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HomeMy WebLinkAbout14147 - --- �- - _.Y ;., � _��� CITY OF DIAMOND BAIi DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES � . 21660 E.Copley Drive Suite 190 , ,', (909)860-3195Fa1c(909)861-3117 PRESS A�'� BUII,DING PERMIT APPLICATION " _ _ FIRMLY , � �� , � _�_ _ -- .,, .. �� � '7 .�'�/�� � APPLICATIQN PERMIT �� y JOBSITE '-�r � �. ,`�P/C o ADPRESS �� ! �°�� �� I�/'�'3 7'J� �/ DATE_�[S "��" g �' NUMBER � ��'l 8 # � ISSUE NPE OCC .- APN LOT TRACT DATE ' "CONST." ` GROUP ' °C .OWNER r � � oO �. , , . �. . . _... ..... .. ._ ... �.�� . ADDRE� .✓1� 'f,s', 20NING SETBACKS � � APPUCANT ��-G:T.P'°�hr TEL. � �a� FRONT - q�ry ❑ CITY� ZIP � TEL.r-,y'9�,r�" �/ RE;4R VVY , ❑ '�-' SIDE/SIQE STREET � '' ; RW ❑ � CONTRACTOR , , SIDE'', , ;o. �� �- Q ADDRESS � PROPOSEDUSE ,�,� _: ��� _ E��� CITY 21P TEL.T _.. ,...... _ _w.:... oARCWENG! I, W 51GNER NO.DWEL. 'NO. , , _ ., NO, Z DE a ADDRESS UNITS STORIBS - BEDROOMS � CITY ZIP TEL. , v> DESCRIPTION SQ.FT. FACTOR PSF' ADJ.AREANALUAFION .'� .., ,.., OWNER-BUILDER DECWRATION . SFR/ADD/REM ���-� �� ' � � :O. . . .. �. . . � ',p 1 HEREBY AFFlRM UNDER PENPL'IYrOF PERIURY THAT i AM EXEMPT FROM THE CANTPACTOflS U- GA(BJBJCB�Ofi � �'CENSEL4WFOHiHEFOLLOWINGREA$ON�SEC.7031.5BUSINESSANDPHOFESSbNSCODE:ANYCIiYOA� ((� U���COUNTVNMICHPEOUIFESAPERMITTOWNSTRUCT,ALTER,IMPROVE,DEMOLISH,ORREPAIRANYSTRUC- W Pfltio/DBCk � � , �z ' TURE,PRqH TO ITS ISSUANCE,Iql50.',REQUIRES THE APPLICANT FOfl SUCdi PERMIT TO RLE A S�GNED W �' �STATEMENT THAT HE OR SHE IS LICENlSED PURSUANT TO THE PROVISIONS OF YHE CONTqAC70R5 U- �g CENSE LAW,(CHAPTEH 9(COMM�NCINO,WITH SECTION 7o00j OF�IVISION 30FTHE BUSINE55 HN�PRO- � PooVSpa � . '� ,�FESSIONSCODE70RTHATHEORSHEIS'�.EXEMPTTHEREFROMANDTHEBASISFORTHEAC�EGEDIXEMP- . (� ."�,''TION.ANYVIOL4TIONOFSECYION!7a81.6:BYANVAPPLICANTFORAPERdITSU&IECTSFHEAPPLICANTTO Z R8-RODF � ' ���;', 'ACIVILPENALTYOFNOTMOREh1ANFIVE�HUNDflEDDOLL4R5(�SaD).); ' � � �❑I,ASONMEROFTHEPRO�ER'n'ORMVEA7PLOVEESWITHWAGESpSiHEIRSOLECOMPENSATION, ❑ COf111118fCiel . � -' � � _ ..g �'�WILL 00 7HE'WORK,ANO 7HE SRRUC�1&iE IS NpT INTENDED OR OFFERE�FOH SALE�SEC.7044,BUSI- J " � ,NESS AND PROFESSIONS COQEI THE C.ONiRACTOFS LICENSE IAW�OES NOiAPPLY TO AN OWNER OF � � � , '�PROP6RTYVdFIOBUILDSOflMAPFOVEST=IEREON,ANDWHODOE55UCHWORKHIMSELFORHERSEIFOR � � � �� �THHOUGFINISORMEflOWNEMPLOYEE3;'PqOYIDEOTHATSUCM�MPROVEMEMSARENOTINiENOEDOR m � � � . 0 �AFFEREUFORSALEIF,HOWEVER71dE�9UILDINGORIMPHOYEMENTIS50LDWITHINONEYEANOFCAMPIE• � . z ��TION,THE OWNEfl-BUILPER WILL�-1AVE THE BUROEN OF PROVING THAT HE OR SHE DID NOT BUILD OR . . , . , _ �,�IMPROYE WR Tt1E PURPOSE OF{SqLEy � . ❑i,AS OVMEROFTHE PROPEHP};�,A EXCWSNELV CANTRACTING WITH�ICENSED WNTRACTOqS „ . � �TO CONSTflUCT THE PflOJECT(�SEC,7�44,:BUSINESS,qND PfiOFES510N5 CODE:THE CONTMCiORS LI- V8IU8tI0f1 ADJ.AREA � , W �.CENSELAWDDESNDTAPPI.VTOANOWNEflOFAPflopERTYWHo6U1LD50RIMPROVESTHEREON.AND �� = I�'�.N'FIOCONTMCTSFONSUCHPROJECT6WITHACONTRACTOR(S)LJCENSE�PURSUANTTOTHECONTRAG � � �' .�runsuc�useuw�. � � QUANTITY DESCRIPTION � FEE - � Q . ��, ❑IIME%EMPTUN�6ISEC.^'. B.&P.QFOflTHISREA N .�' - ' �, U . . . �. DATE '�OWNER i � f' . .. �Z; ' IU1J � LICEt�SEDICONTRACTORS DECLARATION W ` ' � '��. IHEREBV�fFIflMUNDERPENAL'�1',jbFPERAIRYTHATIAMLICENSEDUNDEAPROVISION50FCHAPYER � , � � '����9(COMMENCINOWITHSECTION7000�Qf�DIYI510N30FTNEBUSINESSANDPROFE551�N5CODE,AN� Z ' �LC�'�,AIY LICENSE IS IN FULL FORCE AN6'EF�EC7. �m . �:,'��.LICEN3E CLA53� LIC.NO. � - � j �"�' Q4TE � CONTRACTOR F�� a- . W,; '��,', WORKERS",C4MPENSATION DECLARATION a� - � cn _ U '. IHEflE9YqFFIRMUNDERPcNAL7VOF�ERJURYONEOfTHEWLLOWINGOECLARATIONS: — �'.. i Q � _IHAVEMIDWILLMAINTAINAC�RTIFICATEOFCANSENTTOSELFINSUREFORWORKERS' _ . . . � COMPENSATION,ASPROVIpEDiBYSECPION37WOFTHELABORCO�E,FORTHEPERFORMANCE C� �� OF THE WOflK FOR WHIG�H THI5 PEflMIi IS ISSUED. � �' _I HAVEAN�WILLMAINrA�N WOryKEWS'COMPENSATION INSUflANCE,AS RE�UIRED BY SECTIDN ` � . - - '�=a=�tim���„ � 'y� �' 37o00FFHELABORCOD,E,FOF�THEPERWRMANCEOFTHEWORKFORWHICHTHISPERMITIS ���''�� �` �,y J ;SSUED.MYWORK:AS'COMPE�V9q710NINSURANCEGARRIERAPl�POLICYNUMBERAR6 CONSTAUCT�ON .�_- ���-�',rx �"_"" j cARAiea PLAN EVIEW r ¢� roucvNUMeER , .. . . ELECTRIC i � ' (rtisSEcnovN��raore�ca.�.Er`ooF'n�aew�ur�swaoN�HurnAEowuons(s�ao�oq�ess). PLUMBING �. O a Z' ICERTIFtlYHAT9NTHEPERFOf,SMANCEOFTHEWORKFORWHICHTHISPERMIT�SISSUED,I -MECHANICAL . �- C,�j� SHAI.LNOTEMP40YANYIPERSONINANYMANNERSOASiOBECOMESUBJECTTOiHE ,�oy� WORKERS'COMPENSATIONLAWSOFCALIFOftNIN.AN�AGREETHATIFI���FFFiiiOULDBECOME INSPECTIONFEE ii, -� SU&IECTTOTHEWORK6R5'CQMPENSA710NPROVIS{ONSOFSECTIO�oOFTHELAB��� g A.J7�e,/ � fA�E,l SHALL=OflTHWIiH COMPLV WITH THO E PROVISIONS. F���Z✓"�,,�' ISSUANCE R' ).r p DATE: -�'°` APPLICpNT: ��'�4,� SMIP � WARNiN(i:¢AILUflE TO SECUPE WORKERS'GOMPENSATION COVERAGE IS UNLAWFUL,AND SHALLBE ENERGY P/C . , �y Sl1BJECTANEMPLOYERTOCRIMINALPENALTIESAN�CIVILFINESl1PTOONEHIINDREDTHOUSAN� ENERGYPERMIT � 7- DOLLARS(S9DO,oao),iNADDITION�70TSi�COST OF COMPENSATION,�AMAGE^a AS PROVIOED FOFi IN , ' J�� SEC710N370BOFTHELABORCOpE,INTEREST,AN�ATTORNEY'SFEES ' RETENTIONFEE: ', aCONSTRUCTION LEN�ING AGENCY pRE-ALT FEE: I � ,IHE9EBVAFFIRMUNDERPENALTYOFPERJURYTHA7THEREISACONSTRUCTI�NLEN�INGAGENCY ' /j y!� ZFDRTHE PERFORMANCE OFTHE WOPk FOR WHICN THIS PERMITIS ISSUEO(SEC.3091,CIV.C.). . � , ,g � � u' ,�_`�+����%1/a�` ` a LEN�Efi'S NAME � � �' � '_/l._fC',=�� . � F-- LENDER'SAODRESS � �'. i �,,II, �� ' ICEFTIFYTHATIHAVEREA�THI$APPLI,CATIONANDSTATETHATTHEABOVEINFORMATIONISCARRECT. TOTAL FEES ' �, � ' � . � ' lAGREETQCOMPLYWIYHALLCITYANQ;COUNTYORDINANCESANDSTATEUIWSRELATMGTOBUILOING � � � � CONSTflUCTIQN,AND HEREBY AUTHORI,ZE REPRESENTATIYES aF 7HI5 CAUNTY TO ENTER UPON THE ' . �, � . - , �� ABOVE-MEM7lONEDPROPEFlTY �RIN$P�CTIONPURPOSES. COMMENTS - � � � �- ' '������ �, m ¢ �, GERMI EE NAME(PRIM) 1 . . . . . . , �i , � � _ ��- . � � � �� �� � �- � , � ' SI9NATUR oF PERMITTEE �, OATE -' � ' � � " -( ! , fq , � � - - � RECPT.NO. � PAID 8Y VALIDATIOP�, . � � �� - ' "'WHITE—De artment Co YELLOW—Finance Co PINK—Assassor Co GOLDENROD—File Co GREEN— . P PY, PY, PY� pY, ApPlicanYs Copy �-- .� __ ,. ,_ -��--__=-� --= ���` �+�- �����,�����,���,� i '�:�� ��'��,�°��."����� �����`;��3�� � . . �� . t � � � u� �� � ��� � �. �:� : �, .� � �� � � «����;€� ,. � � �" �` � � �."' ��� � , � � �a��`,a�,��e ��� i I __� t �'��3�.��-� �`i �.1 � i„ �� -'-, -�--�°---�-_ �=s�°�? ��G'�$�t=.�'���. � . � �:�a.����:-��;� ��_ � i ° '' , _ m.�_,.��.�� `°�y�q((p+ ` g�"� �^}g ._._. �_��:._ . 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