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HomeMy WebLinkAbout11773 (5) CITY OP BIAMOND BAI� ^---J�� -���"� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES �p ,; 21660 E.Copley Drive Suite 140 r (909)860-3195 Fax(909)861-3117 �� PRESS �'�ro�°"" BUILDING P�RMTT APPLICATION _.- .. ., . ,. , FIRMLY � JOBSITE / 7 ' ' r��`i''����.� - APPLICATlON /.�y,q �� PERMIT t � P/C � o ADDRESS C_G G �v DATE V � NUMBER � �1 �3 n � APN LOT TRACT � _ DA EE i�s-�� � 1 � ONST. GROUP p OWNER � ADDRES 2 ZONING SETBACKS oCITY . ZIP TEL(��¢��j REART � � �� APPLICANT TEL. SIDE/SICE STREET RW C � CONTRACTOR � � S�QE — C' ADDRESS� � CITY_�'� - � ZIP /_�,��T��—�•�•aa f.�`• PROPOSED USE � ,p___ oARCH/ENG7 � ; " —' � � �� — �z DESIGNER NO.DWEL. NO. NO. a. ADDRESS UNITS STORIES BEDROQMS � CITY ZIP TEL. ti cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER DECLARATION SFRIADD/REM O p I HEREBY AFFlRM UNDER PENAL7V OF PERJURY 7HA71 AA!E%EMPT FFOM THE CONTRACtt1R5 L.I� Gafage/CefpOrt l3J CENSEUWFORTFIEFOLLOWINGPEASON�SEC.7031.SBUSINESSANOPROFESSIONSCODE:ANVCITYOR (n . V CdJNfYWHICHREd11qESAVERMRTOCONSTRl1CT,ALTER,IMPROVE,�EMOL:SH.OAREPAIRANVSTRUG W PatiolDeck Z TUqE,PRIOR TO ITS IS3UANCE,ALSO REWIRES THE APPLICANT FOR SUCH FERMIT TO FILE A SIGNE� W S7ATEMEN7 7HAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF hIE CON7RACtOFS Li- W � CENSE LAW(CHAPTER 9(COMMENCING WRH SECTION 7oD0�OF nIVIS10N 9 OF THE BUSINESu AND PRO- LL" POO'JSpB FESSpN50ODE)ORTHATHEORSHEISE%EMMTHEREFROMpNpTME8A515FORTHEALIEGE�EXEMP� (� TION.ANYVIOLATIONOFSEGTION7031.SBYANVAPPLIGWTFORAPERMITSU&IECTSTHEAPPLICANTTO � Re-Root � A CML PENALTY OF NOT MOHE THAN FVE HUNDREO OIX.IARS(SSoO).): � ❑I,ASOYMEROFTHEPROPEFiTY,Op1AYEMPLOYEESWITHWAGESAS7HEIRSOLECOMPEN5ATI0N, ❑ ComrtlOrCiel WILL DO THE VYORK�D THE STRl1CTURE IS NOT INTENDEO�R OFFERE�FOR SALE(SEC.706d,BUSI� J � NESSAND PROFESSIONS CODE:THE CONTRACTORS UCENSE LAW OOES NOT A7PLV TO AN OWNER OF j PROPERTY 4VFI0 BUILDS Ofi IMVqOVES hiEREON,AND NMO DO�SUCH WORK HIMSELF OFl HERSELF OR Q THROUGHHISORHEROWNEMPLOYEES,PROVIDEDTHATSUCHIMPROYEMENfBAFENOTIYTENDEDOR m '— nOFFEREDFORSM,EIF,FIOWEVERTMEBUIIDINGORIMPflOVEMEN'i5501DWITHINONEYEAROFCOMPIE Z TION,TME OWNER�BUILDER WILL HAVE TNE BUROEN OF PROVINv h!AT HE Ofl SHE OID NOT 9UIl�OR = IMPROYEFORTHEPURPOSEOFSALE), �y ❑L AS OWNER OFTHE PROPERTY,AM EXCLU514ELY CONfRACTING WITH LICENSED COMRAC70R5 (t TO CANSTRUCT hIE PHOJECT(SEC.7041,&1SINESS AND PROFFSSIONS CODE�THE CONTRACTOqS LI- V2IU8IiOf1 _________ ADJ.AREA W CENSEUIWDOESNOTAPOLYTOANOWNEROFAPROPERTVWHOBU1LO50RiMPROVESTHEAEOIJ,AND — — — — � W11000NTMCTSFORSUCHPRQIECTSWITHACONTFACTOp�S�UCENSEOPURSUAMTOTHECONTRAC- QUAN?fTY DESCRIPTION FEE � TORS LICENSE LAW.). . -� r C' �''/' S � ❑1 AM EXEMFr UNDER S�C. ,_.____B.&P C.FOR fH15 RE.RSON Q � ��J'� / • _ � (� A r ^/� -�-- �+-. - ¢ Y G-8 DATE ON'NER__ .,_ V � w __r' C l/ o o.'LS � 3 LICENSED CQPITRRCTORS DECLARATION W __ 2 _ t� Il ..� _7S 7 �� nc IHEREBYAFPIRMUNDEflPENP1.lYOFPERJUAYTHAiIAMUCENSE�UNDERPROVISIONSOFCHAPTER �, � —�--� ��� 1�J+ �� a, B(COMMENCIN(i WITH SELTION 700D)OF DIVISION 30F TFiE 8U5iNE55 HND PROFESSIONS CODc',AND Z ✓`/ ?C MY LICENSE IS IN FULL FORCE IWO EFFECT. / `' � LICENSE C SS C���� LIC.NO._ ����jL'� � � p D L �i � ���V YJ OATE��� GONTRAGTOR�__�1���'J� P_�� CL ��*�—=� ✓T�S � WORKERS'COMFENSATION DECLARATION � VN �'g` � � � 1 HEREBV AFFIRM UNDER PENALTV OF PERIURV ONE OFTHF FOLIAWING DECLARA?IONS: � � �/� !1'�� M� > � _I HpVE ANO WILL MAINTAIN ACEqTIFlCATE OF CONSENT TO SELFINSURE FOR WORKEqS' _ ,.�/� �p — COMPENSATION.ASPROVIDED9YSECTpN37ooOFTHELA80RCODE.FORTHEPERFORMANCE U ���W 7�i�� � OFTHE WORN FOR WHICJi THI5 PF.RMIT IS ISSUE�. � �t� 1 �^� Vc) � _I HAVE RNO WILLMAINTAIK WORKEHS'COMPENSATION IM1SURANCE,AS REOUIRF.�ElY SECTION ' Y, � 37o00F THE LABOR CO�E,FOR iHE PERFORMANCE OF THE WORK FOR WHICH TH!5 PERMIT IS S�J� �O�,v�GT`� -- �j. ISSUED-MYWORKERS'COMPENSATIONINSl1FANC£CARPIERAN'�POLICVNl11d8ERARF: CONS�UCI�ON /� _'y:h�_ °�� j cnaaiEa-'--- ----'-- PLAN REVIEW ! ��.(tcf�Lt�'��v �T _ __ ZPOLICV NUMBER__ --- ELECTRIC __ °Q �x q� �y � (iFGSSECI%)NI�E�NOTBECOMR.EfIDOFiFEPEWes�4SFCa0NEHlA�DPED�(LiRS(S9oo;INaLESS). PLUMBING ___.____,. ��pV (! W ICERTIFYTHATINhIEYERFORAIANCEOFTHEWORKFORWHICHTHISCERM ISISS:iED,1 MECHANICAL � t _—_ _ (J SHALL NOT EMPLOY ANV PERSON:N ANY MANNER 50 AS TO BECCME SUBJ 'TO Tli� � WORKERS'COMPENSATIONLAWSOFCALIfORN1A,AN�AGRE£THATIf.� 04lLDBECONFg INSPECTIONFEE .__.__._, SU&IECTTOTHEWORKEflS'COMPENSATIONPROVISIONSOFSE . aoOFTHEI R r � COOE,1 SFiNLLFORTHWITH COMPLY Wihl THOSE PROVISIONS. � , ISSUAivCE __ __ l __�C)� p GATE: � �� C APPLICANT �'.ey-'_�.,� ^.��./�i,9,�..g=?1._. SMIP _ J WAHNINCFRILURETOSECUREWORKERS'CO�PENSATIONCOYCRAGF5UNLAWFUL,ANOSHAI.LBE ENERGYP/C . __ _ � SU9JECTANEMPLOYER70CRIMINALPENALTIESANDCNILFINESUP ONEHUN�REDTHOl1SAND ENERGYPERMIT [70LLARS(Staa.0oa1.INADDITION TOTHE C0.S70FCOMPF:NSA:ICN.�AGESAS PROVIDED FOR IN ----�- J SECTION370BOFTHcIABORCD�E,INTERF_ST,ANOATTOflNEY'SFEgs. RETENTIONFEE: � —_� QCONSTRUCTION LENDING AGENCY PRE-ALT FEE: .____ __ � IHEREBYAFFIflMl1NDERPENALTYOFPERIURVTHATTHEREISACONSTF�ICT1(NJi_ENDINGAGENCY _____ FOR iHE PERFOHMANCE OFTHE WORK FOR WHICHTHI$PERM7i IS ISSUED fSEC.3097,CIV.C.�. Z W —_.._..' _'.-- . � LENDER'S NAME _ ______ _ —__ F— LENDER'SA�DfiE55___ _ _______._.___ ,� TOTAL FEES �� " � I CEFTIfY THAT I HAVE READ THIS APPIICATION AND STATE THATTHE ABOV`c INFORMATION IS CORRECT � � d I AGflEE TO COMPLV 1MTH ALLCI7Y AN�COl1NTY OHDINANCES AN�STATE UiWS RELATING TO BUILDING CONSTPUCTION,ANO HEREBYAUTFbRIZE REPRESENTATNES OF THIS C�l1NTVT0 ENTER UPON THE ,�.Jq r � ABOVE-MENTKKJED PROVERTV FOR INSPECTION PURPOSES. � f'{1� �i} �p �j y/J Z / COMMENTS �'.�.��7'�-?"a"'�::M ' �..✓L✓'�"" S -��C�3�/�� �� � _._'—' y.,,. ,.. m PERMITTEE NAME(PRIM) � � ./�' i . .% .�� ? l� __'—""'_ ! j' v J/ _`'7'� — . . . , . � SIGN . 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