SETBACKS �W CITY �t�i,vlf?A.1) f�1-/'�IP M1 .TEL � �f REAflT RW O ' APPLICANT�s TEL._ SIDE/SIDE STREET W ❑ � CONTRACTOR l;y, SIDE ❑ � ADDRESS �� � � PROPOSED USE ft�+T /� r� tt a CITY �-�-f,.7/�G,A�� ZIP�-TEL.�G'�b� 3"x��`7 � N b i tr 3 �t��Fl oARCFUENG/ � DESIGNER NO.DWEL. NO. NO. a ADDRESS UN17S STORIES BEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION . � OWNER-BUILDER DECLARATION .-.-���;`- $FR/A�D/HEM � O ;p I HEREBY AFFlRM UNOER PENALTY OF PERJURY THAT i AM IXEMPT FROM THE CONTRACTORS Li- (�a�qgg/CBfpOft W� CENSEIAWfORTHEFOLLOWINGPEA50N15EC.703i.56U51NE55ANOPROFE3SIONSCODE:ANYCITYOR (n _ . U COUMVNMICHREQUIpESAPERMITTOCONSTRUCT,ALTER,IMPROVE,DEMOIISH,ORRERAIRANYSTRUC- -W P3ti0/DeCk - -z -TURE.PRpR TO ITS ISSUANCE,ALSO REq11RE5 THE APPLICANT FOR 5UCH PERMI7 TO PILE A SIGNED W STATEMENT 7HAT HE OR SNE IS UCENSE�PURSUANT TO THE PROVISIONS OF THE CDNTPACTORS LI- �W � � CENSE LAW[piAPTERB(COMMENC�NO WITH SECTION 7000)OF OIVISION 30F7HE BUSINESSAND PH0- � PooUSpa � FESSIDNSCOD�OAiHATHEORSHEISEXEMPT7HEREFflOMANDTHEBASISFORhIEALLEGEDEXEMP- . (� TION.IIM'YIOLATIONOFSECTION7031.38YANYAPPLICANTWflAPERMR5U8JECTSTMEAPPLICANTTO Z Re-Roof , �� A CML PENALtt OF NO7 MORE THAN FNE HUNORED DOLURS(i5ao�.g � � ❑I,ASOYMENOF7HEPROPERTY,ORMYEMPIOVEESWITHWAGESA57HE1RSOLECOMPENSATION. � COR1rt16fC18I " WILL DO TNE WOAK,AND THE e7RUCTURE IS NOT IMEN�EO OR OFFEAED FOR SALE(SEC.70N,BUSI- J NESSAND PROfESSIONS CODE:TrIE CONTRnCTOAS LICENSE tAW DOES NOTAPPLY TO AN OWNER OF � . � PflOPpfliYVA10BUND30RIMPROYESTHEAEON,ANDWHODOE93lICHWORKHIMSELFORHEflSELFOR � OC THHOV6HHI50RHEROWNEMPLOYEES,VROVIDEDTHATSUCHIMVROVEMENTSARENOiINTENDEDOR m � � ,OFFEflmFORSALEIFHOWEVEF�iHEBUILDMGORIMPROVEMBdiI550LDWITHINONEYEAHOFCOMPLE- TION,THE OWNEH-BU14DEfl WILL HAVE THE 6UflDEN OF DROVINfi THAT HE Oq SHE�ID NOT BUILD OR �. IMPIqVE FORTHE PUflPOSE OF SAIE� - ❑1,AS OWNER OF THE PROVEHTV.NA E%ClUSNEIY CONTiUCTIN6 WIfH LICENSEP CONTfiACTORS W CF1IS�EUWDOESNOTMPLVTOANOWNEROFIAPRO�HTYWHOBU�SO�IMPROVE�STH AEON,AND Valuation ADJ.AREA � WFIOCONTRACTSPoRStlCMPROdECTSWITHACONTRAC70FitS)LICENSEDPUflSUPNTiOTMECONTRqG QUANTITY �ESCRIPTION FEE � TORSIICENSEIAWJ. . � . . � 0 O t AM IXEMPT UNDER SEC. B.8 P.4 fOR THIS REASON U � Q LL' DATE OYMEP F' 2 iy o UCENSED CONTRACTORS DECLARATION i j - � IHEREBYAFFIRMUNDERPENALTYOFPERJUflVTHATIAMLICEN5E0UNDERPFlOVI510NSOFCHAPTEfl� . -� . . p_ O�COMMENCINOWITHSECTION7000)OFDIVISION30FTHEBUSINESSANDPROFESSIONSCA�E,AND � Z X MYIICENSE�SINfULLFORCEAN�EffECT. � UCENSE CLASS�9�`l7 !:3 UC.N0.� � �'� j. F— „� V pq7E CONTRACTOR � a� W � WORKEFS'COMPENSATION DECLARATION � � �r l, � !p�� _ � IHEH BYAFFIRMUN�ERPENALTYOFPERJURYONEOFTHEFOLIOWINGDECIARATIONS: � 2 � �IHAYEANDWI4LMAMTAINACERTIFICRTEOFCANSEMTOSELF-INSIIHEFORWORKERS' _ �� COMPENSATKKd,ASPflOVI0ED8Y5ECTION370oOfTMEL4BORCOOE,FORTHEPERFOflMANCE �U OF THE WORK FOR WHICH THIS PERMITIS ISSUED. � � � W _IiiAVEANDWILLMAINTAINWOflKERS'COMPENSATIONINSURANGE,ASRE4UIREOBYSEGTION Q37000FTI1ELABOflCOpE.FOR'fNEPERfORMANCEOFTHEWORKPoRWHICHTHISPERM1T15 J ISSUED.MY WORKERS'COMPENSATION INSURANCE CAPRIERANO POLICY NUMBER ARE� CONSTRUCTION � cnAaiea PLAN REVIEW __-- -- Z Pa1CYNUMBER ELECTRIC __ 4 0 (fF�;SECIqNNEIDNOTBEO�MPLEfEDOF'fNEPEPMfI'�SWAONEHIFARmDa1pR51Sf0o)OALESS) PLUMBING - W � ANIC - ��t� Z 1 CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I (� SHALLNOTEMPI.OYANYPERSONINPNYMANNERSOA5708ECOMESU&IECTTOTHE y WORKERS'COMPENSATION{AWSOFCALIFORNIAhNDAGREETHATIFISHOULOBECOME INSPECTIONFEE � -SU&IECTTOTNEWdRKERS'COMPENSATIONDRONSIONSOFS CTION37000FTHElA80R ,ry COOE,I SHALL FOfl WITH COMPLY WITM T E PROVISION SUA S� G/� � - p ppTE: � APPLICANT: � __ � �a- WJ ENERGY P/C J WARNMG FAIUIRE TO SECURE WORKEflS'COMPENSATION CAVERAGE IS UNLAWFUL,AND SHALLBE � � SUBlECTANEMPLOYERTOCRIMINAIPENALTIESANDCIYILFlNESUPTOONEHUNDREDTHOUSANU ENERGYPERM�T OOLLARS(E10a.aoo).IN ADDITION TO THE COST OF CAMPENSATION,DAMAGES AS PROVIDED FOR IN � S SECTION37080FTHEl..460RCODE,INTEREST,ANDATTORNEY'SFEES. FIETENTIONFEE: li�'� I , OCONSTRUCTION LENDING AGENCY pRE-ALT FEE: . _ � IHEREBYAFFlRMUNOERPENALTYOFPEfL1UflYTHATTHEflEISACANSTRUCTIONLEND�NGAGENCY -� FOR THE PERFORMANCE OFTHE WORK FOR WHICH THIS PEHMIT IS ISSUED(SEC.3097,CIV.C). Z —_ W �� LENDER'9NAME _ : F— LEN�ER'SA�ORESS___ � WICEHTIFVTHATIHAVEREADTHISAPPLICATIONAN�STATETHATTHEABOVEINLORMATIONISCORRECT. TOTAL FEES . � IAGREETOCAMPLYWITHAILCITYANDCOUNTYORDINANCESANDSTATELAWSREIATINGTOBU1L01NCa �� � -� CONS7RUCTION,ANDHEREBYAUTHOH�2EREPRESENTATNESOFTHISCDUN7VTOENTERUOONTHE . Z l30VE-MENTIONEDPROPERTYf-0RINSPECTIONPUHP0.5E5. COMMENTS ._ ` O ��s� � m {YAfTTEE N E(PRIN'n � (q f !V / i i _�t� . . .� f � SH3NATU PERMI7TEE �ATE . = FECPT.NO. PAID BY -� VALIDATION ~ � WHITE—Department Copy,VELLOW—Finance Copy,PtNK—Assessor Copy,GOLDENROD--FIIe Copy,GREEN—AppllcanYs Copy � � - � ...,.�i'....��.i_.�...,._���_' i�_._r__,...r_ � ' �.� _j�;� �. 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