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HomeMy WebLinkAbout12938 � '.` 4--�?\___. CITY OF DIAMOND BAIt (�'��� �" -' " DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES 7 21 X ,� . 21660 E.Copley Drive Suite 190 `�� �,.,,e�,,., (909)560-3195 Fax(909)861-3117 PRE$$ , BUILDING PERMIT APPLICATION FIRMLY � J08SITE � APPLICATION -- PERMIT pQ q o ADDRESS a�1�C�-Lb�� '��t3 �' (,'C DATE NUMBER,�� ��-!Q��J' � ISSUE 1yPE O� APN LOT TRACT DATE CONST.` GRQUP p OWNER '�1 e b r�Y�b �4MSv�,Z p ADDRESS ►l L-l�4'� iv ZONING SETBACKS Z CITY QiG o a�C' ZIP �I765 TEL. U 5 S-I fs4s FRONT RW � g APPLICANT Rm o G�Gt�iYe2 TEI� �Q,���qs REAR �__� SIDE/SIQE STREET RW O_ �. CONTRACTOR SIDE � ADDRESS � � CITY ZIP TEL. PROPOSED USE o ARCH/ENGJ z DESIGNER a ADDRESS NO.DWEl. NO. NO. y ��N ZIP TEL UNITS STQRIES BEDROOMS N DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATtON °� O. OWNER-BUILDER DECLARATiON SF AO EM S � .Q.. I HEREBV AFF7RM UNDER PENALTY OF pERNRY THAT 1 AM EXEMPT FflOM h1E CQNTRACTORS U- G8f0 J8/C8fP0(I - ��W' CENSEUWWp7F{EFOLLOWINGREASON(SEC.7037.58USINESSANDPROFESSIONSCO�E:ANYqTYOR. '(n - - '�C�_ Ca1MVWHICHFEWIHESRPERMiTTO�NSTRUCT,ALTEFl,lMPROVE,DEMOIJSH,OpqEPqIqANYSTRUC- +. W Pa1i0/D9GK �.� - `V TUflE,PRIOR TO ITS ISSUANCE,AL30 FiEpU1RE3 THE APPLICANT FOIi SUCIi PEflM1T N FILE A&IGNED 6-� �� STATEMENT TNAT HE OR SHE IS LIGENSEU PURSUANT IO.THE PROVISIONS OF THE CONTRACTORS Lb .S CENS6LAW(CHAPTER9(COMMENC1NpWITF15ECTION7oao�OF�NI510N30FTHE8USINE55ANDPRO- 'U' Pa01/$P8 ' ' - �� V FE9510NSWDE)ORTHATMEORSHEISfJ(EMPTTHEREFROMANDTHEBASISFORTHEALLEGEDEXEM0. ,(� V T10N,pNYyqLpTIONOF5ECT10N7031,5BYqNYAPRICANiFORAPERMlTSV9JECTSTHEAPPL�CANTTO �z R6•ROOf - � ACML PENIIL7Y OF NOT MOpE THAN FNE HUNDRED D�IARS(y500).�: - � �� �❑I,h50YYNEROFTHEPIiOPER7Y,ORMVEMPLOYEE&WITHWAGESlSTHEIRSOLECAMGENSATION, CommBfcidi " � K1LL 00 THE WORK,ANO THE STAUCTUflE IS NOT INtENDED OA OFFERED FOR 5ALe(SEG 70u,BU51� ��� NESS,WD PROF6SSIONS(�bE:THE CONiqqC7pqS LICF.NSE IAW OOES NOT APPLYTO AN OWNEROF xi�,� �. PROPEHfYW1�10gURDSORIMPROVESTHERE6N,ANDWHODOESSUCNWORKNIMSELFORHERSELFOq � � � � �[L': .TNfl0Ui31iHISOftHEflOWNEMPLOYEES,PROVIDEOTMATSUGHIMPROVEMENTSAflENOTMTEN�EDOR '�m� : �Q��. ,�OFFEREOFONSALE.IF,HOWEVER7HEBUILDINGORIMPROYEMENTISSOLDWiTMNONEYFAROPCOMPLE - � - . �._.Z,��'�TION,THE OWNER-BUlLDER WiLL HAVE?IiE�BUROEN OF DROVWO TNAT HE OR SHE DID NOT BIJIL�OR � - .,��' .IMPROVEPoR7t1EPUHPO5EOF5ALE). . � . � � - . ❑I.AS OWNEROF THE PROPEflTY,AM EXCLUSiVELY CONTqACTMG WI7H licENSED COMflqCTOflS `��, �.TOCONSTRUCT h1E PRQIECT(SEC,704f,BUStNESS AND PROFESSIQNS COOE THE CONTRACTOAS Li� V9�U8ti0f1 ADJ.AflEA � �.W ::CENSEUWDOESNOTAPPLYTOANDYYNEROFAPR�PERTY'NHOBUILpSORIMPROVESTHEPEON,AND � ?�� iMYFbCONTRACTSFORSUCHPR0.1ECT5WfINACONTRAC70R�5)UCENSEOPURSUANTTOTHECONTRAP- OUANTITY DESCRIPTION � � FEE TORS UCENSE LAWJ. ' .�0�� �L!Mf EXEMPTUNOER SEC. _B.S P.C.FOR THIS REASON, � �Q� - ,� . ./��. : .;�t ' , _ C � �q _. q . ��LL� �DATE "� j; CL I � G'�T a�Z_, OWNEfl . . - � (~j 1 P� � ap" . � �r' L� ! �.C� d� LICENSED CON7RACTORS DECf.ARA7'ION •r;' W `' ����`� S c.tf r � � - lHEREBYAFFIRMUNDERPENA.�TYOFPE0.IUAVTNATIAMUCENSEOUN�EFPROVISIONSOFCHAPTEq f. O.�r 9(COMMENCIN6 Wlhi 5ECT10.Y 7aao)OF.OIVISiON 30F THEBUEINFSS AND PROFESSIONS CADE NJD ;�', Z C'�, (��? � a`� '.,}SM MYIICEMSEIS�NFULIWpCEAA�EFPECL ,, UJ t m t �y� ,.00„ UCENSE CLASS LIC.N0. ... � � � . , . �� � �� . .�. _ ., t 'V S: �DATE � CpNTRqCTOR .. ,. d�� � . . � $ �v � � � WOflKERS COMPENSATION DECLARATION � Q ���� lHEREBVAFfIRMUMDERPENqLryOFPERIURYONEOF7HEFOLLOWING�ECLARA710N5: x�-V � /� '-�� � "�� Z Z cl¢i.' � �"d� �._IHAYEANDWILLMAINTAINACERTIFICATEOFCONSEN7TOSELf-IN3UflEF7flWOFKERS - _ - -.,� COMPENS0.TiON,ASPqOV10E08YSECilON3)ooOPTHELABOfifADE,FORTHEPERFOFMANCE �,. W �� � � - � � OF TtiE WORK FOR WMICH THIS PERMIT IS I59UE0. ., � 'W ��.O �1 MAVE AND WILLMAINTAIN WOflKERS'COMPEN6ATION INSURANCE,AS REOUIRED BY SECTION - �� 37000FTHE LABOR CODE.FORTHE PEflFORMANCE Of THE WORK FOR WMICH TFIIS PERMITIS ���r.� � ,J:_ ISSUED.MYV.bRKERS'COMPENSATIONIN9URANCECAqRIERANOPOLICVNUMB£RpRE CONSTRUCTION ��U � >_ caaa�a PLANREVIEW `-0= aoucvNUMseR - ELECTRIC � � � � �� fr�.l�`� . :.:.p; @+ssEc�aur+c�rroreEca.ptErEooFt�aEanar�sFoaoniEFax�naEo��nasls�ao)Oa�ESSI PIUMBING / .9 �.,/�� : Wt �'Z; I CERTIFVTHnT IN 7HE PERFORMANCE OF THE WORK FOR WHICH THIS PEHMIT IS ISSUED,1 MECHANICAL �Cj�3 . _ '.:.-C�SS SHALLNOTEMPLOYANYPEfiSON�NANYMANNERSOAST06ECOMESUBJECTTOTHE — ��(q�; WOAKERS'COMPEMSATtONUW50FCAUFOANIA„qIJ�AGAEETHhTIFISHOUtOBECOME INSPECTIONFEE � �,'��� SU&IECT TO THE WORHERS'COMP&NSA710N PROVISIONS Of SECTION 37o00F THE LABOfl ��..��ry{y R�{�l �� � �^O O CODE,ISHALLiORTHWIhiCOMPLYWITHTHOSEPROVISIONS. ' ISSUANCE ����� , .-'p.��: DATE: � APP�ICANT: .SMIP O Z LO . lL - WARNING:FAILURETOSECUREWORKERS'COMPENSATIDNCOVERAGEISUNIAWFUL,ANUSHALLBE ENERGYP/C J- J. �.��� SU&IECTqNEMPLOYER70CRIMINALPENALTIESMlDCIVILFINESUPTOONEHUNbqEDTHOUSAND � ENERGYPERMIT y ��JDOLLAflS(5100.000).IN A�DI7ION TO THE COST OF COMPENSATIOfi,DAMAQES AS PFWIDEO FOR IN 'r � SECTION37oBOFTHEtA80RCO0E,INTEREST,ANDATTORNE'!'SFEES. � �O�O .�.[[ RETENTION FEE: /� C 7 X ' O CONSTAUCTION LENDING AGENCY PRE-ALT FEE: J� �.��. � INEFEBVAFFIqMUW�ENPENPINOFPERJURYTHAiTHEREiSACONSTRUCTIONLEti01N0AaENCY f/l �+- �-- FOqTHE PERFOHMANCEOF THE WORK FOR WHICH THIS PERMIT�S ISSUED(SEC.3097,CIV.C.). . Z W ",��� LENDEH'S NAME — , _ / .�.1— LENDEH'SADDflE55 - � �,'.� W ICERTIFYTHATIHAVEHEA�7MISAPPLICATIONANDSTATETriAiTHEpBOVEINFOf�MATpNISCOqRECT. � TOTA�FEES � � � d IACRE4TOCAMPLVWITHALLCITVANDCOLINTYORDINANCESAN�STATELAWSRELATINRTOBUILDING � :� � CONSTRUCTION,ANDHEREBVAUTNORIZEREPRESEN7ATIVESOFTHISCOLINTYTOENTERUPONTHE Z ABOVE�M�N ED PROPEflTY FOR INSPECTION PURPOSES. 0 „ COMMENTS m __�� � T c� �ra.M c+�e Z ..Q AERMI� A1N"p . fn �' � SI4NA EO I EE DA7E � � RECPT.NO. 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