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HomeMy WebLinkAbout13473 (17) CITY OF DIAMOND BAx �„�_...--' --�'-- DEPARTMENT OF COMMUNITY 8c DEVELOPNiENT SERVICES : � 21660 E.Copley Drive Suite 190 PRESS (909)860-3195 Fax(909)861-3117 ���� BUII.D'1NG.PEItM1T APPLICATION �_, FIRMLY 1 V"14� �c'�JR.C'hL.A�7'sS � . . : DATE . .. NUMBE . . . . _ . _. _. � JOBSITE APPLIGATION PERMI R 1�""7 �/C o ADORESS 4 � I / � ISSUE � TYPE OCC APN LOT TRACT DATE CONST. GROUP p OWNER ��-+� �� o ADDRESS SAi�1? ZONING SETBACKS W CITY ��� ZIP 1�TEL. �^���P FRONT RW ❑ � APPi1CANT _,. TEL. REAR _ ❑ SIDE/SIDE STREET RW ❑ � CONTRACTOR 4."A�.x'Lir�'�-..a`="Att..&fl.S SIDE _ ❑ � ADDRESS �^�� 1 PROPOSED USE o CITY C��*-��� tZIP '�Z.- TEL� � '� - o ARCWENG/ � DESIGNER NO.DWEL. NO. NO. ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � � OWNER-BUILDER DECLAAATION SFR/ADD/REM O p I HEREBY AFFlRIA UNDER PENALTY OF PERIUHY THAT i AM EXEMPT FRON THE CONTRACTORS L4 Gd(flg0/CafpOA W CENSEUWFORTHEFOLLOWINOREASON(SEC.7031.58USINESSAN�PROFESSIONSCODE:ANYCINOfi (n C� COUN7VWHICHHEOUIRESApERMITTOCONSTRUCT,AI,TER.�MPROVE,DEMOUSH,ORAEPAIFiANYSTRUC- W PatiOlDeCk wNRE,PRIOR TO ITS 153UANCE,ALSO RE�UIRES THE APPUCANT 4'OR SL1CH PERMIi TD FICE A SIGNE� w .� 9TATEMENT THAT HE OFl SHE IS UCENSED PURSUANT TO THE PROVISIONS OF 7HE CONTRACTOR3 LI- � CENSELAWI�PTER9(WMMENCINOWITHSECTION70oo)OFDIVISION30K7HE8USINESSANDPRO- � PooUSpa — FESSpNS CO�E�OR THAT HE Oq SHE IS EXEMPT THEREFqOMAND THE BASiS FOR THE ALIEOEp EXEMP- TION.ANYVIOLAT'IONOFSECTION7031.69YANYAPPLICANTFOHAPERMITSU&IECYSTHEAPPLICANTTO � RB-�lOOf � A CINL PENALTY OF IJOT MORE THAN FNE HUNDRED DOLLARS(E5ooj.1: � ❑I.ASOWNEHOFTHEPROPERT'.ORMYEMPLOYEESWIiHWAGESASTHEIRSOLECOMPENSAiION, � CommefClal WILI DO TNE WORK,AND THE STRl1CTl1RE IS NOT IMENOED OR OFFERED FOR SALE(SEC.7044.BUSI- J NESS AND PROFESSIONS CODE:THE CONTqACTORS LICENSF UW�OFS NO7 APPLY TO AN OWNER OF � PROPERTYWFpBUILO60RIMPROVESTHEREON.ANOWNODOESSUCHWORKHIMSELFORHERSEI.FOH m � TMqqlCiFiF1150RNERONMEMPLOYEES,PROVIDEDTIATSUCHIMPROVEMENTSARENOTINTEND�OR QOFFEREDPORSALEIF,HOWEVERTMEBU�LDMGORIMPROVEMEMISSOLDWITMNONEYEAROFCOMPLE- � �TKKJ,THE OWNER�BULDER WILL HAYE THE BURDEN OF PROVING iT7AT HE OR SHE DID NOT BUILD OR = IMPROVE FOR THE PURPOSE OF SALE�. � � � - _ ❑I.AS OWNER OF THE PROPEFlTI:Ald E%CLUSIVELY ybNYRACiING WITH LICENSED CANTflACTORS � TO CONSTRUCiTHE PRQIECT(SEC.7040.BUSINE55 AND PROFESSIONS CODE:THE CONTNACTORS tl� Vdlll2t1015 _ ADJ.AREA � CENSEUWOOESNOTAPPLYTOANONMEROFAPROPERNWH08UILDSORIMPROVESTHEREON.AND WFiOCONTRAC7SFORSUCHPROJECTSWITHACONTRACTOR(S�LICENSEDPUSiSUANTTOTHECONTRAG QUANTITY DESCRIPTION FEE - � TORS LICENSE LAW.J. �J 0 ❑I AM EXEMPT UPlDER S�C. 8.8 P.C.FOR TNIS REASON � '� ft �'±' DAYE OWNER r W � LICENSED CONTRACTORS DECLARATION W � I HEREBY AFFIRM UNDEfl PENAI.TY OF PERIURY THAT 1 AM LICENSED UN�ER PROVISIONS OF CHAPTER � ��l�C�,7 i � 9�COMMENCINGWITHSECTION7000)OFOIVISION30FTHE8USINESSANDP�OFESSIONSCODE,AND z ��`�—' x MY LICENSE IS IN FULI FORCE AND EFFECL m . . � ,. � u� (-r�/ � � UCENSE CLA55 ��� LIC.NO.� � ``� J V pA7E �"'{� CONTRACTOR��� a W -- � WORKERS'COMPENSATION�ECLARATION Q � U � �HEREBY AFFIRM UNDEA PENALTV oF PFR�t1RY ONE OFTHE FOLLOWING DECLARATIONS: Z Q � _I HAVEAND WILL MAIN7AM ACERTIFICATE OF CONSEN7T0 StLF�INSURE FOR WORKERS' 2 ' ' COMPENSA(ION,AS PROV�DED BY SECTION 3�o00F THE LA00R COQE,FOR THE PERFORMANCE W OF 7HE WOHVC FOR YJi11CH THIS PERMIT IS ISSUED. c` 0 W _I HAVE MD Nd�LL MAINTAIN WORKERS'COMPENSATION INSUpANCE,AS REOUIPED BY SECTION Q 37000FTHELA90RCODE,FORTHEPERFORMANCEOFTHEWONKFORWHICH7HISPERMITIS ISSUED.NVWORK RS'COM�PEN(S�ATIONINSUR/AN�C�EC'�A�RRIERANDPOUCVNUMBERARE: CONSTRUCTION .�j CARPoEA �' "'-' ' "°�"�•`+' � PLAN REVIEW 6 . 0 POLICYNUMBEfl �� � L�`'"� _ ELECTRIC _ � �+�-'` -'`� ¢ A+ ��:;.-" a 0 (IH6SEGTIONNE�f�T0E0IXdPLETEDOF7NEPERAHPI9FORONEI-!Ut�DAE00.7t1A(iSI5100)ORLE6S1 PLUMBING _ .•1 A� d"G ;"O.^%•�. Z I CERTIFY THAT IN 7HE PERFOPMANCE OF THE WORK FOFi WHICH THIS PEAMIT IS ISSUEO,I MECHANICAL �� �'��+-"'s� �� (,�J SHALLNOTEMPIOYANYPERSONINANYMANNERSOA5TD8ECAMESUBJECTTOTHE ,�i� `.i�„�"2`' � `b�'��y � WORKERS'COMPENSATIONLAWSOLCALIFORNIAANDAGREETHATIFISHOUl�BECOA/F INSPECTiONFEE,�p ( e � ( S �SU&IECTTOTHEWORKERS'COM�MSRTP�TFfiOY� SO�SECTIQN370aOFTHELABOR ISSt1ANCE �'Hen����� �`+' �^ �:�^-� CO^DE,ISHAlSc.�FO HWITHCOM WITHTHOSEPROVIS � .„ o J�3"7� ��....�__s�-__.--�,�.,,�z SMIP �� ,v.$^ p OATE: APPLICANT. __._ � W ENERGY P/C s-K��'�- J WARNINQ:FAILURETOSECUREWORKERS'COMPENSATIONCOVERAGEISUNIAWFUL,ANDSH/LLLBE ��, w. LL SU&IECTANEMPLOYERTOCRIMINALPENALTIESANDCNILFlNESUPTOONEHUNDREDTNOUSAND ENERGYPERMIT ��y� DOLLAftS(510D,000�,IN ADDITION TO THE COST OF COMPENSATION,DAMAOES AS PROVIDED FOR W � SECTION 3IOe OF TiE IABOR CO�E,INTEREST,AND ATTORNEY'S FEES. RETENTION FEE: . a CONSTRUCTION LENDING AGENCY PRE-ALT FEE: O � I HEREBY AFFIRM UNDER PENALN OF PERJURV TMAT THEftE IS A CONSTfiUCT10N LENDING AGENCY , FOR THE PERFOFMANCE OFTHE WORK FOF WHlqi THIS PERMIT IS ISSUW(SEC.3091,CIV.CJ. Z W � LEN�ERS NAME F-- IENDER'SAODRESS -- - � WI CERTIFV THAT I HAVE READ THIS APPLICATION AND STATE 7H0.T THE ABOVE INFORMATION IS COftRECL TOTAL FEES � I AGREE TO COMPLY WITH AlL CITY AND COUNTY ORD!NANCESANO S7ATE LP.WS RELAYING TO BUILDING CONSTRUCTION,ANO HEHEBY AUTHORIZE PEPRESENTATNES OF THIS COUNTV 70 ENTEP UPON 7HE ZABOVE-MENTIONEDPROPERTYfORINSPECTIONPURPOSES. COMMENTS � A�a��G-�ac: ---- m PER EE NAME(PRINT).. � -- ¢ r - � � y SIQNATURE OF PERMI DATE RECPT.NO. PAID BY VALIDATION � WHiTE—Depanment Copg YELLOW—Fineace Copy,PINK—Assessor Copy,GOLDENROD-FIe Copy,GREEN-ApplicanPs Copy . . . . . . .. ,... . � .......� ., . �.,:., �.. q.�„ ..`:,.,�;. .. - �. , . � �_c �,r,�� ., , � � . . , :._.. . .' . . . . ., r s y, ..,•. ,�,.,, . . 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