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HomeMy WebLinkAbout16197 (22) CITY OF DIAMOND BAht -- -��'-- DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES ��� ; �w 21660 E.Copley Drive Suite 190 �--~"' (909)860-3195 Fax(909)861-3117 PRESS •� ������'^�"�~ BUII.DING PERMIT APPLICATION FIRMLY �� JOBSITE APPLICATION •�� PERMIT �- P/C o ADDRESS .�3�7 l(-0 LI7T�� ���� DATE •�,y�NUMBER # c� ISSUE TYPE OCC APN LOT TRAC7 _ DATE CONST. GROUP � OWNER _ (L 1 C''i o — ADDRESS S' �'�- - ZONING SETBACKS � CITY ZIP_ 7EL. FRONT RW CI g APPLICANT �. �ta �l(`� _ TEL. CAt"-�c�.i REAR _ ❑ -v�'=-�r�� SIDElSIDE STREET RW fJ � CONTRACTO �IAC"l.�r✓y� C.Q�'O� SIDE l7 � ADDRESS �"t �t�- ��s pROPOSED USE � C�ti I�� t L �J �� � CIN 1.7�-t'� ZIP TEL. .�� �� ARCH/ENG/ � DESIGNER- NO.DWEL. � NO. NO. � a ADDRESS UNITS STORIES BEDROOMS � CITY ZIP^_ TEL. ---- y DESCFIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-BUILDER DECIARATION SFR/ADD/REM O a 1 HEREBY AFFIFqA UNDER PENALTV OF PERJURY THA7 I AM EXEMPT FROM THE CONTqACTOHS Li� G8f8QB/CflfPOfl LLI CENSEUWWRTHEFOLLOWPIGREASON(SEC.7031.5BUSMESSANDPROFCSSIDNSCOOE.ANYCINOq (n C,.7 ppUMYWHICHREWIRE8qPEf11AtTTOfANSTqUC1'.ALTER.IAIPROVE,D[MOLISH,ORHEPAIRANYSTFUC- �{,J PdflO/DBCIC Z NRE,7RIOR TO ITS ISSVANCE,AL50 RE�UIHE9 THE APPLICANT FOfl SUCH PERMIT TO FILE A SIGNED ��� STATEMENT 7HAT HE OR SHE IS LICENSED PUNSt1ANT TO TNE PflOVISION5 OF lHE CONTRACTORS LI� W � CENSE LAW(CHAPTER 9(COMMENCMG WITH SECTION 7000)OF DIVI310N 30FTHE BU9MESS AND PFlO- � POOVSpB � FESSIONSCODE)ORTHA7NEOHSHEISE%EMPTTHEREFROMANDI"HEBASISFOR7HFALLEGEUEXEMP- (� U TpN.ANYVI0UTIONOFSECTION7o31.5flYFNYAPPLICANTFORAPENMIT5UQ1ECT5THEAPPUCMITTO Z Re-Roof � .��Z � ACIVILPENALTYOFNOTMOREiHANFIVEHUNDRED00LIAR5(SSaO).): � � UI.ASOWNEROFTHEPPOPERTY,ORRIYEMPLOYEESWITHWAGESASTI7FIRSO:EGOMPc"NSqT10N, 0 COfTIf1lBfClal � W1LL DO THE M�ORK,AND TNG STRUC7URE IS NOT INTEN�EO OR OFFERED FOR SALE(SEC.7od6,P.USI. J � NESS IW�PpOFE5510N5 OODE:T}IE CONTFACTOAS LICENSE LAW DOES NOT APPLV TO AN OWNER OF � PROPEIiTYWFIOBUIIDSORIMPROVESTHEREON,0.NDWNODOESSUCHWORKH�MSELfORHERSELFOR m � TXRDUGMMISORHEROWNEMPIOYEES,PpqVIOEDTHATSUCHIMPROVEMENTSARENOTINI'ENDEDOR QOiFEREDKOR5ALEIFHOWEVEflhIEBUIL0INGORIAIPROVEMEMISSOL[1WITHINONEVE0.AOFCOMPLE- Z. TION.THE OWNER•BUILOER WILL HAVE TNE BURDEh OF PROYING THR�HF Oq SHE DI�NOT BUIID OR � IMPfWVEFOPTHEPURPO5EOF5ALE) ❑1.115 OWNER OF THE PFiOPERTY.AM EXC�USIVELY CANTRAf.TING WiTM LICENSE�CONTRACfORS :Yy � TO CON&THUCT hIE PRQIECT(SEC.7oae,BUSINESS AND PROFESSIONS COD[::THE CUNTRACTORS LI- VBII1BtI0f1 'd � .___ ADJ.AREA__. ...._ W CENSELAWWESNOTAPPLYTOMlOYMEROFAPROPERTYWHOBUILDSOFiMPROVESTMER'cON,AND � N7iOCONTMCTSFOR9UCHPROJECT6WITHACON7RACTOR(S)LICENSEDVURSUPNTTUTHECON7MC- QUANTITY DESCRIPTION FEE � TORS LICENSS LAWJ. _ o CI IAM EXEMPTUNDEHSEC.___,_,____ B.A P.C.FOR'fHlu REASON ! U __,_Y _„�-�,_ � 3 ------------�---'----�-�-�--�----�--------- � LY u" OATE OWNER ____ V W � UCENSED CO�TRAGIORS U[CLARATION W � IHEREBYAFFIRAll1NDERPENALTVOfPERJl1RYiHATIAMIICENSEDUNOERPROVISIUN50FC11AP�ER � u � a(COMMENCINO WRH SECTt7N 7000)OF UIVIS:UN 9 Df THL BUSINESS ANU f'ROFESSIONS CO�E,AN� Z ,_ ,_ X AIY UCENSE IS IN FULL FORCEAND EFFECT. m L1J / L�� Q LICENSE CLASS_.___l.i�_�__ LIC.NO.�G���,.,(_�.__'__ � U DATE�� �I GONTPRCTOfl�,�`�^� a W � .� � YJURKERS'COMPENSATION DECLARATION -� Q � I HERE6V AFfIRM UNDEF PSN.4LT/OF PE0.JURY ONE OF iH'e FOLLOWING DECLARATIONS. � � Z Q d _IHAVEANDW!lLMA1N7AINACE1iTIFICATEOFCONSENTTOSELFdNSUNEFORWOAriERS' S COMPENSATION,AS�ROVI�ED HY SF.CTION 3700 OF THE LA9(1f7 GOOE FOR THE PEi1�Of�1MANCE C7 d OFTiEWOf�KFORWHICHTHISPERM�TI5155UED. � � ___I HAV?:AND W!LL MAIN7AM WOR%ERS'COMPENSA710N INSUFi�NGE,AS REOUIRED BV SECTIQ� � Q37000F 7NF.LABOR CGDE,FORTHE VERFORMANCE O'r ir1E WORK FOR WNICH THIS PERMIT IS �. ISSUED.MV WORKEAg'COMPENSAT0.lN INSUMNCE CAqRIER AND PCLICY NUMBEF RRE: CONSTRUCTION __ . � ~ /�, ----- ---� �`� -- Q �/• S --- PLANREVIEW -___-___— -- �. CApRIER_____! -- - ----_�_- y POLICYNUMOifl�T��.�-- �� �- ----.- ELECTRIC -_-.-----.-_-.- - Q � (THISSECIIOtIt1T�NOTBE00MfLETmOFhIEPEF34YfISFORONEiiUWAEDWLLARSI510�)ORL65). PLUMBING ---.--"-.------'.--- - 1 ICERTIFYTHATINTHEPC-Rf-0RMAfv'CEOFTMEWORKFORWHICHTHISPERMITISISSUED,I MECHANICAL _..,____—_...._._. � SHPLLNOTEIAPLOYANY7EIiSCNINANYAIANNERSOAST08ECOMESl131FCTTOTHF (n WURKERS'COMPEM1SA7�0Y U�MS OF CALIFOHNIA,�N�ACREE THA71F I$FIOULD CILCOME VNSPECTION FEE __ _ SU0.IECT TO THE N�RXERS'COMFENSATION PH�VISIONS OF SEC710Y 3700 OF THE LABOR : -�j COO£.I SNALI.FOFITHWITH COMALY WiTHTHOSe YPROVISIONS. ISSUANCE �� �-}_, _ � � [IATE:�._���.-5� (APPLICANT:�l1T�T. �C��� SMIP � _. ._'._.-_... ... ...._—�— - W _- �� ,, ,_—_ --� WARNING:FAILUFETOSECUREWORNEflS'COMPENSAi104COVERAGEISUNL�WFUI.,ANOSHALLBE ENERGYPlC ..�.__._�'.,�_yg��;��� e J - ""'....._""'_'— �y SU9J[CTANEMPLOYEPTOCRIMINALPENALTIESANOCIVILFINESUPTOOYEHUNDflEDTHOUSAND ENERGVPERMIT DOLLAFiS(5100,000).IN AD�ITION TO THF COST OF COMPFNSATI04,DAMAGLS AS PftOVIDF.O GOR IN ' T "'""--'"" -""-"' - � SECTION97080fTHELA90fiCO0E,INTEfl[ST,ANDATTORNEY'SFEES. RETENTIONFEE: � _ __ _____._.._... � CONSTRUCTIONLENDINGAGENCY �-- ,___...____.,_,._______ PRE-ALT FEE: � IHEREBYAFFIRMUNDERPENAL(YnFP'cRJUHYTHATTHEHEISACONSTRUCTIONLENDINCAGENCV ____ � FORTHE PERFORNANCE OF THE WORK FOR WHICN THIG PERAAIT IS ISSUED(SEC.3097,GIY.CJ. � � ���� �� I Z W � LENDER'SNAMF__.____..._._ ' F_' LENDER'SADDRE55 -'___'—__..._..__.. .._....._... .."___""'_"-__"___-"_' � ICERTIFVT1iATIHAVENEADTHISAPPLICATIONM;DSTATETHATTHEABOVEINFORMATiONISCORRECT. 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