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HomeMy WebLinkAbout12331 (11) CITY OF DIAMOND BAbt � --�--���— DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES � 21660 E Copley Dnve Smte 190 W $)860-3195 Fax(909)861 311? PRESS .... »� a uu,n����`ai�`�t,rcAr�or� ` . �. '_ ,. :; :.; �, ..: FIRMLY .. � �:�,.., »r:'K.� ��-�-} � JOBSITE ' • �� � ' � ���j� � f,� ApPLICA'tI�N L-� PERMIT � �-- " P/C o ADORESS � r "��� DATE NUMBER # c� ISSUE TYPE OCC r- APN LOT TRACT DATE CONST. GROUP °G OWNER �� O ADDRESS ZONING SETBACK$ CITY ZIP TEL. FRONT RW ❑ ApPLICANT TEL. REAR ❑ � SIDE/SIDE 5TREET RW ❑ r� CONTRACTOR �.s'�- SIDE ❑ OADDRE 8� � PROPOSED USE �� y ClTY 7 ZIP TEL. ,� o ARCHIENG/ � ,�,�"L � � DESIGNER NO.DWEL NO. NO. a, ADDRESS UNITS STORIE5 BEDROOMS � ZIP TEL. .i � r p� D�SCRIPTION SQ.Ft FAGTOR PSF ADJ.AREANALUATION � � OWNER-BUILDEROEQLARATION,_ _ �. '„� � ! "' � ' Q SFR/ADD/REM I HEREBY AFFlRM UNDER PENALN OF PERJUHY THAT 1 AM EXEMP7 FROM THE dONTRAC76fi5 LI� GflltigB/C6fp0�1 W CENSEIAWFORTHEFOLLOVIINOREASON(SEC:7o3i.5BUSIHESSANDPRtlFESS70N5CO0E:ANV6INOR (� CJ COI.INTVWHICHREOUIRESA7ERMITTOCONSTRUCT,AL7ER,IMPROYE,DEMOLISH.ORflEVAIRANYSTRUC• �W PBiIOIDBCK wNRE,PRIOfl TO ITS ISSUPNCE,ALSO REDUIRES THE APPLICAN7 FOR SUCH PERNTI7 TO FlLE A`SIQNEO � STATEMENT TNAT HE OR SHE IS LICENSEO PURSUANT TO THB PROVISIONS OF TH�`CAN7RACTDRS LL � � � CBJSELAW(qi�FTER9(COFiMENCINdWITHSECTION�oo6)OFpIVI510N30FTHE�USINE5�3ANOPRO- �'�' POOUSpa FE5SION5 CODE�OR THAT HE OR SHE IS EXEMPTTHER�FROM AN�THE BASIS FOR THE ALLE6Etl'E%EMP- TION.ANVVtOLATIONOFSECTION7W1.5BYANYAPPLIGANTFORAPERMITSU&IECT5TNEApPL1CANTTO � Re-Aoof r A CIV1L PENAITV OF NOT MOflE THAFI FNE HUNDRED D0.LAFS(5500).). � ' � ❑I.ASOWNEfiOF7HEPROPERTY.ORMVEMPLDYEESWITHUJAGESASTHEIRSOLECOMPEN�5ATION, ❑ Commeroial - YALI DO THE WORK,�ND THE STRUCTURE IS NOT INTEND�D OR OFFEHED FOR SALE jSEC.7od4,BUSI- _,1 � NESSAN�PROFESSIONS CO�E THE CONTRACTOPS UCENSE lAA'OOES NOTAPPL`(TO AN OWNER oF PRpPERTY'M�IOBUILDSORIMPROVESTHEHEON,ANDNMOOOESSl1CHWbHK1iIMS�LFORI-IEASELfOR � � 7HRW�HHISORHEROWNEMPLOVEE5,PROVIDE�THp75UCHIMPROVEMEMSARENOTIN�TENDE00R � QOFFERFAFORSALEIF,HOWEVER,9HE9UILOINODRIMPROVE9AEN7iS'90LDWIiNINONEVEARbFCOMPLE � TtON.THE OMINER-9UILDER WILL MAVE THE BUROEN OF PPOVING THAT HF Oq SHf D16 NdT BU7L0 OR � IMPROYE FOR THE PUflPOSE OF SALE). � �� "' � ❑I,ASOWNEROPTHE PROPERTV,AM EXCLUSIVELV CON7RAC71NG WI7H LICENSEO CON7AACTORS � 70 CONSTFlUCiTHE PROJECT(SEC,7044,BUSINESS AND PROFESSf6N5�CODE:�Ti�CbNTqAqYOR5'll- VelU31i0It ADJ.AREA L61 CENSELAWDOESNOTAPPLYTOANOWNEROFAPROPEFTVWHOBUILDSORIMPROVESTNEREbN,PND � � MRIOCONTFtACTSFORSUCHPFOJEC7SWITY.ACONTR0.C70R(S)LICENSE�PUHSUANTTpTHEWNTFlAG QUANTiTY DESCRIPTI6N FEE � TOPSLCENSELAW.), ..,/ J a O IAM EXEMPT UNDER 3EC. B.&P.G FORTHIS REASON .Q Z �6'�+ 7 LL � � , �sT � " � OATE OK?JER w y � A^ � ¢ LICENSE�CONTFiACTORS DECLARATION � �f' .� l y aC I HEREBYAFPIRAI UNDER PENAL7V OF PEFJURV THAT IAM IICENSE�UNOER PflO�I510N5 OF CHAPTER� .~ �"` � Q� -" - •"7 Q � PRO('ESSIONS CODE.ANO � ...-. �.1. . J9' ../ •...... � 1.�. � i(COMMENCINO WRH SECiKNJ 7oo0J OF�IVIS�N 3 0F THE BUS�NESSAND Xai MY LICENSE IS IN N4L FOFCEAN�EFFE T. (,�+_ yy �.. '�=�"�` ��'�' - / , � LICENS S `� LIC.NO. � �! ��� � .��' "� � �,��� i. D/�� � GF� N. .. w DATE CONTRACTOR� � ..� J �dy �, � �� � r � d � Y '� � s � � ' WORKERS'COMPENSA710N DECLA�ATION ' � j° ��/!� ¢ ���� ��' `T�p e U � IHER6BVAFFIRMUMJERPENILLNOFPERJURYONEbFTHEKOLLOWMGD�ECLARATIbpIS^�,���r'a'�� � �'. � � C P � �., e, A _IHAVEANDWILIMAINTAINACERTIFlCATEOFCONSENTTqSELF�INSUqEFORV/I1RKERS' y fl / � CqMPENSATbN,ASPROVIDED�BVSECTION3'7JOOFiHELA80RCADE,FORYfiE�pERFOR0.AANCE U �r�Cn C R 1 N� r 4 OFTHEWORKFORLYHICHTHISPEflMITISiS5UE0. � �� � � "�� �' � Q � w _IHAVEANDWILLMAINTAINWORKERS'COMPENSATIONINSURANCE,ASREOUIRE�BYSECTION Q 37000FTHELABORCODE,FORTHEPERF�RMANCEOFTHEWOflK�FORWHICH'MISPEFMITIS ISSUE�.MYWO 'COMPEN5710NIr�SURANCE AfiRiERAND CLICYNUMB£RARE: CONSTFlUCTION � CARRIER '� ^ - � / ��..,,(( PLAN REVIEW ,,.. � POUCYNUMBER_ .. � . . '� .�� '°� EL�RIS,� . ¢ f.� • � o (THIS5EC`IONNE�P70TBEp�1.EfIDOFhIEPEA�NI�ISFORCNEMJNbREOCLYWqSI �7��`). PLUMBIN i W I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOif WHICH 1'NIS PERRAI'f IS ISSUEb,I MECHANICAL z (;3 SHA4LNOTEM7LOYAM7PERSONINANYMANNERSDA3TOBECOMcSUBJECTTOTHE ,,, {yJ WORKERS'COMPENSAT�ONUIWSOFCALIFORNIA,ANDAGRE[THATIFISHOUL�BECOME INSPEC710NFEE SUBJECTTO THE WOqKERS'CAPAPFNSATION PPOVISIONS OF SECTION 37D0 OF THE lA@OR � CADE.I A F ITPI GOMPLY WItFi SE PROYISIO �{ �SSUANCE � "' [� DATE� .���APPLICANT: � �� /M�� SMIP J - _y WARNING.FA1 IIFiE TO SECURE VJORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL BE ENERGY P/C � SU&IECTANEMPLOYERTOCRIMINAIPENALTIESANOCIVILFiNESUPTOONEHUNDREOTHOUSANO CNERGYPERMIT �OI.UIRS(Et00,0oa),IN ADDRION TO7HE COST Of COMPENSATION,DAPAAGES AS PROVIOED FOR IN � SECTION37oeOFTHELA80RCO�E,IFfTEREST,ANDATTORNEY'5FEE5. � RETENTIONFEE: a GONSTRUCTION LENDING AGENCY' PRE-ALT FEE: � � O � IHEREBYAFFIRMUN�EPPENALNOFPEtiJUF11'THATTNEREISACONSTRUC?IONIENDiNOAQENCY , - ' � FOp THE PERFORMANCE OFYHE W091C FOR WHICH iN15 PERMITI.S ISSUED'(SEC.3097,CIV.C.).' �-`-- ... ,,,,,R.,, � . � .. W - ' .,.. . , . . . . . . � LENDER'S NAME � ' � ' F� LENDER'SADDRESS � � � ICEPTIFYTHATIHAVEREADTHISA?F�ICATIONAN�STATETN0.TTNEABOVEINFORMAtIONISCARRECT TOTAL FEES � - � w 1 AGREE TO COMPLY N7TH A�l CITYAND COUNTY OR'JINANCES ANO STATE lAWS RELATINd TO BVILDING � � CONSTRUCTION,AND HEREBY AUTHORI2E REGRESENTA71VE5 OF THIS COJNTY TO^�MER UPON THE � ZABOVE-MENTIONED GfiOPER F H INSPECTION PURPOSES. Q COMMENTS__.___,_ , � ��� ��' ��. � -- �V��. ,� � PERMITTEE N ME INT) � �` � � I I� � SIONATUREOF ERMITT ,,, �ATE - ' � '�1':a I�1 . _ . . '` '� �..�,- . _ � - � RECPT.NO. PAID BY 11'1LID,4TION� � . , ...._ . . .., ~ WHITE—De riment Co YEILOW—Finence Copy,PINK=-Assessor Co GOLDENROD--File Copy,GREEN— Pa PY. 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