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HomeMy WebLinkAbout15840 ��_ CITY OF DIAMOND BAA �� „ DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES � �W 21660 E.Copley Drive Suice 190 `� (909)860-3195 Fax(909)861-3117 ._� PRESS ������� BUILDING PERMIT APPLICATION FIRMLY � JOBSITE �,-,�r� APPLICATION ,+"'� � PERMIT C� ' P/C� o ADDRFSS���'`'>L��rL�-�����'� /F. DATE � d�" � �� NUMBER � � # $ ISSUE , �j� TYPE OCC APN LOT TRACT DATE_ � '�V CONST. GROUP p OWNER � • LL ADDRESS . � �` �. ZONING SETBACKS W CITY ZIP TEL FRONT RW ❑_ � APPLICANT f TE r ��';-������� S DE/SIDE STREET RW ❑ � CONTRACTOR_��.F„" _d� ?� G'/C'�� SIDE ❑ o CITY ES _ ZI�� T L.�+� ;�3i;.��' PROPOSED USE � 7 � N ' �. ; :1 ' ��-- w ARCHIENG/ /���'/1f �f�� .EA�i�' �//P__.-�l.Aa f�/!li'� z DESIGNER N0.DWEL. NO. ' NO. � ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION ¢ OWNER-BUILDER DECLARATION SFR/ADD/REM O 1 HEREBY AFFlRY UN�ER PENAL7Y OF PEH.tt1RY THAT I AM EXEMVT FROM THE CONiRACTORS LI- GafdCJO/CdfpOn W CEN5EUWFORTHEFOLLOY/IN6REASON(9EC.�o3i.5BUSINESSAN�PROFESSIONSCODE:AtJYCINOR (n U COIWTVWHICHREWIRE$APERMITTOCONSTRUCT,ALTER,IMPROVE,DEMOUSH,ORHEPAIPANVSTRl1C- W pyt10/DBCK � NRE,PRIOH TO ITS ISSUANCE,AL50 REQUIRES THE APPLICANT FOR SUCH PEFMIT 70 FILE A SIGNED W STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF 7HE CONTRACTOR3 LI. W � CENSE LAW(CFUIPTER B(COMMENCING WITM SECTION 7000)OF DIVISION 9 OF THE BUSINESS AND PRO� � PooUSpa FE6SqN50D�E)ORTHATHEOfl5HE16EXEMPTTHEflEFROMAND7HE8A515FORTHEAILEGEDEXEMP- (� TION.I1NVVqLI.TIQVOFSECTION70.91.5BVANVAPPLICANTFOR�PEHMITSU&lECTSTHEAPPLICANTTO Z Re-Roof � A CIVIL PENAI.TY OF NOT MORE THAN fNE HUNDRED DOLLARS�SSoo�.7: � ❑I,pSOWNEROFTHEPROPERT',ORMYEMPLAVEESWITHWAGESASTHEIRSOLECOMPENSATION, � CORIrtIBfCiBI ' WILL DO TME WORK,AND TF1E STRUCTUqE IS NOT INTENDED OR OFPERED FOR SALE(SEC.704a,B1151� J � NESS AND PROFESSIONS CODE,THE CANTRACTORS LICENSE LAW UD'e5 NOT AGPiY TO AN OWNER Of � VfiOPEH7Y NM1IO BURDS OR IMPROVESTHEHEON.ANU WHO�OES SUCH WORN HIMSELF OR IiERSELF OH � 7MRIX1(iHHISORHEROVMEMVLOYEES,PROViDE�THATSUCHIMAROVEMENTSARENOTINTENDEDOR m QOFFEAE��ORSILLEISHOWEVERTME9�ILDINGOHIMPROVEMENTISSOLOWITHINUNEYEAHOFCAMPLE- Z 710N,THE OWNER�9UILDEli WILL FiAYE THE BURDEN OF PROVING TIIAT HE OR SHE DID NOT BUILD OR � IMPROVE FOR7HE PURPOSE OF SALE} W f71,A50VMEflOFYNEPf10PERfY,AMEXCLU91VELVCOMRRCTIN6WITHLICENSEOCANTRACTORS � TO CONSTRUCT 7HE PROJECT(SEC.7041,BUSINESS PND PROFESSIONS CADE:THE CONTRACTORS ll. V811181i01t ADJ.AREA W CENSELAWD�ESNOTAPPIYTOANOWNEflOFAPHOPERTYWHO�JUILD50RIMPROVESTHEREON,AND � WFfOCONTMCTSFORSUCHPRWECTSWITHRCONTRACTOR(S)LICENSEDVURSUqNTTOTHECONT0.4G �UANTITY DESCFIPTION � FEE y TORSIJCENSEUWJ. � J � ❑i AM E%EAiPTUNDER SEG_ _____e.&P.C.FOR THIS REASON U �_ � — --......--- a LL DATE!__ OWNER '_'______ r Z W � LICENSED CONTRACTORS DECUIRATION � � IHEREBYAFFIHMUNDERFENALTYOFPERJURYTHATIAMLICENSFDUNDERPROVISIOKSOFCHAPTER � p� C(O�MMENCING WITH 3ECTION 7000)OF OIVISION�OF TNE B1151NF55 AN�PROFE5510�5 CODE,AN� Z X MY LICENSE IS IN FULI FORCEAM1D EFFECT. u.� m � ��� ��"LeLae� � LICENSE CUSS uc.No._ J L UATE��'� 1"' �� CONTRAC'fOR��,S�e,� d �W .�E�: WORKERS'COMPENSATION OECLARAI'ION ;�� Q � � U � IHEREBVAFFIRAIUNOERPENALTYOFPFRIl1RYONEOFTHEFOILOW�GUECLARAT10N5'. Z Q � ,.I HAVE M1D WRL M/INTAIN ACERTIFICATE�F CANSENT TO SELF�IN5URE FOR WORKERS' _ COMFENSA710N,A5 PAOVIOEO BV SECTION 37a00F THE LA90R CODE.FOR THE PEflFORMANCE �U _ OF 7HE WOflK FOR WHICH TMIS PERMIT IS ISSUEO. � 0 _ w _IHAVEANDWILLMAINTAINWORKF.RS'COMPE45ATIONINSURANCE,ASREOIIIREUBYSECTION �' � 37000FTHEUIBORCO�E.WflTHEPERFOFMANCEDFTHEWORKFORWMICHTHISPERMITIS _ ISSUEO.MY WORKERS'COMPENSATION INSURFNCE CARRIER M'D POLICV NUMBEN AqF: CUNSTRUCTION _._____,_ ,�� � '� �. , —'"..__._—___ �...__`.._.� _ j CARRIEF �� f 1J�J�---T .:_ ......_._ PLAN REVIEW ---- --- z POLICVNUMBER � p ' � ELECTRIC ... ������,.., ,�.� -----,- , +,.. r '""' _..""'_""' '— d �� �� � :� ''`. � (fHSSECfIJNNE�N�7BE00�WLETmOFT}f�PEM9�6FUfS�NEMN�UIm (sioo aa�6sa PLUMBING �. ..� �� .. `: '-- ---- w 1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUEU,I MECHANICAL Z ;,:... �,.: — -_.—._..__--____ _ �!} SHALL NOT EMPLOYPNY PEflSON INANV MANNER SO AS TU BECOME SU�Jf.GT TO TI�1E ,... ,� ,. (/) WORKERS'COMPENSATION UWS OF CALIFORNIA,ANO AQAEE THAT IF I SHOULD BECOME INSPECTION FEE •, __+• �� <�•�^o:�.•�, � SUBJECTTOTHEWOHNEFlS'COMPENSATIONPROVISIONSO N370oOFTHEIABOH � —r���`��!;s ��( � CODE.ISHALLFORTHWITMGOMPLYWITHTHOSEPROVISI 5. ISSUANCE .._ _ _,.__._ e — —`„�� �'U o ' V '� . ! SMIP � �' '� �� � DAT� "^ r �� APPLICANT: � - � �� ' ----- � '. ,_ __— { ". W . .4, J WARNING;FAILURETOSECUREWOHKEf75'COMPENSATIONCOVERAGEISUNLAWFUL,ANDSHALLBE ENERGYP/C ...._.__...... �- � ����' � •��- �� �.... . . .. � SU&IECTANEAAPLOVLRTOCRIMINALPENALTIESAN�CIVILFINESUPTOON[HUNDREDTHOl15AND ENERGYPERMIT A � ' � OOLLARS(5700,000),INADDITIONTOTHECOSTOFCOMPF.NSATION,OAMACESASNPOVIDEDFOHIN —"-"---""-"" —'--'--""-' � SECTION37o80FTHELABORCODE,INTEREST,ANDAiTORNEV'SFEES. RETENTIONFEE: "_"—'_"—_�__"—'__'...__ ...�._—_ a CONSTRUCTION LENDING AGENCY PRE-ALT FEE: _.__ ..—.—..— O Q I HEREBYAFFIRM UNDER VENALTV OF PEHJUHY THqT 1 HERE IS A CONSTRUCTION LENDING AGENCY __,___ __ � FOR THE P[RFORMANCE OF TH[WOflK FOR WHICH THIS PEflMIT IS ISSU[D(SEC,loel,CIV.C.). --- ��'-�� � � ZW _.___._--._._—...._'_ .__.__—�'—. � LENDER'S NAME � F IENDEH'SADURE55__'_'........_.._...."_----"'-'— ,,l (' � ICERTIFVTHATIHAVEAFJDTHISAPPLICATIONANDSiATETHATTHEABOVEINFORMATIONISCAflRECT. TOIAL FEES � '�'�/ �J' !�s � I AGR[E TO COMPLY WITH ALL CRY AND COUN7V ORDINANCES ANO STATF.tANIS RF:LATING TO BUILUING TRUCTION,AND HEH[BY Al1TVIORIZE REPRESFNTATIVES OF T!IIS COUNTY TO ENTEH UPDN THE Zs VE-MENTIONED PHOPEHTY FOR INSPECTION PURPOSES. COMMENTS___ __.__._._.. —�—__ _ 0 �� -� n^�' 'x �✓� ----------------- ---- -- � ----�---- - m �ERMIi7EE NAME(PRINTI � — "_ -'"—'—'__—. —"'—'�— ¢ , ,�/.,r c�rC7 - ' . � .., _ -- -- UR[OF PEflMITfEE 'DATE ��- - RECPT.N0. � '� � � PAID 6Y __,�,.T_� _VALIDATION---�� ~ WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—Applicant's Copy =• _ ... ... _. . _ _. . - . ., � � , � � � � � , � . , � ; , � �� , ; � �� � � ! � � �� . � � i ! - , , i � i. , � , ,� , , ' "c, � ' I I ' ' i ' , , , � . . , , , �, , � _ __. _ _ . .. .. � ' ,� 3 ' ' ' I ; � • i ' , � , � . , i , i. x d .. � I � • r r:.__ � _ _ - _ , ,.._ i rs i � a � ` . xr _ � i I ' i - ' ' 1 i � i � < � ''', .��. , . �� � ' ��,, ... : ,, I � � '# ,i_- ' ' � - ', r . .; , ... ., . ,. ... � . ,. �. .; ��- , . ,, , � :.- :�. ... . • ,. ..- '� . . ° ' � , . . . , .� � i. - - ...,, , . _ _ ? 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