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HomeMy WebLinkAbout14367 (20) � -� ��'c �`�'� CITY OF DIAMOND BAI� ` -- , '° -- DEPARTMENT OF COMMU1vITY&DEVELOPMENT SERVICE �»_ � 21660 E.Copley Drive Scute 190 '` ��� � � '� (909)8603195 Fax(909)861-3117 PRESS ��� FIRMLY �' , - � � . TTo� �_ . BUII.DING PERMIT APPLICA , . � JOBSITE Z`� •c�IC� ����,� �d� DATE P � NUMBER'L_���-� # APPLICATION � PERMIT P/C o ADDRESS �J �•./ { � APN LOT TRACT �SSUE TYPE OCC p OWNER n�c,� DATE CONST. GROUP p ADDRESS S /I f�Jr.� ZONING SETSACKS W FRONT � CITY ZIP TEL F3'�i' REAR RW ❑ APPLICANT ' TE�. SIDE/SIDESTREET RW C � CONTRACTOR � t�L L� C� SIDE �_ � ADDRESS l �j- f,,,,.,� � CITY � ZIP�J���� TEL.'�7�7!S PROPOSEd USE Y�/ 'S r(�-ICC,"`�� �,/L��j�,,C,,, �Z.�l w ARCH/ENG! ` � w *�S.�J1l,_� Z ` U �s i'Y'+-'� ` L '�- o i��r�:� y��.,n �" z DEStGNER --�—� ...��- w NO.DWEL. NO. p, a ADDRESS � CITY ZIP TEL. UNITS _ STORIES BEDROOMS � rn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER•BUILDER DECLARATION SFR/ADD/REM O I HEREBY AFFIRM UNDER PENALTV OF PER.IURY THAT I AA1 E%EMPT FROM TNE CONTRACTORS LI- G8f290/C1lP01I W CENSELAWFORTHEFOLLOWINOREASON�SEG7031.5BUSINESSANDPROFESSIONSCODE:ANVCITYOR (f� C.) COUMYWHICMREWIRESAPERMYfTOCONSTi1UC`ALiER,IMPRWE,OEMOLISH,ORREPAIRANVSTFIUP W P2110/DBCI( W T/pE,PRqR TO ITS ISSUANCE,ALSO REOUIRES THE APPIICANT FOR 9UCH PERMIT TO FILE A SIGNED W � STATEMENT THAT HE OR SHE IS LJCENSED PURSUANT TO THE PqOVISIONS OF TFIE CONTRACTOqS LI- � '� CENSE LAW(CHqP7ER e(COMMENCING WI7M 5ECTION 7000)OF DIYISION 3 OF THE BUSINESS AND PPO- POOUSpH FESSpNSCODE)DRTHATHEORSHEISEXEMPTTHEHEFROMAN�THEBASISFORTHEALLEGE�EXEMP� (� V TION.ANYVIOLATIONOFSEC710N7031.SBVANVAPPLICANTFORAPERMI7SUBJECTSTHEAPPLICANTTO Z Re-Root � ACIVILPENALTYOFNOTMORETHANFNEHUNDREDDOLLARS(SSaO).): � �LASOWNEROFTHEPROPERTLORMYEMPLOVEESWITHWAGESASTHEIRSOLECOM,PENSATION, COmmOfcial - WILL DO 7HE WOHI(APA THE STRl1CTIlRE IS NOT INTEN�ED OR OFFERED FOR SALE(SEG 70d6,BU51- � � NESS ANO PROFESSIONS CAOE:THE CONTRACTORS LICENSE LAW�OES NOTA7PLY TO AN OWNER OF � PROPERTY WHO BUILOS OR IMPROVES THEREON,AND WNO�OES SUCH WORKHIMSELFOR HER6ElF OR Q THROUGHWSORHEROWNEMPLOVEES,PROVIDEOhIATSUCHMPRbVEMENTSARENOTINTENOEDtlP m G OFFEREDFORSAL.EIF,HOWEVEH,THEBUILDMGORIMPROVEMENTISSOLDWITHINONEVEAROFCOMPLE- Z TION,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PflOYING THAT HE OR SHE�ID NOT BUILD OR = IMPROVE FORTME PURP0.SE OF SALE). ❑I,AS OWNER OF THE PROPEFITY,AM E%CLUSIVELY CANTRACTING WITH LICENSED CONTRACTORS TO CANSTRUCT THE PHQIECT(SEC.7044,BUSINESS AN�PROFESSIONS CODE:THE CONTRACTORS LI- ValUatiOn � : C ADJ.AREA W CENSELAWDOESNOTAPPLVTOANOWNEROFAPROPERTYWH00UILOSORIMPROVESTHEREON,AND � WHOCONTRACTSFORSUCHPROJECTSWITHACONTRACTOP(S)LICENSmPUPS(IANiTOTHECONTRAC- QUANTITY DESCRIPTION FEE � TORS LICENSE tAW.). Q ❑I AM E%EMPT UN�ER S�C. B.&P.G FOR THIS REASON Q � U _ � � / � DATE ONTIER F" : 2 � LICENSED CONTRACTORS DECLARATION W n,, � IHEREBVAFFlRMUN�ERPENALTYOFPEfiJURYTHA7IAMLICENSEDUNDEFPHOVISION50FCHAPTEH �, ,�` d 9(COAIIAENCINCfWITHSECTKKJ700D�OFDIVI510N30FTHE8USINESSANDPROFE5510NSCODE,WJD � L CENSE CLASS�LL F!CEAN�pp�T. LIC.NQ_�����.G�_� � G� t�.� � � L DATE LZ � �� CONTRACTOR____ � ____- a W � WORKERS'COMPENSATION DECLARATION � � I HEREBV AFFIRM UNDER PENALN OF OERJUpY ONE OF THE FOLLOWING�ECLARATIONS: Z � _IHAVEANDWIL�MAINTAINACERTIFICATEOFCONSENT705ELF-INSUFEFORWORKERS' a ,. .�,,,,_....._._...._,... � CAMPENSATION,AS PROViDED BY SECTION 370o OF THE LABOR CODE,FOR THE PERFORMANC�K,,. -^ �` Q OF hiE WORK FOR WHICH THIS PEqMIT I515SUE0. �„✓� QW _I HAVE ANb WILL MAIMAIN WORKER5 COMPENSATION INSURANCE,AS REOUI BY SECTION �/' 370o OFTHE LABOR CODE,FOR'R1E PERFORMANCE OF THE WORK FOR H THIS PERM� ��� J�U ISSUEO.MV WORKERS'CAMPEANSAT,IO/N•I�-N�SURAN(C�E CARRIER AND PO NUMB� ARE;�' UCTIO � � C! ¢ �/l./! / //' : —_ ] CARqIER �..�.'}� ____. _ . N REVI � POLICY NUMBER �� Y � _ LECT p (fF116SECfKYJNE�NOTBEWI.FLETEDOFT}�PEfiWTISFC EHl1NDREDOOLLNiS(51 JOfiLE55� P BING Z ICEflTIFYTHATINTHEPERFORMANCEOFTHEWORKFO WHICHTHISPEPMITISISSUEDI MECHANICAL � �" ' U' SHALLNOTEMPLOVANYPERSONINANYMANNERSOAST ECOMESUBJEC7TOTHE � WORKERS'COMPENSATIONLAWSOFCALIFORNIA,ANDAGRE .LS M INSPECT70NFEE � SU&IECTTOTHEWORNERS'COlAPENSATIONPROVISIONSOFSECTION37o00FTHELAe � B�E,ISHALLFO CAMPLVWITHTHJ�$EPRO ISI S. ISSUANCE p // //� J i p DATE:"'� � APPLICANT: �" � L� SMIP TT�r g�y �����,•� � � ENERGY P/C �A 1 1 V�'�e�.f���-" J WRflNINQ:FAIL E TO SECURE WOFiKERS'COMPENSATION COVERAGE IS 11NLAWFUL,AND SHALI BE y7gg yq,�g'`� p'q7 Sq �y SU&IECTANEMPLOVERTOCRIMINAIPENALTIE5/WOCIVIIFWESUPT00NEHUNDiiE�THOUSANO ENERGYPERMIT __�IJIA.��&1�4JC'1�'���t�'��a DOLLARS(f70D,D00).IN ADDITION 70 THE COST OF CONPENSATION,OAMAGES AS PROVIDED FOR IN - � SECTbN 37oe OFTHE LABOR WDE,INTEREST,ANO ATTORNENS FEES. RETENTION FEE: __ OCONS7RUCTiON LENDING AGENCY PRE-ALT FEE: � IHEREBYAFFIRMUNOERPENALTVOFPERJURYTHA77HEREISACONSTRl1CTIONL,E4DINGAGENCV FOR THE PERFOFUAANCE OF THE WORK FOR W41CH THIS PERMIT IS ISSUED(SEC.30e7,CIV.C.). . Z W � LENDER'SNAME - F- LENDER'SADDRESS ///^^��y w ICERTIfVTMATIHAVEREADTHISAPPLICATIONAND5TA7ETHATTHEABOVEINFORMATIONISCORRECT. TOTPIL FEES ��`�/4 �/�J � 1 AGREE TO COMPLV WITH AlL CITV ANO CAUNIY ORDINANCESAND STATE LAWS RELATING TO BUILDMG ( / (�/ CONSTRUCTION.AND HEHEBY AUTIiONIZE REPRESENTATIVES OF THiS COUNfv TO ENTER UPON THE Z ABOVE-MENT ED 7ROPEiliV FOR INSPECTION PU��^-- - / COMMENTS � ��_���'',�4 /��'•���'�'i�jl�L J � m PER E(P IN� - � ��� � 7 �. � S� NATUREOFPERMITTE DAT � RECPT.NO. � PAID BY VALIDATION WHITE—Depahment Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENROD--File Copy,GREEN—Applicant's Copy .. . , ,...y.. .. . ,. .. . .. .. � � ., n , .i , _.. ..�. ., ..� , "..�.... .. !'v�� i.i� , ..n�. .. ,�. . .. . . (. . 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