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HomeMy WebLinkAbout15427 (20) G � � ::-�---- t F _�� CITY OF DIAMOND BAI� DEPARTMENT OF COMMUrTITY 8t DEVELOPMENT SERVICES : � 21660 E.Copley Drive Suite 190 (909)860-3195 Fa�c(909)861-3117 PRESS � y�'"., BUILDING PERMIT APPLICATION _. FIRMLY,''/ o� JOBSITE �_�_ APPLICATION�( � �,�� PERMIT �� �- /C ADDRESS_��J�I�L� ��`'� ����� I>I��.L'sAM '� DATE t, ' NUMBER � Y � $ APN LOT TRACT �SSUE /^ � IYPE , OCC � DATE i CONST. GROUP p OWNER �Z MS4:'+ o ADD, ESS�;��Q 1--f��� �' �:.�`.' �' � ZONING SETBACKS Z CITY��if-ilIl�� ��fC ZIP ' �l.,!> TEL� '6 S 'd�` 9 REART RW a g APPLICANT TEL. SIDE/SIDE STREET RW ❑ � CONTRACTOR SIDE ❑ g ADDRESS - CIN ZIP TEL. PROPOSED USE oARCH/ENG! Q Z DESIGNER NO.DWEL. . / N . � ADDRESS UNITS STOAIES BEDROOMS � CITY ZIP TEL. ui DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREA/VALUATION � OWNER-BUILDER DECLARATION SFR/ADD/REM O Q 1 HEflEBY AFFlflM UNDER PENALTY Of PERIUHY TH0.T I AM EXEMPT FROM THE CONTRACTORS LI- Ggf890JC81pOff W CENSELAWFORTHEFOLIOWINGREASON(SEC.7037.58USWESSANDPROFESSIONSCODE:ANYCINOR ' (� . U COUMYNkitCHflEIXlIRESAPEFNAITTOCONSTRUCT,AI,TER,IMPROVE,OEMOLISH,ORREPAIflANYSTRUC- W patio/Deck W TURE,PRpfl TO ITS ISSUMCE.AL50 HEDUIRES THE APPUCANT fOR SUCH PERMIT TO PILE A SIGNE� � STATEMENT THAT HE OR SHE IS UCENSE�PURSt1ANT TO THE PROVISIONS OF TNE CONTRACTORS L4 CENSEUW�CHAPTER 9(COMMENqN�WITi SECTION)000)OF DIVISION 30FTHE BUSMESSAND PHO- �' PooVSpa FESSpNSCWE)OR7HATHEORSHEISEICEMPi7HEflEFROMANOTHE8ASI5FORTHEALLEGEDEXEMP• , (� TION.INYVIOI.ATIONOFSECTION7037.SBVANYAPPLICFNTFORAPERMITSUBJECTSTHEAPPL�CANTTO '�- Z pe-Roof � ACMI PENALiV OF NOT MORE THAN FNE HUNORED DOLIARS(SSo�).): �. ❑I,MSOV/NEHOFTiEPFOPERT'.OFMYEMPLOYEESWITHWAGESASiHE1R50LECOMPENSATION, . � CommBfCtal . � WILL00 TNE WOPoC,ANU THE STHUCTUAE IS NOT INTENDE�OR OFFEfiEO FOR SALE(SEC.70M,BUSI- - J � NE&S AND PROFESSIONS COOE:THE CANTMCTORS LICFNSE lAW DOES NOT APPLY TO AN OWNER OF � ? PROPERTY VIl10BUIL�SOR IMPflOVES THERC-0N,ANO WHOOOES SUCH WOflK HIMSELP OR HERSELf OR � THFlOUGHHISORHERONMEMPLOYEES,PROVI�EO7HATSUCHIMPROVEMENT5ARENOTINTENOEDOR � m � -�, _OFFEAEDFORSFI.EIF,HOWEVE0.TMEBUIl01NGORIMPROVEME�iTISSOLDWITHINONEVEAqOFCOMPLE• z. TKKi,7HE OWNER-BUp.DER WILL HAVE THE 6URDEN OF PROYINO THAT HE OR SHE DID NOT BUILD OR _� IMVROYE fOR TME PUHPOSE OF SALE). ❑I,AS ONTIER OF THE PqOPEHTY.AM ExCLU51VELV CONTRACTW6 WITH tICENSE�CONTRACTORS - Q TO CON9TflUCT iHE PRQIECT(SEQ 7014,BUSINESS AND PROFESSIONS CO�E:THE CONTRACTORS L�- V8IU8II0� ADJ.AREA . LLI' CENSEUWDOESNOTMPIYTOPNOWNEROFAPpOPERlVWHO8UILDSOflIMPROVESTHEFEON,AND �-- -N7iOCONTRACTSFORSUCHPRQIECTSWITHACONTRmCTOR(S)LICENSEOPLIFSUANTTOTHECONTRAG QUANTITY DESCRIPTION FEE - � TORS tJCENSE LAW.J. � ❑1 AM EXEIAP7 UNDER S�C. B.&P.G FOR THIS REASON � � - ' � V i e _ � LL DATE OWNER `'+ �-�, ,., U , . , Z W } � LICENSED CONTRACTOAS DECLAFiATiOiV , w i .�- IHEflEBYAFFlHM UNOER PENALN OF PERJURY THATI AM UCENSED UNOEfl PflOVISIONB OF CHAPTER �� � g ��- 9(COMMENCING WITH SECTKKJ 7000)OF OIVISiON 30FTHE BUSINESS AND PROFESSIONS CA�E,AND _ Z ���' MYUCENSE151NFlAl(-0RCEANDEFFECT. � .o,. LICENSE CtASS UC.NO. � a J � � -�j-. DATE__�__ CONTRAGTOR ' a LLl _�� WORKfiRS'COMPENSATION DECLARATION . -. ¢ . . ; -�� IHEREBYAFFIRMUNDEHP6NALTYOFPER1UtiYONEOFTHEFOLLOWINGOECLARAT10N5: � � zQ �- �IHAVEANDWILLMAINTAINACEHTIFICATEOFCON5ENT70SELF-INSUREFORWORKERS' ��. 2 Z COMPENSATION,ASPfiOVIOEDBV9ECTION37000FTHElA00flCODE,FORTHEPEflFORMANCE �� U Q OF THE WORK FOR WHICH 7HIS PENMiT IS ISSUED. � � 0. '�-. _I HAVEAND WILLMAINTAIN WORKEfl3'COMPENSATION INSUflANCE:AS REQUIREO BY SECTION j -Q,. 37000FTHELABORCODE,FORTHEPEAFOFMANCEOFTHEWORKFORWHICH7HISPERMITIS . f� _ IS5UED.MYWORKERS'COMPENSATWNMSURANCECAflR1ERANDPOLICYNUMBERAflE: CONSTRUCTION - � ��- CARRIER PLANREVIEW .z_ PIX.ICYNUMBER ELECTRIC "�� ¢ (I}4SSECTpNNE�NDTBECOAiPLETIDOF7HEPEFi�.STISFORONESdN�OREDDOl1AR4(Si001�LESS� PLUMBING ..�� .. . . ��� � �Z; I CERTIFYTHAT INiHE PERFORMANCE OF THE WQHK FOH WHICH THIS PERMI7IS I5SUE0.1 MECHANICAL -�a1�31�1 � .(;}� .5HALlNOTEMPWYANYPEN60NINANYMANNER50A5T08ECOMESUBJECTTOTHE ��'��� •N WOHKERS'COMPENSFTIONI.AWSOFCALIFORNIA,ANDAGREETNATIFISHOULOBECOME INSPECTIONFEE .� J L ^ SUBJECTT07HEWORKEHS'COMPENSATIONPROVISIONSOFSECTION37000FTHELABOR ����'� ry, ��� ���� .�; CODE,ISHALLFORTHWI7HCOMPLYWITH7MOSEPROVISIONS. ISSUANCE ¢3�-_ a'9. t)��' C ¢ �^ j '.�- SMIP ���I��q � �p-� DATE: APPLICANT: . ������ �y-��r,� . ENERGY P/C r�� �;�J:',- -WRRNING:FAILUftE TO SECURE WORKERS'COMPENSATION COVEPAGE IS UNLAWFUL,ANO SHALL BE � �^ -,LL- SU&IECTANEMPLOVER70CPoMINALPENALTIESANDCIVIlFMESUPTOONEHUNDflEDTHOUSAND ENEiiGYPERMIT ���� DOLLARS(57oo.oa0).IN ADDITION TO THE COSTOF COMPENSATION.DAMAGES AS PROVIUED FOH IN -¢_� SECTIONJ7080F'(HELABOflCODE,INTEREST,ANDATTOHNENSFEES. ' RETENTIONFEE: ___ ��:. CONSTRUCTION LENDING AGENCY PRE-ALT FEE: � 1 HLf1EBV AFFIRM UNDER PENALTV OF PERJURY THATTHERE IS A CONSTflUCTION LEN�ING AGENCY � - ' �- FOR THE PEFFORMANCE OF TH[WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.3oB],CIV.C.). � Z ;LLJ. --_� . , �- LENDER'SNAA/E ____.___ � F- LENOER'SADURESS____ - � +� �� ICERTIFYTNATIHAVFNEADTHISAPPLICATIONANOSTATETHATTHEABOVEINFORMATIONiSCORRECT. TOTAL FEES - � IAGREETOCAMPLYWITHALLCITYANDCAUNTYORDINANCESANOSTATELAWSREIATING708UIL01NG CONSTRl1CTION,AND HEREBY AUTHORI2E REPFESENTATIVES OF THIS COUNN TO ENTER UPON THE � � ABOVE�MENTION[b VROflERN FOR INSPECTION PURPOSES. 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