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HomeMy WebLinkAbout13180 _ _ - - - - - - - - - -- __ ---_ . _ ja4 ^ �,� CITY OF DIAMOND BA& � DEPARTMENT OF COMMUNITY&�DEVELOPMENT SERVICES � , 21660 E.Copley Drive Suite 190 9�,,,, (909)860-3195 Fas(909)861-3117 PRESS' BUILDING PERIVIIT APPLICATION __ ' FIRMLY �' JOBSITE ,� i1 f°;• ' � ,. " f APPLICATION � � PERMIT � P/C Q ADDRESS � R '� r a � 4."�i'� '�t� �, a 4ATE NUMBER � # � ,n ISSUE TYPE OCC `^ APN LOT N i.� TRACT �r���� DATE CONST. GROUP p OWNER C,�. .�-' �`� a n �� LL � ''� � ���`'IP.� � TEL. . „,:% � � ' NING SETBACKS Q ADDRE�S � � a � �1 ZO z CITY 0 fl� f°�'�t�`�1^,�f7� v� Z FRONT RW ❑ o APPLICAN'f ..���'�0� , TEL. "� �' � REAR ❑ � � SIDE SIQE STREET RW ❑ ' � CONTRACTOR �, . _ _ �--r- � cirX ��� �i��..s zi��°�?re�. � .�- ,�' . � ADDR S � �' pROPOSED USE , Q ARCHlENG!'. . , , z DESIGNER ^ w NO.DWEL. NO. NO. a ADDRESS OMS ' � CITY ZIP TEL. UN`DESCRIPTION SQ,F.�.STORIE ACTOR PSF ''' ADJ�.AREANALUATION ' Q DWNER-BUILpER DECLARATION SFR/ADD/REM OI � p,��., � 1 HEREBV AFF7RM UNDER PEN/LTY OF PERJURY THAT f AM EXEMPT FROM 7HE CONIRACTORS LI� �� ,(�`afB.g0/C9lpOfl ' � W�i CENSELANFORTtdEFQILOWMGREi450N(SEC.7031.5SUSINESSAN�PROFESSIONSCADE:ANYCIStlOR,; � � C�I .'COUNTVWHICHflEOU�RESAPERMITTOCONSTRUC'AkTERiMPROYE,DEMOLISN,ORREPAIRANYSTRUC- � +. �',W i �,TURE.PRIOR TO ITS ISSUANCE,AL50 REQl11RE5�7}1E APPLICANT fOFi SUCH PEHMIT TO FIIE A S�GN'eD ��W ��'patl0/DBCK - "' STATEIAENT hiqT HE OR SHE IS IICENSEO PURSUANT TO THE PROVISIONS Of TNE CANTRACTORS LI- � ' � � 5�j GENSELAW(CHAPTERB{COMMEICINGWITHSECTION7ao0)OFOIVISION30FTHEBUSINESSpNDPRO- '� POOVSPB � ',,,, . ;� �� '��'. �FESSIONSCODE)ORTHATHEQRSHEISEXEMPT7HEREFROMANDTHEBASISFOF7HEALLEGEDEXEMP� � ;�;"� ��; " �� � � ' � .',TION.ANYVIOLATIONOFSEC410N7031.58YAN7APPLICANTFORAPERMITSUBJECTSTHEAPPLICANTTO 'Z',"RB-ROO} � ACMLPENALiYOFNOTMOHETPiANFIVEHUNOW��OLLARS(S5o0).): � � o���, ❑I,ASONMEROFTNEPROPERN,ORMYEA�LOYSESWITHWAGESASTWEIRSOLECAMPENSA7i0N, '��� CommEfClel � ��, I,WILL DO iHE WORK MNO�THE STRI1QTlIRE IS NOT IMENOEO.Op OFFERE�FOR SALE(SEC.7od0.BU51� J � � ��, �NE53 AP1D PFOFESSIONS COOE:THE CANTRACTORS LICENSE LAW DOES NOT APPLV TO AN OWNER OF ��.��. ��, � 'PROPERTYNMOBURDS.ORIMCROVESTHEFEON,ANDNhi000ESSUCHWORKHIM6ELFORHER9ELFOR �. � � �'��, .THFlOUf3HHISORHER'OWk'EMPCOYE£S,PROVIDEDTHATSUCHIMPROYEMENTSARENOTINTENDEDOq m . - �� �.. , Q ��,OFF9iEOFOR3ALEIF,HOWEVEfi,h1EBU�LDINGORIMPROVEMENTI550L6WITHINONEYEAP.OFCOMPLE- ' ' ��, '�710N. OWNER-BUILDEH-WILL HAVE THE BUfl�EN OF PROYING THAT HE Oft SHE�ID NOT 6UILD Ofl ,.., IMPRO�FORTFEPURP�SEOFSALE). � � � � � ���� � � ' ,.W'� . I,ASOWNEROFTHEPROPEFiTV,MAEXCLU5IVELYCOMRACTINGWITHLICENSE�CONTRACTOAS � . ,Q' �'TOCONSTRUCTTHEPRO.IECT(SEC.7046,B115WESSANDPROFESSIONSCO�ETHECONTRACTORSU- '���'V9I1J9�IOP � ADJ.AREA � � ��� Wi 'CENSELAWDOESNOTAPPLYTOANOVRdEROFAPROPERNYVHOBUBL�SOqIMPROVESTHEREON,AND '� , � ' �'';F'� ��i�Yh1000Nl'RACTSFORSUCHPROJECTSWIhlACONTRACTOR(S)LICENSEUPURSUANTTOTHECONTRAG "QUANTITY DESCflIPTION ' "' ""' FEE ' '� '���' .Y�, .7DRS IICENSC LAW.). �p ❑I AM EXEMPT UNOER SEC. � B.&P.C.FOR THIS REASON Q ��� - ' 3 V LL . �ATE�"� �GriNEfi P� . F�— .. . . . ... � � , � Q .w . , � .W ' ' -' ... ,....... . . ' �,�,c[�, LICENSE�CONTRAC� RS DECLARATION � 'W � � � ���� OC��� 1 HERE6YAFFIRM UNDER PENALTY OF PEAJURY THAT!AM LICENSED UN�EH PROVISIONS OF CHAPTER �,Z . i �, :��� �9(COMMENC�Nq WITri SECTION 7000)CF DIVISION 3 OFTHE BUSINESS AND PROFESSpNS CODE,AND ' '�. MY LICENSE IS IN FULL FORCE AMD EFFECL m ' ���`A�'`�� �� � � �� UCENSE CL.N55 ��� LIC.N0. � ,V��. ���ATE �_��"'�� �CONTRACTOR_�.Y�P"�" '- . .. ll.i -� � WORKERS'CDMPENSATION DEC�P,RATION � �`� Q � � ''f /1 �'�����IHEREBYAFFIRMUNDERPENAL7YOFPERJUAYONEOFiHEFOLIOWWGDECLARATIOta� � Z `�� _ ,,�.,��a,,� � �, �IHAVEANDWILLMAINTAINACERTIFICA7EOFCONSENTTOSELF-INSUREFORWOHKERS• ¢ � � 2 �� COMPBJSATION,ASP410VIDEDBYSECTION37000FTHELABORCODE,FORTHEPERWRMAPICE U "'-' �.��� Q OFTHE WORK FOfi WHICH THIS PERMIT IS ISSUED. � . � '�� �_IHAVEANDWILCMAINTAINWORI�RSCOMPENSATpNINSURANCE.ASREdUItiE�BYSECTIDN �� - � . ...., .. . . . . � �Q 37000FTHELABORCO�E,FORTHEGERFOPMANCFOF7HEWORKFORWHICHTHISPERMI715 � ISSUEO.MY WDRKERS'COMPENSATION INSURANCE CAqR1ER AND POLICY NUMBfRARE: 'CONSTRIICTION .g . . �� m9�,y� . , .. . .. � . > CARRIER rt3°^"� r� 'FLAN REVIEW � PoucvrduMeeR ���� 1����� d'7 -' '"�I �LECTRIC B Q (fHISSECTqNNE�tdOTBEGUWIA_EfEDOFiHE?EiUNTISFORONEHUMREDDC{1MS(5100)ORLESS�. �PLUMBING Z ICERTIFYTHATINTHEPEflFORMANCEOFTHEWOflKFONWHICHTHI5PEfl6AITI5155UED,1 "�"NIECHANICAL "' � �d'� C,°'f SHALL NOT EMPLOY ANY PERSON IN ANY MANNER 50 AS i0 BECOME SU9JECT TO THE �(/) WORKERS'COMPENSATIONLAWSOFCALIFORNIA,ANDAGREETHA7IFISHOULOBECOME '.INSPECTIONFEE '�' SU&IECTTOTHEWORKERS'COMPENSRTIONPFOVISIONSOFSECTION37000FTHELABOR �' , � CAOE,ISHALLFORTHWITHCOMPLVWITHiHOSEPROVISIONS. ISSUANCE �� +F o� 0 �p� OAYE: APPLlCANP. � ;.��SMIP ,�'v�y'+cy � ° � �,J WARNINGFAIWRETOSEC'JREWORKERS'COMPENSATIONCAVERAGEISUNLAWFUL,ANDSHALLBE "ENERGYP/C A.�Sk 4f���&f^+�U~�.1��^��k�3�6� '�,� SU&/ECTANEMPLOYERTOCRIMINALPENALTiESAN�CIVILFINESUPTOONEHUNDRE�THOUSAND ""�'"NERGYPERMIT���� ��$����'g�,'� OOLLARS($t0o,000),IN ADDITICN TO THE COST Of COMPENSAYION,�AMA�ES AS PROVIDEa WR IN � SECTION57080FTHELABORCADE,INTEREST,Atd�ATTORNEI"SFEES. ' I WETENTIONFEE: , O CONSTRUCTION LENDING AGENCY ���PRE-ALT FEE: � � ',�. I HEREBV AFFIRM UNUER PENALTV OF PERJURY THATTHEAE ISACON57RUCTION LENDING AGENCY I,,, � � . �'n-� FORTHE PERF-0RMANCE oFTHE WORK FOR WH7CH THIS PERMITIS ISSUED(SEC.aos7,CIV.C.). Z W �,��„ l.ENOER'S MAME . ' - . . "�F-�� LEN�ER`SADDRESS � ��' ILERTIFYTHA7IHAVEREADTHISAPPLICATIONANOSiATE'MATTHcA90VEINFORMATIONISCORRECT. TCjT'AL FEES i �'�' I AGREE TO CAMPlV WITH ALL CITY ANO CIXINTY OqOINANCES AND STATE LAWS RELATING TO BU�LDING ' ,��'� 1'� � .'�.��� CONS7RUCTION,AND HEREBYAUTHORIZE REPRESENTATIVES OFTHIS COUNTYTO EMER UPON THE , � , � . , 2; ABOVEMEMIIX�IEDPROPEFITYFORINSPeCTIONPUFPOSES. COPr!IMENTS -- �„ � PERA1 EE N E � � � CPS" 4 � SIGNRTUFiE MITTEE UATE ���. - REf�PT.NO. PAID BY VAIIDATION��'' - WHITE—Departmeot Copy,YELLOW—Finance Copy,PINK—As��'ssor Copy,GOL�ENRQD—File Copy,GREEN—AopliranYs Copy� � � � . 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