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HomeMy WebLinkAbout17014 (42) �� C1TY OF DIAb40ND IIAR � ' DEPARTMENT OF COIvIIv[UNITY R.DEVELOPMENT SERVICES � ,�� 21825 E.Coplcy Drive (909)860.3I95 Fax(909)861-3117 PRESS � BUILDING PERMIT APPLICATION FIRMLY � JOBSITE r APPLICATION ���a-•�`NUM�R ��IL �/C o ADDRESS S l3 �� �I� DATE �J � ISSUE TYPE OCC APN LOT jRACT DATE CONST. GROUP p OWNER� �� p ADDRES �(� ZONING SETBACKS gCITI'9�1E.nuQ �}/�_ ZIP�� E����( FRONT RW O APPLYCANT TEL. REAR p SIDE/SIDESTREET RW p ¢ CONTRACTO � �� SIDE _ �p QADDRESS�(�,�[ � ��.��Y � CITY�/�y�Zp� ZIP TEL. - .(�� R P US o ARCH/ENG/ iz DESIGNER NO.DWEL. NO. NO. N ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � N DESCRIPTION SO.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-OUILDER DECLARATION SFR/ADD/REM O � 1 HEREBY AFFlRM{1NDEli PEIULTY OF PEiWRY THAT I A1.1 E%EMPT LHOM TNG CONIMLTOAS LI� G9f3ge/Cefp0ll W CENSEUWFOHTHEfOLLOWiNGHEA50N($EC.70]1.SBUSINESSANDFROFESSqN5CO0E:ANYCITYOR (n C� GOUNTYWWCMREOUIRESAPENMITTOGONSTRIKT,AITEfi,IMPROVE.DEMOLISH,ORREPAIRANYSTRUC• w w 7URE.PRqH TO ITS 65UANCE,QSO REOUIRES TNE AVPUCANT FOR SUCH PERMIT TO FILE A SiCNCD W Patio/peck � STA7EMENT 7HAT HE ON SHE IS LICENSED VURSUANT TO TME FRONSIONS OF TH[CONiMCTORS LI- � � CENSE UW(dU7TEN i(CO/AMENCINO WITN SECTKIN 7000)OF DIVIS�ON f OF THE BUSME55 AND VRO- POOUSPO 0 FESSiONSCOD[)ORTHA7HEORSNEISExEUPTTNEREFR01AI110h1EBA5I5FOH7HEILLLEGfDE71EUP- (� V TION.MIVVIOLATIONOFSECTION7071.6BYANYAPPUCMITFO�ACERMITSUOJECTSTHEMPLIGNTTO Z �B•Rpp( �,,,_ A CMl VENA�TY OFlqT AqRE TW W FNE HUNDREO DOIURS�f5o0)�� Z04�OWNEROFTHEGROPERTY,ORMYEMPLOYEESWITMWAGESASMEIRSOLECOMVCNSATqN, O COrt1R10fCi8I Y11LL DO TNE WOHI(,AND TNE STRUCTURE IS NOT INTEM1�EO OR OFFEREO fOF SA:E(SEC.7W�,BUSI• J � HE55 ANO PROFESSIONS COOE:7ME CON7RACTORS UCENSE UW DOCS NOT A➢PlV TO AN OWNER OF ? VROPEHTY Y/Ii0&1RD5 OR IMPROVES iMCREON.IHD NMO OOES SUpi WORK HIMSELF OR HERSELF OR Q THRWGHNISORHEROKTlEA1PLOYEES,VROVI�EDTHRTSl1CH1A17ROYEYEN75�R[NOTINTENDEOOR CO Q OiFEREDFOqS�lEIF,110WEVERiMEBUILDINGORNnCROVEM[NTISSOLDVnTNINOHEYEAROFCOMitiE- Z TION.THE OWNER-BUILDER WILL HAVE THF BURDEN OF PqpyiNO THAT HE OR SNE DID NOT BUItD OR � MPROVEFORTHEPVRPOSEOFSALE4 W O1�.70'NNEROFiHEPROPEflTY,AMEX0.U51VELYCONTRACTMGWITHLICEN5E000NTMCTORS � TO CONSTHUCT THE PROJECT(SEC.70��,BUSINESS AND PROFESSqNS CODE:TXL CONTRACTORS u� Valuation _ADJ.AqEA W CENSEUIWDOESNOTAPPLITOANOVYNEHOFAGqOPERTYMhqBUILDSORIM7ROVESTXEREON,MlD � Yl/qCANTMCTSFORSUCHGRO.lECT5KITHACONTMCTOR(SILICENSEDPURSUANTTOTHECONTMC• QUANTITY DESCRIPTION Y TORS LJCENSE UW.1. FEE � O IAM E%EAIPT UNDER SEC. B.a P.C,FOR THIS REASON Q � U � DATE OYMER F- 0 W � LICENSED CONTRACTORS DECLARATION W � I HEREBV AFFIRIA UNDER DEN.LLTV OF OERJURV TNAT IAM LICENSfD U�DER VPOV1510NS OF G/MTER � p� Y(COAIMENCINGWRHSECTION7o00)OFDMSION�OFTNEBUSINESSANDPROFESS:ONSCOC[,AND Z X MY LICENSE IS IN FULL FORC�E A/ND�EFFECT. � LICENSE C SS� IIC.NO.��/� _� � V DATE��r Z�� �r CONTRACT01�,(��, d W � WORKERS'COMPENSATION DECLARATION a NINEREBVAFFiRMUNOERPENALTYOF�ERJURVONEOFTHEFOILOW.NCOECLAMTqNS. Z . � �IHAVEANDWIL�IANNTAINACENTIFICATEOFCONSENTTOSELF-INSUREFORWORKEPS' a S Q COMPENSATION,ASPRONOEDBYSECT10N77oDOFTHEU80RCODE,FORiHEPERFOHMANCE U Q OFTHEWORKFORW11Ip17H15PERMiTI5155UED. � QW _INAVEANDWILL4AINTAINWORNERS'CpAOENSATqNWSURANCE,A5RE0UiREDBVSECTION ]700 0F TNE LAOOR WD[,fORTHE PERFORIAANCE OF THE WORK FOR YMICHTHiS V[RMIT IS �D� '�I J ISSUED.MYIW ERS MPENS�TqN�I �NCECARRIEFANDPOLILYNUMBER�RE: CONSTRUCTION � POIICYNUMOER�i(/� ZJ��� E ECTRI�EY� ¢ 0 (fH65ECT10NNEmNOTBENMRETmOFTfPERMTBiORONE�I►q1EDD0UAfL5R�a1C��ul PLUMBING Z ' I CERTIFV THAT N THE iEkiOWAANCE OF THE WORK FOR WMICM THIS PER1AiT IS ISSUCD,1 MECHANICAL U' SMALL NOT EMPLOY ANY PERSON IN ANY M0.YI:ER SOAS TO BCCAME SUBJCCTTO TME � WORKERS'COMPENSATIONlAW50FCAJFORNIAAN�l1CREETMATIFI5//0UL09ECOME INSPEC710NFEE 'ti��-�" - '� SUBJfCTTO7MEWORKERS'COIAPENSATqN7ROV15lONSOFSECTION]]OOOFTMELABOR �_""'�i^�\- , s CODE,ISH/1LLFORTMYATHCdJPLYWITHTHOSEPROVI5lON5. �SSUANCE - � - \�Q O � � DATE: APPLICANT: SMIP fi � n n n. wWARNINC;F�0.URETOSECVRGWOtINERS'CMIPENSA1qNCOVER►GEISUNUWFULANOSNALLBE ENERGYPlC �Y LL SUBJECTANEIAPLOYERTOCRIMIYALPENlLL71ES/J:OCMLFWCSUPTOONENUNORCDTMOUSANO ENERGYPERMIT DOLLARS�SIOD.000),H AOOITION TO TH[COST OF COMPENSATIpN,DAMAGES AS PROVIDED FOR IN � SEGTI�N7]OeOFh1ElABOACODE,WTEREST,/J:OATiORNEY5FEE5. RGTENTIONFEE: FIY� . ` . .. a CONSTRUCTION LENDINGAGENCY PRE•ALT FEE: � � ��� � � � O � IHEREBYAfFIRMVN�ERFEN�LTYOFVERNRYTHATTHEREISACOfrSTRUCTIONIENDPlOAGENCY FOR TME GERFORMANCE OF THE riORK FOR WHICM 7H15 PERMiTI5135UE0(SEC.7o97,CIV.C.) Z W � LENOER'SNMIE S � LENDERSADDRE55 � TOTAL FEES I �S I O ¢ ICERTIFlTNATIMAYEREW'i1115APPUCATIONANOSTATETMATTME�BOVEINFORM�TqNISCOflRECT. W I AGREE TO LOA�PLY WITX ALL CITY M!0 CAUNTY OR�INANCES/�ND STATE UWS REUTWC TO BUIIDING \ � CONSTRUCTION,AN�HER[BYAUT/IORREREPRESENTA7IVESOFTHiSCOUN7YTOENiERUPONiHE Z �BOVE�MENT�ONEDPROPERTYFORINSVECTIONPUiiPQSES. � COM�A[NTS 0 � m ¢ DERMiTTEENAME��WNn � i � (n SIGNATUFEOFPERMI - � � D��-� � � RECPT.MQ _PAID 8Y � , VALIDATION WHITE—Department COCY.YELLOW—Fnance Capy,PINK—Asse55a COpy,GOIDENRO�File COpY.GREEN—AppliCanl'S COpy . .. ,. . ._.. , , ... . _ . _... . _ . _ .. . , .. . , . . , , , _ . .. .. � . . .. . . . .. . . ,.. . . . . . ..,. . . ci��• �, �f�:r�;or��� �,��.;� li.!S�'FG i iUi+ F�LCG�:J I►��=1:��c;���c��vi .._._-----f�'r:.�'�� -----.I►`!-`l:��l.c--�c2,,__�.__-._.___f��E:l:!-:c:. :l�^iCl _'._..--------r'�_�t`- �------I,yl-'i�l=.,�����'ea��� . '--- ---... - .- -....- --�- -•--.. . ---...__ - :..=-•-_----..... ._.... .. ...... .... ...... . SET BF;CY. .. ....._ ...... ..._. ._.. 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