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HomeMy WebLinkAbout13085 (16) J,� CITY OF DIAMOND BAA . ^ DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICE �/ � . 21660 E.Copley Drive Suite 190 / PRESS (909)860-3195 Fas(909)861-3117 ���'y�° BUII,DING PERMIT APPLICATION FIRMLY yN,' JOBSITE � : � APPLICATION`� L G� PERMIT P/C o ADDRESS �-0 a f � ���=��•' ���'��'.�" DATE � �� NUMBER��� # � ISSUE TYPE OCC *- APN LOT TRACT DATE CONST, GROUP p OWNER f�+z-7✓'s��'��s�a,E' -� — � ? ''s s � '* ZONING SETBACKS ADDRESS s. v t� :i�''r.. S,c.. z CITY �°�d����i��'� ��19 ZIP`' � �' � TEL. tSi:�(�/�."�/af� FRONT RW U � APPLICANT TEL. REAR ❑ SIDE/SIDE STREET RW ❑ � CONTRACTUR_ � .� ,',f� _ SIDE n_. � ADDRESS � CITY ZIP TEL. PROPOSED USE w ARCH/ENG/ -- � DESIGNER � NO.DWEL. NO. NO. a ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � y DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-BUILDER DECLARATION SFR/ADD/REM O Q 1 MEfl�Y AfFlRM UNDER PENALTY OF PERNFY THAT I AM E%EMPT FHOM THE CONTRACTORS LI- G9f9JB/C91pOR W CENSELAWFORTHEFOLLOWINGpEASON�5FC.70.71.iBUSINE55ANDPROFE5510NSCOUE:ANYCIiYOR (n U (,'p�ltdTyWHICf{REWIRESAPERMRTOCONSTRUCT,ALTEH,IMPFWE.DEMOLISH,OFflEPAIRANYBTRUG W Paiio/Deck W TURE,PRqR TO ITS ISSUANCE,ALSO REQUIfiES THE APPLICANT FOR SUCH PERMIT TO FlLE A SIGNED W STATEMENT THAT HE OR SHE IS UCENSED PURSUANT TO THE PROVISIONS OF THE CONTflACTORS L6 � CENSE UW(CHNPTEfl 8(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSMESS AND PRO- � POOVSPd � F�SIONSCODE)OflTlKTHEOFiSHE15EXEMPTTHEREFROMANOTNEBA515FORTHEALLEGEOEXEMP� (J V TION.ANYVIOLRTIDNOFSECTION7D37.5BYANVAPPLICANTFORAPERMITSU&IECTSTHEAPPLICANTTO Z Re-Roof � ACIVILPENALTYOFNO7MORETHANFIVEHUNDRED�OLLAHS(SSoo).): � qI,A50WNEROFTHEPqOPERTY,ORMYEMPLOYEE5WITMWAGE5A5THEIRSOLECOMPENSqTION, I' Commercial � WILL�O'fHE WORK,AN�THE STR11CTl1RE IS NOT INTENOED OR OFFERE�FOfl SALE(SEC.7od4,911S1. � � NES&AND PROFEBSIONS CODE:THE CANTRACTORS LICENSE lAW UOES NOT APP1Y TO AN OWNER OF ? PROPEHTY YiYlO BUILDS OR IMPROVES TMEREON,JW D WMO DOES SUCH WOflN HIMSELFOfi HERSELF OH Q TNROU(iFIHISORHEHOWNEMPLOVE�.PROVIDEDTHATSUCH!MPROVEMENTSARENOTIYTENDEDOP m oOFFEREDFORSALE.IF,HOWEVER,THEBUIIDINGORIMPROVEIAENTISSOWWITHINONEYFAROFCOMPLE- Z TION,iNE OYYNER-BUILDEF WILL FWVE THE BUR�EN OP PflOVING THNT HE OR SHE DID NOT BUILD OH = MPROVE FOR7HE PURPOSE DF SPLE). w tl1,/ISONMEROFTNEPROPEpTY,dUAE%CLUSIVELVCONTRACYINGWIiHLICENSEDCONTRAC70RS � TO CONSTRUCT hIE PROJECT(SEC.70li,6USINE55 AND PROFESSIONS CADE'.7HE CONTRAC70PS ll- V8IU8�10f1� ADJ.AREA � CENSELAWDDE3NOTAPPIYTOANOYMEROFAPflOPEHTVWHOBl/1LDSORIMPROVESTHEHEON,AND -- — WVIOCANiMCTSFORSUCHGRQIECTSWITHACANTRACTOR(S)LICF.NSEOPURSUANTTOTHECONTRAG QUANTITY DESCRIPTION FEE Y TORS LICENSE UW.). O ❑I AM EXEMPT UNOEH SEC. _._ __B.&P.G FOR THIS REASON I _ Y I � .i .. - � � �y -y � ��, . � ...�.,L„�.•. :..t,y�.", s DATE s OWNEfi Z ` �s LICENSED CONTRACTORS DEGLARATION W S I HEREBY�FFIRM UNDER PENALTY OF PEH.IURY THAT IAMI LICEIiSED UNDER PROVISIONS OF CHAP7ER n, B(COMMENCINOWITHSECTION7000)OFDIVISION3OFTHE6USINESSANDPROFESSIONSCUDE,AND X AIV UCENSE IS IN FULL FORCE PND EFFECT. LLI � LICENSECUSS __., LIC.NO. V DATE__ _._ CONTRACTOFl d I IYI � WARKERS'COMPENSATION DECLARATiQN Q �r �/ � U ?'f.-„- C�... r,'J r.° f.��t:� Y'..!L'`� a -F � IHEREBVAFFIRMIiNDERPENALTYDFPERILIRYONEOFTHEWLLOWINGDECLARATIONS: Z �"- q d 'I`"Lx�' ��' �r'�.s�/ _ �A�J-� < �.. � __IHAVEMIDWILLMAINTAINACERTIFICATEOFCONScNTTOSELF-IN5UREFORWORKERS` _ y ,��e� i C'qMPENS/TiOtJ,AS PROVIDED BY SECTION e7o00FTHE IABOR CODE,FORTHE PERFORMANCE C) �r/ ''�^���' «�'� `'��F"'�`T�����af �- � OF THE WOLiK FOR WHICH THIS FERMIT IS ISSUED. � W _I HAVE AND WILL MAINTFIN WOflKERS'COMPEIVSFTION INSURANCE,AS REOUIRED BY SECTION Q37ooOF7HELA90RCWE,FORIHEPERFORMANCEOFTHEWORKFORWHICHTHISPERMITIS _ ISSUED.MYWOflKF.RS'GOMPENSATIONINSUAANCECARRIERANDPOLICYNUMBERARE: CONSTflUCTION ,.__._____._._,.,,_._______...____,..___._._.,_ ___ ycanwEFt .-- —'--�--------------�-- Pt1�NREVIEW --- -'..._ .__._._ .,_.—_..— � POLICVNUMBER __ ------"'----' ELECTRIC ___'___ ______ _ � � (i>LL45ECl/JNNE�NOTBE90Ah'LE7EDOF71'IEPERhYfI�SFOFQVEFRR�DREDDd1ARS(5f00)ORLESS} PLUM6ING ` --..._.. Z I CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS IS6UE0,I ANICAL� __.__...,��_!_� C7 SHAILNQTEMPLOYANYPEft50NINl1NVMANNF:RSOA5TO8EGOMESUBJECTTOTME � � WORI(ERS'WMPENSA7ioNLAWSOFCALIFORNIA.ANDAGREE7HATIFISHOl/LDBECOME INSPECTIONFEE ...._....__......._._—._ SIJ&IECTTO THE WOflKERS'COAAPENSAiION PROVISIOYS OF SECTIOU 9700 OF THE IABOR � CADE,ISHALLFOflTHWITHGOMPLYWIiHTHOSEPROYISIONS. ISSUANCE ___��G�� �.__ Q SMIP i L �In'7;��,1 -----._....._ p �ATE: APPUCANT. ___ -----�'---'----- — � ENERGY P/C ���`7��'�✓��a['�" WAflNINGFAILUAETOSEWREWORKERS'COMPENSATIONCOYERAGEISUNLAWFUL,ANDSHAILBE �—.Ir'�+;'-� �����f3y.'�'�' ���',�----�----------�— �y, SU&IECTqN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TOONE HUNDREO TMOUSFND ENERGY PERMIT �"'i�T��� T» :��•r �- .F+ .� DOLLARS(f100,00o).WADOITIONTOTHECOSTOFCAMPENSATION,DAMAGESASPROVIDEDFORM ,y�.f2^�y;!.�._ r-' . . . . J SECTION 9�o00FTHE LABOR CODE,INTERE.ST,AND ATfORNEY'S FEES. �� � ��� � RETENTION FEE: _._,.,_...,___._ _ pw., CONSTRUCTIONLENDINGAGENCY PRE•ALTFEE: ___._._. � .._......-----....---�-�---�-- -- � IHEREBVAFFIRMUNDELiPENALiVOFPERJURVTHATTHEHEISACON5TRl1CTIONLENDINGAGEf.CV � FOH THE Pf:RFORMANCE OFTHE WORK FOR WHICH THIS PERAIIT IS ISSUED(SEC.3oa7,CIV.C.). -"-----'� ��- �-��— -- ----�' Z W ._- ".'—'---.._ — � �END[R'SNAAIE .___.___ � LENDER'SADDRE55__ _..__..___.__—_---___._.. � ICERTIFY7HA71HAVEREADTHISAPPLICATIONANDSTATETHATTHEA90VEINFORMATIONISCARRECL TOTAL FEES ✓ � w I AGREE 70 COMPLY WITH ALl CITV AND COUNTY ORDINANCES AND S7ATE IAWS FiEUTING TO 6UILDING � CONSTRUCTIIXJ,ANDNEREBYAUTHOflIZEREPflE3ENTATIVE50FTHI5COUNTYTOENTFflUPONTHE � ABOVE•MENTIONEDPROPERTYFORINSPECTWNPURNOSES. 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