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HomeMy WebLinkAbout16170 (20) .o-�=�='°'"'c'rr , _ . , � ^ �,� CITY OF DIAMOND BAbt �, I � � � � DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES 21660 E.Copley Drive Suite 190 � � (909)860-3195 Fax(909)861-3117 PRESS ���'+�°� BUILDING PERMIT APPLICATION . _ FIRMLY o� JOBSITE ��'''� APPLICATION PERMIT I P/C ADDRESS ����_��� �._._..'"j"��� DATE NUMBER lP �� # � ISSUE TYPE OCC APN LOT TRACT DATE CONST. GROUP p OWNER o ADDRESS ' "T� ZONING SETBACKS Z CITY IP TEL.� � REART RW C� g APPIICANT TEL."�CS��{��F4' SIDEISIDE STREET RW C � CONTRACTOR SIDE ❑ � �...-- c- — � ADDR� ��` +� •� , � ��� PROPOSED USE CITY �.3 �.x S ZIP TEL."�[� � � ARCH/ENG/ � DESIGNER � '� ADDR�S , .ca • NO.DWEL. NO. NO. � UNITS STORIES BEDROOMS � CITY L� rn-_��c_ Z!p TEL."3Csv-L�� � DESCRIPTION SQ.Fl: FACTOR PSF ADJ.AREANALUATION Q OWNER-BUIL�ER�ECLARATION SFR/ADD/REM O I HEREBY AFFIRM UNDER PENlLLTY OF PERJURY?hiAT t AM E%EMP'r FROM iH TRACTORS U- G3f8JB/CBfPDff W CENSELAWPDRTHEFOILOWINGREA50N(SEC.7031.5BUSINESSANDPROFE55 CODE:ANVdTYOR (f� � COUNTYMMICHREWIHESAPERMITTOCONSTRUCT,ALTER,IMPROVE,DEMO ORREP0.IRANYSTRUP W PatiO/Dedc W TURE,PRpR TO ITS ISSUANCE.QSO REQUIRES THE APPLICAN7 FOR PERMIT TO FILE A SIGNW W .� STATEMENT THAT HE OR SHE IS LICENSED W(iSUANT TO THE PRD ONS OF THE CONTRACTORS ll- � CENSE lAW(�PTER S(COAIMENCINO WITH SECTION 7000)OF SIOH 3 OF THE BUSINESS AND PitO- POOUSpd r FESSIONS�E)ORTHATHEORSHEISEXEAIPTTHEREF OTHEBASISFOHTHEAILEGE�E%EMP- (� V TION.ANVVIOUTIONOFSECTION7031.5BYANYAPPLICA ORAPERMITSUBJECTSTHEAPPUCAMTO Z Re-Raof F„ AqVIL 7ENAL7V OF NOT MORE THPN FNE NUNDRE� RS(f5o0).j: � ❑t,ASOWNEROFTHEPROPERTY,ORMVEMP EESWITHWAGESASTHEIR&OLECOMPENSATION, � COR1f118�C181 - WILL DO THE WORK,AND THE STPUCTURE IS INTENDED OR OFFEFED FOR SALE(SEC.7o41,BUSI• J N NESS AND PROFESSIONS CODE:THE CANT CTORS LICEN9E UW OOES NOT APPLY TO PN OWNER OP = PROPERTYWFpBUILDSOHIMPROVEST REON,ANDWHODOESSUCHWORKHIMSELFORHERSELFOR � TFIHOUl3Fl NIS OR HEP OWN EMPLDV ,PR9VIDED THqT SUCM IMPR4VEMENTSARE NOT INTENOE�OR � QOFFEREUFOfl5N.E1F,MOWEVE E6UILOINGOHIMPROVEMENTISSOIDWITHINONEYEAROFCOMPLE z TION,THE ONTIER-BUILDEH HAYE THE BURDEN OF PfiOVING THAT HE OR SHE DID NOT BUILA OR � IMPROVE FORTHE PURPO Of SALE1. W ❑I,ASOWNEROF PROPEH7V,AMEXCLUSIVELVCONYRACTMOVYRHLICENSE�CONTRACTOPS � TO CONSTRUCT THE ECT(SEG 7044,BUSINESS ANO PROFESSIONS CODE:THE CONTRACTOqS U- VBIU8110n ADJ.AREA W CENSELAWDOE TAPPLYTOANOWNEROFAflHOPER7YWHOBUILDSORIMPROVESTHEREON,AND - � N'FiOCONT FOFSUCHPRQIECTSWITHACONTRACTOR(S)LICENSEDPURSUANTT07HECONTRAG QUANTITY DESCRIPTION FEE � TORS LICE LAW.�. AM EXEMPT UNDER SEC. B,8 P.C.FOR THIS REASON Q 3 U t� � DATE OWNER � 0 w F, LICENSED CONTRACTORS DECLARATION � � I HEREBV AFFWM UNOER PENALTY OF PERIURY THAT I AM LICENSED UN�ER PROVISIONS OF CHAPTER � a, 9�COMMENCYlOWITHSECTION7000)OFDtV�SION30FTHE8USMES$ANDPROFESSIONSCOOE,AND Z l•C MY IICENSE 15 IN FUIL FORGE AND EFFECT. / `Q LICENSE C LIC.NO. � `—Y—�-�—`, � ,�!� �y�� J V DATE I �� CONTRACTOR :�:�_t "— � n- tlJ � WORKERS'COMPEhSATION DECLARATION d � � I HEREBYAFFIRM UNDER PENALTY 6F PEFiIURY ONE OF THE FOLLOWING OEGUflATIONS: Z O __IHAVEMIDW!IIMAMTAINACERTIPlCATEOFCONSENTTOSELFaNSUREFORWORNEFS' S Q COMPENSATpk,AS PROVIOED BY SECTIAN 3]o00F THE LA60R CODE,FOR THE PERFORAIANCE `U OF iHE WORK FOR WHICH THIS PERMIT IS ISSUEO. � O � AVE AND WILL PAAIMAIN WORKER5 COMPENSATION INSURANCE,FS FEOUIRED BV SECTIqN Q 37000FTHEi.AB6RCODE,FORTHEPERFORMANCEOFTHEWORKFORWHICHTHISPERM1T15 � lSSUEO.MY WORNERS'COMP NSATION INSURANC ARRIER AND,P,/q�LICY NUMBER ARE: CONSTI�UCTION � CARRIER�� � d�–� � PLAN REVIEW d � POLICV NUMBER !_�{���, '"�-/�—_� ELECTHIC 0 (�H65ECiIpVNEEDNOTBECp.&lFfEbOF1TfPEPoXTFSFORONEHl/NDRmDq1N15(51o0)OR'.6SSG PLUMBING � .� L Z I CEATIFYTHAT INTHE PERFOPMANCE OFTHE WORK FOq WH H THIS PERMITIS SSUEO.1 MECHANICAL (��' SNALL NOT ElAPLOY AtJV PERSON IN ANY MANNF.R SO AS T COME SUBJE THE � WORNEAS'COMPENSATKKJL4WSOFC4lIFORNIA,AND EETNATIFI LOBECOME INSPECTIONFEE S SU&lE TOT NbRNEfiS'COMPENSATIONPC7�V! SOF��CTlO �OOOFTHELABOR COD SH FORTHWITHCAMPIY WIR{YHD�� VI51 pS ISSUANCE �� �'J V O p �ATE: > APPLICAN SMIP LSJ J WApNIN �FAIL E TO SECURE WORKEF75'CO NSATION CAVERAGE IS UNIAWFl1L,AND SHALL BE ENERGY P/C LL SU&IECTANEMPIOYERTOCRIMINALPENAL ANDqVILFWESUPTOONEHl1NDPEDTHOUSAND ENERGYPERMIT DOLURS(5100.000).IN ADDITION TO THE C OF COMPENSATION,�AMAGES AS PFOVIDEO FOR IN � SECTION 97aa OFTNE LABOR CODE,INT sr,allo arroariErs FEEs. qETENTION FEE: OCONSTRUCTION LENDING AGEN PPE-ALT FEE: � � I HEREBV AFFlRM UNDER PENALN OF PERJURV THAT ACONSTRUCTIDN LENDING AGENCV � ' � ' FOR THE PERFORMANCE OF TNE WORN FOR IS PERAdiT IS ISSUED(SEC.3091,CIV.C.). . . Z W � LENDEN'S NAME � F— LENDEH'SADD � TOTAL FEES , "� � I CER THAT 1 HAVE READ THIS APPLICATION AND STATETHAT THEABOVE INFORMATION IS CORRECT. W I AGREE TO CAMPLV WITH ALL CITY AND COU TV OFDINANCESAND STATE UWS RELATING TO BUILDING � CONSTRUCTIpN,AND HER60Y AUTNORI PRESENTAT VES OF TNIS COUNTY TO ENTER UPON THE � ABOVEMENTIONEO PROPERTV FOR TION P RPO ' o .,:��� COMMENTS � /,• m PERM�1`TEE (P . . Q � � ON R E DATE � RE PL NO. PAID BY __. ___VALIDATION WHI7E—Depertment Copy,YELLOW—Finance CoUX PINK—Assessar Copy,GOLDENROD--File Copy,GREEN—ApplicaM'S Copy �... ',.�'...:,, �� -.'<,, . .,w�x..: e -.:f..: .. .,.,. -i. .,. r.,�:a.. ���.-.;:'. . .. ., �t. �. . .VLAY�; . .YV... �r wh:_ ...j ..:y.,lY:�`+'w6k; �.. . ' 'P � . .�,i.: ...... .,.:,.., :..��.:�. ..,a�y .i�..re. ,:.�c.... ,... 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