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HomeMy WebLinkAbout12585 (11) ,,> , 4,. � ; ��^ CITY OF DIAMO1tfI)BAR �� DEPARTMENT OF COIVIMUNYTY&DEV�LOPMENT SERVICES � 21660 E Copley T7nve Smte 190 (909)$60-3195 Fax(909)861 3117 PRESS ,�"`� BU�DING"P�RMTf A�'LICA'�U"N ' �Q, , _ � ��� LY . . � .v , .r FfRM o� JOBSITE � � ' , v �5� -,{� � DATE�CATION NUMBER`��#,C ADDRESS �-.�' � ISSUE� TYPE OCC APN_�� LOT CT DATE CONST. GROUP p OWNER ' ADDRESS f\'� ZONING SETBACKS � CE C�- IP FRONT RW ❑ g APPLICANT � TEL.�� S� `�7�53 REAR ❑ SIDE/SIDE STREET RW ❑ � CONTRACTOR � 5��� � ADDR� • " � ��� ���.,,�1�_� PROPOSED USE o GTY ��•�„ ZIP�% TEL.�tir�-�'2..�.53 wG ARCHIENG/ � DESIGNER NO.DWEL. NO. NO. ry, ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.FT: FACTOR PSF ApJ.AREANALUATION � OWNER-BUILDER DECIARATION , SFR/ApD/REM O 0 I HEREBY AfFIFM UNDER PENALTY OF PERJURV THAT 1 AM E%EMPT FpOM THE CONTRACTORS LI- � Garage/Carport 1 W CENSELAWFORTHEFOLLOWINGREASON(SE47o3t.58U51NES5ANOPROFE5510NSCOPE.ANYCITYOR U COUMYWHICHREGUIRESAPERMtTTOCONSTRU,CT,ALTER,IMPROVE,OEMOLISH.ORREFAIRlU1`iSTRUC• w pyiio/D9Ck w7U�IE,PRIOR TD ITS IS3UANC�E,�AL36 REQU�flE$THE APPUCANT FOR SUCN PERMITTO KILE A'�SIGNED .,dr SI'pTEMENT THAT HE OR SHE IS LICENSEO PURSUANT TO�iHE-PROV1910N8 06 PHE CONTRACfORS LI- � CE9-0SELAWI�P7ER9(COKIMENCINGWIhiSEC7lON7oo0)OFpIVISiON30iTHEBU51hY,ESS'AFibPqO- U'" Po0USp8 PEiSqNS COOE�Oq THAT HE OR SHE IS EXEMPTTHEHEPROM ANb THE BASIS FOR 7HE'ALLEGED EXEMP- TION.ANVVIOLATIOMOFSECTION7a31.6BVANYAPPLICAN7FORAPERMITSU&IECTSTHE"APPLICANTT� Z R0-ROOP � AGIVILPENALNOFNOTMOflETHANFIVEHUNDREDdIXAARS(55oo),): "'" - � � ❑4��WNEROFTHEPROP£RTY,ORMVF.MPIAYEESWITNWAGESASTHEIFSOIE(%7fAPEt�SATiON, Q COtT7fI10fC19I ' MAtl DO THE YVOHN,AND THE 3TRUCTURE IS NOT INTENDE�OR'tlFFERED FOR SALE(S�C.t04d,BUSI- _.I NEa^S MA PROFESSIONS CObE:THE CONTHACTORS 410ENSE LAW DOES NOT APPLY TO-AN OWNER OF � VqpPERTYVNiO8UNA50RIMPROVESTHEREON,AN�WHODOE55UCHWORKHIM3ELFCihNERSELFOR � CG THRW6HHISORHEROWN&MPLOYEES,PROVIDEDTHATSUCHIMPROVEIAEMSARENOY7N7EIJDE�OR � � OFFEREDFORSAL6IFHOWEYERhIEBUIL�INGORIMPROVEMEN7'ISSOW'NiTMN4NEYF1iR4FCaMPLF• � TION,THE OWNER-BU0.AER WIl1 NAVE 7HE BURDEN OF PROVING 7HAT HE OR SNE pID NpT BUILD OR � IMPROYEFORTHEPUflP0.5EOFSALE). �� � -�` � O I.ASOWNER Of THE PPOPERTI;AM EACLUSIVELV COMRACTING W�tN LICENSE�C�ON7RACTOR5 � TO CONSTRt1CT TFIE PRQIECT(SEC.7041,BUSINE55 ANO PROFESSIONS CODE:YHE COfJTRAC�'OR$li- Valueti0ll ADJAREA � CENSEUWDOESNOTAPPLYTOANONMEROFAPROPERTVWHOBUILP60RIMPROVESYHEREpN,AND WHOCONTMCTSf-0RSIIiSIPRnIECTSWITHACOMRACTOfl(5)LiCENSEOPURSU0.NTTOYHECdhITiiAF pUANTITY DESCRIPTION FEE � • T0193LICENSEUW.F .. . L "'i 0 ❑IM1 EXEMPTUtmERSEC. 8.8 P.0.FOR7HIS PEASON U � _ Q � DATE OWNER U � LICENSED CONTRACTORS DECLARATION � � w IHEFE9YAFFIRMUNDERPENIU.TYOFPERJURYTHATIAMLICENSEDUNDERPflOVI510N50FCHAPTER � p,,, e(CAMMENCINOWITHSECTION7aoo)OFDNI510N30fTHEBUSiNESSAN�GROFES510M1ISCODE,AND y� X MY LICENSE IS IN FULL FORCE AN�EFFECi. � `�_�_� � � � � LICENS G4AS _ LIC.NO. . +•' , � J l � � V pq7E � CONTRACTOfl _ _ n- W � � OFKERS'COMPENSATION DECLARATION �� �� � � IHER�VAFFIRMUNDERPENALTVOFPERJURYONEOFTHEFOLLAWING�ECLARATIONS: � � Z Q 0 _IHAVEANOWILLMAINTAINACERTIFICA7EOFCONSENTTOSELF-INSUREFORWOR ERS' S - � COMPENSATION,AS PROVIDED BY SECTIDN 37POOFTHE LABOP CODF,F�R THE PERFORMANCE W ___� � OFTHE WOftK FOR WHICH THIS PERMIT IS ISSUED. � � , W --� I HAVE ANO WiLLPMIM0.IN WORNERS'COMPENSATION INSURANCE,AS REOJIPED 0Y SECTION 4 37aoOFTHEU180flGODE.FORTHEPERFORMANCEOFTiEWORKFORWHICHTHISPERM1Ti5 193UED.MY` EArS'�COMPENSATI NINSURANGF\CAsR��Po AN POLI4VNUMBEH RE:� CONSTAUCTION j cnARiER�v .��1.��,��_i.�Sa � � PLANREVIEW Z POLICYNUMBER � ...._ __�� ELECTRIC .,� rr Q (iNISSECIIONNE�NDTBEWMPLEfED�FTHEPERhtlTISFOROh'E NDRE� (SimlbR PLUMBING .,� Z ICERTIFVTHATINTHEPERFORMANCEOFTHEWORKFORWHICHTHISPERMITIS SSUED.I MECHANICAL Qy�����Q'�tY"7SeA T'1 (� SHALLNOTEMPIOYANYPERSOtJ�NANYMANNERSOAST08ECAMESU&IECTTO7HE � WORKERS'COMFENSATIONIAWSOFCALIFOPNIA.ANDAGFiEE A71F15HOU109E ME INSPECTIONFEE .� ^ � SUBJECTTOTHEWO(iKERS'COMPENSATI PROYI51 NSOF ECTION OFTH BOii �SSUANCE �,��,` Yi���t CAOE, SHApL�L NTHWITH COMPLV W� TH SE P tON � p DA7E: V' APPUCANT: _.. - SMIP 7 . . O �� W ENERGY?/C � WPANING FA1 URET SECURE WORKERS'COMPENSA710N COVEAAGE ISUNLqWFUL,AND SHALLBE �'�J' � SU&IECTANEMPLOYERTOCi11MINALPENALTIESPNDCIVILFINESUPTOONEHUNDREDTFiOUSANO ENERGYPEf1MIT �■Y� �OI.LARS({100,000�,INl�DITION TO iHE COST OF COMPENSATION,DAMAGES AS PROVIDEb FOH�N J SECT�ON 37oe OF THE LA60R CODE,INTEREST.ANO ATTORNENS FEES. RETENTION FEE: - Q p�_, CpNSTHUCTION LENDING AGENCY PRE-ALT FEE: �` O . ..,... ... . � I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGFNCV' -� - � FORiHE PERFOHMANCE OF THE WORK FOR YJHICH THIS PERMIT IS ISSUED(SEC.3097,qV.C.). . Q;1 W � j'�F� � LENDER'S NAME / - F- LENDER'SADaRESS � C Y � ICERTIFYTHATIHAVERFJI�THISAPPLICATIONANDSTATETHA7TNEABOVEINFORMATIONISCORRECT, TOTAL FG�S w I AGREE TO COMPLV WITH At1 CITV AND COUNTV ORDINANCESANO STATE L0.WS REIATMG70 H111L01NG �� � CONSTRUCTION,AN�HEREBYAUTFtORIZEREPRESENTATIVES�OF'THISCOUN7YTOEIJTERIIPONTHE , z PBOVE�IAEMIONED PROPERTV FOR INSPEClqN PURP ES; ,� � � / �� COMMENTS - � ' � " �� � � l�J�f� u 'I m PERMITTEE NAME(Pftl � �� I� � SIf9NA7UREOF PE I E - DATE � ' � � ��� = r' - - �� RECPT.NO. PAID BY VALIDATION ~ WHITE—Department Copy.YELLOW—Finance Copy,PINK—Assessor Copy,GO�DENROD--File Copy,GREE AppliranYs Capy ��� � � ��� � � : � m��� ' k . � �s � � � E � ��� . .: .. . � .:.. .. �,., ...... ... ,!;.. .. . .-�-: . .. � .��;.: : .. ,... . , . .:... . . .�R . . _ �' :::- .. ..,.. .. ( ��?���'� . E ( F�C�a`��J�I�'" � s €�"'� t i°`1-���c����g:� i• ,�_—+—._� #- ��Ef�Ft ��'2��' `_. a._, ___� � � .._._. }.. 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