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HomeMy WebLinkAbout13133 (17) �� CITY OF DIAMOND BAB � - DEPARTMENT OF COMMLJNITY&DEVELOPMENT SERVICES �` � 21660 E.Copley Drive Suite 190 6 (909)860-3195 Fax(909)861-3117 PRESS ���M� BUILDING PERMIT APPLICATION FIRMLY �� JOBSITE / e �_/ �� APPLICATION � �� � PERMIT � ���� P/C ADDRESS L-� Q� DATE NUMBER '� #_ � ISSUE z , TYPE GCC APN LOT RA T._ DATE `�=��'����CONST. GFiOUF p OWNER ��H,g��_.CJ�Q ADDRESS • ZONING SETBACKS $ CITY ZIP TE t ���,j FRONT RW � � APPLICANT TEL. REAR _ �_ � SIDElSIDE STREET RW ❑ � CONTRACTOR _ SIDE _ r�_ � ADDRESS � CITY ZIP TEL. PROPGSED USE oARCH/ENG! z DESIGNER � ADDRESS "- NO.DWEL. NO. NO. UNITS__ STORIES BEDROOMS N CITY ZIP TEL.____ DESCRIPTION SQ.FT. FACTQR PSF ADJ.AREANALUATION 1 OWNER-BUILDER DECLARATION SFFlADD/REM O I HEREBV AFFIRM UN�ER PENALTV OF PERIURY THAT 1 AA!E%EMPT FROM T4[CONTRACTORS.I- Gefe9ElCefPOfi W CENSEUWFORiHEFOLLOWINGFEASON(SEC.7o31.58USIkESSANOPROFE5SbN5CADE:ANVCITYOR (n C� COUMYNAiICHREWIRESAPERMITTOCONSTRUCT,AI,TEfi,IMPHOVE�EMOL15H2OqREPAIRANYSTRU0. W patio/Deck w TURE,PRION TO ITS ISSUANCE,AL50 REOUIRES THE APPLICANT FOR SUCH PERMIT TO Fl.E A SIGNED W � STATEMENT THAT HE OR SHE IS LIGENSE�PUR3UANT TO THE PqOVI510N5 OF THE CONTRAC70R5 LI- � � GENSE LAW(piqPTER B(CAMMENCING WITH SECTION 1000)OF D!YISION 3 OFTHE BUSMESS AND PFO- POOJSPa FESSIONS CODE)OR iHAT HE OR SHE IS EXEMPT TNEREFROM AN6 THE BA515 FOR THEALLEGEC EXEMP- V TION.ANVVKKATIDNOfSECTION7031.5BYANVAPPLICANTFORAPERMITSU9JEC'STHEA9PLICANTTO � Re-AOof � ACML PENALTY OF NOT MORE 7HAN FNE HUN�RED DOL�RS(SSoo).)� .__ � ❑I,ASOWNEROFTHEPHOPER?V,OHAlYEMPLOVEESVJ�THWAGESASTHEIFSCLFCO�APENSATION, C� Commercial __ WILL DO THE WOAK,MD THE STRUCTURE IS NOT INTENDEG OR OFFERED FOR SFiE(SEC 7044,BUSI- J � NE3S AND oiiOFESSION3 CODE:THE CONTFlACTORS LICENSE lAW DOES NOT APPLV TO AN OWNER OF = PROPERTY WliO BUIL�S OR IMPROVES hiEREON,AND WMO�OES SUCH NfORKHIMSELF OR 4ERSELF OR Q TMROU(3MlHSOHHEROWNEMPLOYEES,PROVIOE�THATSUCH!MPROYEMENTSARENOTINTENDEDOR m ----� QOFFEREDFORSALE.IF,HOWEVER,THEBUILD:NGORIMPROVEIAENTISSOLOWITHINONEYEAROFCAMPLE- Z TION.THE OWNER-BUILDER WILL HAVE THE BUqDEN OF AROVINC THAT NE OR 54E OID NOT Bl11LD OR = IMPROVE FORTHE PURP0.SE OF SALE). W L'I,ASONMEROFTHEPROVESiTY,AMF.%CLUS!V[LVCONTRACTINGWITHLICENSEDCCNTRACTORS � TO CONSTRUCT TFIE PRQIECT(SEC.7016,BUSINESS AND PRO�ESSI045 CODF_:THE CONT9ACTCRS I.I- VeiU3tIOP A�J.AREA W CENSEUWDOESNOiAPPLYTOANOWNEHOFRPROPERTVWHOBUIL�SOPIMPHOYEST}i.REON,AND --`- ---- — - � YAIOCOMMCTSFORSUCHPR0.IECTSWITHACqNTRACTOR(3)L'GENSEDPURSIJpNTTOTI�E00N?flAC (]UANTITY DES'� IPTJ�ON FEE Y TORS LICENSE LI1W.). _ I� ,,,_ �p _ f� � OIAMEREMPT DERSEQ_ _ B.6PCFORTHISREP50!J Q _ G.�. _ � ,_LJ � _— r U � � '__—_— '--5—____ � _ D OWNE F' O __ _ _' U _� � r_ �/ n �J Q L'CENSED CONTRACTORS DECI.ARATION W� '• • • � LL I HEREBV AFFIRAI UN�ER PENALTY OF FERJURY THAT 1 AM LICENSED UNDFR PROVISIONS OF CHaPTER u � � 9(COMMENCINO WITN SECTION 7000)OF�IVISION 3 OF THE BUSINESS AN�PfiOFE5SI0N5 COvC,AND �� � MY LICENSE iS IN Fl1LL FORCE AND EFFECT. � R'i � LICENSE CUVSS _ LIC.NO.__ __._ j, �- a -- V DATE CONTRACTOR_________ _ W I � VJORKERS'COh1PEN5ATiON DECLARATIOY Q � _� � I HEREBV 11FFIRId UNDER PENALTV OF PERJIJRY O.'JE OFTHE FOL:.OWITC DECLARATIONS: Z � a ____—_1_ 0 I HAVE AND SWII.L MAIYTAIN A CERi1FICHTE OF CONSEKT 70 SELF�INSURE FCR WORKF.RS' _ � CONRENSATIOtd.ASPROVI�EOBYSEC?ION37000FTHElABOpCO.^.E.F!]RTHEPER.'OHPRANC[ w _____.___�f. _ Q OF TME WORN FOR VJFllqi TH!S PERM!T IS ISSVED. '� � W _1 HAVE AND WILL MAINT0.I.V WORKERS'CAMPENSATION INSUf1ANCE,AS H[CJIFCD BY SEC7:OV � � 37000FTHELABCRCO�E.FORTHEPFRFOHAfANCEOFTIi'eWORY,fURWI�ICH7HISPENMiTIS ISSUED.MVN'OHKERS'COMPENSATIO�;INSLRANCECARPIERANDPO'J�YVUMBERARE CUNSTRUCTION J __' _'_ - _ j CARHIER__ '—____'_-_'_'___"'_— PLP.PI REVIEVJ ' _' zPIXICYNUMBER _ _____'__' ' __'__ � ¢ ELECTRIC �' �_ � (TF45SECilIX4NEmNOTBfO�MPIETEDOFTF�R'FNPo715fOi7bNEViUPARED0011NS(S:�OiCR�E55� PLUMBIVG Z I CERTIFVTHAT IN 7HE PSRFURMANCEOF iHE VJORN FOR WHICH TH!S PEFMIT IS ISSUED,I MECSiA�'ICAL _._��_ ___ ('S SHpLL NOT EMPLOY M1Y PEFlSON IN ANV MANNEfi 50 AS TO BECOME 6UBJc'CT'OTHE � (q WORKERS'COMPENSATIONIAWSOFCALIFl7RWA, D�flEETHATIF�SNOULDBECAPAE INSPFC?iONFEE SUBJEGTTO THE YNFKERS'COMPENSATION P I IONS OF SECTION 3'0o OF THe BOR `M� � "'1. � O � CQ�E, SHALLFORTHWI7HCOMPLY WI7H E �SIONS ISSUANCE ,._.,__ �n� �',.�y�_�,�j�. p DATE: � APPLICANT: _"___" "_ _' '____'_'__ I JMIP _____. �_;�•`.��`1 _— � � � E�.EFG1'P/C --F.�,_,4 EL`-,+�'`y- J WARNING:FAILURE TO SE RE WORKERS'COMPENSATION C FAGF.iSI:NLAWFUI.,AN�SIiALL BE �--��- p`+�,.:';-��� ---------- � LL SU&IECTAN EMPLOYER TO CRIMINAL PENALTIES ANO CIVIL FINES UF TO CNE f1UYDRE�THOUSAN'� F_NERGY PERMIT ��„ .- z•� (`�r.�s� } DOLLARS(5700.0OO1.WADOI710N707HECOSTO�COA!PENSATION,DAMAGESASPROV�DE�FORIN " ,� '1�--�-�:,�,�- ' J SECTbN 37�8 Of THE LABOR CO�E.M7EiE5T.AN�ATTORNErS�=�Es. FETENTION FEE: , + ' � —�--- — OCONSTRUCTION LENDING P.GENCY PRE-AIT FEE: _�`� 5t'"y�-'��• � IHEREBYAFFIRMUNDERP[NAL'YOFPERJURVTVIATTHEREISACONSTRUCTION'..END:NGAGENCY ___ __ __ �f' FOR THE PF.RFORM/WCE OF 7HE WORK FOR WkICH TNIS PERMI715 ISSiIFD ISEC.3007,C!V.C.). ""� W ___...'__'_"_"'_— +� � LENDER'S NAME � F-- LENDER'SADORE65 ____ ___ _______ � TOTAL FEES w I CERTIFY T�IAT I HAYE READ THIS APPLICATION AND STATE THATTN[ABOVE INFORRiATION iS CORRECi. � I AGHEE 70 COMPLY WITH ALL CITY AN�COUNTV ORDINANCESMJD STATE UYIS RELATING TO BUILOING � CONSTRUCTIDN,ANOHEREBYAUTHORREREPRESENTATIVESOFTNISCOUNTYTOENTERUPONTHE Z ABOVE�MENTIONED PROPERTY FOR INSPECTION PUpCOSES. COMMENTS p � �� '_'____"'__-- ' J � . — ---' '_--_ __ _ m PERMRTEE NAM ) �J Q � '_____-'- _ � SIGNA7URE OF P MITfEE e��i�� �n_ = RECPT.N��_. 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