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HomeMy WebLinkAbout16298 (23) i � � CITY OF DIAMOND BAB ��'� � �----��'� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES 2166U E.Copley Drive Suite 190 — (9f19)860-3195 Fax(909)861-3127 PRES$ ���� BUILDING PERMIT APPLICATION FI LY - - - _. � o DDRESS ��l � �"�f'C��� � DATECATION �,� � NUMBER���� #�' '� c� ISSUE TYPE OCC APN��,;� LOT TR T DATE � CONST. GROUP p OWNET�.:�r'p./�"f-� � � ADDRESS �°Q" ZONING SETBACKS Z CI � o ZIP ����TEL. 'f��d""�� FRONT RW ❑ ', g APPLICANT TEL. REAR ❑ Z SIOE/SIQE STREET RW ❑ I � CONT4�ACTOR G S ��-� SIDE _ ❑ � � ADDRE55 PROPOSED USE �f'�'� /�� O CITY ZIPd��TEL.__�������d.a'a'�� ' o AREH/ENGf � DESIGNER NO.DWEL. NO. NO. �- � nW. ADDRESS UNITS STORIES BEDROOMS � CI7Y! ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION �'.� ��, � � � OWNER-BUII.DERDECLARATION - SFR/ADD/REM � O' �'� 'o I HEAEBY AFFlRM UdiQER PENALTV-O�r PEAlURY THAT i AM EXEMPT FFOM THE CONTRACTOiiS LI- � ('jgf898ICdfPOfS .W'' CENSEtAWFORTHEFOLIAWIH(i.pEASON(SEC.7031.5BUSINESSMIDPROFESSIONSCODE:ANYCITYOq , .�.�, COUNTVNMfGNREGUIRESAPERMYfTdCONSTflUCT,ALTER,�MPROVE,DEMOLISFi,ORREPAIRANYSiRUC- I� patiolDeck � � W� �,NRE,PRIOR TO ITS 155UMICE,ALSC ftEQUIRES THE APPIICANT FOR SUChI PERMR TO FILE A SIGNED � r��� STATEA9ENT THAT HE OR SHE IS LIC�NSED PUR5UJiiVFiQ,THE PROVISIONS OF THE CONiRACTOflS ll- � � CENSE LAW(CHAPTER 9(COMMENCING WI7H SEOTION 7o0oD�fl�flO�SION 3 OF THE BUSiNESSAND PRO- � PooUSpa � FESSWNSCO�E)ORTPo&THEDRSHEISE%EMP?7HEHEFRd.fANDTHEBA5ISFORTHEALLEGE�EXEMP- v, �TION.ANVVIOLATIONOFSECYION7031.56YANYAPPLICANTFORAPcRMITSU&IECTS7HEAPPLICANTTO Z P.B-ROO� � - � � A CIV{6 PENA6TV OF NOT MORE THAN FlVE HUNDRED�OLLP.RS(ibW).): - ��, ❑I,ASOWNEROFTFgPRCPERTY;OftMYEfAPLOYEESWITHWAGESASTHE1R50LcCAMPENSA710N, O COf11f110fCi81 � . � �WILL DO THE WORK,AND THE STRl1CTURE i5 NOT IN7EPfCED OR OFFERE�FOR SALE(SEC.7044,B1151- ..J NESS ANO P�FESSIONS CODE:�THE CUiJTFiACTORS LICEWSE LAW DOES NOT APPLY TO AN OWNER OF � ��� �PROPERTYNRi68UILASORIMPROVESTHEREON,ANDWHO�0E5SUCHWORKHIMSELFORHERSELFOR = iHROl1GHHISORHERONTIEMALOYEES,PROVIDE�THATSUCHIMPROVEMEPlTSAREN071NTENDEOOfi m „Q�'i, ,OFFERWFORSM.EIF,HOWEVERTF7EBUILDINGORIMPROVEMEMISSOIIIWIhiINONEVEAROFCAMPLE- ' �TION,THE O`NfdER-BUILDER WILL HAVE THE BURD6N OF PROVING THAT HE OH SHE DID NOT BUILO OR � Wi IMPROVE FORTHE PURPOSE OF EAI.Ej. ' � ' �C�I,p50WNER Of THE PRopERTY,AM EXCLU3IYELY WMPACTIPIO WlTH LtC�ENSE��NTRACTORS y='i'� TO C�NSTRUCT lHE PP6VEGT(SEG.?044,BUSINE55 AN�PROPESSIONS GODE:TFIE CONTftACTOFS LI- V@WBTIOf1 NDJ.AREA � .,.W=I��,. CENSELAWDOESNOTAPPLYTOANOWNEROFAPWOPERTYWH99UILDSORIPrIPROVE57P1eREON,MID .. � � 4MiOCONTRACTSFOqSLCHPROJECT5WI�IA�B'RACTOil(S)LICENEEDPURSUAfdTTflYHE:ANTRAG (]9J,qNTITY DESCRIPTION FEE . � ..Y,I..:. TORSIJCENSEtAW.). . — . . i, �� ❑I AM EXEMPT UND6R SEC. 0.&P.C.FOR THIS FEASON Q ' � U ¢ � Z onr= owraER F— w �, ����� . � L10EN3ED GONTRACTORS DEGLARATI�N �y � ' � � � � , ''� 1 HEqEBYAFFlRM UN�EA PENALTY OF PEpJURV THAT f AM LICENSED UNDEfl PROVISIONS OF CHAPTER � o s 9�T'� T'27 B(COMdAENCIN(i WITH SECTION 7UNJ)OF DP/ISfON 30F TNE BUSINESS AND PROPESSIONS CADE,AND � !ev- i r //L�. MY LICENSE IS IN FULL FORCE ANyD E CT. i m I, � LICENSE CLASS �y�"��/ tfC.NO. - �L ��/a� � � �� ���� .�ATE ���'s��—��f�'b' CONTRACTOR �"�` � I W ��— �' �� WORKEfiS'COMPENSATION DECLARAT!OPl --� ��., .� I HEREtlYAFFIRAA UNDER PENALTY OF PEPoJURY ONE OF THE FOILOWWG DECLARATIONS: @�' I� �.�� �I HAYE hND YViLLMA9NTAIN A CERTIFICATE�Df CANSENTTO SELF-INSURE FOR WDRKEAS' =li COMPE N,A5 PROVI6E0 BY SECTIDN 3"/W OF TNE LABOfl WDE,FOR THE PER WRMANCE LU � O WORK FOR 1NHICH TH;S PERMIT IS�SSUcD. ���, �� �'�' _IHAYEANDWII164AIN7AINWORKEFS'COMPENERTIDNWS N ASREQUfR[DBYSECTION �, � 97WOfTHE � F.rGF,THEPERfCR OFT FORWHICHSHI£PEFtAiIT15 , OSSUED.AIY ORI( S'CAAVPENSATSONINS Al! CA OLICYNUMBERAFlE: CONSIRUCTION . ��I �.. " _ _ i �; CAARiER PLAN REVIEW _ �', ���� POLacYNUMeEa___ �/i�`1'9a.a�w%s�A �' ELECTRVC I �: . °o s •r as�C.a�.—'" . i � (1H5SEt,'T10NNcH)NOT�E�Lf1EDOF7}¢,�'EPMRIS EH�I FEDCC 5(5100)OFLE55� PLUMBiNG � ff�. II � ICEAYBFYTHATINTHEPEpFORMANCEOFTHEV'dOR WNICHT SpER IYISISSUED.i MECHRNICAL �i (f S1iA4t NOT EMPLAY ANV PERSON IN ANY M NE O TO BE SU9 CT TO THE . 'I vy wos�KFr�,s�coMaENSAr�oNuwso�c wa .,-a I IS OUlOBECAME INSPECTIONFEE �i � SU6JECTl'O THE WfARKERS'COMPEN ATION P E ION 00 OF THE LABOR ' , � coo�;iswr+u.FowrH I'fiiCOBiPLY i �cv io s. ISSUANCE a SMIP II � OATE:,��APPLICAN7 � �� �':. WARNINGFAILUHETbSECUP.EWtlRKERS'COM SA?IO OVEiiAGE15UNLAWFUL,ANOSHALL6E ENcRGYPlC I '� SUBJECTANEMPLOY�ftTOCRIMINAIPENALTIES .LFINESUPTOONEHUN�REDTHOUSAND ENERGYPERMIT DOLLARS(510D,ODC).IN ADflITION TO THE COSTOF COMPENSATION,DAMAGES AS PROVIDED FOR W jl ,� SECTION37nBOFTHELABORCODE,IN7ERE5T.ANDATTOANEY'SFEES. RETENTIONFEE: ��¢�,. CONSTRUCTION LENDING AGENCY PRE-ALT FEE: O ����,�' IHEREBYpFFIRMUN�ERPENAI.NOFPERJURYTHATTHEREISACONSTRUCTIONLEN0INGAGENCY �, FORTHE PERFOflMANCE OFTHE W'ORK FOR WHICH THIS PEflM{T IS ISSUEO(SEC.3097,CN.G}. . I ',LS'�J.' . . I ���� LF.NDER'S NAME __ � � � �F�, . 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