HomeMy WebLinkAbout10006 (5) CI1°Y OF DIAMONI�BAI2 . � COMMUNI'TY I>EVELOPMENT I)EPARTMBNT .;,,� . 21660 E.Copley Drive Suite 190 PREf�'�J'` "•�°, BUILDING PERMIT�APPLICATION FIRM LY � J08SITE � � '. '�'� ' APPLICATION PERMIT /�0�� P!C o ADDRESS � f6� ��G��� �� DATE��_��!�� NUMBER # � ISSUE TYPE OCC r- APN LOT TFACT DATE CONST. GROUP Z OITYN�S �lJo �f�� /�L�EL. S'T ZONING SETBACKS .;_..:.,. ; :,, . ,. w FRONT RW ❑ g APPLICAN--�� TEL. S DE/SIDE STREET RW G � CONTRACTOR � S , .�_G4-�/N� SIDE C ADDRESS B Z po .4t�_�..__ pROPOSED USE � CITY�L��/� 21P � TEL.�)38a6�'ts� Q ARCWENG! z DESIGNER NO.DWEL. NO. NO. a AD�RESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � OESCRIPTION SQ.FT. FACTOR PSF ADJ.ARE ALUATION � OWNER-BL'ILDER DECLARHTION SFR/ADD/REM O p I HEREBY AFFIRM UNDER PENALTV OF PERJURY 7HAT i AM E%EMPT FROM THE CON7RACiORS LI- G8f8g0/CHfpOR - - �- " W CENSEUWFORTHEFOLLOWMGREASON(SEC.7031.5BUSINESSANOPROFESSIONSCODE:ANVCIT'OR (n C3 COUNTYWHICHRE�UIRESAPERAIITTOCONSTLiUCT,ALTER,IMPROVE,DEMOLISH,ORREPAICiANYSTHUC- W Patio/Deck � TURE,PRIOR TO ITS ISSUANCE,ALSO REOUIRES THE APP�ICANT FOR SUCH PERMIT TO FI�E A SIGNED W � 57ATEMENT 7HA7 HE OR SHE IS LICENSED PURSUANT TO THE PPOVISIONS OF THE CONTRACTORS LI- � CENSE LAW{CHAPTEH 9(CbMMENCING WI7H SECTqN 70Do)OF DIVISION 9 OF THE 9USINESS AND PR0. � PooUSpa Q FESSIONSCOOE)ORTHATHEORSHEISEAEMPTTHEREFROMAND7HEBASISFOP7HEALLEGEDExEMP- U TION.ANYVIOLATIONOFSECTION7031.SBYANYAPPLICAfdTFORAPERMITSU8JEC7STHEAPPLICANTTO Z RB-R001 � ACIVILPENALTVOFNOTMORETHANFIVEHUNDREDDOLLARS(5500)�.)! � ' '���-��- -'�-'-'-��� � � ❑I,ASOWNEROF7HEPROPEF7Y,ORMVEMPLOYEESWITHWAGESASTHEIRSOLECOMPENSATION. � C0�I7r�6fCi21 Z WILL DO THE WORK,ANO TNE STRUCTURE IS NOT INTENDED OR OFLERE�FOR SALE(SEC.7044,8US1- _1 NESS AND PROFESSIONS CADE:TNE COMRACTpRS LICENSE L4W OOES�OT APPLY TO AN OWNER OF � PROPERTYNhiOBUILDSORIMPROVESIHEREON,ANOWHO00ESSUCHVJORKHIMSELFORHERSEIFOR � p[ THROUGMHISORHEROYVNEMPLOYEES,PROVI�EDTIIATSUCHIMPROVEMENTSARENOTINTENDEDOR � LL1 OFFERED FOH SPLE.IF,HOW EVER,iHE BUILDING OR IMPROVEMENT IS SOLD WI7HIN ONE YEAR 6FCAMPLE � TION,THE OWNER-BUILDER WILL HAVE THE 9UROEN OF PROVING THAT HE OR SHE DID NbT BUILD OR Z IMPROVEWRTHEPURPOSEOFSALE). - � � _ ❑I,ASOWNEROFTNEPROPERTY,AMEXGLUSIVELYCONI'RACTINGWITNLICENSEDCONTRACTORS "- � TO CONSTRUCT THE PROJECT(SEC.7od4,BUSINE55 AND PROFESSIONS CA�E:TNE CONTRACTORS ll- V3IUfliiOfi ADJ.AREA W CENSELAWDOESNOTAPPIVTOANONMEROFAPROPERNWHO8UILDSORIMPROVESTHERFON,AN� � VhIOCONTRACTSFORSUCHPROJECTSWITHACONTRACTOR�S�LICENSEDPUpSUMITTOTHECONTRAC- QUANTITY DESCRIPTION FEE TORS UCENSELAW.). y�.�� � G I AM EXEMPT 11N0ER SEC. _8.&P.C.FOR THIS REASON � �� //^-^^� SW� � � aC .�'6 /X U�5 �'L" DATE OWNER �"� � z W ,�_.3 c . �., O LICENSED CONTRACTORS DECLARATION w / O� /L1�T�/� �� ' a � � I HEFEBYAFFIRAI UNDER PENALTY OF PERJURV 7HA71 AM LICENSED UNDER PROVISIONS OFCHAPTER ' . � B(COMMENCING WITH SECTION 70ao)OF DNISION 30F THE BUSINESS AND PROFESSIONS COOE,AND z � w MV IICENSE IS IN FULL FORCE AN�EFFECT. m r• � � LICF.NSE CLAS/S��,`l-—•� ���.No._ n e.� _ V DATE�/ .�'p�" .._�CONTRACTOR ��- � +� u,� � ' . . ,;:, ;:; � WORKERS'COMPENSATION DECLARATION Q � � � � I HEREBYAFFIRM UNDER PENAITV OF PERJURV ONE OF TNE FOLLOWING DECLARATIONS: � z Q � I HAVE AND WILL MAINTAIN A CEfiTIFICATE OF CANSENTTO SELF-INSU�PE F9R .S COMPENSATION.AS PROVIOED BY SECTION 370D OF THE IABOR CQDSyFOR THE PER CE 'C) Q OF THE WORK FOR WHICH THIS PERMIT IS I55U'e0. :!'�a I.� W �'� �HAVEAND WILL MA�NTAIN WORKEP.S'COMPENSATION MSURANCE,AS Q ED BV SE , � Q 37o00F THE L480R CODE.FORTHE PERFORMANCE OF TFIE WORK FOR THIS PE � ISSUED.MY WORKERS'CAMPENSATION INSURANCE CARRIER AN7 POLICY U�ABEfl ARE: � CONSTRUCTION j cAqqi�p �L'k _�"I.li�/D 't�� � PLANREVIEW r/ z POLICVNUA@ER /�-��p�a `'� EIECTRIC �7- o_ ¢ 0 (fHISSECTICNNE�NOTBEWMPLEfEDOF1FEPERI+XfISFORCt1EHUNDqEDWLLARS(5100)ORlE5S). '; PLUMBING Z ICERTIFYTHATINTHEPERFORMANCEOfTHEWORKFORWHICFITHISPERMITISISSUED,I � MECHANICAL (,J'' SHALL NOT EMPLOY ANY PERSON IN ANY MANN'cR SOAS TO BECOME SU9JECT TO THE � WORKERS'COMPENSATIONLAWSOFCALIFORAIA,ANDAGREETHATIFISHOULOBECOME INSPEC710NFEE _ = SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF 7HE LPBOR CODE.I SHALL ORTHWITH COMPLY WITHTHOSE PROVISION5. / ISSUANCE o �/�,�.�_--y SMIP w �ATE:� APPLICANT. _���`"C��� � r ENERGY P/C � WARNI G FAILURE TO SECURE WOFKERS'COMPENSATION COVERAGF.IS VNUWFIJL,AN�SHNLI BE �y SUeJECTAN EMPLOYERTO CRIMINAL PENAL7�ES ANO CIVIL FINES UP TO ONE HUNDRED THOUSAND ENERGY PEAMIT DOLLARS�S�Oo,000).IN ADDITION TO 7HE C0.5T OF COMPENSATION,OAMAGES AS PqOVIDED FOR IN J SECTION 37oB OF THE LABOR CADE,�NTEflEST,AND ATTORNEY'S FEES. RETENTION FEE: � d CONSTRUCTION LENDING AGENCY PRE-AlT FEE: � 1 HEREBYAFFI0.M UNOER PENALTY OG'PERJURV THAT THERE IS ACONSTRUC7IDN LENDING AGENCV � FOR THE PERFORMANCE OF THE WORK F-0R WHICH THIS PERMIT IS ISSUED(SEC.3087,C�V.C.). Z W � LENDER'S NAME _. F-- LENOER'SADORE55 - -. . , , � �. � ICEATIFVTHATIHAVEREAOTHISAPPLICATIONAN�STATETNATTHEABOVEINFOPMATIONISCORRECT. TOTAL FEES �� � � � '�� � IAGREETOCOMPLVWITiiALI.CITYANDCOUNTYORDINANC�SANQStAiElANSREIATIN6TOBUIL�ING �- � ��, „ _ � CANSTRUCTION,�AND`HEREBYFUTNORREREPqESENTATIVESOPTHISCWI�Ii1'70ENTEfiU70tJTHE � ABOVE�MENTIONEDPROPEHTYFORINSPEC7iON�PURPOSES. COMMENTS � � = C�ET i�, �G4•�v�'- ;., m PERMI EENAMElPR1N � . �'- � . ,. u� ' :,._�"�.. , .. �'..�,; ���/9 7 . �., i i �:'�. � SIOHATUREDFPERMIjR-�--� __�__ �__� '_ _ _ � .4 �,,..,, RECPT.NO. 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