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HomeMy WebLinkAbout12877 (13) � ,. _�._ _--,...''�- _1,��_ C�ITY OF DIAIVYOND BAI� l'''— DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES � 21660 E.Copley Drive Suite 190 (909)860-3195 Fas(909)861-3117 . PRE$S ��"'�"��� BUQ.DING PEItMIT APPLICATION FIRMLY o �Z��v• sue g��2 . . .....> .. .. � JOBSITE r �- APPLICATION `t S TyPE E �� #/C� ¢ ADDRESS L�� /N�/� � APN LOT 2 6 TRACT �- �J �S I �-�J7,� OCC � OATE CONST. GROUP p OWNER L�+� o ADDRESS 6 YG ZONING SETBACKS � CITY�L� ZIP TEL 0 _ FRONT RW ❑ APPLICANT E�. REAR � � SIDE/SIDE STREET q�n/ p CONTRACTOR SIDE ❑ o ADDRESS / CI ZIP TEL. PROPOSED USE � �� - R � �` ���E� �f�I►.�5� w RC NG/ �/� �� z ESIGNER w NO.DWEL. NO. � Np, � a ADDRESS 2 E1:t/�T cn � / UNITS STORIES BEDROOMS � CITY °[..F��i(//� ZIP TEL. 6 � DESCRIPTION pSQ.Ff. FACTOR PSF ; _ ADJ.AREANALUATION O OWNER-BUILDER DECLARATION. SF ADD/REM p (� SS�'�'f ,Op � p I HEREBY AFFlRM UNDER PENALTV OF PEPJURV 7HAT I AM E%EMPT FROM h1E CANTpACTORS LI� �1 W CENSEUWFOR7F1EfOLlOYVINOREAu^ON�3E0.9ai1.58U51NE55ANDPflOFESSIONSCODE:ANYCITYOR � GaragelCarport � 2+ 3�9SS� dd C� COIINfYNR11CHREWIRESAPERMITTOCONSTAUCT,ALTER,IMPROVE,DEMDLISH,ORREPAIRANVSTRUF W PdtiO/DBCk /� W TURE,PRIOH TO ITS ISSUANCE,ALSD RCUUIRES THE APPLICANT FOR SUCH PERMIT TO FlLE A SIGNEO W 7 7 L DO .� STATEMEN!THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI� LL � CENSE UW(CHAPTER B(COMMENCINQ WITH SECTION 7000)OFDNISION 3 OF THE BUSINESSAND PR�. POOVSpe � FESSIONSCODE)ORTHATHEORSHEISEXEMPTTHEREFROMANDTHEBASISFORTHEALLEGEDEXEMP- (� TION.ANYVIOLATIONOFSECilON7D37.5BVANYAPPLICANTFORAPERMITSUBJECTSTHEAPPLICANTTO Z Re-Roof � A CML PENhLTY OF NOT MORE THAN FlVE HUNDf1ED DOLIARS(t500�.): � ❑�,ASOWNEROFTHEPROPERT;ORMYEMPLOVEE9WITHWAGESASTHEIRSOLECAMPENSATION, � CommerCial � . - WILL DO THE WOHIC,AND THE STRUCTURE 15 NO7INTENDED OR OFFEHED FOR SALE(SEC.7044,BU51- J � NESSAND iROFES510NS CO�E:THE CONTRACTORS LICENSE LAW OOES NO7 APPLY TO AN OWNER OF = PROPERiY ViF10 BUILDS OR IMPqOVES TMEREON,AND WHO OOES SUCH WpRK W MSELF OR HERSELP OR .. . Q THRIXIOHHISORHEflONMEMPLOYEES,PROVIDEDTHATSUCHIMPROVEMEMSARENOTiNTENDEDOR m ��-��� 0 OFFEREDFORSJLLEIF,HOWEYERTHEBUILDIN60fiIMPHOVEMENTIS50LOWfTHINONEVEAROfCOMPLE- Z 'TION,THE OWNER•Bl11LDEH WILL MAVE THE BUR�EN OF PROYING hIAT HE Ofi SHE DI�NOT BIJILD Op � IMPROVEf-0RTHEPUF�OSEOFSALE). W ❑I,ASONMEROFTHEPROPEHfV,AMIXCLUSIVELYCqNTRACTINOWITHLICENSE�CONTRACTOR3 (r TO CONSTRUCT THE PROJECT(SEC.'loM,BU9INESS AND PROFESSIONS COOE:THE CONTRACTORS U- V8IU8SIOI1 � � ADJ.AREA W CENSELAWOOESNOTAPPLYTOANOWNEROFAPpOPERTVYMOBUILDSOqIMPROVESTHEREON,AND - � WFIOCOMMCTSFORSUCMCROJECTSWITHACANTRRCTOq(5)LICENSEDPURSUANTTOTHEWNTRAG qUANTITY DESCRIPTION FEE TORS IJCENSE UWJ. 0 ❑I AM EXEMPT UNDER SEC. B.8 PG FORTHIS FEASON Q i � '+y U LL DRTE OWNER 1- Z� U r. � � LICENSED CONTRACTORS DECLARATION W • � I HEREBYAFPIPM UNDER PENALTY OF PERJURY THAT IAM LICENSED UN�ER PROVISIONS OP CHAPTER � '� y� � 9(COMMENCINO WITN SECTION 7a0�)OF DIVISION 3 0F THE BUSINESS AND PfiDFESSIONS CODE,AND Z ��� MY LICENSE IS IN FUIL FORCE AN�EFFECT. ' m V � � � � LICENSECLASS � q LIC.NO. 4 �,�I� G.`�q � V DATE � CONTRACTOR��1�1 O�J -�'+V� d � � � WORKERS'GOMPENSATION DECLARATION Q � N �HEREBVAFFIRMUNDERPENlLLTYOFPE0.tt1RYONEOFTHEFOLLOWINGDECLAF7ATIONS: Z � _IHAYEANDWILLMAWTFINACERTIFICATEOFCONSENTTOSELFdN5l1REFORWORKERS' _ COMPENSATION.ASFROVIOEOBYSECTION37o00FTHELA80RCODE.FORTHEPERFORMANCE U Q / OFTHE WORK iOR WHICH THIS DEqMI715ISSUED. � �..W_, �I HAVEAND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRE�BY SEC710N - � 370D OF THE LABOR CODE,FORTHE PERFORMANCE OF THE WORK WR WHICH THIS PERMITIS '2,�/ �,L(�7 � ISSUED.MY WOP,ICERS'COMPENSATION INSUfiANCE CARqiER AND POLICY NUMBER ARE� CONSTRUCTION .� b (V � 2 �, CARRIER � L � _ P,LAN REVIEN! � �• ✓ � POLICYNUlAHER �[��' � '"� I ELECTRIC 2�� � ° �� " � � (IFIISSEC1ti7NNE�NO7BE00MPLETEDOF7HEPEPMTISFORONEHUNORE00q1NiSry100)Oq�ESS) PLUMBING ; � S� � 'I �-/� . , ...... .. ... . . „ Z I CEFTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I MECHANICAL � _.1���J✓ C!T SHALL NOT EMPLOV ANV PERSON IN ANY MANNER SO AS TO BECOME SUBJECTTOTNE - N WORKERS'COMPENSATIONUlW50FCALIFORNIA,ANDAGF ETHATIFISHOULDBECOME INSPECTIONFEE SU&IECTTO THE WORKERS'COMPENSATI PROYISI NS SECTION 3T00OF THE LABOR �.q �j GODE,i HA FORTMWITHCOMPLY WITM T SE PRO I51 5. ISSUANCE ,��,/� p �ATE: I �� APPUCANT. _ _ ___ _ SMIP J WAPNINO:FAIIVRETOSECUREWORKERS'COMPENSATION' V.RAGEISUNLAWFUL,ANOSHALLBE ENERGYP/C � � � � SU&IECTAN EMPLOYER TO CFIMINAL PENA�TIES ANO CIVII FINES UP TO ONE HUNDRED THOUSPND ENERGY PERMIT y�d. DOLIARS(510D,OOOj.IN ADOITIONTO THE COSTOF COMPENSATION,DAMAGES AS PROVIDEO FOR IN J SEC710N 3lae OFTHE LABOR CODE,INTEREST,ANO ATTORNEYS FEES. p� RETENTION FEE: ��C� � CONSTRUCTION LENDING AGENCY PHE-ALT FEE� �J � I HEREBVAffIPM UN�ER PENAL7V OF PERIURV THAT THEHE IS ACONSTFiUCTION LENDING AGENCV (� '3�_3��. / d FOR THE PERFOFMANCE OF THE WORK FOR WHIGH TNIS PERMIT IS ISSUED�SEC.909'l,qY.4�. W �� . � LENDER'S NAME -� t- LENDER'SAD�RESS � TOTAL FEES �//r��� /// tt � ICERTIFYhIATIHAVEREADTHISAPPLICATIONAN�3TATETHATTHEABOVEINFORMAT10NI5CORRECT. � I AGREE TO COMPLY N7TH ALL CITY AND COUNTY ORDINANCES AND STpTE LAWS RELATING TO OUILDING ^� � �� � � ��� / / � � CONSTRUCTION,ANOHEREBVAUTHORIZEREPRESENTATIVESOFTHISC�UNT]=30EMERUPONTHE ��++�� a �r��- � z ABOVE�MENTIONEO PqOPERTY FOR INSPECTION PURPOSES. t � C� Dll T$ � � � � PEA I E N � � SIONAT ERM DATE = RECPT.NO. 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