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HomeMy WebLinkAbout14686 (17) ,. . C/�.-e'/!'�� CITY OF DIAMOND BAIt � �' � - " DEPARTI��4ENT OF COMMUNITY&.DEVELOPMENT SERVICES ������ � 21660 E.Copley Dtive Suite 190 �'��'��' BUILDING PE'RMI'i'APPLICATION FIRM Y — _ __,.. .. , o DDRESS a 3 g� G—a�h N U c��-rr �e,• DATE CATIOt� NU BER � #/C .J � ISSUE TYPE OCC APN LOT TRACT DATE CONST. GROUP p OWNER C11R'Q C E��A M�TdI�I " ADDRESS ZONING SETBACKS Z CITY �i A�MD�D }�,J�Q ZIP�S TEL.�I Dq_f�GD-J y FRONT RW ❑ g APPLICANT TEL. REAR ❑ SIDE/SIDESTREET RW ❑ � CONTFIACTOR 51DE ❑ � ADDPESS � CITY FD�{+i L1. (�n r✓� ZIP�i'9!�I D TEL. - (r S PROPOSED USE w ARCH/ENG/ � DESIGNER � ADDRESS NO.DWEL. NO. NO. � CITY ZIP TEL. UNITS STORIES BEDRODMS � DESCRIPTION SQ.Fl: FACTOR PSF ADJ.AREANALUATION � � OWNER-BUILDER DECLARATION SFR/ADD/REM O 0 I FIER�Y AFFlRM UN�ER PENALTV OF PEFJURY THAT 1 AM E%EMPT FflOM THE CANTRACTORS ll- G8f8CJBIC3f(101T W CENSELAWFOHTHEFq.LOWINCiREA90N(SEC.7037.6BUSINESSANOPROFESSIONSCODE:ANVCITYOR (n _ C..7 �pUNT'WHICMREQUIHESAPERMITNCONSTRUCT,AITERIMPROVE,DEMOUSH,ORREPAIRANYSTRUC- W patio/Deck � lURE,PHIDR TO ITS ISSUANCE,Q50 REW�RES THE APPLICAN!FOR SUCH PEFMI7 TO FILE R SIONED STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF 7HE CONTRACTORS U• � CENSE UW(CHAPTER 9(COMMENCINO WITH SECTION 7000)OF DiVISION 3 OFTHE BUSINESS AND PRO- � PODVSpO FES910NS CO�E)OR THAT HE OR SHE IS EXEMPT THEREFROM AN�THE 8A515 FOR THEAlLEOED EXFh1P- TION.ANYVIOt.ATIdJOFSECTION7o31.5BYANYAPPLICANTFORAPERMITSUBJECTSTHEAPPLICANTTO z Re-Roof � 11 CML CENALiV OFNOT MORETHAN FNE NUNDRED O«I.AFS(S6ao).j� � � ❑I,ASOWNEROFTHEPROPERT',ORA/vEMPLOVEESWITHWAGESA5THEIRSOLECAMPENSATION, 0 COmmefClal - NALL 00 THE WORK,ANU THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC.�O4a,BUSI- J � NE35 AND PROFESSIONS WOE:THE CONTRACTORS LICENSE LAW�OES NOTAPPLY TO AN OWNER OF = PROPERTY WNO BUILOS OH IMPROVES THEREON,IW D MMO DOES SUCH WORK HIMSELF OR HERSELF OR CC TNROUOMH150RHERONMBAPLOVEES,PROVIOEDTHATSUCHIMPROVEMEN75ARENOTIMENdE00R m Q ,OFFF.RmWF51LLE1F,HOWEVER7HEBUIIDINGORIMPROVEAfENTI550LDWRHINONEYEAROFCAMPIE- Z TION,THE OWNEfl�BUILDER WILL HAVE TNE BURDEN OF PROYIN(3 7HA7 HE OA SNE 01�NOT BUILD OR = IMPROVE FOR THE PURPOSE OF S�LE�. � ❑1,ASOWNER OFTHE PROPERf`/,AM EXCLUSIVELV CONTR�CTING WITH LICENSED CANTRACTORS � TO CONSTRUCT 7HE PRNECT(SEC.toa6,BUSINESS ANO PROFESSIONS CODE:THE COMRACTORS LI- V8ltlaltion ADJ.AREA W CENSELAWDOESNOTAPPLVTOANOWNEHOFAPROPERTYWHOBl11LDSORIMPFlOVESTHEREON,AN� � VRiOCONTRACT6FONSUCHPROJECiSWITHACONTRACTOR(5)UCENSEDPURSUANTTOTHECONTRAG QUANTIIY DESCRIPTION PEE � TORuIACENSELAW.). ❑I AM IXEMPT UNDER S�C. 6.fi P.G FORTHIS REASON U � UATE OKTIER � Z W � LICENSED CONTRACTORS DECLARATION -� � w 1 HEREBV AFFIfW UNDER PENALTV OF VERIURY THAT IAM LICENSED UNDER PROVISIONS OF CHAPTER � � 9(COMMENCINO WITH SECTION 7000)OF DIVISION 3 OFTHE BUSINE55 AND PROFESSIONS CODE.AND Z MY LICENSE IS IN FULL FORCE AND EFfECT. m 0 UCENSE CLASS lC1'' �4 ���.No. S aG o "^' � V DATE -3� �'I-� b� CONTRACTOF v W � WORKERS'COMPENSATION DECLARA N _ � I MEREBYAFFlPM IRiDER PENALTY OF PERJURV ONE OF THE f-0LLO O�ECLARATIO : G/� � � �IHAVEANDWILLMAINTAINACEf{TIFICATEOFCANSENT7 SELFINSUREFORWORKER 2 � COMPENSATION,AS PROVIDEO BV SECTION 370o OFTHE L BOR CODE FOR O C� OFTHE WORK FOR WHICH TNIS PERMIT IS ISSUED. � W �1 HAVEAND WILL MAINTAIN WORKERS'COMPENSATION INSUflANCE,AS RE�l11RED BY SECTION 6 37000FTHELABORCODE.FOHTHEPERFORMANCEOfTHEWORKFORWHICHTHISPEHMIT ISSIIED.MY KERS'�pMPENSATKKJINSl1RANCECARPoERANOPOLICV�lUM6£RARE: ST UCTION � CARRIER S �C�--� t L"�'�U LA EVIEW � — � POLICV NUMBER �S to 738'3--�"i__. _ crRic _ � (IH55ECIpNNE�No7BECl�NPLEt�oFn1EFERlMTISFORONE1n1WaEo ( a PLUMBING Z ICER'fIFYTHATINTHEPERfORMANCEOFTHEWORKFORWHICHTHISPERMITI ISS ED,I MECHANICAL (7' SHALL NOT EMPLOY ANV PERSON IN ANY MANNER SO AS TO BECOME SUBJECT T HE � WOPoCERS'COMPENSATIONLAWSOFCALIFORNIA,AN�AGREETHATIG'ISHOULDBE INSPECTIONFEE � � Sl1BJECTTOTHEWORKERS'COMGENSATIONPROVISIONSOFSECTION37000FTHELA80R — CADE,I SHALL PORTf M1YITH COMPLV OSE PROVISIONS ISSUANCE _� ._ '` 0 3 '1 � , �, ., � :_T- p OATE: 'I �1" APPLICANT: l. �,�AN� SMIP �_ . � ENERGY P/C ��� WAFNING FARLIRE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL.AND SHALL BE �/ LL SUBJECTANEAIPLOVERTOCRIMINALPENI1lTIE5AN�CIVILFINESUPTOONEHUNDREDTHO�SANO ENERGYPERMIT wS'l�l !3 DIX.LARS�fto0.000).IN AD�ITION TOTHE COST OF COMPENSATION,DAMAGES AS PROVIDED f-0P IN .� � SECTION3708OFTHEUIBORCODE.INTEREST,ANOATTORNEY'SFEES. RETENTIONFEE: .=.rltlS�ll v.�,. a CONSTRUCTION LENDING AGENCY PRE-ALT FEE: ___ O � 1 HEREBV AFFIRM UNDEH FENALN OF PERJURV THAT TMERE IS A CANSTRUCTION LENDING AGENCY n- FOHTHEPERFOFiMANCEOFTHEWORKFORWHICHTHISPEPAIRISISSUED(SEC.3o97,CIV.G). Z W � LENOER'S NAME F— LENDER'SADDRE55 � ICERTIFVTHA7IHAVEREADTHISADPLICATIONANDSTATEhiATTHEA80VEINFORMATIONISCOFRECT. TOTAL FEES � 1 AGREE TO COMGLY WITHALICITV AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING CONSTRUCTION.AND HEREBV AUTHORIZE REPRESEMATIVES OF THIS CAUNTV TO ENTEH UPON THE � ABOVE-MENfIONEDPROPERTVFOliINSPECTIONPURPOSES. COMMENTS � - ��t ls� ��lE�l� m ER EE NAME(PfYNT�) �--� ' � r d 12___.�✓�A�P�"Y+•�. 3' `�`�� _ � 510 . PERMITfEE OA7E � RECPT.NO. PAID BY VALIDATION WHITE—Depa�ment Copy,YELLOW—Finen�Copy,PINK—Assessor Copy,GOLDE OD—Fla Copy,GREEN—ApplicanYs Copy ,....�. ,: . _ , �,. 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