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HomeMy WebLinkAbout10967 (5) _...... , .;_ . _ _.. . _.�, ...� <.,w.,.,�,�,....�.,.,:..��.�,�-,� _. .._ ._. .., . _.�,,._ — � +'yW CITY OF DIAIvIOND BAR COMMUNTI'Y DEVELOPMBNT DEPARTMENT p 21660 E.Copley Drive Suite 190 PRES.� (909)860-3195 Fax(909)561-3117 '��" BUILDING PERMIT APPLICATION FI R M LY � JOBSITE �"� ` ^'"" �C f APPLICATIO PERMIT P!C o ADDRESS �/ � / �C'��� ��' DATE��� � � NUMBER � # o ISSUE 7YPE OCC � APN JLOT TRACT pAeE CONST. GROUP °C OWNE�C-✓:s''�-.¢i3O� o ADDRESS_ .�-� `_-�..� � ZONWG SETBACKS z CITY ,��" "',ZIP��,1 TEL � � - FRONT RW ❑ ZAPPLICA�JT TEL. REAR ❑___�_ SIDElSIDE STREET RW ❑ ¢ CONTRACTOR Y -� .�_'����7��' r' -. SIDE ❑ � � �'� .�' swr ��_' �i'- ADORE S > ' ,,. , �., .-- � � PROPOSED USE o CIIY��'�%�,.L'a ZIP��"_'�TEL.�`__�'��-.�^'�* -- w ARCH/ENGI z DESIGNER NO.DWEL. NO. NO. a ADDRESS UNlTS_ STORIES BEDROOMS � CITY ZIP TEL. __ � pESCRIPTION SQ.FL FACTOR PSF ApJ.AREANALUATIQN � � OWNER-BI:ILDER DECLARATION SFR/ADD/REM Q p I HEREBY AFFIRM UNDER PENALTY OF PERJURY THPT I AM F.XEMPT FROM THE CONTRACTORS LI� � GaragelCarport W CENSELAWFORTHEFOLLOWINGREASON�SEC.7091.SBUSINESSAN�PFOFE5510.�1SC05F:ANVCITVOR —, _ _ U GWryTVWHICHREQUIRESAPERMITTOCONSTRUCt,ALTEP,IMPROVE�EMOl15H2ORREPAIRANI'BTRUC� W patiolDack W TURE,PRIOR TO ITS'SSUANCE,AL50 REQUIRES THE APPLICANT FOR SUCH PERMIYTO FILEA SIGNEO w � STATEMENT TH/1Y HE OR SHE IS LICENSEO PUFSUANT TO 7HE PROVISIONS OF Th1E CONTRACTOPS l6 � CENSELAW(CHAPTER9(COMMENCINGWITHSECTION�000)OFDIVISIbN30FTHE6USME5§ANDPaO� �" POOVSpfl � FESS�ONSCODE�ORTHATHEORSHEISEXEMPTTHEREFROMANDTHEBASISFORTIIEALLEQ�C�E%EMP� (� U TIO�.ANYVIO�ATIONOFSECTION7o31.5BYANVAPPLICANTFORAPERMITSUBJECTS7HEAPP!_ICANTTO 2 Re-Roof � ACIYILPENALTVOFNOTMOfIETNAN�FIVEHUNDRED�OLL.AR5��3500j.): � � � O�.ASOWNEROFTHEPROPERTY,ORMYEMPLOVEESWITHWAGESAS7HEIRSOL[COMPENSA710N, C Comrnerr,ial Z WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENOEO OR OFFEFED FOR SALE(SEC.70a4,BU51� J — � NE55 AND PROFESSIONS CODE:THE CONTRACTOFS LICENSE LAW D�ES NO7 APPIY TO AN OWNER O� � PROPERTVWHOBUILDSORIMPROVESTHEREON,ANDWHO�OESiUCHWORKHIM56L�ORHEFISELFOA � Q THROUGHHISORHEROWNEMPLOYEES,PROVIDEDTHHTSUCHINPROYEMEN'fSARENOTINTENCEDOPI W OFFEREDFORSALEIF,HOWEVER,TH=BUIL�MGORIMPROVGMENTISSOL�WITHINONEYEAROFCOMPLE� 0 TION,THE OWNER-BUILOEFi WILL HAVE THE BURJEN OF PROVING THAT HE OR SHE�ID NOT BUILD OFl � = IMPROVEFORTHEPURPOSEOFSAIE�. � _Y ❑I,AS OWNEF OF THE PROPER7Y.AM EXCLIISIVELY W NTRACTING W I?H LICENSED CONTRACTOR$ � TO CONSTRUC7 THE PROJECT(SEC,�oaa,BUSINESSAND PROFESSIONS CADc:THE CONTRAcroqs u- Valuation �_^ ADJ.AFtEA W CENSELAWOOESNOTAPPLYTOANOWNEftOFAPROPERTY'NH06UILOSORiMPROVESTHEP.EDN;AN[} � WHOCONTPACTSFORSUCNPROJECTSWITHACONTRACTOR(S)CICENSEOPURSUANTTOTH6CONTRAC� QUAPITITY DE5CRIPTION FEE Y TORSLICENSEI�IW.)_ � ❑I AM EX'eMP7 UN�ER SEC. 9.8 P.C.FOR-H15 REA5ot5 Q � � U � LL' CATE ON/NER F _ Z � � �'L`.L7 G' f�C.. _i r- � LICENSED CONTRAGTORS DECLAPATION . w ` ` e � 1 HEREBY AFF�RM UND[R PENALTV OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER G � 9(COMMENCING W�7H SECTION 7000)OF DNISIpN 3 OF TH�BUSME55 AND PPpFESS10N5 CO�E.AND Z ._ ,X MV LICENSE IS IN FULL FORCE ANO EF-ECT. �,.,, L,,,= m � LICENSE C SS !r�� L% LIC.NO. � ���,� � U DATE ' �.'����L COVTRACTOR�,� -��,_ • J � W � ��� � WORKERS'COMPENSATION�LARATI -N � � Ei� ��-7 .�^ e. � ,., ( s � IHEFEBYAFFIRMUNOEFiPENALTYOFPERJUflYONEOFTHEfOLLAWMGDECLARATI� t � � fs^�'G.°{"""" � �''`/� � � �IHAVEANOWILIMAIN'AINACER"'IFICATEOFCONSFNTTOSELF-INS�REPORWORKERS' �� _ COMPENSATION,ASPROVIDEDBYSECTION37COOFTHELABOflCODE,FORTHEPERFORMANCF C: Q OF THE WORK FOR WHICH ThIIS PERMIT IS ISSUED. � � w _I FAVE AND WILL MAINTAIN WORKERS'CAMPENSATION INSURANCE,AS REqUIRED BY SEGTICN Q 370D OF TNE LABOR CO�E.FORTHE PERFORMANCL OF THE WORK FOfl WF'ICH THIS PERMIT IS � ISSUED.MY WORKERS'COMPENSATION INSURANCE CARqIEP AND POLICV NUMBER ARE:-� � CONSTRUCTION J j CAP,qIEP PLAN REVIEW � POUCYNUMBER_____ E�ECTRIC � Q � (iFIISSEGTONNEEDNO`BECOMFLEfEDOFTI�IEPERMfTISFOFlONEFU�RE0DIXIARS�$1C0)ORLESS) FLUMBING Z ICEFITIFYTHPTMTHEPERFORMANCEOFiHEWO RYlHICHTHISPERMITI5ISSUE0,1 I MECHANICAL i ('3 SHALLNDiEMPLOYANVPER50NINANYMANN SOh TOBECOMESUBJECTTOTHE � WORKERS'COMPENSATtON L4W5 Of CAUF IA,AND REE THAT IF I SHOt)LO BECOME I INSPECTION FEE _ Sl1BJEC?TA THE N� flKEftS'COMPENSATI PRO'/I51 S OF SECT � Of THE 41BOR = CODE,IS AL�FO HWITHCOMPLYWIT 'HOSEPRC�ISIONS.���� ISSUANCE _ __ � � r� � f �,,.�'P . p DATE: T� '{APP:ICANT �''✓ -�-a'� /�"'"""` SMIP r W � ) � � � WARNINGFIWHETOSECURE�WOflKERS' MPENSATION ERAGEISUNLAWFUI,ANDSHALLEE E!VERC�YP/C _ LPB��(I A C) 'IC�7Atl} LL SUBJECTANEMPLOYERTOCRIMINALPe TIESANOCN FINESUPTOONEHUNDREDTHOUShND ENERGYPERMIT DOLLARS(5100,aW),INAOOITION70TN OSTOFCOMPENSATION.'JAMAGESASPRO`/IJE�FORIN — J SECTION 31�e Of THE LABOR COOE.INTEREST,ANDATTORN[Y'S FCCS. RETENTION FEE: Q — d CONSTRUCTION LENDING AGENCY PRE-0.�T FEE: _ O � IHEREBYAFFIRMUNDERPENALTVOFPERJURVTHATTHEREISACONSTRUCTIOMIF_!JDMGACENCY f n- FOR THE PERFORMHNCE OF THE WORK FOR WHICri THIS PERMIT IS ISSUED(SEC.3097,CIV.C.). y I —'— Z I I W � LENDER'SNAME � '� F= LENDER'SAD�flESS � - �� �� � -7-q /wy W ICERTIFVTHATIHAVEREAOTHISAPPLICATIOYANDSTATETHATT4ENBOVEINFORMATIONISCORPECT. TU IP1�FEES �,. - 9 /j � IAGREETOCOMPLVWITHALLCITYANDCOUNTYORDINANCESANDSTATEIAWSRELA?INGTOBUILb'�IJG� , / C `� � � CONSTHUCTI A�HEREBY AUiHORIZE REP NTATNES OF THIS CGUNiY TO ENTER UPO�!TNE ' � ,,.. .. , . , � z ABGVE�MEN ONE PROPERTVFORINSPECT N P RPOSES. Q g COMMENTS J �./d � , .� �.��C�_ _ , � '� ¢ PE EN� E(PRIYT) �y ,.. ,� '. . .� ;�. 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