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HomeMy WebLinkAbout12054 (13) CITY OF DIAMOND BAK ����R E D ^---1�'— DEPARTMENT OF COMIVIUNTT'Y&DE E PM SERVICES . w ai66o E.copieY��e s,�ce i90 0 C T 0 3 20+J0 (909)860-3195 Fax(909)861,-3117 . PRE$S ��° ' BLJILDXN�PERMI'T'AY'�Y.ICA'�'YC�N ` _, +���F���l( < r . : . .. . ;^, . - . .,,, , ,. a� , -�.: _, _. .... w ._�. _..... ,. . . �.. � JOBSITE J // / APPLICATION ( � PERIl11T/ (`� P/C o ADDRESS � � �76��£'� Jfi/v �ir DATE �..--�V � NUMBEI9�"� A# c� ISSUE TYPE OCC APN LOi7j TRACT DATE GONST. GROUP p OWNER �✓ti u.8� -r A Gi we�'�t� p ADDRESS Saana C- ZONING SETBACKS � CITY C3�a✓ ZIP TEL. flEART RW ❑� APPUCANT TEL. SIDE/SIDE STREET RW ❑ � CONTRACTOR ���V�✓'�ou'�'�� �a _ SIDE ❑ N o C DRESS `� ZIP�4� TE��3ffS"S�!(� PROPO5EDUSE ��°?L�fJ �'. S Gt- �, C,� r w ARCWE G/ � z DESIGNER `� W NO.DWEL. N . NO. � ADDRESS � CITY ZIP TEL. UNITS STORIES BEOROOMS cr� cn DESCRIPTION SQ.FC FACTOR PSF ADJ.AREANAIUATION p� OWNER-BUILDER DECLARATION SFR/ADD/REM �O I HEREBY AFFIRM UNDEP PENALTV OF PERtt1RV THAT I AM EXEMPT FROM THE CONTRACTOqS LI- Gd('d4JB/C0fF101'[ CENSELAWWHiHEFOLLOWINGREA&ON(SEC.7a31.5BUS�NES6ANDPPOFESSIONSCOOE:ANYCIT'OP (n , , GOUNT'/WHICHqEQUIRESAPEFUdITTO00NSTRUCT,ALTEF,IMPRpVE,DEMOUSH,OR�REPAIRANVSTRUC- W PdSlO/DBCk TURE,PRIOR TO 17S ISSOANCE.ALSO�REQUIRES THE APPLICANT FOR Sl1CH PERMITTO FILE A SIGNED w STATEMENT TiiAT HE OR SHE IS LICENSED PURSUANT TO THE F�AOVISIONS OF THE�CONTRAbTORs U- � CENSE UW(CHAV7ER 9(COMMENCINO WITH SECi'ION 7000)OF DIVISION 3 OF THE BUSINE85AND PRO� � POOUSp2 FESSIONSCOOEJORTHATHEORSHEISEXEMPTTNEREFROMM1p7HEBASISfORTNEALIEGEDE%EMP- (� a+g TION.ANYYpLATIONOF5ECTION7031.6BYPNYAPPLICANTFORAGEPMITSUBJECTSFHEAPPLICANTTO Z RB-ROOf "�" ACIVIL PENALTY OF NOT MORE THAN FIVE HUNDRE�DOLLIR5(f50o�.): ❑I,ASONMEHOFTHEPFOPERTV,ORMVEMPl.OVEESWITHWAGESASTNEIRSOLECOI.IPENSlTION, � Z Commercial - WILL DO TME WORK,AND THE STAUCfUHE IS NOT�N7ENOED OR��OFFEFiED FOR SAI.E(SEC.7044,BUS�- J � NESS AN�PqpFE9SION3 CODE:THE CON7RACTORS LICENSE LAW DOES NOT AGPLY TO AN OWNER OF � PROPER7Y WFiO 8U11:05 OR IMPROVES hiEREON,ANO WHO DOES SUCH WORK HIMSELF Ofi HERSELF OR Q TNROU(3HHISORNERONTIEMPLOYEES,PROYIDE�iHATSUCHIMPROVEMENTSAf1ENOTINT�NOEDOR � � OFFEREDWRSALEIF,HOWEVER'M1�EBUILOINGORIMPROVEMENTISSOIDWITHINONEYEAROFCOMPIE- Z �TION,THE OWNER�BUILDER N1LL HAVE THE BUADEN OF PROYIN6 THAT HE OR SHE DID NOT BUIL�OR = 9.WROVEFOR7HEPURPOSEOFSALE�. � - W ❑I,ASOWNEHOFTHEPHOPERTY,AMEXCWSNELVCONTRACTINGWITHLICENSE�CONTRACTORS � TO CONSTRUCT THE PROJECT(SECJo14,BUSINE55 ANO PROFESSIONS CODE:THE CONTPAC70R5 U- V8�11811Cf1 ADJ,AREA W CENSELAWDOESNOTAPPLYTOANOWNEROFAPROPERNWFIOBUILDSORIMPROVESTHEREON,ANO � WFiOCOMRACTSFOR60CHPRO.IEbTSWI7NACONTRACTOR(S)LICENSEDPURSuqNT70THECONTRAC- (a�Jq�.J'T'ITY DESCRIPTION FEE � TOR5 UCBISE UW.). � ❑I AM EXEMPT UNDER S�C. B.&P.C.FOR THIS REASON Q 3 � ,L a DATE OWNER �� � UCENSED CONTRACTORS DECLARATION W V � 1 HEREBY AFFIRM UNDER PENALTV OF PEiUURY THAT IAM 410ENSED UNOER PROVISIONS OFCHAP7ER .-� � 9(COMMENCINOWiTHSECTiON7oW)OFDIVISION30FTHE�BUSINESSANOPROFESSIONSCODE,AND �� LLI ���CENSE IS IN NLL FORCE AND EFFEC7: �� � LICENSE Ct�pUSS ` "•`s ✓ LIC.NO. �`�L7 i d O'�-�� f� ~ DATE t1 "��l'-� � CONTRACTOR hi�ld qefY �^..� ;.J W � WORKERS'COMPENSATION DECLARATION ��}' �d,..-�j �R� W `✓'�� ! � I HEREBYAFFlRM UNOER PENALTY OF PERJUPY ONE Of THE FOLLOWING OECLAR0.TION5: � � ___IHAVEANDWiLLMA1NTAINACERTIFIGATEOFCONSENTTOSELFINSUPEFORWORKERS' _ Q COMPFNSA710N,AS PROVIDED BY SECTION 37000FTHE LABOR CODE,FOR THE PERFORMANCE w Q oF tNE WORN FOR WHICH THIS PERM�715155UED. � .. W `I MAVE ANO WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS RE�UIFIED BY SECTION Q 37000FTHEL480RCODE,FORTHEVERFORMANCEOFTHEWOFKFORWNICHTHISPERMITIS 55UED.MYWORKEaRS�'�oq/MPENSATIONINSURANGECARfl1ERANDPOGCYNUMBERARE: � CONSTRUCTION _ o jcnaqiEn ��+^�-�-' ��rn q �/� PLAPI REVIEW � POUCY NUMBER���.1 "`�,;if d_Uf-+e✓�,� ���_� S ���CTRIC � � (iHI55ECTIJN4E�M�T9ECdJIPLETmOFiHEPEFA�I�iSFORONEHUfdNiEDCIX�(s�oe�oR�ssx PLUMBING Z I CERTIFY THAT IP1 THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.1 MECHANICAL (^3 SHALLNOTEMP�OYANYPERSONiNANVMANNERSOAST08ECOMESUBJECTTOTHE � WOqKERS'COMPENSATIONLAWSOFCALIFORNIA,ANDAGREETHATIFISHOUL�BEbOME INSPECTIONFEE � SU&IECT TO THE WOPKERS'(:OMPENSATIDN PROVISIONS OF SECTION 37qo 0F 7HE 1A80R � CpOD�E,ISHALLFORTHWITHCOMPLYWfTHTHOSEPqOVISIONS. ISSUANCE 0 � DATE: 0`J"�� .�`� P� � � ^_i�� p APPLICANT: �G19 \+Sc? �__ �SMIP J WPANINO:FAILURC TO SECURE WORKERS'COMPENSATION COVERAGE IS UNIAWFUL,ANO SH0.LL B6 ENEAGY P/C � SV&IECTANEMPLOYERTOCRIMINALPENALTIESAN�CIVI�FINESUPTOONEHUNDREDTHCUSANO ENERGYPERMIT DOLLARS(E7oa.000),IN ADDITION TO THE COSTOF COMPENSATION,DAMAGES AS PROVIDm FOR IN � SECTION 37oe OF THE LABOft CODE,MTERE57,ANOArOqNEY'S FEES. RETENTION FEE: OCONSTRUCTION LENDING AGEIdCY PRE-ALT FEE: � IHEREBYAFFIfiMUNDERPENALTYOFPERJUPYTHATTHEREISACONSTRUCTIONLEN0INGAGENCY � � - FOR 7HE PERFORMMICE OFTHE WORK FOR WHICH h11S PERMIT IS ISSUEO(3EC.3087,CN.C,�. . � -- � . Z W � LENDER'S NPAIE � � F— LENDER'S.IDDRESS w� TOTAL FEES ( � ICEPTIFVTHATIHAVEREAOTHISAPPLICATIONANUSTATETHATTHEABOVEMFORMATIONISCORR6CT. � �� � 1 AGREE TO COMPLY WRH qLl CIiY AN�COUNTY ORDINANGES AND STATE UWS RELA7ING TO BUILOING ! ,,//{{ � j +7 CON5TAUCTION,AN�HEREBY AU7HOR�ZE REPRESENTATIVES OFTHIS COl1NTV TO ENTER UPON THE � �� i� /�/'(� �� 4.� . � � Z ABOVE-MENTIONEDPFOPERTYFORINSPECTIONPURPOSES. COMMENTS fi� - 6 . � '' �Ct eo� � PQ�P'✓ m ¢ PEfibIFfTEEN RINT) __ '__ r , � -�-'% -�- � SIO E OF PE ITTEE DATE " � � - RECPT.NO. � L "` PAID BV .J . 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