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HomeMy WebLinkAbout15435 (23) _��_ CITY OF DIAMOND BAt� j� — DEPARTMENT OF COMMUNTf Y&DEVELOPMENT SERVICES ` � , 2is6o E.c.�iey�;�e s�c�190 PRESS ,�;.., . (909)860-3195 Fax(909)841-3117 ;, Bua..n�vc P��amr n�p�;Acn�rio�,... .;. . ;. , ,. FIRMLI�. �4��( �l� � ,G��� } ` _. . � JOBSITE ,�-I � APPLICATION . �ERMIT PIC ��„_;�� � p ADDRESS ' A� DATE �� NUMBERI� 35 # � ISSUE [� TYPE OCC APN LO,T_-�-/� TRACT ____ DATE_P CONS7 ' GROUP p OWNER �-%�'F�'`-�l..,V N� � ' ADDRESS--��-_+,�-�- ZONING S TBACKS Z CITY � ZIP TEL. REAR RW C] g APPLICANT TEL. SIDE/SIDE STREET� RW ❑ � CONTRACTOR G� � SIDE ❑ ADDRESS PROPOSED USE 'f(�'���-' f� � CITY ZI d� TEL o ARCH/ENG! � DESIGNER NO.DWEL. NO. NO. ADDRESS UNITS STORIES BEDROOMS � C17Y ZIP TEL. y pESCRIPTION SQ.FT. FACTpR PSF ADJ.AREANALUATION � � OWNER-BUILDER pECLARATiON . SFR/A�DIREM O � I HEPE6Y AFFlR.1 IINDER 7ENALTY OF PEP.JURY THAT I AM D(EMPT FROM THE CONTRACTORS U� � Garage/Carport W CENSELAWFOPTHEFOLLOWIN6REASON(SEC.7031.68USINESSANOPROFESSIONSCADE:ANYCITYOR � COUNtYWHICHREQUIRESAPEHMttTOCONS7HUCT,AITERIMPROVE,DFAtOLISH,OfiREFAIfiANVSTRUC� w pyti0/DeGk TURE,PRpR TO ITS IS3UANC�►LRO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE'A S�GNED .�.. .jr STATEMENT THAT HE OR SME i5 LICENSED PUR9UANT Tb htE PROVISIONS Of THE C6N'fRAC70fiS LF -� �� � � CENSELAW(CFUPTER 9(COMEIENCINO WITH SECTION 7000j OF�IVISION 9 OF THE BUSINE55 AN�PRO� U'" PDOUSpB FESSIONS OO�E�OR THATHE OR 3HE 19IXEMPTTHEREFROMI ANp THE BASIS FOR 7HEALLEGED E%EMP- TION.ANYYIOLA710NOFSECT�ON,.7IXi1-6BVANYAPPLICAIVTFORAPERMITSUB:IECTSTHEAPPLICANTTO Z RB-RODf � ACIVILPENALTI OF HOT MORETIiAN PNE HUNDFiE�OOLI.ARS(l500).�: . , � � ❑t,ASOWNERQFTHEPROPERTY,ORMYEMPl.OYEESW17HWAGESASTHE�R50LECAMPENSATION, G� Commercia� WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENOfiD OR OFFERED FOR SALE(SEC.YbOd,BU$4 J NESS AN�PROFESSIONS GODE:THE CONTRACTORS LICENSE LAW�OES NO?APPLY TO AN OWNER OF � PROPER7YWIWBUXOSORIMPROVEShIERE�N,+�N�N�F�ODOESSUCHWORKHIliSELFORHEtiSE�fOq � Q THRIXIOH HIS OR MEROWN EMPLOYEES,PROVIDED THAT SUCN IMPROYEMENTS ARE NOT INTENOED OR QOFFEREDiORSALEIFHOWEYERTME8U1DINdONIMPROVE,MENTISSOIDWRHINONEYEAROFCOMPLE Z �TION,THE OWNER-BUILDER WILL HAVE THE BUR�EN OF PROVIN6 TriAT HE OR SHE Dlp NOT;BU�LD OR = IMPi�VEFOFlTHF_PURPOSE�SAL�. w pI.A90WNEROFTHEPROPERT;AMEXCLUSIVELVCAN7RACTINOWIhILICENSEQCONTRACTORS S �'+i�-^^' qDJ.AREA W CENENUWWESNOTA�PPLYTOANONRJEROFAPpOERTYWHOSU�ILDSORMPROYESTHEF�ON,ANO valuaticn � YVFIOCONTRACTSFORSUCHPROJECTSWITHAC4N7'RACTOR(3;LICENSEDPURSUANTTOTHECONTMG QUANTITY DESCRIPTION . �� ' � FEE � Y roas ucaase uw.�. � J (-,� 0 ❑tAIA EXEMPT UNDER S�C. 8.8 P.C.FOR THIS FEASON � V^, 3 Q ' ' � OATE _ OWNER_._ V Lll �r[ UCENSED CONTRACTORS DECLARATION �j _ p[ 1 HEREBY AfFIflM UNDER PEN�l.TY Of PERJURY THAT IAM LIC6NSW UNDER FROVISIONS OF CHAPTER � ,�, d 9(Gb61MENGINOWITHSECT10N7000�OFDIVISION30FTFiEBUSINESSANDPROFE5510N5CACE,AND z � X MVLICENSE i51N FULI FORCEAND EFFECT. � o� U `� LICENSE CI.ASS `-�'~�� LIG.NO._�?��y�_ J a ' V pq'�_�_��a^`�v�l ` CONTHACTOR_���`.."(�L 0. W _. � WORKERS'COMPENSATIpN DECLARATIpN r � � IFiF.REBYAFFIRMUNDERPENALTYOFPE(iIURYONECFTHEFOLLOWMGDECLARATIO�S: ' Cd� a CJ _I HAVE M1D WIL:MAMT.VItl A CERTIFIGATE OF CONSENTTO SELF-INSURE FOR WOqKERS' T � COMPEN60.TION,M16PROVIDWBYSECTION3'1000F7HELABORCODc',FORTHEPERFOpMANCF w _ O'THE WORK FOii WHlCH Th115 PEtiM1T IS ISSUEO. ra f� __I k1AVEAND WILL MAIRITAtN WORKERS'COMPENSATION INSURANCE.AS REOUIREO BY SFCTION sr' ��p�, � 37a0 OF TME IABOR CODE,Foq TME PERFORMkNCE OF THE WOPot FOF WHICH THIE PEPMIT IS - ,��o G� o ' ISSUED.MY WORKERS'COMPENSATION INS,�UR,A�N�CE�CARflIERAND POLICV nUMBERARE: CONSTRUCTION _ � CARRIEP����--"""�-_�� PLAN REVIEW�� .,, � � p�tcr Nun+eEA,.� e.'�" r���".� ELECTRIC a� , � (iHISSE(.TIONNEH7NOT9EOJA9PLEfEDOF7tiEF'Et�i'ISFORCiJENUPDRE�COilARS(51W)ORIESS} PLUM9�f,�`°3,"1'6J� + � _�i �g � 1 CEflTIFV THAT IN THE PEfiFORMANCE OF THE WORK fOR WHICH'fH15 PEftM1T IS ISSUE0,1 MECHX�.�1�G�i �yl ���L` � �}' SF#ALLNO'fEMPLOYANYPERSqdINANYlAANNERSOASTOBECOMESUBJECT70THE �'�"�-��9� , �S'�� � WORKEHS'COMPENSATIONLAWSOFGALIFORNIA,AND�REETHATIFISHOULDBECOME INSPECTIONFEE SU&lEC7 TO TNE WORKERS'COIAPENSATION PROVISIONS OF SECTION 3700 OF THE LA9OR � CODE,I SHALL FORTHYV17HCqNPIV WiTH TNOSE PROVISIONS. �SSUANCE ` a ��)�'�� `� A�,,r'a SMIP Q OATE:�—l�`SL�.� APPLiCANT. _ .._ J ENERGY P/C ---�-__--- —_- � WARNING:KAIWRETOSECUPEWORKERS'COMPENSAiIONCOYER GISUNLAWFUL,ANOSHALLBE � SU&IECTPNEMPLOYEFTOCRIMINALPENALT�ESANDCIVILFMESU TOONEHUNDREDTHOUSAN� ENERGYPERMIT DOILARS(4100.00DJ.PI ADDITION TO THE COSTOF COMPENSPTION.�AMAGESAS PROVIDED FOR IN � SECTION37CBOFTHEU80RCODE,INTEREST.ANDATTORNE�"SFEES. RETENTIONFEE: _�y� r..�����a�y� � � CONSTRUC710N LENDING AGENCY PREALT FEE: /1 ..--./ � � Q e ' . . . . .. _.. . � I HEREBV AFFIRM UNDER PENALTYOF PERJURY THAT THERE IS A CON57FUCTION LEN�ING AGENCY �gr� FOR THE PERFORMANCE OF THE WURK FOR WHIqi THIS PERMIT I5 155UE0(SEC.3097,qV.C.), �-�y`,,,,. . Z � LENDER'S NAME y�`,. F_„ LENDER'ShODRE55_ - �.��,���//'�� � WICERTIFYTHATIHAVEREADTHISAPPLICATIONANDSTATETNAT7HEABOVEINFORMATIONISCARRECT, TOTAL FEES � � �� `/ ' _ �: :. � IAGREETOCOMPLVWITHALLCI'YANDCWNTYORDINANCESANDSTATEIAV✓SREL4TINGTOBUILDING - � CONSTpUCTION,ANOHEREBYAUTHOPIZEREPflESENTATIYESOFTHISCOUNTYTOENTEflUPONTHE � . . � ABOVE�MENTIONEO pROPERTV FOR INSPECTION PURPOSES. COMMENTS �� � �'�,..-�"+�.�°i. l � __'�- ___{:������]��� m —_ U " - = — _ . 51(iNATUqEp P�INT) • Q PERMITfEE NAM.. .-.. .1 V. ,,, g.., _,: .., .. . . [n ....., ... ,_ .. . .,........ ����_0.s� ... �7 _' �Y E �: ' rE RECPT.NO. 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