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HomeMy WebLinkAbout17184 (23) _J��_ CITY OF DIAMOND BA& � DEPARTMENT OF COMMLTNITY&DEVELOPMENT SERVICES _ w , 21660 E.Copley Drive Suite 190 ",__.,.,•� (909)860-3195 Fax(909)861-3117 PRESS "��' BUII,DING PERMIT APPLICAI'ION FIRIUr�� . .� ,._ ., , ,,, . .. , . .,:ry,h.�:. , o� JOBSITE ��/_���� 1, 9�y� Q 1'� APPLICATION f(1 �--�� NUMB R � #/C ADORESS r� �/��'c� �-•� DATE 4� i �� � ISSUE 7YPE OCC APN T TRACT DATE CONST. GAOUP p OWNER _ p ADDRESS ZONING SETBACKS W FRONT � CITY & ZIP TEL. �' _ REAR Rw ❑� APPLICANT EL. SIDE/SIDE STREET Ryy ❑ � CONTRACT R SIDE � ADDRESS p ��Ty �y��r , Z�P ry� � PROPOSED USE oARCWENG/ z DESIGNER ,� ADDRESS UNITS EL STORIES BEDROOMS � CITY ZIP TEL. cr� cn DESCRIPTION SQ.Ff. FACTpR PSF ADJ.AREANALUATION � OWNEF-BUILDER DECLAPATION SFR/ADDlREM O p 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM E%EMPT FRDM THE CONTRACTORS U- `�`gfage/Cd(�')ofi LiJ CENSEUWFORTHEFOLLOWINGREASON(SEC.7031.5BUSINESSANOPROFESSIONSCODE:ANYCIT'OR (� V CqUNTYWHICHREWIRESAPERMITTOCON$TRUCT,ALTER,�MPROVE,OEMOLISH,ORREPAINANYSTRUC- W P8I10/DBCk W TI1HE.GRIOR TO ITS tSSUANCE,QSO REDOIRES 7HE AVPLICANT FOR SUCH PERMIT TO FILE A SIGNED W � STATEAAENT THAT HE OR SHE IS LICENSED PURSUANT TO 7HE PROVISIONS OF THE CONTRACTORS LI- CENSE tAW(CFiAP7ER 9(COMMENCINO WITH SEC'fION 7000)OF DIVISION 3 OF 7HE BUSINESS AND PRO- LL' PoOVSpB FE6SIONSCODE)ORTHATHEDRSHEISEXEAIPTTHEFEFROMANDTHEBASISFORTHEI1LlEGEDE%EMP- � TION.ANYVIOUTIONOF3ECTION7oJ7.5BVANYAPPUCANTFORAPERMITSU&IEGTSTHEAPPLICANTTO Z Re-Root � A CML PENALiY OF NOT MOHE THAN FNE HUNDRED OOLIARS(SSaOJJ: � ❑�,ASOWNEROFTHEPNOPERTY,ORMYEMPLOYEESWITHWAGESASTHEIRSOLECOMPENSATION, � CO(Ortl8fci81 - YVILL DO THE WORK,AND THE STRUCTURE IS NOT INTENpEO OF OFFERED FOR SALE(SF_C.7044.BUSI- J � NESS AND PROFESSIONS CODE:THE CONTRACTORS LICENGE UW DOES NOT APPLY TO AN OWNER oF PROPERTYVhKlBl10.DSORIMPROVEShIEREON,AN�WHO�OESSUCHWOPKHIMSELFORFIERSELFOR � � THROl1(3HHISORHEROWNEMPLOVEES,PROVIDEDTHATSUCHIMPROVEMENTSARENOTINTENDEDOR m Q OFFEREDi'ORSALEIF,HOWEVER7NEBUILOINGORIMPROVEMENTISSOLOWIiHINONEVEAROFCOMPLE � TION,THE OWNERBUILDEfl WILL HAVE 7HE BURDEN OF PROVINO THAT HE OR SHE DID NO7 BWLD OR MAPROVE FOqTHE PURPOSE OF S/LLE). W ❑I.ASOWHEROFTHEPROPEHTY,AMEXCLUSI'JELYCONTRACTINCWIiMLICFNSEDCON(-RACTORS ¢ TO CONSTRUCT THE PROAECT(SEC.7W4,BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI- VAI113110f1 _,ADJ.AREA 41J CENSELAWDOESM7TAPPLVTOANOWNEROFAPROPERTVWHOBUIL�SORIMPRQVESTHEflEON,ANp � WFIOCONTiiACTSFOFlSUCHPR0.IECTSWITHACONTRACTOR(S�UCENSEDPURSUANT707HECONTMG QUANTITY DESCRIPTION FEE � TOiLS UCENSE UWJ. 0 �IAM EXEMPT UIJOER SEC._. B.8 PC.FOR THIS RE4SON Q � V W � _ DATE _OWNER M— 0 — W � LICENSED CONTRACTORS DECLARATION W � I HEREBY AFFIRM UNDER PENALTY OF PERJUHY THAT 1 hM LICENSED UNDER PROVISIONS OF CHAPTER �, d 9(COMMENCIN(3WITHSECTION7000)OFDIVISION30FTf1E8USINESSANDPROFESSIONSfA�E,AND Z p MV LICENSE IS IIJ GULL FOFCE AND EFFECT. � � UCENSE C �J LIC.NO._�_��� _ � V DATE �j_'�__ CONTiUCT6R__ � „�_ a W � WOfiKERS'COMPENSATION DECLARATION Q � I NEREBY AFFIRM UNDER PENALTY OF PEfUURY ONE OF THE FOLLOWING DECI.ARATIONS: z � __I /WOWILLMAINTAINACERIIFlCATEOFCONSENTTOSEIF-M3UREFOFWORIfEFS' a — PEWSATION,AS PROVIDE�BY uECT14N 370o OF THE IABOR CODE,FOA THE PERFORMANCE U p OF 1HE WDAK FOR WNICH THIS PERMIT IS ISSUEO. � � __i HAVE/WD WILL MAINTAIN WORKEP,S'COMPEN. TION INSURANCE,AS REOt11RED BY SECTION Q37000f THE 1A80R CODE.FOq7H[PEAFORMA CE OF 7HE WORK FOR WHICH THIS PERMI715 � ISSUED.MY WORK S'�M/'PE�N'S�AT!ON INSUF F CAPRIEP.AND POL'CY NUMBFR ARE; CONSTRUCTION ,_____ > CARR�ER__����� PLANREYIEW � POLICYNUMBeA ELECTRIC B d (IHISSECiK7NNE�NO7BECOMPLETEDOFh1EPEW�MISinRONEMADf1m0IX1AR5(ttoo)ORLES57. PLUMBING p Z I CERTIEYTHAT INTHE PERFORMANCE OF7HE WORK FOfl WHICH THIS PERMI?IS ISSUED,I MECHANICAL .....�.-�����-��;�„rr�""'� i�3 SHALLNO7EMPL YANYPERSONINANYMANNEFlSOASTOBfCOMESUBJECTTOTHE �: -�-'""f,;,-�w "'i�(�� ; i ryy, �/} WORKEfi'COMP NSATION L0.WS OF CALIFORM19A.AND AGREE THAT IF I SHOULD BE INSPECTION F [ `"� -.e�,. � � � SU&IEC O THE RKERS'C0IAPEN PROVISIONS OF SECTION 370o OF TH OR I[" �� 'R� ,I HALL RTHWITHCOMPLVWI HT ROVISIONS. ISSUANCE �' � � o � d7 g --�,� p OAlE: v ' APPUCANT: _ SMIP �_�� Q i '-� WARNING:�AILURE TC SECURE WORKERS'COMPENSAi ION CDVERAGE IS UN.AW L L BE ENERGY P.�C � J LL SUBJECTANFMPLOYERTOCRIMINALPENALTIESANOCIVILFINESl1PTOONEVRIND OTNOUSANO ENERGYPERMIl'� DOLLARS�f100,000),IN ADDITION TO THE COSTOF COMPENSATION,OAMAGES AS PROVIDED FOi71N — J SECTION3]o80FTNELA80RCODE,INTEREST,ANDATTORNEY'SFEES. � '�"��-' � RETENTION FEE:i.,..�.�n��-_�._..__--�..-----..F--'"--.._ _ . OCONSTRUCTION LENDING AGENCY PRE-AL7 FEE: �v y 0. I HEREBYAFFIRM LINOER GENALTV OF PERJLIRV THATTHERE IS ACONSTqL1CTION LENOING AGENCY FOfi THE PERFONMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUEO(SEC.3097,CIV.C.). , Z W � LEN�ER'SNAME_ - I— LENDER'SADDRESS_ � ICERTIFYTHATIHAVEREADTHISAPPLICATIONAN�STATETHATTHEA60VEINFORLIATIONISCORRECT. TOTAL FEES * W I AGREE TO COMPLY WITHALL CITY ANO COUNTY DINANCES AND STATE LAWS fiELATING TO Bl11LDWG � CONSTRUCTION,AtUHEAEBYAU ORIZEREPR ENTATNESOFTHISCOUNTVTOENTERUPONTHE zABOVE�MENTIONEDPROGERN INSPECTIO VURG0.SE5. 0 COMMENTS � m �d PE I VRIM) � � � SIGNAT OF PEFiMITTEE - DATE = RECPT.NO. 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