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HomeMy WebLinkAbout14290 (19) �r� _�� CITY OF DIAMOND BAbt �� DEPARTMENT OF COMMUNITY&DEVELOPMENT S E � 21660 E.Copley Drive Suite 140 . (909)86Q-3195 Fax(909)861-3117 PRESS ,.,... BUII.DI'NG 1'ERMIT'APPL�CA�`�O�T �°- , .�«� k ., ;,... � �,. ... ; .,. - , ._.,.,.,. ,.,�.,_ . ..F. „ _-. ,, .. ,_„ RM Y .: ,w . ., . .,.:.... y JOBSITE Q�' APPLICAT90N J (,,�, �'PERMITp �J P/C o ADDR SS. s7 � �� � OATE V 6 L�'4 �NUMBER� # � ISSUE TYPE OCC APN LOT TRACT DATE_ CONST. GROUP p OWNER ' i � ADDR 5 ZONING SETBACKS � CITY ZI � . TE . PRONt RW ❑ APPLICANT TEL. REAR ❑ � SIDE/SIDE STREET pW ❑ � CONTRACTOR r LE �'1 51D� ❑ o CDdRE S � � �"Z�P TEi. PROPOSED USE t��t ARCH/ENG/ �z,, DESIGNER NO.DVJEL. NO. NO. � ADDRESS UNITS�_ STORIES BEDROOMS � CITY ZIP TEL. c,n --' rn DESCRIPTION SQ.FC FACTOR PSF ADJ.AREANALUATION Q OWNER-BUILDEFi DECLARATION � SFR/ADDIREM O p I HEREBY AFFIRM UNDER PENALN OF PERtt1RY THAT I AM EXEMM FROM THE COMNACiORS��J- Ga1'a e/C& oR � SJ.J CENSELAWFOflTMEFOI.IOWINGREASON�SEC.703Y.5811SINESSANOPflOFESSiDNSCADE:ANVCI7YbA � 9 � CJ COUNTYWHICHREIXJIRESAP�RMITTOCONSTRUCT,ALTER,IMPRpVE,DEMOUSH,ORREPAIRANVSTRUC- W pytl0/DBCk Z 7URE,PRIOR TO ITS ISSUANCE,ALSO REOUIRES 7HE APPLICANT FOR SUCH PERMIT TO FILE A SIGNEO � STATEMENT hIAT HE pR SHE IS LICENSE�PURSUANT TO THE PPOVISIONS OF THE CON7NACTORS'L4 � . � CENSELAW(CHAPTER9(GOMMENCiN�WITH5EC710N700o)'OFDIVISbN�30FTHEBUSIN�ESSAND'pfi0� POCl/Sp0 FESSIONSCODE)ORhiATMEORSHEISE%EMPTTHEREFROM�ANDTHEBASISFOFiTHEALIEGEDEXEMP- (+� , U TION.IWYYIOLATIONOFSEC710N7031.68YANYAPPLICANTFORpPERMITSU&IECTSTHEAPPUCANT70 Z RE-ROOf � ACIVILPENALTYOFNOTMORETHPNFNEHUNDREDOOILARS(f5001J: � �I,ASONMEHOF7HEPROPERTV,ORMYEMGLOYEESWITHWAGESASTHEIRSOI.ECAMPENSATitlN, QpmmBfCi81 - � WILI DO THE WORK�NO?HE�STRUCTURE IS NOT IN7EN�ED�OR'OFFERED FOR SALE(SEC,>044,BUSI- � � � NESS ANO PqpFESSIONS CODE:THE CONTfiACTOqS I,ICENSE I,AW DOE$NOT APPLY TO AN OWNER'OF � PPOPERN WFIO BUIL�S OR IMPROVES THEAEDN,AND WF1000E5 SUCH WORK HIM$ELF Ofl HERSEIF OR � TMROUGHMISORHEROYdNEMPLOYEES,FROVIDEDTHATSUU'iIPAPROVEMENTSARENOTWtENDEUOR m � ,OfFENEDWRSALEIF,HOWEV�RT1iE8UILDINGORIMPROVEMENTISSOLDWiTHINqNEYEAROfCqMFN.E- Z T�ON,THE OWNEH•BUfIDER WILL NAVE THE BUflDEN OF PROVING THAT NE OR SNE�DID NOT Bt71LD'Oq = IMPROVE FORTHE PUR70.SE OF SALE). ��' � py� ❑�.ASOWNEROFTHEPqOPERTY,AMFXCLUSIVELVCON7RACTiNGWiTMLICEN5EDC6Y7r1ACTORS � TO CONSTPUCT THE PRQIECT(SEC.7049,9USINESE AND PqbFESSIpNS COCE:TNE CONTRAC70R5'LI- V81U8t1Of1 ADJ.AREA W CENSE lAW DOES NOTAPPLYTOAN OWNER OFA PROPERTY WhIO BUN.OS Ofl iMpROVES 7HER�ON,AND — � WHOCONTRAGTSFORSUCHPROJECiSW1Tl1ACONTRACTOR(3)uCEN5EDPURSUANTTOTY,ECONTRAC� f]UANTITY DESCRIP'TION FEE TORSLfCEN5ELAW.). 'o �I AM EKEMPT UNDER SEC.__ B.6 P.C.fORTH15 FlEASON q � � �� 'y'� � L 3 � � � DATE OWNER !� �— � — U �+� LICENSED CONTRACTORS DECLARATIOIV w CL I HEREBYAFFIRM UNOER PENAI.TY OF PERJURY TNAT I AM IICENSED UNDER PRONSIONS OF Ct1APTER � � � B(COMMENCINp WITH SECTqN 7000�OF DNISION 3 OF THE�USINESSAND PROFESSIONS CODE.AND Z X YY UCENSE IS�N FIk.L FORCE AND EFFECT. m UJ �_�Fq��11�t' � UCENSE CL�AySS�_J��y UC.NO. � �_._.__�_ � _ V DATE�_.�.7./�_ CONTNAC'fOR_ � � ._�^}� .,� �W ' �,,,,.1�.�f -� WOFKERS'COP�A�ENSATION DE,'IARATIf.DN ��i" ,� � i HEREBV AFFIRM UNpER PENALTY OF VER.7UAY ONE bF iHE FOLLON/ING DECIARATIONS: � � _I HAVE AND WILLiAAiNTAIN A CERTIFfCA7E OA fANSENT'fQ SELF•INSURE POfl WORKERS' � ^ COMPENSATION,AS PROVIDED BY SECTION 37ooOF THE 4ADOR CODE,FOFl TNE P[RFORMANCE � � OF THE WORK FOR WHICH THIS P[RA41?IS ISSUEO. � � _I HAVE APO WIU.MAIfdTA1N WORKERS'COMPENSATION INSURANCE,AS REQUIRED BV SEC710N Q� 37D0 Of THE LABOR CODE,FOR TNE PERFURMANCF OF?HE NJORK FOR WFIICH THIS PEPMIT IS , � ISSVED.IdYWOFiKE S'L:OMPENSATIONINSUAANCECAFRIERANDPOL'CYNUM6ERAftE', I-CONSTRUCTION � cnRwER �� ` ryA 'g��—� �a "' �/,�LAN NEVIEW 0 POLICV NUMBER_._ � �F7S 6A�!� z� --�r----�` e a �ecrRic 0 (iF-06SECIICNNE�M�TOE(XY�.�LEfFDOFi}fiPEfq9TISF9tiONEFIUNdRE000LlARS�S1tl0)6PLESS). � P,�JJ1d64NLa D � 1 CERTIFYTNAT IN THE PEHFORMANCE OF TNE 4VORK FOR WHICH THtS PERMIT IS ISSUED,I MECHANICAL C.'„� SNALLNOTEMPLOYNlYPERSONtNAtVYtvIANP1ER50A5TOBECOME5U8JECTTOTHE (q WORKERS'COMPEPJSATIONIAWSOFCALIFOF;NIA,NNOAGREETHATIFISHOULDBECOME WSPECTIONFEE i —�— � SU&)ECTTO'fHE WORKERS'COMPENSATbN PAOVISIONS OF SECTION 97090f TNF LA00t7 � � �J ,/� = CADE,I SHALiFORTHWI'MCOMPLY WITNTHOSE PROVISIONS. ISSUANCE _���o�� ���CY • � 4+' 0 C ll Y 1 . p� DA7E:_ � APPLICANT: SMiP r� � WARNINa:FAILURETO SECURE WORKERS'COMPENSATION COVERAGE I5 UIJLAWfUL.AND SHALLBE �NEPGY P/C �'' ���-.J.Pc°���'�•�����q�^„p i4 6G �y SU&IECTIVJEMPLOYERTOCRIMINALPENALTIESANDCIVILFWESUPTOONEHl1NbRE�THOl1SAND }��g9''�+�^�,F�y^ti p,�,eg k9`�r^+� ' - - DOIURS(S1oo.o00).IN ADOITION TO THE COSTOF COMPENSATION,pAMAGE.S A5 PROVIDED FOR IN ENERGY PERMIT H+'.�d.�.E1'�i LY.2 F'.�'..'6'.LaP�Y'!G'�r•.8 � � SECTpN 3]oe OFTHE LABOR CODE,INTEREST,AND AITORNEY'S FEES. Q RETEN710N FEE: � CONSTRUCTION LENDING AGENCY PRE-ALT FEE: � IHEREBVAFFlFMUNDERPENALTVOFCFRJUFYTHA'THEREISACANSTRUCTIONLENDINGAGENCV GOR TNE PERFORMANCE OFTHE WORK FOR WHICN THIS PEqMIT IS ISSUED�SEC.a0B7,CIV.C.). , Z I.SJ � IENDER'S NAME —_ —___— - ..... .,. F— lc'NOER'S+WDRE55 � I CEPTIFV THAT I HAVE READ THIS APPUCATION AN�STATETHATTHE ABOVE INFORMATION IS CORRECT. TC��P11,��EES ' ' ���R.—�y ���� W IAGREETOCAMPLVWITNALICIT'ANDCAUNTYORDINANCFSANOSTFTELAWSRELATINGTOBUI!DING � J � � CANSTRUCTION,ANpHEREBYAUTHORIZEREPRESENTATIVESOFTHiSCOUNTVTOENTEAUPO1dTFIE - ' / � ZABOYE-MEtY7IONE0 PROPERTY FOR INSPECTION PURPOSES. - � ,.,�/-� COMMENTS � � �-/✓ /�d�L-���..-�//Z��.'�l� m PERMITf gE, _p�{RRII �/�'�/°' / y . 4 � +�"..�./��` B'� // ^ � /, �17 �.°'c`.ar �-a�.� . . � � SIGNATURE oF PERMITTEE E s � -- �� . _ � - RECPT.NO. _ PAID BY �- VALIDATION - ~ WHITE—Departmant Copy,YELLO�JV—Finance Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—Applicant's Copy ..., . .., r., . ...,r f.�,'.y�. ,...��.'.�,..' :..� ...w�.. � ..:.e�.,,. � :..:"ffi�l .. . } � ���,.C��n:.��� �r:d.%��+m';g'���.!. u .:, ,.. . �h::�..�, � _.��xh. i . .., , .. .. .x. .i. . . � . . . , O *way� .. , . . . . � . �«� .���>u . . . .. . . z "::_' . .. ," :. ;`..:'. p��e;.���"'".`l������4#.. ��-.�:����,' . . �� �:� :'. '� z;�at �``"i a�. 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