HomeMy WebLinkAbout14851IO D I{1R i
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CITY OF DIAMOND BAI
DEPARTA>4ENT OF COMMUNITY & DEVELOPMENT SERVICES
21660 E. Copley Drive Suite 190
909) 860-3195 Faz (909) 851-3117 PRESS
BUII1lING PERMIT APPLICATION FIRMLY
JOBSItE , + (, },
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DATECATION -' (
NUMBEF, #/
CADDRESS _ i. 'i T IfJ1 K. h C
ISSUE TYPE OCCAPNLOTTRACTDATECONST. GROUP
OWNER
ADD S 1(. ZONING SETBACKS
CITY ZIP TEI - FFONT RW
APPLICANT TEL. REAR
SIDE/SIDE STREET' RW
CONTRACT J . (,.,, 'Q j SIDE C
ADQRESS_
CITY G'n1tS-r (y ZIP G,rTEL ' 7 1a PROPOSEDUSE
ARCH/ENG/
DESIGNER
NO. DWEL. NO. Np, ADDRESS UNITS STORIES BEDROOMSCITYZIPTEL.
DESCRIPTION SQ. FT. FACTOR PSF ADJ. AREANALUATION
OWNER-BUILDER DECLARATION
SFR/ADD/REM
I HEHEBY AFFIRM UNDER PENAITY DF PEFUURY 7HAT I PM p(EMM FFOM THE CONTFACTORS U- G8f8Q9/CHffIOflCENSELAWFORTHEFOLLOWINREASON(SEC.7031.5BUSMESSANDPiiOFESSIONSWDE:ANVCITVOR (n
COUNTYWHICMNEWIRESAPERMfT7000N5TRUCT,ALTER,IMPROVE,DEM0U5H2ORREPAIRANYSTRUG W PatiO/DeCkNRE, PRIOR TO IT3 ISSUANCE, ALSO REIXlIRES THE APPLICANT FOR SUCH PERMIT TO FiLE A SIGNED W STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROV SIONS OF TNE CONTRACTORS LI-
CENSE LAW (CHAPTEp B(COMMENCINO WITH SECTION 7000) OF DIVISION 3 OFTHE BUSINESS AND PRO- Pool/Spa
FESSIONSCOOE)ORTHATHEORSHEISEXEA/PTTHFAEFROMANDTHEBASISFORTHEAllEOEDEXEMP- (
TION.ANYVIOLATqNOFSECTION7031.6BYANYAPPLICANTFORAPERMRSU&IECTSTHEAPPLICANTTO Z Re-RoofCIVILPENALiYOFNOTMOFiETHANFNEHUNDRW OLLARS (f5a0J.):
I,ASOWHEROFTHEPPOPERTY,ORMVEMPLOYEESWITHWAGESA9THEIRSOLECOMPENSATION, O Commercia WILL DO TNE riORlf, AND THE STRUCTURE IS NOT INTENDED OR OFFEREO FOR SALE (SEC. 7oU, BUSI- J
NES^s N70 PRpFE5S10N3 CADE: THE CONTRACTOflS LICENSE UW DOES NOTAPPLV TO AN OWNEP OF =
PqOPEpTY Wl10 BUILDS OH IMPROVES 7HEREON, ANU WHO OES SUCH WORKHIMSELF OR HERSELF OR
THRd10HHISORHEROVJNEMPLOYE6,PROVIOEDTNATSUd11MPROVEMENTSAqENOTINTENDEDOR m
OFFERW FOR SALE IF, HOWEVERhiE BUILOING OR IMPROVEIAEM IS SOLD WITHIN ONE YEAR OFCOMPLE-
iION. THE OWNEN BUILDER WILL HAVE THE BLIRDEN OF PROVING THAT HE Op SHE OID NOT BUILD OR
IMPROVE fOR THE PURPOSE OF SALE).
1, AS ONMER OF THE PROPERTV, AM E7(C USIVELYCOMRACTING WITH IICENSEO CONTRACTORS
TO CONSTRUCT TH[ PROJECT (SEC, 70 4, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LI- V8W2tlOf1 ADJ.AREACENSELAWDOESNOTAPPYTOANOWNEROFAPROPERTYWHOBUILDSOR MPROVES THEREON, AND
N71000MRACTSFORSUCHPROJECTSWITHACONTRACTOii(5)LICENSEDPURSUANTTOTHECONiMG pUANTITY DESCRIPTION FEETORSUCENSELAWJ.
I MA EXEMVT UNDER SEC. B. fl P.C. FOR THIS RPASON Q
U
DATE OWNER
W
LICENSED CONTRACTORS DECLARATION W
IHEREBYIIFFIRMUNDERPENALttOFPERJURYTHATIAMUCENSEDUNDERPROVI51pNSOfCHAPTER - /
9(COMMENCINO WIiM SEC7pN 7a00)Of DIVISION 30FTHE BUSINESS ANO PROFESSIONS CO E, MJD Z t l
MY LICENSE IS IN FULL FORCE AND EFFECL
Z y
m
UCENSE CLASS LIC. NO. 'J J
DATE `" ' i ' lil3 CONTRACT "+•
WORKERS' COMPENSATION DECLARATION t 4
IHEflEBYAfFIpMUNDERPENALTYOFPERJURYONEOFTHEFOLLOWINGDECLARATION' = Z
IHAVEANDNALLMAINTAINACERTIFICATEOFCONSENTTOSELF-INSUREFORWORKERS' _
COMPENSATION. AS PROVIOED BYSECTION 3700 pF 7HE LABOR CODE, FOR THE PERFORMANCE U
OF THE WORK FOR WMICM TMIS PEqMIT IS i55UED. W
HAVE ANO NALL MAINTAIN WORI AS' COMPENSATION INSURANCE, AS iiEQl11RED 8Y SECTION
3700 OF TNE U1BOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THI6 PERMITIS
ISSUED. MY WORK/E RS' COryMPEN3ATION INSURANCE CARRIER AND PoLICY NUMBER ARE: CONSTRUCTION
CARRIER {" L.k'
J--
7C,\`
n`
n„ PLAN REVIEW
POLICVNUMBER „+y, 1 !°7 1 " ELECTRIC
i
iHl55ECTI0NNE NDTBE00MPLETEDOF'f1ffPEF/MlSFORONEHJI I7R 001.lAliS($f00)ORLESSA PIUMBIN
I CERTIFV THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUEO, I MECHANICAL
SHALL NOT EMPLOY ANV PERSON IN ANV MANNER SO AS TO BEGOME SUBJEGT TO THE
WORKERS'COMPENSATIONUWSOFCALIFORNIA,ANDAGREETHATIFISHOUL BECOME INSPECTIONFEE ,r /"' ('1"'
SU&IECT TO THE WdRKERS' COMPE ATI PROVISIONS OF SE N 37W OF THE LABOR A., +`1 —
CODE,ISHALLFORTHWI7HCOMPLYW HOSEPROVISIONS. ISSUANCE /
DATE: '1- I • (Z APPLICA : - SMIP
WARNING: FAILURETO SECURE WOHKERS'CAMPENSATION COYERAGE IS UNLAWFUI SMALLBE ENERGY P/C _ R
SU&IECT qN EMPLOYER TOCflIMINRL PENALTIES AND CIVIL FINES UP TOONE HUNDfiL ousnn
ENERGY PERMIT "f`iT nr s.v mOLLARS (5100.UOD). IN AO ITIIXJ TO TME COST OF COMPENSATION, OAMAGES AS PROVIDE fOR IN .
SECTION 37oB OFTHE LABOR CODE, INTERES7, AND ATTORNEI"5 FEES. RETENTION FEE:
CONSTRUCTION LENDING AGENCY PRE-ALT FEE:
I HEREBYAFFlRM UNDER PENALTY OF PER.IURY THAT THERE IS ACONSTRUCTION LENDING AGENCY
FOR TME PERFORMANCE OF TME WORN WR WHICH THIS PF_RMIT IS ISSUED (SEC. 309, CIY. CJ.
LENDER'S NAME
LENDER'SADDRESS
ICEfiTI THATIHAYEREADTHISAPPLACATKKJANDSTATETHATTHEABOVEINFORMRTIONISCARRECT. TOTAL FEES "I I
IAGR CAMPLVWITHPLLCfiVANDCOUNTYORDINANCESANDSTAiEIAWSRELATINGTOBUILOING -"
CONS R ION, ANO HEREBY AUTHORIZE REPRESENTATIVES OF TMIS COUNTY TO ENTER UPON TNE
V-M IONEO PROPERNFOR INSPECTION PURPOSES.
COMMENTS
P I EENAME(PRINT)
f_
NATUHE OF PERMITfEE OATE
RECPT. NO. ' PAID BY VALIDAl10N
WHITE-0epartme t Copy, YELLOW—Finance Copy, PINK—Assessor Copy, GOLDENROD—File Copy, GREEN—ApplicanYs Copy
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