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HomeMy WebLinkAbout12318 (13) i' vV� _!� CITY OF DIAMOND BAI� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES ;. 21660 E.Copley Drive Suite 190 (909)860-3195 Fax(909)861-3117 PRESS �����' � BLTII.DING PERMIT APPLICATION FIRMLY '�`' JOBSITE [�� /r ,r� ^ APPUCATIO �`J PERMIT � P/C ¢ ADDRESS ��L7�I. C.�"'�{� �.-i_P'C�{� r �r li, p T DATE NUMBE # � ISSUE TYPE OCC APN LOT TRACT DATE CONST. GROUP °C OWNER O o ADDRESS 6 ZONING SETBACKS W CITY �I64MIy.1Q� ZIp��� TEL��,�-Ih, FRONT RW ❑ �' APPLICANT TEL. REAR ❑ SIDEISIDE STREET RW ❑_ �; CONTRACTOR �.� ��=7�n'V " SIDE ❑ o. ADDRESS ` � PROPOSED USE R�`�"IO��F' I�J�14� �Y(,�-L' �� �;t� L�� o CITY H� /e ZIP � TEL. �.- � . � w� ARCH/ENG/ —r— z DESIGNER u� NO.DWEL. NO. . � ADDRESS , �" CfTY ZIP TEL: UNITS STORIES '` �/ BEDROOMS �G:�� ���, � cn DESCRIPTION SQ.Ff: FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER DECLARATION SFR/ADD/REM O. I HEREBV AFRPoA UNDER PENAIiY OF PEfUURY THAT I AM EXEMPT FROM THE CONTRACTORS LI- GHfflga/CelPOd W CENSELAWWRTHEFOt1.OWINGRE4SON(SEC.7031.56U6MESSANDPROFESSIONSCOOE:ANVCINOR ((� U COUNiYWHiCHRE�U1pESAPpRMITTOCON5TRl1CT,AlTER,IMPROVE,OEMOLISH,OPFlEPA1flANYS7PUC- W pgti0/DBCk Z TURE,PRIOR TO ITS ISSUANCE,AL50 REUUIHES THE APPUCAN7 FOR SUCH PERMIT TO FILE A SIQNED � � W STATEMENT THqT HE OR SHE IS LICENSED PURSUONT TO THE PROVISIONS OF THE CONTRACTOHS LI- � W � CENSELAW(CHAPTERB(COMMENCW(iWITHSECTION7a0o)OFDIVISION30FTHEBUS�NESSANOPRO- V'� PooVSpB FESSIONSCODE)ORTNATHEORSHEISEXEMPTTHEREFROMANDTHEBASISFOHTHEALLEGEDEXEMV• (� T�ON.ANYYKKATKKJOF&ECTION7031.56VANYAPPLICANTFORAPEflMITSU&IECTSTNEAPPLICANT70 Z Re-Roof ACML PENAITY OF NOT MORE THAN FIVE HUNDRFD DOLLARS(S5oo).�: a �I,ASOWNEROFTHEPROPERTY,ORMYEMPLOYEESWITHWAGESASTHEIfiSOLECAMPENSATION,� � COfI7f118fCi21 � �� Z N7LL DO THE WORK,AN�THE S7RI1CTl1RF IS NOT INTENUED Op OFFEAED FOR SALE(SEC,�044,8�51- _I � NESSAND PqOFESSIONS CODE:h1E WN7RAC70R&UCENSE tAW DOES NOT APPLV 70 AN OWNER OF . � , PFiOPEflTY WFp BUIlD50R IMPROYESTHEflEON,AND WHO DOES SUCH WORK HIMSE�F OR HERSELF OR � 2� THROUQlIHISORHEROWNEMPLOYEES.VROVI�EDTHATSUCHIMPROVEMENTSARENOTINTENDEOOR : m - Q ,OFFERWFORSALEIF,HOWEVER,7HEBUILOIN60RIMPROVEMENTIS501DWITHINONEVEAROFCOMPLE- � - _ Z �TION,THE OWNER�BUILOER WILL HAVE THE Bl1R�EN OF PROVING THA7 NE OR SHE DID NOT Bl11LD OR� . . . � IMPROYEFOflTHEPURPOSEOFSALEI . W ❑I,ASOWNEROFTHEPROPEHfY,AMEXCLUSIVELYCOMRACTiNGWRNUCENSEDCOMRACTOR4 Q TO CONSTRUCT THE PRQIECT(SEC.70M,BUSINESS ANO PPOFESSIONS CODE:THE CANTflACTOflS LI•. VHIUBSIOf1 ADJ.AREA . W CENSE UW ODES NOTAPPL7 TOAN OWNEH OFAPROPERTY WMO BUILOS OR IMPROVES THEflEON,AND --- 1 W{�p�pN7pqCFSFOR&UCHPRQIECTSWITkACONTRACTOR�S)LICENSEDPURSUANTTOTHECONTRAG � QUANTITY - DESCRIPTION FEE � � TOHS 110ENSE LAW.). , . . �IQM�J(ER!PTl1NQER5�C. B.&P.GFORTHfSREASON Q .. � - � ...--. . _ . . � . .., , LL DRTE OWNER - - - f'� Z W �d L�CENSED CONTRAGTORS DECLARATION W (L 1HEREBYAFFIRMUNDERPENALNOPPEflJUliVTHATIAMUCENSE�UNDERPROVI510NSOFCHAPTEF- •�� _ � CL 9(COMMENCIN(iWITHSECTION7to0o)OF�IVISION30FTHEBUSINESSANDPROFES5IONSCO�E,ANO Z . X '�MV LICENSE IS IN NLl WRCEANO EFFECT. ' L��� �IICENSE CLASS � LIC.NO. �J�Z���_ � . V DATE� - _ CONTFiACTOR�� (,���. 0- . . W Z2��� � WORKERS'COMPENSATION DECLARATION -j � ¢ � IHEREBYAFFIRMUNDEflPENALNOFPERJURVONEOFTHEFOLLOWMGDECLARATIONS: Z-" " ' ' - Q O IHAVEANDWILIMAMTAINACERTIFICATEOFCONSF.NTTOSELF.INSIJREFORWORKERS' _ - � COMPENSATION,ASPROVIDEDBVSEC710N3iDOOFTHEIABORCO�E,FOFTiEPERFORMANCE `U OFTHE WORK FOR WHICHTHIS PERMIT IS ISSl1E0. l� � � W �I HAVE AN�WILLMAINTAIN WOFKERS'COMP£NSAT�ON INSURANCE,AS REOUIRED BV SECTION � Q 37000FTHELABORCO�E,fORTHEPEflFORMANCEOFTHEWORKFORWHiCHTHISPEFMITiS �S5UED.MY WORKERS'COMPENSATION INSURANCE CARflIER AND POLICY Nl1M8ER ARE: CONSTRUCTION ���� a CARRIER� � __ � PLAN REVIEW - � POLICYNUM6ER �.� �� - ELECTRIC , Q .. _'__.."'__'_'._ . 0 ((Fi5$ECTpNNE�NOTBE O iHEFERMfTISFORONEMN�DRED�(E700)ORLESS� PLUMBING Z ICERTIFYTHATMTHEPERFORMANCEOF7HEWORKPoflWHICHTHISPERMITISI55UED,1 MECHANICAL �$ SHRLLNOTEMPlOYl1NYPERSONINANYMANNER50ASTO8ECAMESUeJECTTOTHE Uj WORKERS'CAMPENSATbNLAWSOFCALIFORN10.aN�AGREETHATIFISHOULDBECOME INSPECTIONFEE SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR � S CA�E.ISHALLFORTHWITHCAMPIVWIiH�THO\SEPHOVi510N5. � �SSUANCE p- DATE: "���� APPLICAN2 1 lo`�,�,..-��.V..^-w -SMIP �.°� � � � WARNI :FAILURE T09ECURE WORKEfiS'COMPENSATIDN COVERAGE IS UNLAWFU�,AND SHALlBE ENERGY P/C `y. SU&1 TANEMPLOYERTOCRIMINALPENALTIESANDCMIFINESUPTOONENUNDREDTHOU5AN0 ENERGYPERMIT - DOLLARS({100,000),IN PDOITION 70 THE COST OF COMPENSATKKJ,DAMAQES A5 PROVI�ED FOR IN J SECTION37080FTHELA80RCODE,INTEflEST,ANDATTORNEI^SFEES. RETENTIONFEE: ' Q - a� CONSTRUCTIONLENDINGAGENCY PRE-ALTFEE:-� - Q IHEflEBYAFFIPMUNDERPENALTVOFPERJURY7HATTHEREISACANSTFUCTIONLENDINGAGENCY �'-'�i.= - ' � FORTMEPERWRMANCEOFTHEWORKfORWHICHTHISPERMITISISSUED(SEC.3097,CIV.C.). ' . - Z W � LENDER'S NAME ______. �� F- LENDER'SADDOESS__ - ♦ � ICERTIF1'THATtHAVFREA�THISAPPLICATIONANDSTATETHATTHEABOVEINFORMATIONISCARRECT. TOTAL FEES - � - r W IAGREETOCAMPLVWITHALICITVANDCOUNTYOR�INANCESANDSTATELAWSREL4TIN�TOBUILDIN6 - � � CIXJSTRUCTION,ANDHEREBYAUTHORIZENEPflESENTATIVESOFiHISCOUNTYTOENTEflUPONTHE ' Z ABOVE•AIFNTIONED PROPEHN POR INSPECTION PURPOSES. COMMENTS � � ,�/� S �� i �� J 4 PEflM E AME(PRINn � F' u� __µ�v:--�. � /�"' ' � SIC OF PERMITTEE DATE = RECPt N0. 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