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HomeMy WebLinkAbout13008 (16) .�� �� CITY OF DIAMOND BA& �, DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES � �w 21660 E.Copley Drive Suite 190 �-- � (909)86a3195 Fax(909)861-3117 PRESS � � ���'A�°��� BUII.DING PERMIT APPLICATION FIRMLY � JOB5ITE ( APPLICATION o ADDRESS � I�� LU.� I�_ �TJ� /�Q��, DATE� � � NUMB R �� . P!C , 2� J � APN LOT .S TRACT _S(1 1 , �SSUE TYPE OCC �p` , DATE CONST. GROUP p OWNER S�'! E� J��HfIC�� �PIN�.'wt lA � o ADDRESS � ' � LC7 - LE RLj ZONING SETBACKS �W CITY ,blf}MdF� S�I��i ZIP � �TEL.(��7 REART RW n . APPLICANT ��SR�`I�I 1�15�( TEL SIDE/SIQE STREET RW ❑__ � CANTRACTOR SIDE ❑ _ ADDRESS o CITY ZIP �TEL. ' PROPOSED USE �•f ��� O �JG l.�5� ��� a ARCHlENG/ z DESIGNER w NO.DWEL. NO. NO. p, ADDRESS � CITY ZIP TEL. UNITS STORIES �- BEDROOMS_�_ , � cn DESC TION SQ.FT. FACTOR PSF A A ANALUATIO Q OWNEH-BUILDER DECLARATION SF A r` � � �L O I HEflEBY AFFlRM UNDER PENALTY OF PERJIIRV THRT I AM ExEMPT Ff10M THE CANtRqCTORS LI� a(dJ9/C2fPOP1 W CENSEUWFORTHEFOI.I.OWIN6FEASON(SEG7031.5BUSMESSANOPROFESSbNSCODE:ANYCITYOR I C.� COUNTVVYHIdiREWIRESAPERM1T7000NSTRIJCT,ALTER,IMPROVE,OEMOLISH,OpREPAIHANYS7flUC- W PBIiD/DeGk . Z. TURE,PRIDR TO IT5 ISSUANCE.ALSO REOUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNEO � STATEMENT THFT HE OR 9HE 19 1lCENSED PURSUANT TO THE PflOVI510N5 OF THE CANTRACTOR5 LI� � . CENSE LAW(CHAPTEp B(COMMENCIN6 WITH SECTION 7000)OF OIVISION 3 OF THE BUSINESS AN�PRO- POOUSP2 � FESSqNSCODEjORTHATHEOH5HEI5EXEMPTTHEREFROMAN�THEBASISFORTHEALLEGEDEXEMP� (� � TION.ANVVKKATIOPIOFSECTION70.91.6BYANYAPPIICANTFORAPEHMITSUBJECTSTHEAPPLICANTTO z Re-Fiaat r ACIVIL PENALTY OF NOT MORE THM1 FIVE HUNORED DOLURS(f5o0)J: � ❑I,ASOWNEROF7HEPROPERTV,ORMVEMPLOYEE6WITHWAGESASTHEIPSOLECOMPEN6A710N, COfI1(flBtCi91 ' WILL DO TME WORIC AN�THE STRUCTURE IS NOT INTENOED OR OFFERE�FOR SALE(SEC.7044,B1151- � � NE55 AND PI'pFESS10NS CODE:THE CONiRA(:TOflS LICENSE LAW DOES NOT APPLY TO AN CWNER OF � � , � ` � PF�PEHTYN'F708UI1➢SOHIMPROVE3hIEREON,ANDYMO00E55UCHWONKHIMSELFORHENSELFOH , � THAOVGFIHISORHEqOWNEMPLOYEES.PROVIDEDTHAiSl1CHIMPROVEMENTSAflEN071NTEN�EDOfl � � � . y � ,OFFEqEOWRSALEIF,HOWEVER7HEBU1L01NGORIMPROVEMENTISSOLOWITHINONEVEAROFCAMPLE- � TKKi,THE OWNER�BUILDER WILL HAVE THE BURDEN OF PROVINa THAT HE OF SHE DID NOT BUILD OR IMPiqVE FOR THE PURPOSE OF SALE). W ❑I.ASOWNEROFTHEPFOPERTV,AMEXCLUSIYEIYCONTRACTINGWITHLICENSEOCOMRACTORS � �q � TO CONSTRUCT TNE PRQIECT(SEC,7oa,BUSINESS AND PROFE5510N5 COOE�THE CONTRACTORS LI- HIU8f1011 ��v���f�1 ADJ.AREA , � GENSELAWDOESNOTpPPLYTOANOWNEROFAPROPERTVWHOBUIL0.50HIMPqpVE5TFIEREON,AND � -- - -- LNiOCONTRAC(SFORSUCHPRQIECTSWITHACONTRACTOR(5)LICENSEOPURSUANTTOTHECOMMC- QUANTITY DESCRIPTION FEE � TOH9l10ENSEUW.). �p �7 � ❑IAA9E%EMPTUNOERSEC. __---8.8P.C.FOflTHISREA50N � Q � L�a.(F! � G�IT[uI � . � ¢ � "IL �--i � . u" �ATE�7 �— ONMER �__ � z W � LICENSED CONTRACTORS�ECLARATION w � I HEREBY AFFINM UNOER PENAI.N OF PEFJURV THAT I AM LICENSED UNDER PROVISIONS OF CHAPTEp � � ,9�COMMENCPiO WITM SECTk)N 7oao�OF DIVISION 30F TME BUSINESS AND PflOFES310N9 COOE,AtJD Z � !��, ' ��� MY LICENSE IS IN FULI FORCEAND EFFECT. m � � � C: .��}Qit1�i4 � .LICEfdSE CLASS LIC.NO.__ ___._,_.____ � � J 'DATE CONTRACTOR______. d .�, W � WORKERS'COM?ENSATION DECLARA710N � ' �'� JQ��p�(Jf) 4f `d. � � I HEREBV AFFIRM UNDER PENALTY OF PERJUPV ONE OF THE FOLLAWING DECIARATIONS�. [/� ¢ � _IHAVEANDVfiLLMA1NTAINACEfiTIFiCATEOFCONSF.NT708ELFiNSURFFORWURKERS' _ � COlAPENSATKKJ,ASPROVIDFDBVSECTIOH37000FTHELABORCODE,FOpTHEVERFORMANCF W OF THE WORK FOR WHICH THIS PERMIT IS ISSUE�. � G w �I HAVE AND WILL MAINTAIN WOAKERS'COMPENSATION INSURANCE,AS FE�UIRF.D DY SFCTION � Q 37o00FTHE LA90H CO�E,FON THE PEflWHMANCE OF THE WORK FOR WMICH THIS PERMIT IS �� � y �C` � ISSUED.MY WORKERS'COMPEN3ATION INSURANCE CARflIER AND POUCV NUMB:R ARE: CONSTRUCTION � _ . . • I� �y j cnRAien ---- ----. PLAN REVIEW ��{fi��-'--- �,L,� C �' L�(�—o� � le 7—� � POLICYNUMBER_ _'_ "__'__'_ ..'_ __—"" - " ELECTRIC � (tF165ECTI0NNE�NOTBE(SSYWLEfEDOFhEPEWW(�SfORONEHUNDFIEDDOIlARS(S1ao)ORLL55). PLUMBING ___'.__ _'__ � J � W /�/� I Z IC[RTIFYTHATINTHEPERFORMANCEOFTHEWORKFORWHICHTHISPERMITISISSUEqI MECHANICAL __ .______ ✓ v C) SHALLNOT EMPLOYANY PERSON IN ANY MPNNEfl 50 AS TO BECOM[SUBJECT TO THE � WORKERS'COMPENSATIONLAWSOFCALIFONNIA,ANDAGFEETHATIFISHOUL09ECOMF: INSPECTIONFEE ..,_..___.,__.__� � SU&IECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION J70o OF THE I�BOR ' /°�� � CO�E,1 SHALL FORTHWITH COMPLV WIh1 THOSE PHOVISIONS. �SSl1ANCE _ 7�'- ' _ C/:�l°�77 � SMIP �.C7F�� ,.__:..___ .(.Ll_�':a' p DATE:__ APPUCANT. -�-ey'" ---- . 'J WAqNING:FAILURETOSECUREWOFlKERS'COMPENSATIONCAVERAGEISUNLAWFUL,ANDSHAU.BE ENERGY,P/C. ,�.`�� _ � LL SU&IECTpNEMPLOYENTOCRIMINFLPENALiIESANDCIVILFINESUPTOONEHUN�REDTHDUSAND ENERGYPEHMiT ' ' � OOLLARS(5100.000),INADDITIONTOTHECOSTOFCOMPFN3ATION.�AMAGE�ASPFiOVI�EOFORIN -�- "- - - � J SECTION 370B OF TNE IABOR CODE,INTEHEST,PNO ATTORNE'f5�ees� RETENTION FEE: __� � oCONSTRUCTIONLENDINGAGENCY PRE-AITFEE: , � � �v,�.}^�,��___ _____ � IHEREBVAFPIRMUNDERPENALiVOFPERJURYTHATTHF.FEISACONSTFUCTIONIENDINGAGENCY .,�TTTY Y�1XATd� �eT'�:'�k ���'']'V' � d FORTHE PERFORMANCE OF THE WORK FOR WhIICHiH15 PERMIT IS ISSUE�(SEC.7a97,CIV.G.). -�� ��� �`""%A^'��t�a�•�-- W. , i_—__ '_""" _ '___" " � � �� LENDER'S HAAIE __ —_ . —---- _ _ '___________ __— 1= LEN�ER'9."JDRE55,_ __.—. —..._._. _. y„ � � ICERTIFYTHATIHAVEREADTIISAPPLICATIONANUSTATETHRTTHEABOVEINFORMA7IONISCAHRECT. TOTAL FEES� C'L p • ` d IAGREETOCAMPI,VWITHALLCT'ANDGOUNTYOF�INANCESAN�STATEIAWSRELATINpT09UILDING r I CONSTPUCTION,AKO HEREBV AUTHORIZE REPRESENTATNES OFhIIS COUNTY TO ENTEft UPON iHE I � PBOyE-MENTIONEOPROPEHTYFORINSPECTIONPURPOSES. COMMENTS ..____._._._, . � s' Gc��1 -- — — � J m ¢ PERMITTEE NAM PHINT) � �__ cn �.—.�7��_. — $ S' Y� � SiQNANRE MITfEE �ATE " ----- �- ) i = RECPT.NO.__ _PAID BY _ VAUDATION_ ~ WHITE--0e rtment Co YELLOW—Finance Ca PINK—Assessor Co GOLDENROD—File Go GREEN—A icant's Co � Pe PY. PY. CY. D9. 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