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HomeMy WebLinkAbout16135 (9) + _�` CITY OF DIAMOND BAI+t DEPARTMENT OF COM[MUNITY&DEVELOPIViENT SERVICES ;; � ' 21660 E.Copley I3rive Suite 19p � � (909)860-3195 Faz(909)861 3117 PRESS ..,.. BUII,D��PE�iM' IT AF��'LICA'TIUI� . . . 91M . .. .�v„, . :-:.„�•. .. ...., ...n,u: . ., '.,.� , ^::�n... r ...�..,: »... .... .,, ��. .�s. ..�.:,w.l k� �:;y ,.a ,:'t�- ... _ ;:. FIRMLY ....4.�.N. - .... o� JOBSITE r - � ' ° �"' APPLICATION �, � +�� f NUMB R��� #/C ADDRESS DATE � � ISSUE TYPE OCC � APN, LOT T�CT DATE CONST. GROUP °C OWNER�C'�.-fL �'(.,Pi O �� p ADDRESS l� ZONING SETBACKS Z CITY/�""✓�- ZIP�� TEL. FRONT RW ❑ g APPLICANT TEL. REAR ❑ SIDE/SIDE STREET RW ❑ � CONTRACT "f" `` SIDE � ❑ � C�E�P T� Z�� �.�s�- !J^ PROPOSED USE � � � � �� w� ARCWENG/ / r z DESIGNER_ NO.DWEL. NO: _ NO. � ADDRESS UNITS STOf$IES __y�___BEDROOMS � CITY ZtP TEL. � us DESCRlPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-BUILDEF DECLARATION SFR/ADD/REM O — p I MERE9Y AFFlRM UNDER PENALTY OF PEFJURY THAT I AM EXEMPT FROM THE CONTRACTORS�I� (a^p�pgpJC8�0lI LLI CENSEtAWF041THEFOLLOWBJGREh.$CW(SEC.70.91,5BUSINESSANDPROfESS10NSCODE:ANVCITYOR (f) U COUN7YWHICHREIXIIRESAPERMITTOCONSTRUCT,ALTER,IMPROVE,OEMOLISH,ORREPAIRANYSTHUC- W P3tio/OBCk Z TL1RE,PRIOH TO ITS ISSUANCE,AL50 REOUIRES THE APPIICANT FOR Sl1CH PERMI?TO"FIL�A SIGNED w 9TATEMENT THAT HE OR SHE iS LICENSED PURSUANT TO THE-PROVISIPNS OF THE�CONTfiACTORS ll- W '� CENSELAW(CHAPTERB(COMMENCM�WITHSECTION?000)'bF01VISION�9'OFTHEHUSME55ANDPRO- � POOVSp2 FESSIONSCOOE)OflTHATHEDR5HE1SExEMPTTHEREFROMANR7HEBA515FOflTHEALLEO[DE%EMP- � 710N.ANVVKKATIONO'rSECTION703t.5BYANYAPPLIC0.NTFORAPERlAITSU&IECTSTHcAPpLICANTTO 'Z R0-ROO( � A 4YVIL PENALT'OF NOT MOHE THAN FIVE HUNDRED DOLIARS(SSDo).j: � ❑I,ASOWNEROFTHEPROPERTY,ORMYEA4PLOYEESWI7NWAGESASTHEIR50LECOMPF.NSATION, 0 Commercisl - WILL DO THE WORK,AND THE�STRUCTURE IS NO'f INTENDEO OR OFKF.RED'FOR SAi.E(SEC.7C46,BUSI- ,.,J � NE55 AND PROFESSIONS(�E:THE COMFACTORS LICENSE lAW IJOES NOT APPLY TO AN OWNER OF � PROPERTV Vhp BUIIDS OR�MpROVES THEliEON,AND WH6 DOES SUCH WORK HIMSELF OR HEASELF OR pC THROUGH NIS OR HER OWN EMPLOYEES,PROYIDEO TFSA75UCH IMPROVFMEMS ARE NO7INTENDED OR m W OFFEREDFORSILE.IF,HObVEVER,THEBUILDINGORIAIPROVEIAENTI$SOIDWITHIN6NFVEAROFCAMPLE- � TION,THE ON�NEfl•BUIIDER WILL HAVE THE BURDEN OF PROVIN(=.'TFiAT HE aP SHG biD NP7 9UILp OR = IAAGiIOVEF4RTHEPUpP09EOFSALE). � W OI,ASOWNEAOFTHEPROPERTY,A'AEXCIUSNELVCt)NTRACTINGVJITr'LICENSEDCONTRACTORS [[ 70 CONSTRUCT THE PflO.fECT�SEC.70M,BUSINESS ANO PflUFES51bN5 CAD'c:TF7E vaMftACTURS LI- V8fU8fion . ADJ.AREA W CENSE L4W 60ES NOTAPPlYTO AN OWNER OF A PROPERTY WHO pUILDSOR IMPqOVES THEREON,ANO - � NM9CONTMCTSFORSUCHPROJECTSYVRt1ACONTRACTOfi(5)LK:ENSEDPURSUANT70THEIXDNTRAG l]UANTITY DESCRIPTION FEE � Y 70RSLICEN3ELAW.} . _! - e . . ,. . .. .. � ❑I AM EJfEMPT UP7DEP SF.C. _, 9_&PG FOR TMS REASON Q ' - w� � _, � W � DAfE ._.___OWNER.___�_____.�_ U � W o LIGENSED CONTRACTqRS DECLAflATION �� � f HEREBYAFFIRM UNDER PENALN OF PERJURY THAT I AAt LICENSED UNDER PROVISION&OF CHAPTER � ~ d, 9(CqAMENCING WITH SECf10N 7oao)OF DIVISION 30FTNF BUSWF5S AMQ PROFESSIONS CO�f_.AIvD z ?G MY LICENSE IS IN FVLI FOFCE N!D EFFEC'i. � Q UCENSE CIASS �� 1JC.NO.��✓�� ('_=�__ � ,�.� / r ��. ~ DATE�—,�PL'� '��, CONTfiAGTOft "�''s'�"'"x �- V �__ W � WORK�RS'COMPENSATION DECLARATION Q � V � IHEREBVAFFIRMUNDEAPEMALTYOFPERJURYONEOFTHEFOLLQWINGDEGLAflATIONS: Z $ � _IHAVEANDWILLMAINTAINACEHTIFICATEOFCONSENTTOSFLF�INSURfiFORWORNERS' S COPAPf,NSATiON,ASpROViDEDBYSECtIOhl3�oof:FTHCUr/30RCODL,FORTHEPERFOFlMANCC C.) � OFTh7EWORKFOqiNHICHTliISPERMITISISSUEO. � Q ''L° R!HAVE FN�W!:i,MAINTRIN WORKERS'CAMPENSA710N INSURANCE,AS REQUIRED BV SF.CTION � 9iW QF7ME Ld.60fl IX�DE,FOrl TFiE PEFFO�4MANGE OFThiE WORK F0f1 Wf'ICN 7HI5 PERMiT IS ��, �� ISGUEC.MY ' EK l'VON URA�iCE RIERANDPOi.ICYNVMBERARE CONSTRJGTlDN d "� �. CARRIEP.�� . _�.�___. PLRN REVIEW � POLfCY IdUMBEfl��� � r _ _ — e�ecrftic Q � (1Hl5sEL'fK%VNEi�lAit3ECOM1�EfFaOFit�PEFU.9Ti5FORP^7'eHtinDREo00t.U�PSf51CA)aFiL.ESSI PLUMBING _ -,,A , — � 1 CER7IFY 7HAT INT 1E?6RFORMANCE OFTHE WOF7K FbR WH�CH THIS PERJIT IS ISSUFD,I MECHFlNICAL _ ' '�" - .� �`�� ('� � SHALL NOT EMPLOY A:dY PERSON IN ANY MANNER 30 AS TO BECOME SJBJECT':O 7HE M - � WO�KERi'COMPENSA'IONLAWSOFCALiFORNIA,ANUAGREF7NATIFI5H0' DBECOME INSPECTIONFEE . _ 9UBJECTTOTHE W(7RKER5'COMPENSA'ION P(�OVISK1N56F SEC � :THE lA°AR �- � 1• ' ('1 � ~ cC�AGE,I SHALL FOF1�'�TN COAIPLY W E PROVI540NS. ISSUANCE _ - � "1 p DkiE:�-/� `°���-� YPPl.icnh�7. '�--' SMIP '� � LL ' A — .;7K T, . -� WAFlNINO:FAILURETO SECURE WORKERS'COMPENSATION G�YERAGE ISUNIAWFUL,AN�SHALLBE ENERGY P/C � J SU&1ECTANEMPLOYERTO(xiIN�INALPENAl71E5ANOCIVILFWESUPTOONEFIUNDREDTHOUSAND � �04URS(S�OO,OeO�,IN ADDI710N TOTHE COSTOF COMPENSATbN,DAMAGES AS PROVIDF.D FOR IN ENERGY PERMIT _ J SECTION 37080F 7HE LABOR GODE,INTEREST.AN�ATTORNEY'S F�ES. RETENTION FEE: � � CONS"iRUCTION LEN�ING AGENCY pqE-ALT FEE: O � I HEREBY AFFIflM UNDEF PENpLTY OF PEflJURY THAT THEqE IS ACONSTFUC710N LENDING AGENCV n- FOR TNE AEFFORMANCE OF THE WORK FOR WHICH THIS GERIAIT IS ISSUED{SEC.308�,CIV.C.). '� . - Z � _____ � LEN�ER'S NAME � F— LEN�ER'SAODRESS_ . W IGEflTIFYTHA7IHAVEflEAUT.'HISAPPLICATIONANDSTATETHATTHEABOVEINFORMAiIONISCOPRECi. TOTA�FEES � - � I AGREE i0 COIAPLY WITH ALL CITY AN�COUNTV ORDINANCF.S AN�STRTE L4W5 F7ELATMG TO BUILOING , , , � CONSTPUCTION,ANDHEREBYAUTFIORIZEFEPRESENTATNESOFTHISCOUNNTOENTEHUPONTHE , � ABOVE-MENTIONEO PflOPEFiTY FOR INSPEC710N PUflPOSES. 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