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HomeMy WebLinkAbout12726 _��, CITY OF DIAIvfOND BAI� �� DEPAR'Y'MENT OF COMMUNITY&DE,VELOPMENT SERVICES w 21660 E.�opley Drive Suite`190` , (909)860-3195 Fax(9b9)861 3117 PRESS .._. BUILD �P��in�tr'r A�h��,icA�i"b�r FIRMLY � . ., :,,. ,,. .., ,. -� ; . �r ,,: , .t,.. . . , .., �.� ,.,�, . . ;.... .. . �,.a . , .�,,� -7- . ...... . , f ., � ,, . ,., oJOBSITE ' � L ,A �{ N` • SSU�ATION h G��� PTErPM1T � / P!C ADDRESS ��'�� ���! �'��� �"'�'��� DATE /�'�U 'L NUMBER,a' vC� # � APN LOT!� TRACT����, DATE CO ST. GROUP p OWNER y " ADDRESS - ' `^�i -"`"" • ZONING SETBACKS w r ZIP�' e -�'� TEL�.�G��S �'tl4�C" FRONT RW ❑ Z CITY A�i. J�'t�:.% g APPIICANT �y�,� l,;�i�,/ TEL.��„�,�,�;, REAR p � SIDE/SIQE STREET RW Q CONTRACTOR �! a A .'' �.:- SIDE � p� ADDRESS ;:Z9r..ti'. �"7"� `i'� _ , .� � • PROP�SED USE o CITY x�,.�-,�.8-� ZIP'Y' �,�TEL.�'^ — � w AACH/ENG! ��t�� �� � z �ESIGNER��� NO.DWEL. NO. 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FACTOR PSF ADJ.AREANALUATION QOWNER-BUIIDER DECLAFaATION ' SPR/ADD/REM [] I HEHEBY AFFIRM UNDER 7ENALTY OF PERriIRY THA7 I qM EXEMPT FROM TNE CONTRACTORS LI- � G2fe90/CBfPOA L[J CENSELAWFORTHEFOLLOWMGHEASON�SEC.7031.5Bi1SINESSAND�PROFE§SIONSCODE:ANYCI7YOP V COUNfYNMICHREWiAESAPERMITTOCONSTRt1CT,AlTER,IMPROVE,OEMOLISH,ORREPAIRANVSTqUG W paf10/DBCI( W NiiE.PRIOR TO ITS ISSUANCE,ALSO REQUIRES THE APPLICANT FOF SUCM PERMIT TO FILE A SIGNED W .� STATENENT THAT HE OR SHE IS LICENSEO PURSUANT TO'THE PflOVISIONS OF THE CbNTRACYOPS LI� � CENSE LAW(diAPTER B(C'OMMENCIN6 WITH SECTION 7000)OF OIVISION 3 OF TH�9USiNESS'ANb PitO� u" POOUSpB FESSIONSGODE)ORTHATHEORSHEISE%EMMNfTHEREFROMANOTHEBASISFOR7HEALLEdEDEKEMP� � TION.ANYVIOLATKKdOFSECTION7o31.6BYANVAPPUCANTFORqPEPMI7SU&IECTSTHEAPPLIi:ANT7b Z R9-ROp} � ACIVILPENAL'fVOFW07MORETMANFIVEHUNDftED00(lARS(55oo).J: � � ❑I,ASOWNEFtOFTHpPHOPERTY,ORMYEMPLOYEESWITHWAGESAS7H[IR$OLECOMPENSA7fON, O CamrnBfCi81 ' - WILL DO THE WORK ANp TNE STRUCTUPE�S N071MEN�ED OR OFFERED FOR SALE(SEC.7b4a,BUSI� �I � NE55 ANO PROFESSION5 CODE:THE CONTPACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF PqOpERTYN'FIOBUILASORIMPROVEShiEFEON,ANDWHODOESSUCHWORKHIMSEIFORHERSELFOk � � THRIX1GFiHI50RHER�OWN'EMPLOYEES,PROVI�EDTHA7SOCHIAIPR�OVEMEIVTSARENOTINTENDEO'Op � QOFFEiiEDFpR3ALEiF,HOWEYER7HEBUILOINGORIMPROVEMENTISSOLDW17171NONE1'EAROFGOMdL�' Z TION,THE OWNER-BUILDER WILL HAVE THE BUROEN OF PROVING 7HAT HE�Oq SHE DID NOT 9UIL�'OFY = IMPpBVEFORTHpPURPOSEOFSALE). ❑I,AS OYaNER OF THE PROPEFii1:APA EXCLUSNELY CqNTpACTING WRH UC�NSED CONTRAC70RS � TO CONSTpUC'f THE PqOJECT(SEC.70f4.BUSINESS ANO PRDFESSIONS CODE:7NE CANTRACTORS lG Val�atl0fl ADJ.AFEA W CENSEL4WDOESNOTAPPLY70ANONMEROFAPROPERTYWHOBUILDSORIMPROVE&YHEREON,AND � WHOCONTHACTSFORSUOiFPQ1ECTSWITkACONTRACTOR(S)LK:ENSE�PUFSUAMTOTFIECONTRAG QUANTIIV �ESCRIPTION FEE � TORSLICENSEUW.1. J Q ❑IAN EXEMPT LINDER S�C. `_B.S P.G FOR THIS REASON Q '� / -i� � � � � OATE OWNER U o LICENSED CONTRACTORS DECLARATION � —� � w I HEREBYAGFIRM UNDER PENALTY OF PERJURY THAT I AM�ICENSED UNDER PROVI&IONS OF CHAPTER � � B(COMMENCINQ WIiH SECTION 7000�OF DIV�SION 3 OF iHE BUSINESSAND PROFESSfONS CODE,AND � 1C AIY IICENSE IS IN NlL FORCE AND EFFECT. ., LLl f';�/� �.., m � UCENSECl.hSS I �� LIG.NO �,y�����J ,a`f� �P . � U DATE F�,!� �� � CONTRACTOR�,�I./V L%�/-Ys��� Ll�� � �. � WORKERS'COMPENSATION DEC!_ARATION -i � � U � IHEREBYAFFlRMUN7ERPEN0.LT'OFPERJURYONEOFTHEFOLLOWING�ECLAFAYIOIi'S:��� - C!3 � C3 _IHAYEdWOWIILMAINTAINACERTIF7CATEOFCANSENTTOSELF-INSUREFOHWORKERS' � +�d- C,OMPENSATION;ASPROVIDED9YSECTION'J7000FTHElA80R�C(SDE.FOR�7HE'P�pKpRMANCE� W oF THE WOAK WR WHICH THIS PERMIT IS ISSUED. � d w _I HAVE AN�WILL MAIMAIN WORNERS'COMPENSATION iNSURANCE,AS REOUiRED BYSF_CTION Q 37o00FTHELABORCOOE,F�RTHEPERFORMANGEOFTHEWORKFORWNICNTHISPERMITIS ISSUED.MYWORKcRS'COMpENSATIONINSURANCECARRIERANDPOIICYNUMBERARE: CONSTRUCTION � CARRIER Cs �_"P�'F')L�_�.�_���' . PLAN REVIEW . � /�-� Z FOLiCY NUMBF.R �'�� � . ELECTflIC �/ (,L. Q Q (ni15sECfI�NfdE�tao76ECOh�1.ErEooFniE ISwa:MIEt1u�wFlEooaLAfisj5lw)OalEss). PLUMBING Z I CEpTIFY THAY W THE PERFOftMANCE Of THE WORK FOR WHICH THIS PEfiMl1'IS ISSUED,I-� MECHANICAL (� SHALINOTEMPLOYANYPERSONINANYMANNERSOASTOBEC�MESUBJEC7TOTHE y WORKERS'COMPENSATIONIAWSOFCALIFORNIA.ANDAGREETHATIFtS710VLDBECOME iNSPECTIONFEE � SU&IECTTOTHEWOflKERS'COMPENSATIONPROv�SIONSOFSECTION97000F7HEUlBOR ��� CODE,ISHAIIFORTHWITHCOMPLYWITNTH , PFOVSIQ7�S, ISSURNCE r o 2 , �' �"' " _��r,��: T �y. D � nqTE��(.��.4PPLICANT. - 1./I f1,. � SMIP --, WAaNING:FA�WRETOSECURfN'ORKERS'COMPENSATIONCOVERAGEISUN W L,A SHALLBE ENERGYP/C � SU&IECT AN EMPLOYER TO CRIMINAL PENALTIES AM�CIVIL FINES UP TOONE H t�RED HOUSAND � DOLURS�EIOD,oOo),INADDITIONTOTHECOSTOFCAMPENSATION,DAMAGESASPROVIDEOFORIN ENE4iGYPEflMIT _. � SEC7iDN37080FTHELA90RCO0E,lAITEREST,ANDATTORNEY'SFEES. RETENTIONFEE: ___ � �._.__. a CONSTRUCTION LENDING AGENCY PRE-ALT FEE: O � IHEREBYAFFIRMUN�ERPENALNOFPER,.'URYTHATTHEREISACONSTRUCTIONLENOINGAGENCY , FpRTME vEAFOFMANC�OF THE WORK FOR WHICH THIS PERMIT IS ISSIJED(SEQ 3oBl,CIV.C.j. Z� .. .... , .... . _ .. � IENDER'SNAME__.__ - �� F— LEND6fl'SPDORESS , � � ICERTIFYTHATIHAVEREADTHISAPPLICA710NANDSTATETHATTHEABOVEINfORMA710NI5CARRECT. TOTAL FGEt7 .. ' ' "���" �'I� � IAGREETOGOMPLVWITHPLLCIT'ANDCWNTYOfl�INANCESANDSTATEIAWSflELATINGTOBUIWING � ' " ,' � CONS7RUCTION,AND HEFEBYAUTHORIZE REPRESENTA7NES OF THIS COUNTYTO ENTER UPON THE . - - A90VE�MEMIONE�PROP�RTY FOR INSPECTION PURPOSES. Z f COMMENTS�_ � �a/'�� �y�,� ti�/�-L '��,.• � PERMITTEE NAME(PRIMn _� :/ � • !/� vj SIONAIUREOFpERMfTTEE OATF " �" � RECPT.N0. PAID BY VALIDA7ION�"��� r WHIi'E—Department Copy,YEU.OW—Finance Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN— plicanPs Copy � ., .., � , ,,,.�--:. ,, �.. ;;: � . .� ��. , 3 � , ,� ,, � ., . ,�< , � . , �.. ,�. 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