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HomeMy WebLinkAbout16451 (22) B i'�/� �, !�_ CITY OF DIAMOND BAI� ;-: DEPARTMENT OF COMMUNITY&DEVELOPMENT SBRVICES �� �;� �r �,,=-';� � ��•� 21660 E.Copley Drive Suite 190 PRESS �. ���i;�.� ,'�+,,1i:;:s , ":��,., (909)860-3195 Fax(909)861-3117 BUII.DING PERII�YIT APPLICATION FIRMLY � JOBSITE 1 ` /� APPUCATION PERMIT ti..- P/C ili �, .�1DD ES � ��� �G^ �z ����'' DATE � � � � NUMBER �� J� # � �5 APN . LOT TRA T �SSUE NPE OCC DATE CONST. GROUP p OWNER - et'e ' {n •. l o ADDR $ ? L� GI �/9G�• ZONING SETBACKS Z CITY���PGr�ad _ ZIP T �J TEL. ' �� REART_ RW _ Lnl -- g APPLICANT TEL.�_ SiDE/SIDE STREET RW C7 � CONTRACTOR "� � �v�J ^___ SIDE CI i o ADDR �S �'69�-'.. �. ' �y ,[ o CITY�' L' ZIP ��� g � PROPOSED USE .- � � L.,�,,,x'' . C � J rj o ARCH/ENG/ � �`'Z- W DESIGNER NO.DWEL. NO. NO. p. ADDRESS—�y�� UNITS STORIES BEDROOMS yCITY �" ZIP TEL._i --- � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION Q OWNER-BUILDER DECLARATION SFR/ADD/REM O I HEREBY AFFlPo.1 UNDER PENALTV OF PE0.IURY THAT�AIA EXEMVT FROM THE CONTRACiORs LI. G8/flQB/C8fF70ff W CENSELAWFORh1EFOLLOWINGflEASON(SEC.7o31.5FiU51NE55ANDPROFE5510NSCADE:ANYCITYOR (n S� COUMYWHICHRE�UIRESAPEflM11TOCANSTRUC7,ALTER,iMPROVE,DEMOLISH,OHREPAIRMIYSTRUP W p8110/OeCk W NRE,PRIOR TO RS ISSUFtiCE,AL50 RECIUIRES THE APPLICqNT FOR SUCM PERMIT TO FILE A SIGNED W STATEMENT TNAT H�OR SHE IS UC[NSE�PURSUANT TO THE PROVISI04S OF THE CONTRACTORS LI� � CENSE LAW(CHADTER 9(COMMENCINp WITH SECTKKJ 7ooe)Of DIVISION 3 OF THE OUSINESS AND PRO- LL POOVSpB FESSIONSCODE)ORTHATHEOfl5HE1SEXEM�TThfERF.fROMMVDTHE8A31SFORTH[AL�EGf:UEXEMP� (J TION.AMYVIOIATIONOFSECT10N703f,58YANYADPLICANTFORAPERMITSUFiJEC7STHEAPPIICANTTO Z He-Raot � ACMI PEN/�LTY OF NOT MORE 7HAN FIVE 4U�DRED DOLlAfiS(f5o0).�: - � fJI,ASOWNEROFTHEPROPERiY,OR1AYEMPI.OYEf.SW!THWARESASTHEIRSOLF.COMVENSATION, � CORIf11BfC181 WILL DO TNE WORK,ANU THE STP.UCTUflE IS NOT INTEN�ED OFi OFFERFD FOH SALE(SEC.7044,fiU51- J Nf55 AMO PflOFES910Po5 CODE:THE CONTPAC:OR5 LICENSE LAW DOc NOT FFPL'i TO.1V'OWNeR OF � VpDPEfiT1'YM1iOBUILDSORIYPHOVES7HEREIXJ,ANDN710DDESSUCHWORKHIIASELF�RHERSELFOR � [[ THqOUGHMISORHERONRiEMPLOYEES,PROVIDEDTMATSUCHIMPROVEMENTSAflENOT!NTENDEDOR OOFFEREDFORSILLEIF,HOWEVER,THE9UIlDINGOflIA1PROVEAIENTIS50LDWRHWONEVEAROFCAMPLE __� Z TION,THE OWKER-BIIILOER WI:L HAVE TI{E tiURCEN CF PROYING TMAT HC OR SHE bIP NOT OUILD OH � IMPFiOVEWRTHEPURPOSEOFSKE). !]I,AS OWNEH OF THE PROPfR1Y.AM EXGLUSN[LY CONTRACTINO WITH f.ICENSF.�COMflRC70R5 � TO CONSiRUCT THE PR(UfGT(SEC.7064,OUSINESS AND PROFESSIONE CODE:THF.CON71iACTORS LI- ViIIUflI10l1 ___,____.__,_.,,_. A�J.ARFA...__ W CENSELAWOOESNOTAPPLVTOANOWNEROFAPFlOPEHTVNiHOBUil�50HIMPROVESTHERE�N,AND � VIliOCONTFACTSFORSUGHPRWECTSWIIMACGWTRACTOR�S)LICEN@EDPURSUANTTOTkECONTRAG QUANT�TY UESCRIPTION FEE � lORS LICENSE LAW.), _ � J � ^ ❑IAMEXEFIPTUNDEfl&�C-^,__,_,__ - - _6.'sPC-4�Cq';FiISREA50� Q __ __` � � �'� S V � � — OA1E __.._.._ oNMER__�""._.._ � ...'— U w � LICEN9ED CONTRACTORS DECLpRATION W _ aC 1 HEREBYAFFIRM UNDER PENALTY Of PEtiIURY THAT I AM I.ICF.NSE�UNOER PROVISIONS OF CHANTF..R � a 9(COMMENCINCiWITHSECT10N7000)OFCIYISION30FTHE�USIM1ESSM'�JPFOFEEeIUNSCODE,AND Z �, X AdY UCENSE IS IN NLL FORCE/AJND EFFECT. � LICFNSE CLASS,___—=.`___ LIC.tJO.__���"� • _ � � � 7 F, �y�� � �( ��y J _'_ _ U DATE�Si_`//._(-_✓�(/_� CON7RACTOR.,_ , v ' f.��J'��' d w � _..�._— r� WORKERS'COMPENuATiON�ECLARATIOff�� ��/'ZC! � � qqq � INEflEBYAFFIRAtUNDERPENALTYOFP[RJURS'ONEOFTHEFOLLOWItiGDFCLARATIUNS: .c,�•- ' Z Q f/� "-� `__ � __,._IH�VEAN�WILLMAINTAI4ACEFT�IFICATFOFCONSENTTOSELF-INSUflLFORW:)f'iKLiiS' _ CR#APENSATION,AS PROVIDE�BY 9ECTION 37ou OF THE IABOH CC�E,FOH THE PFPFORMANCE �U OF THE WORX FOR WH!CH THIS PEFMIT IS ISSUED. � � __I HAYEANO WILL MAINTAIN WOFiKEFS'COMPENSATION InSURANCE,AS RE�!IIR[U tlY SECTKKJ � 370a OF THE LMOR CODE,FOA'i HE PERFOPMANCE OF iHE WOR%FOR WHICN THIS PERMIT IS 0 ISSUE�.MY WORKERS'IXJAiRENSA710U IYSL'PAhCf:CARRIERAN[]Fk'.i ICY NUM6ERAqE: CONSTRUCTION _____._____ ______ --'..._ �j cneaiEa---------'--------..—'_---'-'-"_--- —.- PLANREVIENI _.. _:-' � ' - Z POLICYNUMBER --�-.---- [LECTRIC -' __-- �/'jf ��}} _..— " Q ""---�-,. _...(_.!�_�__�.....' "_—" _ l p (n+•ssEc110NNEt3�MorsFa�r.1F![rEooFn�EF[R\vrtSra�au[raNiNiE000u,+asis�oo)oa�6ss;. �PLUMBING _ _......-----....... _.._..--------.- � ICERTIFYTHATINTNEPERFOR!AAHCEOFThIEWURKFORWr1iG11THI5PERMITI5155UED,l MECHANICAL _ __________.._____ _____..,____,___.__. (} SHAII lrOT EMPLOY ANY PEF1SCNi IN ANV MANNF.R 50 AS TO OE�ME SUB T]]]TO TNE (n WORKERS'CAIAPCNSA710NLAWSOFCALIFORNIA,P.NUAGFl[F:TitATI . OU��EGOME INSPECTIONFEE __ .__. .___���� � SUOJECTTOTHEYIORI(ERS'CGMP 5/�iION' i51 SUFSE' IE37C0 TNELABOR � cooc.isHa�iFonnivmHcw�. �w'vmT�+Tr+os visious �� ISSUANCE __... _.__ _ _._ ___ O `� �� SMIP -..._ p OATE:_�J m�"��� APPLI ANT. _-_ .�,. __..___..-_. —_._.._.'_ ......--_._..._.- __ _'.. .-._— ..e_.,..�s . . W - """°_""'1 ENERGI'P/C """° J WARWING:GAILl1RE TO SECUNE WORKER E ATION CO LRACE IS UNLAWFUI..qND SI�IqLI BE '�;��"1-"'""""' -' I �y SU0.IF.CTAflEMPLDYFFTOCR!MINAIP�" 71ESANUCIVILFINf.5UP700NEHUNDREDTHCUSAND ENERGYPERMIT , DOLURS(5100,OD0).IN ADDITIONTOTflE COST OF COMPENSATION.�AMAGES AS PROVIO[D FOR IN '- J SECTION97090FTHELABOR�DE.INTE'iEuT,AYDATTORNEYSFF.ES. ���>��/ > ��r�q � ____'_-" � RETEN'fION FEE: -i�f�I--�.. ....:1-t.yt/--t-----1'---��------------ OCONSTRUCTION LENDING AGENCY pRE-ALT FEE: _ __.,^_____ � I HEREBV AFFIRM UYDER PENALTYOF PERJURY THATTHEFE IS A CONS'FUCTION LENDINO AGENCY FOR TNE PERFORMANCE OF THE WORK FOR WHICH THIS PERMI71515SUED(SEC.3097,CIV.C.). _ "—"' _ . � •__" _ .__ " '_'___'_........_......._._....�.: -. � LEN�ER'SNAME___`"""_'_...._...._._.._....__._...._..___..._..__..__.......'"_— F- LENDER'SADDRESS __....._.__ WICEHTIFYiHATIHAYEftFADT1115A�PLICATIDNANUSTATETHAT'fHfAFiOVEMfOflMAiIONISCORRECT. TOTAL FEES � tA6FEETOCOMPLVWITHALlCI7YANDCOIiNTYOR�INANCE5ANO5TpTELAWSRELATINGTOEUl1.01NG CONSTRUCT IXJ,AND XEREBY AUTHORIZE REPRESENTATIVES OFTHIS COUNTV TO[NTER UPON 7HE � AUOVL�ME IONEDPS70P[RTY O INSPFCTIONV F'S. COM ENTS t _ � __ � j�. // I � —"".... � � �/ .��Id� J^/ � �_... _ _—"'__ '__'� J / ' ` } , � _ . �� -. -�] ----- �`L� Q PERMIREENAM ( INT)9 ,. / �/ , J/['/'�/ _.__ - � } / "_ ' _ _'_"____ _-_"' '_" ' '� / d� , �_-Jr. I '_ _'_ . . . _ _____'___.'__ —_"'_..."'_'._"" _ SIGNATURE F � DATE ' , �� �L.� RECPT.NO.._ __PAID BY __ �..._ _._,__VALIDATION ~ WHITE-Department Copy.YELLOW-Finence Copy,PINK-Assessor Copy,GOIDENR D--File Copy,GREEN-Applica t's Copy .. _ .. . . . - � _ __ ; � '� , � � , � i � � , � ! '� � ,. ; I ; ! . ; ,. .. � ' � I ' ; � � � r � � � , ; ' i � �� ������ �� i ' � € � j � � � �I. � � 1 ' , , ' � E � �� � �� i � � � . � , � ,- : ,,_ ' �.. .' . _ _ - - � �` �' , ' � � ' � I �. i. 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