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HomeMy WebLinkAbout14585 (19) � CITY OF DIAMOND BAbt � � � � `�� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES �n ,� ,y 21660 E.Copley Drive Suite 190 \ .», W (909)860-3195 Fax(909)861-3117 PR E$� •9N" BUILDING PERMI_',C APPLICATION -: �,=-_ , FIRMLY � JOBSITE , APPLICATION ''��/��.0�'� PERMIT 1 �� /C o ADDRESS DATE �'� NUMBEP' # � ISSUE TYPE OCC -- APN LOT TRACT DATE CONST, GROUP p OWNER p ADDRESS ZONING SETBACKS � CI � ZI TEL. ^ � REApT RW ❑ APPLICANT 7EL. SIDE/SIDE STREET RW ❑ � CONTRACTOR�eY��� ,.-,� �� SIDE ❑ � ADDRE�SS� „�! ''� � — — �Rpp�ED�US CI ZIP TEL t 9'W w ARCWENG/ ��� z DESIGNER � ADDRESS O. EL. NO. NO�� � � UNITS STORIES 8'F,�ppG144S � � CIN ZIP TEL. u� DE5CRiPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDEF DECLAHATION SFR/ADD/ftEM O I HEREBY AFFIRM UNDER PENALTY OF PEfUURY THqT I AM EXEMPT FROM THE CONTRACTORS LI- Gfl(8(JB/Cd1y012 W CENSELAWFORTMEFIX.LOWINOREASON(SEC.7031.5BUSINESSANDPROFESSIONSGO�E:ANYqTYDR (n U (pUNTYWHICHREaU1RESAPERMITTOCON57RUCT,ALTER,IMPROVE,OEMOLJSH,oqRE�AIflANYSTFUC- W Patia/Deck � NRE,PRWR TO1T$ISSUANCE,ALSO REWIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIONED w STATEMENT THAT HE Ofl SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE COMRqCTOpS L4 W � CENSE LAW(CHAP7ER B(COMMENCINO WITN SEC710N�000)�F DIVISION 30P THE BUSINESS AN�PRO- �'�' POOUSp3 FESSpNSCODE�ORTHATHEOPSHEISEXEMPTTHEREFqOMANDTNE8ASI5FORTHEALLEGEDEXEMP- (� V TION.ANYYI(H,ATIONOFSECTON70S1.66YANYAPPLICANTFORA�ERMITSUBJECTSTHEAPPLICANTTO Z (j�-Fjpp� � A GML PENPLTYOF NOT MORE THAN FNE HUNDRED OOI.LARS(SSoo).): � ❑I,ASOWNEROF7HEPROPERTY,OflMYEMPLOYEESWITHWAGESASTHEiR50LEC06APENSATION, C� Cpmmercial - WILl00 THE WORIC,AND THE STpUCTUflE IS NOi INTENDEO OR OFFERED FOR SALE(SEG.70a4,6USI- J � NESS AND PROFESSIONS CODE:THE CONfRACTORS UCENSE U1W OOES NOt APPLY TO AN OWNER OF = PROPERTY VhIOBUILDS OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSEIF OR HERSELF OR � lHROU@HHISORHEROWNEMPIAYEES,PROVIDEDTHATSUCHIMPpOVEMENTSARENOTMT9JDEDOR m � ,OFF6HEDFOHEALE.IF,FiOWEVERTMEBUILDINGORIMPPOVEMENTISSOIDWITHINONEYFAROFCAMPIE- z �TION,THE OWNEF4BUIl0ER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DIO NOT BUILD OR IMPflOYE tOR 7HE PURPOSE OF SALE]. W ❑I,ASOWyEROFTMEPItOP,EHTY,AMEXCLUSIVELYCONTRACTINOWITHUCENSEDCON7RAC70R5 �,,,. � TQ CONSTRUCT THE PHOJECT(SEC.701a,BUSINE55 AND PROFESSIONS CODE:THE COYTRACTORS LI� Valuff4ion _ ADJ.AREA W CBdSELAW00ESNOTAPPLYTOANONRJEROFAPHOPERTYWHOBUlLDSORIMPROVESTHEREON,AN� 1 W�IpCpNTRACTSFORSUCHPROJECTSWITHACONTRACTOR(S)LICENSEDPUFiSUANTTOTHECANTRAG QUANTIN �ESCRIPTION FEE � � TORS UCENSE UW.). O IAM E%EMPT UNDER SEC. B.8 P.C.FOR THIS REASON a 3 U ���rfi' a a R=:Fj:� a�. � � _"'__ DAiE OWNER ',U W � LiCENSED CONTRACTORS DECLARATION ��W � I FIEflEBY APFIRM UNDER PENAITV OF PERJURY THA71 AM LICENSED UNOEfl PROVISIONS oF CMAPTER ,� � 9(COMMENCINCiWITMSECTION7000iOFD1YIS10N30FTHE6U51NESSANDPROFE5510N5GODE,AND �z ��� MY LICENSE IS IN FULL FORCE AND EFFECT. /� �[� � UCENSEClASS LIC.NO.�������/- � V DATE CONTHACTOfl a W � WORKERS'CpMPENSATION DECiJ+RATION Q � I HEREBV AFFIRM UNDER PENNTY OF PERIURV ONE OPTHE FOLLOWING DECLARATIONS: � � � O „_IHAYEANDWIILMAINTAINACERTiFYCAiEOFCONSENTTOSELF-INSUREFORWOPoCEflS' � � COMPENSATWN,ASPROVIDEDBYSECT10Na7ouCiF7HELABORCOOE.FOR7HEPERFORMANCE CJ 4 OF THE WORK FOR WHICH TWS P6PR11T IS ISSUED. � O _I HAVEAND WILL MAINTAIN WORKERS'OOMPENSATION INSUqANCE,AS qEOUIRED 0Y SEC710N � ' �-� Q . 370o OFTHE LABOR CODE,FORTHE PERFORMPNCE OF THE WOHK FbR WHICN 7HIS PEPMIT IS ISSUED.MYWORKERS'COMPENSATION�NSURANCECARRIERANDPOLICYNUMBERARE: CONSTRUCTION t ¢ �p-�p/.—d� CARRIER PLAN REVIEW � POIICVNi��/aFw I�_/CL> LL>�' ELECTRIC , � � (IFitS5ECf10NNE�NDTBECOMPLEfF�OF7HEPERA�STISfnRONEFA1NDFlmWLLAR5f510010q�FSS1 PLUMBING Z I CERTIFY THAT IN THE PERFORMANCEOF THE W9RN FOR WHICH'fH15 PERMIT IS ISSUED,I MECHANICAI (;}� SHALLNOTEMPLOYANYPERSONINANYMANNEft.50ASTOBECAMESUBJECTTOTHE , � YJORKERS'COMPENSATIONIAWSOFCALIFORNI0.ANOAGREE7HATIFISHOULDBECOMc INSPECTIONFEE . . � SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTI6N 3700 OF THE LA90N = CADE,1 SHALL FO HWITH COMPLY WITH THOSE PROV SIONS. ISSUANCE _ '�� � 0 SMIP ��rT$4�TPAT!':`. 14�RTg��.�;�,_'i"'�"�v��-- f i p DATE: APPIlGANT. _ . . � ENERGY P/C . WAPNING:FAII E TO ECUPE WORRERS'COMPENSATION COVERAGE IS UNUWFUL,ANO SHALL BE LL SUBJECT AN EMPLOY TO CRIMINAI PENALTIES AND CIVIL FINES UP TOONE HUN�RED iHOUSAND ENERGY PERMIT DOLLARS(Si 00,000),IN A��ITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOFI IN - .'~J SECTION 37oe OFTHE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. RETENTION FEE: � d CONSTRUCTION LENDING AGENCY PRE-ALT FEE: __ � IHEREBYAFFIHMUNOERPENALNOFPERJU9VTHATTNEREISACqNSTHUCTIONLENDINGAGENCV � �- FOR THE PERFORMAIdCE OFTHE WOAK FOP WHICH THIS PEFlMIT IS ISSUED(SEC.30a�,CIV,C.). Z W .�Z LENDEMS NAME �/' -' ��. . " — , .. . . , . . F�- LENDER'SADONEceI/1S�u �'��y� tsp .r/� � ICERTIFY7HATIHAVERE/I�THISAPPLICATIONANDSTATETHATTHEABOVEINFORMATIONISCORPECT. TOTAL FE S / � .l """� W IAGflEETOCOMPLYWITHALLCiTY/WDCOUNTYOflDINANCESANDSTATELAWSflELATING708UILDING e����,n r�G9•� . . 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