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HomeMy WebLinkAbout16133 �� CITY OF DIAMOND B AR }„� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES . � 21660 E.Copley Drive Suite 190 (909)860-3195 Fax(909)861-3117 PRESS ��:��''°` BUII.DING PERMIT APPLICATION �FIR f( 4 DDRIESS 2�3� �-n d iU n Cre.�K � o � '' PPLICATION , ��: PERMIT + � P/C p ATE ^ � NUMBER k � APN �OT TRACT ISSUE �TYPE OCC ---�-�— DATE CONST. GROUP p OWNER ��-..S T �.G � ADDRESS �- W'"'"1 A ��. ZONING SETBACKS "'� CITY � - frY�C6! ZIP TEL. FRONT RW C � APPLICANT �'I� Gt.O �'EL. • i� t - r REAR p SIDElSIQE STREET RW ❑ r� CONTRACTOR R CJY"`" SIDE ❑ � ADDR SS `�° CITY " �' ZIP��U� ' TEL. (�' -( � PAOPOSED USE � ARCH/ENG/ — -- DESIGNER NO.DWEL. NO. NO. ADDRESS_ UNITS STORIES BEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER•BUILDER DECLARATION SFR/ADD/REM p I HEHEBV AFFlRM UNOER PENALTY OF PERJURY THAT t AM EXEMPT FROM THE CON7RACTORS LI- � Garage/Carport ll,l CENSEL4WFORTHEFOLL6WIN6HEASON(SEC.7031.50USItiESSPNOPROFE5510NSCODE:ANVCITYDR C.7 (;qip7YWHIp1REWMESAP6RMITTOCONSTqUCT,ALTER,IMPROVE,DEAIOUSH.ORREPAIRANYSTRUP � pytl0/DeCk ZNRE,PRIOR TO ITS ISSUPNCE.N.50 REOUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED W .� STATEMENT THAT HE OR SHE IS LICENSE�PUqSUANT TO THE PROVISIDNS OF THE CANTRACTORS LI- � CEN3E LNW(CMNPTER B(COMMENC�Na WITH SEC7pId 7000)OF pIVI510N 9 OF THE BUSINE&S AND PRO- � PooUSpa _ FESSqNSCODEJORiHATHEORSHEISE%EMPTTMEREFROMAN�TMEBASI5FDRTHEALLEGE�IXEMP- TpN,AM'VIOLATH7NOFSECTION7�1.56VANVAPPLICANTFORpPERMITSUBJECTSTHEAPPLICANTTD Z Re-Roof �, �CML PENFITY OF NOT MURE THAN FIVE HUNDRED DOLLARS(i600)J: � ❑I,ASOWNEROFTHEPROCERTY,ORMYEIAPLOYEESWITHWAGESASTHEIRSOLECAMPENSA710N, � CommerCidl -� WILL OD THE WOPoC,AND THE STRUCTURE IS NOT INTENOED�i OFFEREO FOR 3ALE(SEC.7oad,BUSI- _1 NESS ANO DAOFESSIONS COOE THE CANTRACTORS LIC[NSE LAW DOES NOT APPLY TO AN OWNER OF � PROPERTYNhiOBUNASORMPROVEShiEREON,ANONMODOF.SSUCHWORKHIMSELFORHERSELFOR � � THMU(3HNISORHENOWNEMPLOYEES.PROVIDEO7HATSUCN�MPHOVEMENTSARENOTW7EN�EOOR m pOFFEREDF6RSIlE1F,NOWEVERI}iEeUILDINOORIMPROVEMENTISSOIAWITHINONEVEAPOFCAAiPLE- Z TION,TNE OWNER-BUIIDER WILL HAVE THE BUROEN OF PROVIIVO THAT HE oR SFiE DID NOT BUILD OR � IMPROVE FOH TNE PURPOSE OF SAIF). O�,ASOVYNEROFTHE PROPERTI',AM E%CLU3IVELY CANfR0.CTINC3 WITH IICFNSED CON7RACTORS � TO CONSTRUCT T}!E PP0.IECT(SEC.)oU,f9USINESS ANO PROFESSIONS CODE:IHE CONTRACTORS LI- ValU8ti0f1 ADJ.AREA W GENSEIAWDOESNC>TAPPLYMANOW4EROFAPROPERTVWHOBU1LD50fiIMPROVESTNEREON,AND — � ri'FIOCONTMCTSFORSUCNPR0.IECTSWITHAGDNI'RACTOH(5)UCENSEDPUHSUANTTOTHECONTR0.F QUANTITY DESCRIPTION FEE � TORSUCENSEIAW.�. _ ❑I AM EXEMPT UNDER SEC. B.8 P.C.FOR THIS REASON � Q 3 � w � DATE ONMER___ F' 2 W Q LICENSED CONTFIACTORS DECLARATION W � _ � IHERE9YAFFIRMUNOERPENALTYOFPERJURYTHATIAMLICENSEDUNDER'PROVISIONSOFCHAPTER � "��- ' "' � Y�WIAMENCINQWITHSECTION7000JOFDIVISION30F7HE91151NE5SANDPROfES510.VSCODE,AND Z 7�f MY LK:ENSE IS IN FUL ORCE AND EFFECT. m � 461 C,, _� LF°�Z�a�J� � o LICENSE CL4SS ,'J.� L1C.NO. /Jy� J V �ATE _ CONTRACiOR_ �1��_ �*'I• �I a W � � WORKEFlS'COhSPENSATION DSCLARATION U, � IHERE6VAFFIRMUNDF.FPENN.TVOFPERJURYONEOFTHEFOLLOWING�F.CLARATIONS: iI� Z Q � _.__._IHAVFqNDWILLMAINTAINACEpTIFlCATEGFCIX�SENTTOSELF-INSUAEFORWORKERS' _ CAMPERSATION,AS PROVIPED BY SF.CTIQN 37oaOK1HE UBOP CODE,FOR THE PERCJRMANCE `U OF THE WORK FOR WHICH THIS PERMIi IS IuSUE�. � � W _IHAYEANDVd1LLMAINTAMWORKfRS'COMPENSATIONINSURANCE,ASPEQUIREDBYSECTION � 37000FTHE I.ABOR COnE,FCRTH.F.PERFORMANCE DFTHE WORK FOR WHICHTHIS PERldITI^u a ISSUED.MY I(RS'dXJMPEkSATION�URANCE�C,e,yp RIEaAN�POLICYNl1MBERARE CONSTRUCTION jCARRIER�� J�_ U��,} PLAN FiEVIEW � FOLICY NUMBER K�'���� ELECTRIC 4 �0 (nils5Ec7lOPJn�C-ONc�76ECJT6L.EfmoF"MEPEPo+w715fnRpNEHUt�OPEDDaIARsrytoo)atLess). PLUMBING Z 1 CERTIFYTHAT iN THE�'E.RFOflMANCE OF THE WORN FOft WHICH THIS PERMIT IS ISSUED,I MECHANICAL (� SHdLLNOTEMPIOYANYpERSONINANYMANNER�0A5T08ECOME5U8JECTTOTHE N WOftKER5'COMPEN5ATIONLAWSOFCALIFORNIA,ANDAGpEETHATIFISHOULDBECOME INSPECTIONFEE SU9JECT TO THE WORKERS'COMOENSA710N PRO✓I,SIONS OF SECTION 3700 OF THE LABOR `� � CODE,ISHALLFORTHWI7NCOM?LYWITIiTHOSiEPROVIS10N5�.J 1 ISSUANCE �-' �" � �"1`�(3`� t.-v!111�V��� SMIP ' OATE:___ APPLICANE wWARNiNG FAILURE70 SECUflE WORKERS'COMPENSATIqV COVEflAGE IS UNIAWFUL,AND SHALL BE ENERGY P/C �' ����___ _ �y SV&IECTANEMPLOYERTOCRIMINAI.PENACTIESANDCIVILFINESUPTOONEHl/NOREUTHOUSAND ENEFGYPERMIT DOLLARS(it 00.000�.IN ADDITION TO THE CAST OF COMPENSATION,DAMAOES AS PROVIDEO FOR IN � SECTION37080FhIELA80FCODE.INTEREST,ANDATfOHNEYSFEeS. RETENTIONFEE: 0. CONSTRUCTION LENDING AGENCV PRE-ALT FEE: O 0. 1 HEREBY AFFIRM UNDEfl PENALTY OF PERJURY THAT THERE IS A CONSTRUMION LENDMG AGENCV FOR THE PERFOflMANCE OF THE WOflN FOP WHICH THIS PERMIT IS ISSUED ISEC.3097,CIV.C.). Z W � LENDEa'SNAME_, . __ F- LENDER'SAO�RESs � ICERTIFVTHATIHAVEREA�THISAPPLICAiIDNANDSTATETHATTHEA80VEMfORMATIONISCARRECT. TOT/"1L FGES �,��J� � I AGREE TO GOMPIY WITH ALl CRY AND COUNTY ORDINRNCESAND STATE LAWS PELATING'O BUILDING �C � CANSTRUCTION.ANOHEREBVAUTHOFIZEREPRESENTATIVESOFTHISCOUNT'TOENTERUPONTHE ABOYE-MENTIONEO FROPERTV FOR INSPECTION PUROOSES. COMMENTS � r l� V�v! '� QVE IT7EEN E(PRINT� ' �j [/) ('7�p� � // , •--.L.i4.�� � SI UREOFPERMITTEE� DA .= RECPT.NO. � �"PAID 8Y \. 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