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HomeMy WebLinkAbout13331 (16) x ` f' ��� _1� CITY OF DIAMOND BAx L�, � �`L� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES 5 \� %1 . �� 216Cs0 E.Copley Drive Suite 190 (\ pR�SS (909)860-3145 Fax(9d9)861-3117 9�'� 'BUILDING PERMTI'APPLICATION FIRIWLY � JOBSITE �7/ D p APPLICATION n,n PERMIT 2 P/C Q ADDRESS L�7�� ��'J7 1��1�E� �K..�lA�'Id/�J� DATE ���"'i�'i. NUMBER ��✓�� # ISSUE �_���(�, TYPE OCC � APN LOT TRACT DATE '��`� CONST. GROUP � OWNER D(�,�7��AMI'REZ ADDRESS � I T �� . ZONING SETBACKS "' CITY AM�nI� BRR ZIP �7�oS TE� Ug 'I FRONT RW ❑ � APPUCANT b6ERT� RAM2REZ TE . �,,�Q� REAR ❑ SIDE/SIDE STREET RW ❑ � CONTRACTOR SIDE O � ADDRESS PROPOSED USE � CPi� � CITY ZIP TEL. � ARCWENG! � DESIGNER NO.DWEL. NO. NO. • ADARESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.Ff. FACTOR PSF ADJ.AREANALUATION �. � O OWNEfl•BUILDER DECLARATION SFF/ADD/FEM - p-; 1 HEREBY AFFlRM UNDER PENALiY OF PERJURY THAT I AM EXEMPT FROM THE CONTPACTORS LI- (�`y,f098/C8R.10tI � � W CENSELIWWRTHEFOLl01VW6REA50N(SEC.7031.58USMESSANDPROfESSIONSCODE:ANVCIIYOR' (f� U. WUNiYWHICHREQUIRE9APERMITTOCONSTflUCT,ALTER,IMPROVE,OEMOlISH,ORREPAIRANYSTRUG W P8TI0/DeCK W- 7UflE,PflIOR TO ITS ISSUANCE,AL50 REWIqES 7HE APPUCANT FOR SUCH PERMIT TO FILE A SIGNED � W - �_ STATEMENT THAT HE OR SHE I3 LICENSFA PURSUAN7 TO THE AROVISIDNS OF THE CANTRACTORS LI- � CEN9E LAW(CHAPYER B(C00.1MENpNQ WITH SECTION 70ao)OF UlVISION 30FTHE BUSINESS AND PRO- u' POOI/S(J2 � PESSpNSCODE�ORiHATHEOR5HEI5EJ(EMPTTHEREFROMAND7HEBASISFORTHEAILEGEDEXEMP• ' TION.ANVVIOLATIONOFSECTION7031.5BVANYAPPIJCANTFORAPERMIT5U81ECTSTHEAPPLICANTTO Z Re•Roof �., ACIVILPENALTV OF NO7 MORE THAN fIVE HUNDRED�OLLARS(Ssoo).): ❑I,ASOWNEROFTHEPROPERTY,ORMYEMPLOYEESWITNWAGESAS7HEIft50LECOMPEN5AT104, � COf(IfI78fC13I - - ��.�� WILLDO THE WORIC AND iHE STHI1CTl1RE IS NOT INTENDED tlR OFFERED FOR SALE(SECJ044,BUSI- .J � NESS MID PROFESSIONS COOE:THE CANTRACTORS UCENSE LAW OOES NOTAPPLY TO AN OWNER OF ��' PF�PERTYVItiOBUILDSORIMPROVESTHEREON,ANDN710DOE55UCMWOflKHIMSELFORHERSELFOR � m �'; THROU(WHISORHEFOWNEMVLOYEES,PROVIDEOTNATSUCt11MPROVEMENTSpRENO71N7EN0E�oR - - W'; pFFEpEp(ppBAL,EIF,HOWEVER,THEBUILDINQORIMGROVEMENTISSOLDWITHINONEYEAROFCAMPLE- . , ��''� ��7101V,THE OWNER$UIIDEH WILL MAVE THE BUflDEN OF PAOYINQ THAT HE OR SHE OID Nai BUIID OR - � _:_ �IMPROVEWRiHEPURPQSEOfSALE). ❑I,/S ONTlEROF THE PIiOFER1Y,AM EXCLUSIVELYCONTRACTING W:TH lIC�1SED CONTflACTOftS �., -TO CANS7RUCT THE PROJECT(9EC.)014,BUSINESS M!D PflOFES510N5 CAOE:THE CONTRACTORS li� V81Udti0n ADJ.AflEA �.W-;;.CENSELAWDOE5NOTMPLYTOANOWNEROFAPROPER7YWIiOBUILDSOftIMPHWE57MEREON,AND --�_� NAIOCONTMCTSWkSUCHPR0.1EC7SWITViACONTRACPOR(5)tICFNS�PURSUANTTOTHEWNTflAG QUANTITY DESCRIPTION FEE .TORS UCENSE UW.�. :�;- . � � � - , Ar�. ❑IAM EXEAAPT UNDER S�C. B.&P.C.FOR 7HIS PEASON ; U S` � : �Z�'� DATE � OWNER � U . Ot J ;�¢..; LICENSED CONTRACTORS DECLARATION W � � -OC;' I P1EflEBYAFFIRM UNDER PENALTY OF PERJURY THAT 1 AM LICENSEO UNDER PROVISIINJS OF CHAPTEfl . � '-;p:": 6(COMMENCINGWITHSECTION7000)OFDIYISlON30FTHEBUSINESSANDPflOPE3510N5CODE,AND Z ' y[ MYLICENSE IS IN NLl FORCEAND EFFECT. : � . .�.l1Js�� . ,10;_ ..: �L :�„ LICENSE CLASS LIC.NO, q: J _-V;7, DATE . COMRACTOR d . W; - :�a�i�� WORKERS'COMPENSATtON DECLARATION � J :y`., : p ���;� IHEREBYAFFlRMUNDERPENALTYOFDEWURYONEOFTHEWLLAWINGDEClARA740NS: . z Q -0;+ IHAbEANDWILIMAINTAINACERTIFICATEOFCONSENTTOSEIF�INSUREFORWORKEHS' �-. _ - �.;_ �-COMPENSATION,ASPROVIDE�9YSECT�0.437a06FT11ELABORCWE,FORTHEPERFORMANCE , 'U OF 1NE WORK GOA WHICN TNIS PEHMIT IS ISSUED. � ...L7;. � _- . . _._ -W" _I HAVEAND WILLMAINTAIN WORKERS'COMPENSPTION INSURANCE,AS RE�UIqED BY SECTION �._�Q_� a7000F THE LABOA CODE,FOA THE PEAFORMAkCE OF THE kY0.9N FOR WHICH TNIS PERMIT IS ��•Ci�� ISSUED.MY WOHKERS'COMPENSATION INSURANCE CARqIER AND PDLICY NUMBERAFiE: CONSTRUCT�ON �a il" ��'� CAflRIER PLAN REVIEW r Z; Pa�cYNUMBER ELECTRIC �"� �'°�a� �° .¢�, - L�`�� �t-��y��''�•'r ...W, (ItissEcipNNEk'�NOT8Eao1J+'I,E�EuoF'fFEPEPtNTISPoAQVEfM1R�DREoOaiAfiS(E1a)atLEss} PIUMBING ; _Z�, I CERTIFYTHAT IN THE PERFOHMANCE OF THE WORK FOR WHICN THIS PEFMIT IS ISSLIE�,I MECHANICAL �' �t :\,�'—��5�.�� --'-(�` .SHALLNOTEMPL�YANYPEf1SONINHMYMANNER50A5T00ECOMEBUBJECTTOTHE '-:� �' �"�+} �-�> WORKEHS'COMPENSA7ICNtAWSOFCAI.IFORNIA.ANDACiREETHATIFISHOULDBECOME -INSPECTIONFEE �� _ � SUBJECTTO THE WdRKERS'COMPENSATION PitOVISIONS OF SECTION 37000F THE LABOR �; §.: �' ' '.,-�j-' CADE,ISHALLfORTHNflTHCOMPLYWITMTHOSEPFlOVI510N5. ISSUANCE � ,�l'v �pr OATE: APPLICANT: -SMIP -�`� '�- ��`- ��`,. L�� WAPNINa:FAIWflET03ECUREWORKERS'COMPENSATIONCOVERAGEISUNIAWFUL,ANOSHAILBE ENERGYP/C l--�.�'�"�' _ �y„�- SUBJECTAN EMPIOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TOONE HUNDflEDTHOUSAN� ENEiiGY PERMIT � OOLI.AflS(S1a0,0a0�,IN ADDITION TO THE CAST OF COMPENSATION.DAMAGES A5 PROVIDED FOR IN �_ SEClION 37080F 1HE LABOR CODE,INTEREST,ANDATTORNEY'S FEES. ' RETENTION FEE: � ��� CONSTAUCTION LENDING AGENCY PAE-ALT FEE: �. : � IHEPEBVAFFIflMUNDERPENAL7VOFPERJURYTHA77HEREISACONSTRUCTIONLENDINGAGENCY FOR THE PERFOHMANCE OFTHE W��1K FOR WHICH TNIS PEPMIT IS ISSUED(SEC.3D87,CIV.C.). Z' W. _.�. LENOER'S NAME __ _____ � F-�_ LENOFR'SA�DRESS .. �� ICERTIFYTNATIHAVEPEADTHISAPPLICATIONAN�STATETHATTHEABOVEINFORMATIONISCOf7RECT. - TOTAL FEES W�' IAOREETOCAMPLVW1THAlLCITYANDCAUNTYORDINANCESANDSTATELAWSRELATINGTOBUILDINO - � CONSTflUCTION,AND HEREBYAU7HOflIZE REPRESENTAT S OFTHIS COUN7V TO ENTEfl UPON THE ZABOVE-MENTIONE PERTf FOR INSPECTION PUH - COMMENTS - � �.P�l,l � �����C(�G�G� Z_ � m PERMITTEE NAME(PRI � _ N -27-� � SIONA7UftEOFPE ITTEE OATE t RECPT.NO. PAID BY VALIDATION 2 ~ WHI7E—Depehment Copy.YELLOW—Finarwe Copy.PINK—Assessor Copy,GOLDENFOD--File Copy,GREEN—ApplicanYs Copy ,- , � S 'v�z3; 4 `F� ; � � , � � �� s f i , iC f ..^�= t �� '� -. ..;I I � € J 6 $ e..... 3 . ��� w" 8 t � r � g � r�v �,p i.� . C" 'f�Y'�i ➢F � �� '` ,`� i ..,i ra}��3P'. t r � ;�+ '; � � ' "� + :� � � I � C, r� " { 4„� "C � �- -; _ �.,��°a�:.a �a , z �". � i , { ` j - ` a 1� �"'� r i� .'�i� `°3 .. 3 ti I u ( _ � ,� ._ t ,3„e � j� ��� � .c7. 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