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HomeMy WebLinkAbout13986 (16) . .... . . .. . :. . . _._�._ : .. .. ... . .�,.'.F -;... . ' .. . .... ' .. . : . ', . CITY OF DIAMOND BAB t--��� -----��i DEPARTMENT OF CdMMtJ1vITY&DEVELOPIVIENT SERVICES � � w . 21660 E Copley Dnve Sarte 190 , (909)8b0-3195 Fax(909)861-3117 �. o�.., BUILDTNG 1'EY2MiT APP�.TCA1'ION " . . µ:: $ F��Y , ,.. ..,�. ....�._. w ,.. . , .�..:� . . ,; �: :.,. �„ � JOBSITE � APPLICATION���. „�"d�� PERMIT t�� P/C A ADDRESS C� ��J�' r(:l���T,�-��'�' DATE � NUMBER�� # � ISSUE TYPE OCC APN LOT TRACT �ATE CONST. GROUP p OWNER �."a'�AI�S'Y ��/LL1P� o ADDRESS��1P�6 F�'fGi/�1�.,�i7�4�A filnD�T"'''��"y_ 20NING SETSACKS "' CI7Y D(r4/Nrs+/OO�.��P ZIP�"'"TEL.���y���s1�2. FRONT RW � � APPUCANT �Zttf1.4.l�..,lJ C�'urlS TE a REAR ❑ � �'��-�� SIDE/SIDE STREET RW ❑ � CONTRAC70R��(,� �/AMcJas�� SIDE ❑ � ADORESS"��J/ e�.a�f4d� pROPOSEp USE G_ C 81i 'T"` o cirr '(.,�i[.t� �e r-�° zi��L�2 TEL��i�l:2s"'�-�5 �,(�,�,F..�.t"' o ARCWENG/ �(6(�g z DESIGNER NO.�WEL. NO. 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FACTOR PSF ADJ.ARErWALUATION Q OWNER-BUILDER DECI.ARATION SFR/P.�D/REM O p I HEREBY AFFIRM UNDER PEN/LLTV OF PERJUqY THAT I AM E%EMPT FROM YHE CONTRACTOflS LI� G2f3 J&C01QOfL LLl CENSELAWFOR7HEFOLLOWiNGREASON(SEC.7o3t.5BU51NESSANDPROFf.SSIONSCROE:ANYdNOR (n � OWNTY WHICH REQUIRESA PERMRTOOOtdSTRUCI;ALTER,�MPRDVE,DEMOIJSH,OR REPAIR ANYSTRUC� 1URE,PRIORYO ITS I5SOANQE,AI.SO�REQUIRES THE APPLICANTFOR SUCH"PERMITTO FILEA SIGNEO W PatlO/DBCk W STA7EMENT 7HAT HE OR SHE IS LICENSE6 PURSUAN7 TO TNE�PPOVISIONS�OF THE COYJTRACTpRS ll� � � CEPoSE LAW(CHAPTEFi e(COMMENCINO WITH SECTION 7000)OF DIVISION 9 0F THE BUSINE35AND PRO� � PooVSpa FESSIONS COOE�OR THA7 HE OR SHE IS EXEMPT7HEREFROM AND THE BASIS FOR THE ALLEGEO EXEMP• TION.ANYVKK.A7KKJOFSECTION7o37.SBYA.NYAPPLICANTpORAPFqMITSU&IECTSTHEAPPLICANTTO z R@-Roaf I � ACMLPENA�TYOFNOTMORETHANFIVEHUN�flEDDOliARS(�500).�: — � ❑I,ASONRJEROFiHEPROPERTV,ORRIYEA1PlOYE�SWITHV�AGESA5THEIRSOLECOMPENSATION, ❑ CommerCidl -- WILL DO THE�WOAK,AND THE S7RUC?URE IS�NO7INTENDEp OF OFfEREp FOR SALE ISEC.7o4<;BUSI- _S � NESS ANO PROFESSIONS C06E:THE CONTMC70RS UGEN3E lAW DOES NOT APPL�TO AN OWNER OF PROPER7Y`M�bBUqD50RIMPROVESTHEREDN,ANDWHODOES5UCHWORKHIMSF.LGOANERSELFOR m OC THROUGHNISORHEHOWNEfNPLOYEES,PFOVIDED7HAT5UCN�IMP%OVEMENTSARENOTINTENDEDOR � OFFEREDFORSALEIF,HOWEVER,iHEBUIIDINGORMPR04EMEMISSO(.tlWI7HINONEYEA470FCdMPLE- y` TIDN,7H£OMrtJER-BUILDEFl WiLL HAVE 7HE BUFlDEN OF PAOVING TNAT H6 OR SHF DID NOT DUII�OR � IMPRDVEFOP7HEPUHPO5EOFSALE). � � ❑I,ASONMEROFTNEPpOPEpTV,M:F:XCIUSIVELYCONTR0.CING1NhILICENSEbCONTFIACTORS (r TO WNSTRUCTTHE PRQIECT(SEC.7o44,BUSiNE55AND PROFESSIONS�AOE:YtIE CONTRliCTORS U� V21Ua[i0tl_ ADJ.AREA W CENSELAWDOE3NOTP£PLYTOANOWNE'ROFAPROPERTVWNOBUIL650RIMf-'ROVESTNEPEON,AN� -- F� WViOCOIdfpACTSFOqSUG{ppp;ECTSWITf{qCONTRACTOR(5)LICENSF.DF'URGUANTTOTHEbONTPAC- QiJqNT1T1' DESGRIPTION PEE � TORSUCENSEIAWJ. _ ... o ❑1AM EXFMPT UNDER SEC. "_ N.&P.C.FOa THIS PEASON Q C7 , � ,, GC � oarE owwEa---- °�'l-- �;p � �!'_.M � LICENSED CO�ITRRCT.7RS DECU1RA710f3 �( � I HEdiEBY qFF{fl!R UIVDER P[iVAI,TY OF?ERJURY THAT 1 AM L'�CENSEO UNDER PROVISIONS OF CHAPTER � � 9(COMMENCINGWITHSECTION7o0u�OFDiVI5lON30FTHEAU51NG55ANDPROFESSIONECO�F.,AND -� Z _ �_ Xu MY UCENSE IS IN FULL FO(iCE AND EFFECT. � LU �p� 0 LICENSE C s 2k7 t;o.�{rs i.ic.No.�,.,±_C_L i�� . . . . � .a��t___s2_� J V DATE ��__,_ CONTMCTOR.�� f � W � WORKERS'COMPFiJ3ATiQPd DECIARATiON �a c ,3'Z;j.� S'T't,'C. L � IHEREBVleFFIRMUNDERPFNRLTYOFPERIURYON60FTHEFOLivlhh4GDECiA4ATIONS: ,iZ �i�,d. . .. .. ��.� !r�' � "._IMAVEANDWILLMAINTAINACERTtFlCATECFCONSENTTO^eELF-INSUAEFORWORKcRS' 2 - � ' COi.1PEN5ATIOk.ASPflOViOE�BYSECTIOfV37006FTf�ELAB(SFlCO�F..FOFlTH�PERFOFIA+,ANCE � OFTHE WOFK FOR WNICH TNIS P�EFIIlAIT IS ISSUED. � - . � - ISSUED.MYWORXERS MPE.NSP,T,�IONIWSIi�IANCE � � n W �iHAYEAN`JWIILMHIA"'.51N'NORKERS'COMPEH�AT!O��fN6URANCE,ASREQI/R[OBYSECTION � � '' �r " ' ns7ao OF THE LA80P.C6DE,FOR riiE CcAFORMANCE�F iNE WORK FOR W41CH Thl'S PERlAIT IS ��L `C'A/R�R�I�_L^R AfNf]�P641CV NUMBLR AflC; � CONSTRl.JCT��N � __��_la����- T'�� '!�T� /C:7M'� PLAN REVIEW ' , �. CARRIFR � voucY4UMBER_Q,�,.�C���PL�__�,_ EIECTRIC Z ---.— �K o� Cruss[c�rvwE�Hc7sFar,��oovn-.er��rar�s�aaeHuu�ame�wsry�ae)oa�ss;. PLUMSING Z t CE47T1FV THAT IN THE PERFORMdNCE OF THE VMJftK FOfl WHICH THIS PERMIT IS�SSUED,I MECHA�N�cA� '� (S SHALL NOT EMPLOV ANY PERSON!N fiNV MANNEFl SO AS?O BECOME SUBJECTT6h1E � WOFKERuCOMPENShTIONL4W50fCALIF'OFNIA,ANOAGqEETHATIFISHOULDBECOME INSPEC?IONFEE � SUB.IECTTOTHEWORKERS'COMPEIJSATONPRO�/'� NS F EC71ON37o00F7HEV�ROfi A ` COO,ISH FGRTHWITHCOMPlY1MhiTHOS R I N. ISSUANCE � � � SMIP p DATE: � APPLICANE � ---- J WAPWNG:FAILURE TO SECUfiE N'ORKERS'WMPENSATION COVE`GE IS UNLAVlfUL,ANO SNAIL BE ENERGY P!C Aq LL SU&IECTANEMPLOYEPTOCRIMiNALPeNALTiESANDCMLFiNESUP7'OONEMUNDREDTHOUSAND ENERGYPERMIT w�3��--� � §?`�;+,'� �OLI.ARS({100,D00),IN ADDITION TO THE COST OF COMPENSATION,�AMAGES AS PROVIOED FOq IN � SECrI�N37080FiHELABORCODE,INTEREST,ANDAT70RNE1"SFEES. RETENTIONFC`�G`' __ .. . .. .._, LLl �r��� A".:.e';,.i'�.i:'�:`'u..F.'4:i.8 i.bd",.n�. a CONSTRUCfION LENDING AGENCY PRE-ALT FEE: . _ _ . � IHERFBYAFFIRMUNQERPENAl7YOFPERJURVTH0.TTHEREISACON5TRl1CTIONLENDINGAGENCY ��� ��� �ex ���' 4 �'��� ' � FOR THE PERFOfl1AANCE OFTHE WORK FOR WHICH THIS PEHMIT IS ISSUED(SEC.3097.CIV.C}. "—"-----i . � W � LENDER'S NAME _ 1— ��NOER5A�DRE55 � I CERTIFY THAT i HAVE READ THIS APPUCA710N AN�STATE THATTHE ABOVE INFOftMATION IS CORR[CT. TOTAL�EES � W IAG1iEE TO COMPLV WRH ALIqTY AND COUWTY ORDWANCES ANO STATE LAWS REI.ATING TO BUII,OING � CONSTpUC710N,ANDHEREBYAUTHOR2EREPRESENTA7NESOFTHISCOUNTYTOENTERUPONTHE � z ABOVE�MENTIONE�PpOPERTYFORINSPECTIONPURPOSES. 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