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HomeMy WebLinkAbout12317 (13) _ __. CITY OF DIAMOND BAI3 " " ' - ''�j _,,. - --��— DEPARTMENT OF COMMUIVITY&DEVELOPMENT SERVICES �-f"��� � 21660 E.Copley Drive Suite 190 " l ,,,,, (909)860-3195 Faz(909)861 3117 sun.�irnrG rEr�i[rr a�r�.icarYc��r , t°` . ,. FIRMLY Alf� '� ,.s„ . ..�.- . ..� i,.xw -'....e: s 1"`�'[�+ k .:3i� �. ... . . .. -... .., . �n, . ': . " .. . . ..,. .. .. - .. .. .:,..,'...,.., µ ���� �1 � JOB$ITE �`�l 9 � � , � Y APPLICATICSN`Q�.. 7L� C� PERMIT P/C o ADDRESS � / � �i�'r�� � G � ,`- ('- L DATE NUMBER # � ISSUE TYPB OCC APN lOT TRACT DATE CONST. GROUP p OWNER __�I�/?.�� J'C�°✓6!� o ApDRESS�'.��►- '�j�,r-� C-"�-'�-- , ' ZONING SETBACKS � r' ... J FRONT RW ❑ CITY,��i'_i„ '> ZIP T� , -4� � qEAR ❑ APPLICANT TEL. SIDEJSIDE STREET RW � � CONTRACTO�i � � L SIDE ❑ Q ADDRESSh"`1�%�s . �" � cir�r � ZIPf" TEC,�� PROPOSED USE w ARCH/ENG! z DESIGNEq_ �' ADDRESS NO.DWEL. NO. NO. � CITY ZIP TEL. UNITS STORIES BEDROOMS cn cn DESCRIPTION SQ.Fi: FACTOR PSF qDJ.AREANALUATION p� OWNER•BUILDER DECLARATIAN SFR/A0D/REM O 0 1 HEREBY AFFIPoN UNDER PENAl.7Y OF PEfl.IURY THAT I AM EXEMPT FflOM THE CON7RACTORS LI- (�`81'8.9BIC81NOfI ' „ W CENSEUIWFORTHEF4llOWINGREASON(SEC.7o31.58U51NESSANDPROFESSIONSCObEiMlY'CITYOR (n v 'COUNTYWHICHNEOUIRESAPERMfTTOCANSTRUCT,ALTER,IMPROVE,DEMOLISH,ORREPAIRANYSTRUG W Pa1io/DBCk � 111FF,PRIOR 70 ITS�SSUANCE./�4s�REQUIRES TNF..APPL ICANT FPA SUCH PEqM�TYO FlLF A SICiNED � STpTEMENT TH1VT HE OH SHE IS LICENSEO PURSUANT TO THE PROVISIONS Of THE CONTRACI'pq5 lK � . � CENSE LAW I�HAPTER B(CqMMENCINp WITH SECTION 7o0a)OP DIVISION 3 OF THE BU5MESS AND PRO• U'" POOVSpa " FESSIONSCODE)ORTHATHEORSHEISE%EMPTTHEREFROMANDTHEBASISFORTHEALIEGEDE7CEMP- (� TION.ANYVKKATIONOFSECTION7031.58YANVAPPUCANTFORAPERMITSU&IECTSTMEAPPLICANTTO Z Re-Root � A CINL PENALTY OF NOT MORE THAN FlVE HUNDRED DOLLARS(5500)J: � '� '� "`�-'° �� O� ❑4�ONMEROF7HEPROPERN,OFMYEMPLOYEESWITHWAGESASTHEIRSOLECOMPENSATION, � COffIfIlOfClfll �' ' Z VlILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED F-0R SAIE(SEC.�044,BU51- J � NESS ANU PROFESSIONS CODE:THE WNTHACTORS LICEN5E lAW OOES NOT APPLY TO AN OWNER OF � Pip�PERTY1NFi0 BUILOS OR IMPROVESTNEREON,AN�NMO DOES�SUCH WORK HIAASEI.F OR HERSEI.F OR � 7HROUGHHISORHEROVJNEMPLOVEES.PROVI�E�THA7BUCHIMPROVEMENTSAREHOTM7ENDEDOR m Q ,OFFERmFORSALEIF,HOWEYER,h1EBUIL�INGORIMPROVEMENTISSOLDWRHINONEVEAROFC0AIPLE- z TION,TME OWNER-BUILDER WILL HAVE 7HE&1R�EN OF PROVING THAT HE OR SHE bl�NOT BUILA OF = IMPROVEWRTHEPURPOSEOFSALE�. � � '� � '� � yU ❑I,ASOWNEROFTHEPROPERIY,AMEXCLl1SIVELYCANTRACTINQN/THLICENSEDCANTRqCTORS — pC TO CONSTHUCT 7HE PROJEC7 jSEQ To44,BUSMESS ANO PROFESSIONS CA�E:THE CONTR0.CTORS LI- V01U8fion ADJ.AREA W CENSELIIWOOESNOTAPPLVTOANOWNEROFAPROPERTVWIiOBUtLDSORIMPROVESTHEREON,AND F N'FIOCONTMCT3�OHSUCHPROJECTSVJIiHAOJNTRACTOfi(S�LICENSE'OPURSl1RN�TOTHECONTRAG (]UANTITY DESCRIPTION FE TORS LICENSE UW.). � - o ❑IM1D(EMPTUNpERS�C. B.dP.CFORTNISflEASON Q -^�'f � �d+y"�/ ��� � U''. � Q OAiE ONMER U 0 � UCENSED CONTRACTOHS DECLAAATION W; � I HEREBYAFFIHM UNOER PENAIT'OF PEflJl1RY THAT I AM LICENSE�UNOER PROVISIONS OF GHqPTEF �i i � 9(COMMENCINOWITHS6CTION700D)OFDIV�SION30FTHEBUSINESSANDPF70FESSIONSCO�E,ANO .Z 6dA ��ICENSE IS IN FULL FORCE AND EFFECT. ;m 0 LICENSE CpLASS � �/// LIC.NO ���."�, s✓' '�°�q j V DATE_�/.��4� CONTRACTOR��'�� '� .. ..... d t�.0 j � WORKERS'COMPENSATION DECLARATION j ��� Q � 1, � � i HEREBVAFFIRM UNDER PENALTV OF PERJURY ONE OF THE FOLLOWING�ECLARATIONS: Z L] �INAYEANDWILLMAINTAINACEflT�FICATEOFCONSENTTOSELF-INSUREFORWORKFRS' _ — Q COMPENSATION.ASPROVIDEOBYSEC710N37o00FTHElAeORCODE,FORTHEPERFORMANCE � Q OFTHE WORK FOR WHICH THIS PERMIT IS ISSUED. � � _I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS RE�UIRED BY SECTION � Q 37o00FTHE LABOH CODE.FON THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.MY WORKEflS'COMPENSATION INSURANCE CARRIEF AND POLICV NUMBER AR�� CONSYRUCTION � CARRIER� -�° "e��°� __�� ; PLANREVIEW �Z POUCYNUMOFA� ��� � '' _ t EC�FIC�-3 <t �j Q (iHISSEi,'110NNEHJNOTBEUJIuPLE1"EDOFhEPE Ft�RIXJEHUNIX�DDGIARS($10010R1E5Sj. PLUMBING ---.—.- --- Z I CERTIFY THAT IN TNE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSt1HD,1 MECHANICAL C}� SHALLNO7EMPl.OYANYPERSONINANVMANNERSOASTOBECOMESUBJECTTOTHE � YJORKERS'COMPENSATIONLAWSOFCN.IFOFNIA,ANDAGREE7HATIFISHDULOBECOME INSPECTIONFEE SUBJECT TO THE WORKERS'COMPENSAT�ON PROVISIONS OF SECTION 3700 OF THE LP.90R ~ DE,ISHALLFORTHWITHCOMPLYWITHTHOSEPROVIfiIONS. ISSUANCE � p �ATE: �- :"� f APPLICANT��� y~___;,�r�`� _ SMIP J WARNING FAILURE O SECURE WORKERS'COMPENSATION COVEflAGE IS UHUWFUL, � SHAIL 0E ENERGY P/C _._ _. y� SU&IECTANEMPLOYEFTOCRIMIN/1LPENALTIESANDCIVILFMESUPTOONEHUNDREOTHOUSANO ENERGYPEFMIT bOLLAqS(E10o,000),IN MDITIOM TO THE COSTOF COMPENSATION,DAMAGES AS PROVIDED FOq IN � SECTION 37080F THE IABOfl CODE,INTEREST.ANO ATTORNEY'S FEES. RETENTION FEE: oCONSTRUCTION LENDING AGENCY PRE-ALT FEE: � IHEREBVAfFIRMUNDERPENALTYOFPEflJURYTHATTHEREISACONSTRUCTION4ENDINGAGENCY � ��FOR THE PERWRMANCE OFTHE WOflK F-0R WHICH THIS PERMIT IS ISSUED(SEC.7087.CN.C.). � . Z ,..� W � IENDER'S NAME F— IENDER'SA�DftESS � TOTAL FEES ` � 1 CERTIFY TOiAT 1 HAVE qEADTHIS APPUCATION AN�STATE THPTTHE ABOVE INFORMATION IS CAPRECT. - W IAGREETOCOMPLVWITHALICITYANDCOLINTYOR�INANCE5ANO5TATELAWSRELATIN6TOBUILDING -' � � CONSTRUCTION.AND HEHEBV AUTHOflIZE REPqESENTATIVES OF THIS COUNTYTO ENTER UPON THE � � zA90VEMENT�NED PftOPERTY FOR INSPECTION PURPOSHS. � ' O y COMMENTS J ..�iy�." �.e��� '...!-L. � .. � sE'1 — m OERMITTEE NAME(PRINn ' � ..............� "'`� . � sior+e PERMIT7EE DATE RECPT.NO. 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