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HomeMy WebLinkAbout13814 (14) 1� CITY OF DIAMOND BAli DEPARTMENT OF COMMiJ1VITY&DEVELOPMENT SERVICES � � . 21660 E.Copley Drive S ' �f����` l (909)860-3]9S Fax(909) 61-3117 � PRESS '��° BUILDING PERMIT CATION FIRMLY y� JOBSITE `,� � � � ���w APPLICATION�/� PERMIT 'P/ /, ¢ ADDRESS L�.2� =Kl��� cT�""Cr`'� L�/� `f' � , � � ~�V p ./�� DATE NUMBE ' # � ISSUE TYPE OCC APN L T TRACT DATE CONST. GROUP p OWNER "� ADDRE S� � J-� ��1�?�� ZONING SETBACKS �� FRONT CITY f'3 . _ ZIP � TEL � ' ���t REAR RW ❑ APPUCANT TEL. SIDE/SIDE STREET RW � ONTRACTOR t c..+�" SIDE � AODAESS � � CI ZIP�-_ TEL. PROPOSED USE " � �+ . , y'�G �C� � ARC G/ , � ��,, / yc-�-'��3�'/ -� Z SIGNER_��✓�V � ADDRESS L NO.DWEL. NO. NO. -�-�r �� UNITS STORIES BEDROOMS � CITY �,f�'./�r�/'�___ ZIP L. � � cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREA/VALUATION � OWNER•BUILDER DECLARATION SFR/ADD/REM O I NENEBY AFFIFAI UNDER PENALTY OF PERJUqY THAT 1 AM EXEMPT FROM THE COMRACTORS LI- G81'8 JB/C8l�OfI W CENSELAWFORTHEFOLLOWINGREASON(SEC 7031.SBUSINESSANDPROFESSIONSCQDE:ANYCITYOF (� � � ZCOUNfVWHIWREWIRESAPERMITTOWNSTRUCT.ALiER,IMPROVE.�EMOLISH.ORREPAIRANYSTRUC- W PatiO/DBCk TURE.PRqH TO ITS ISSUANCE.QSO REWIRES THE APPLICANi FOR SUCH PERMIT TO FILE A SIGNED . ��� STATEMENT THAT HE OR SHE IS LICENSED PURSUANT Tb THE PROVISIONS OF THE CON7RAC70R5 U- W � �^- � � k��,;. ., ' � CENSE LAW(CH/.OTER 9(CbMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO- �'�' POOVSP2 r"� . -''„+" Z FESSpNSCOUE)ORTHATHEORSHEISEXEMPTTNEREFROMANDTHEBASISFORiHEALLEGEOEXEMP- � TqN.ANVVIOUTIONOFSECTION7037.58VANVAPPUCANTFOpAPERMITSUBJECiSTHEAPPLICA4TT0 Z Re-Root � ACMI PENAL7Y OF NOT MORE THAN FIVE HUNDRED DOLLAAS(SSaO�J: � ❑I,ASOWNEROFTNEPROPERT/,OflMYEMPLOVEESWITHWAGESASTHEIFSOLECAMPENSATION, � CORIrt18IC18I WILL DO 7HE WORK,ANO iNE STPUCTURE IS NOT iNTENDED OR OFFERED FOR SAIE(SEC.7044,BUSI- J � NESS IW�PROFESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES NOTAPPLY TO AN OWNER OF = . _w`. � PROPERTY WFIO BUIL�S OR IMPROVES THEREON,AND WHO OOES SUCH WORK HIMSELF OR HERSELF OR (i V � TMROUGHHISORHEROWNEMPIOYEES,PHOV�DED7HATSUCHIMPROVEMENTSARENOTINTENDE�OR m OFFEREbFORSALE1F,FiDWEVERTMEBUIL�INGORIMPROVEMENTISSOLDWITHINONEVE4ROFCOIAPLE- . 6� Z TION,THE OWNER$UfLUER WILL HAVE THE BURDEtJ OF PROVMG THAT HE OR SHE DIO NOT BUIL�OR � G �� = IMPROVE FORTNE PUFPOSE OF SAIE). ❑I,AS OWNER OF TNE PROPEFTfY,AM EXCLUSIYELY CONTMCTING WITH l tCENSED ODNTRACTOFlS �� � TO CQNSTRUCT THE PRQIECT(SEC.7044,EUSINES3 AND PRpFE5510N5 LODE:THE CONTRACTOFS LI- V81U8I1Of1 � ADJ.ARE W CENSELAWDOESNOiMPLYTOANOYMEROFAPROPERTY+NMOBUIL�50RIMPRpVESTHEPEON,AND — " � WlIOCOMMCTSFOPSUCMPROJECTSWI7HAOON'iRAC70R(S)IICENSEUPURSUPNT70THECONTRAG QUANTITY I , FE � TORS LICENSE LAW.). / ❑I AM E%EMPT UN�ER SEC. 0.8 P.C.FOq TNIS REASON J O V 3 _ � � OATE OWNER__ F- � w � LICENSED CONTRACTORS DECLARATION W � i HEREBY�FFIftM UN�ER PENAITY OF PEFiJURY THA7 I AM LICENSEO UNDER PflOVISIONS OF CNAPTER � � D(COMMENCINO WITH SEC710N 70ao)OF DIVISION 3 OFTHE BUSINESS AND PROFESSIONS CODE,ANO Z _ X MVLICENSE IS IN'rULL FORCEAND EPFECT. �LLI � [D UCENSE CCASS LIC.NO, `'� r+� � � � J U �ATE � CONTRACTOR � �W � WQqKERS'COMPENSATION DECLARATIO� .��� U � I HERE FFlRM UNDER PENALTY Of PERiURY ONE OF THE FOLLOYlING DECLARA7IONS� Z � _IHAVEMlDWII.LMAINTAINACERTIFlCA7EOFCONSENTTOSELFINSUHEFORWORKERS' a 2 � CAMPENSATION,AS PFOVtUED BY SEGTION 370o OF THE UBOfl CODE,FOR THE PERfORMNNCE U Q OF THE WORK FOR WFlICH THIS PERMIT IS ISSUEO. � W � F �1 HAVE AND NAtl MAIGdTAIN WqRKERS'COMPENSATION INSUPANCE,AS REQUIRED BY SECTION �Q 370o OF THE LABOR GC�DE,FOR 7HE PERFORMANCE OF THE WOFK FOR WHICH THIS PEqMIT IS ISSUED.MYN'ORKERS'COMENSATIONINSUAANCECARRIERANOPOLICYNVMBERARE: CONSTRUCTION/� � ¢Q cqqRiER_ PI.ANREVIEW � ��-�_-- P=,-� - 2 - Z POLICYNUMBER__� � S"' 7 Z- � �- ELECTRIC . 'd Q Rti+55Ecr�oNNE�do7sEcoAARFrEooFirlEaEwNrswRavEi+unaaWoou.oas(E�ao�oa�Ess1 PLUMBING Z 1 CEFTIFY THAT IN TNE PERFORMANCE OF THE WORK FOR WMICH THIS PERMIT IS ISSUED,I MECHANICAL (!S SHALL NOT EMPLOY qNY PERSON IN ANY MANNEfl 50 AS TO BECAME SUBJECT TO THE � WORNERS'COMPENSATION L0.WS OF CALIFORNIA,ANDPGflEE THAT IF I HOULD BECOME INSPECTION FEE ' � S SU&IECT TO THE WOflNERS'COMPENSRTION PFOVI NS OF SECTIO � OF THE LABOR _ COD ISHALL THWITHCOMPLYWITHT SEP � ISSUANCE l p OATE: �Z^ APPLIC� . � SMIP / J WARNING:FA�URE TO SECURE WORKEAS'COMP NSATION RAGE IS UfJLAWFUL,AND SHALL BE ENERGY P/C _ � SU&IECTMIEMPLOVERTOCRIMINALPENALTIESAN�CIVIL 54PTOONEHUNDREDTHOUSAN� ENERGYPERMIT DOLLARS(f1aD,DaO),IN ADOIT:ON TO THE COSTOF COMPENSATION,OAMAGES AS PROVIDE�FOR IN � SECTION 37oe Of THE LABOR OJDE,INTEREST,AND ATTCRNE`fS FEES. RETENTION FEE s OCONSTRUCTION IENDiNG AGENCY pR ALT FE�:� ; � 1 HEREBYAFFIRM UN�ER PENALTV OF PERJURV THAT THERE IS A CONSTRUCTION IENDING AGENCY FOR THE PERFOFU.fANCE OF THE WORK FOF WHICH THIS PERMIT IS ISSUED(SEC.3097,CIV.C.). Z W � LENDER'S NAME F— LENDER'SADOPESS �� W ICERTIFYTHATIHAVEflEADTHISAPPLICATIONAN�STATETHATTNEA80VEINFOPMATIONISCORRECT. TOTAL FEES ,� Q � IAGREETOCOMPlVW1TNALLCITYANDCAUNTYORDiNANCE5ANO5TATEU4W5flEtATiNGTOBUILDWG __._ CONSTPUCTION,ANOHEREBYAUTHORREREPRESENTA7lVESOFTHISCOUNTVTOENTEFUPONTHE , r�.�` P/� /J`*j � f� � � ABOVE-MENTIONEOPROPERTYFORINSPECTIONPURPOSES. COMAAENTS'�V r� • �� � n L/,/,,'-'��r �� i � � — — � PERMITTEEN (PfiINT) � ..�J �� !_ ( y SI EOFPEfl / DATE ` � ,/ RECPT.NO. PAID BY VALIDATION WHITE--Department Copy,YELLOW--Finance Copy,PINK—AssessoyCopy,GOLDENROD—File Copy,GREEN—ApplicanYs Copy . . > . . .. . : . . , � , ,„ ., .�.., ,.,., .. . . . 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