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HomeMy WebLinkAbout12323 �� CTTY OF DIAMOND BA� DEPARTMENT OF COMMUNITY&DEVEL PMENT SERVICES � 21660 B.Copley Drive Suite 190 (909)860-3195 Fa�c(909)861-3117 PRESS A�°��� BUII.DING PERMIT APPLICATION � �� fIRMIY � JOBSITE / �ry �'-'� APPLICATION � PERMIT 7� �//I /C o ADDRESS 9 � �1.� w � DATE �a� ' NUMBER � v�`_. c� ISSUE TYPE OCC APN LOT TRACT DATE CONST. GROUP °C OWNER 0 ADDR S � � ZONING SETBACKS Z CITY � ZIP TEL� REART RW ❑❑ g'' APPLICANT TEL. SIDE/SIDE STREET RW ❑ � CONTRACT C�' � SIDE ' • � � ' ❑ p CITY�t.�� ZIP TEI. � - PROPOSED USE �!`� `,C`1nS-1-� � . � ARCH/ENG/ �z DESIGNER NO.DWEL. NO. NO. a ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. y` DESCRIPTION SQ.FT: FACTOR PSF ADJ.AREANALUATION .-.� OWNER-BUILDERDECLARATION - $pR/A0�/REM � Q�__ I HEREBY AFFlflM UNDEH PENALiY OF PERIURY THAT 1 AM E%EMPT FROM THE CONTRACTOR5 LI• G8fflg8/C8(POtf �W` CENSEUW WNiHEfOLLOW�N6HE4SON(SEC.7031.68USINESSANDVROFESSIONSCA�E�ANVCITVOR �;(n _ U COUNTYNMIdiflEQU1RE9APEFiMITtt]CON8TRUCT,ALTER,IMPflOVE,DEMOLISH,ORREPAIRANYSTRUC- -� Pg2i0/DBCIC ' Z-. TUHE,PflIOR TO RS ISSUANCE,ALS�HHE�UIRES THE APPLICANT WR SUCH PEHMIT TO PILE A SIGNED '.W -�; STATEqENT THAT HE OR SHE IS LICENSED PURSUANT TO 7HE PROVISIDNS OF THE CONTRACTOPS LI- ' CEN9E LAW(CtillPTEfle(COMMENCINO WITH SECTION 7Wo)OF DIVISION 30F THE BUSINESS AND PR0- '� POOVSp2 �� FESSpN300DE)ORiT1kTHEOF5HEi5EXEMPTiHEREfflOMANOTHE8A515FORTHEAILEGEDE%EMP- . � _ TION.ANVVIOUTIONOfSECT10N7037.5BVANVAPPLICANTFORAPERMITSIlB1ECTSTHEAPPLICANTTO -� Z Re-Roof �: ACMLPENAL7YOFNOTMDRETHNIFNEHUNDREODOLtARS�55oo).): p�,iV40WNEflOF7HEPHOPERTY,ORM7EMPLOYEESWITMWAGESA5THE1flSOLECOMPENSATIDN,. ' � Commercial ,�.�- WRL 00 THE WORK,AND THE STRl1CiL1RE IS NO?INTENDED OR OFPEREO FOR SALE(SEC.7044.BUS�- : J NE33 AND PFiOFE5510N5 CODE:THE CONTRACTORS UCENSE LAW DOES NOT APP�Y TO AN OWNEq OF- -��� PROPERTVW110BUILOSORIMPflOVE57HEREON,ANDN71000E55UCHWORKHIMSELFORHEflSELFOR �' m . -- '�;': 7Np0U6lIHISORHERONM�EMPLOYEES.PPOVIDEDTHATSUCHIMPROVEMEMSARENOTBJTENOEOOR -W;; p�fEpEpFpRSPLEIF,HOWEVEfl,iHEBU1lAINGORIMVROVEMENTISSOLDWITHINONEYEAPOFCOMPLE °��� `TION,TME OWNERAUIIDER 1NLL HAYE THE BURDEN OP PROVINa THAT NE-OH SNE DID NOT BUIID OR -�:_�- IMPROVEWRTHEPUPPOSEOFSAIE). - � � O 1.AS OVMEfiOF THE PROPERTY,AM EXCLUSNELV CONTRACTIN6 WITH LICENSED CONTRACTORS ���± .7000NSTRUC7 THE PRQIECT(9EC.�OMi,BUSINESS AND Pi�FESSIONS CODE THE CONTfiACTORS LI-' VdlUdilOft ADJ.AREA :W' .CENSEUWDOESNOTMPLYTOANOWNEROFAPROPERttWHOBUtLDSORIMPflOVE5TMEREON,AtdD '��:. WHOCONTMCTSFORSUCHPR0.IECTSWI7HACONTti0.C70R(5)LICENSEDPUfi5UANTTOTHECONTRAG QUANTI7Y DESCRIPTION FEE - _ .TORSUCENSEUW.). . . '�' ❑I AM EXEMMUNDEH SEC. 8.8 P.C.FOR THIS flEASON ; � � J�.- , - �. U . ��-�OATE OKTlER `�. � . i W �, LICENSED CONTRACTORS DECUIRATION : � �; : w 1 HEREBYAFFIRM UNDER PENALN Of PERJURYTHAT i AM LJCENSEO t1NDER PHOVISIONS OF CHAPTER O..- 9(COMMENGNQ VATM SECTION 700U)OF DIVISION 30F THE BUSINESS ANO PROFESSIONS CO�E,AND i Z � � :�X`; MV LICENSE IS IN FULL FORCEAND EFFECT. ,� m - LiJ` - �; UCENS LA55 � LIC.NO. � -� � ,�� �, .-):; DATE _CONTflACTOR a W :�. - WORKERS'COMPENSATION DECLARATION .;. Q . . . �. � U ���' .IHEREBVAFKIRMUNDERPENALTYOfPERJURVONEOF'fHEWLLOWINGDECLARATIONS: ,.�, ZQ ';G= __IHAVEANDWILIMAINTAINACERTIFiCA7EOFCONSENTTOSELFdNSUREFORWOPKERS' G�. 2 ��,��` : ��� COMPEN3ATION,ASPROVIOEDBYSECTION97aoOfTHELA80RCO0E.FORTHEPEPFOqMANCE � W OF'THE WOHK FOR WNICN THIS PEHMIT IS ISSUED. �, � Or �W' �IHAVEANOWILLMNMAINWORKERS'COMPENSATI�NINSUflANCE,ASflEQUIfiE08Y5ECTION -� '�-Q 37000FTHEL0.80RCODE,f-0RTNEPERfORMANCEOFTHEWORKFORWHICHTHISPERM1T15 ^o� ISSUED.MYWDRNEAS'COMP RTKKiINSURANCECARRIERANDPOLICYNUMBERARE: CONSTRUCTION ��.�% caraaien �/�� � �y� �y PLANREVIEW T�<f POLiCVNUMBER �'� ���E�(e7� c�G.. ELE Q! :-_0, (IMSSECi1CNNE�NOTBEO�P.�LEfIDOFhEPERh91'ISfCfladEFN�DREDDOI.LAR.41EtOqORLESS� PLUMBI G I��� A:-Z: ICERTIFYTNATIN7HEPEFFORMANCEOP7HEWOBKFORWHICHTHISPERMITISI5SUE0,1 ANICAL � - . ==(�= . SHPILNOTEMPLOYANYPERSONINANYMANNERSOASTUOECOMESl1&IECTTOTHE _ _ _ _ �;.��, WORKERS'COMPENSATIONLAWSOFCALIFORNIA,ANDAGREETHATIPISHOULDBECOME IN$P TIONFEE ���� SUBJECTTO THE WbRKERS'COMIPENSATION PROVISIONS OF SECTIDN 37oaOF THE LAHOR SUANC f;t-�r �. CAOE,1 SHAUr.�FOPRaT�HWIiH COMPLY WITT7 E PROVISIONS. "p( �ATE: '�I��'• P APPLICANT: S IP � _____ ___ . W ENERGY P/C ";`LL- �-WRflNIN6:PAIIUflE TO SEWRE WORKERS'CAMPENSATION VERAGE IS UNIAWFUL,ANO SHALLBE ' -511fl1ECTANEMPLOYEflTOCRIMINALPENPLTtESANDCIVILPINE5UP700NEMUNONEDTHOUSAND " ENERGYPERMIT - DOLLARS(Si00.0ao),INADDITIONTOTHECOSTOFCOMPENSATION,DAMAGESASPROYIDEOFOHIN _ � �_.�� SECTION�70BOFTHELABORCODE,INTEHEST,ANDATTORNEI"SFEES. RETENTIONFEE: a CONSTRUCTION LENDING AGENCY PHE-ALT FEE: O _���. IHEREOYAFFIRMUNDERPENALNOFPERJURYTHATTHEREISACANSTRUCTIONLENOWGAGENCY FOflTHE PERFOPMANCE OF THE WORN FOR WHICH THIS PERMIT IS ISSUED�SEC.30B7,CIV.C.�. ' ��.. IENDER'SNAME ___ !� ' ' .F-� LENDER'SA�URE55 {^ ' ���W' I CERTIFY THAT I HAVE READ iHIS APPLICATION AND STATETHATTHE ABOVE INFORMATION IS CORFECT. �: TOTAL FEES �`�m �- 1 AGREE TO COMPLY WITH ALl CITYAND COUNTV ORDINANCESAND STATE LAWS REIATING TO BUILDING WNSTHUCTION,PN�HEREBY AU7HOflIZE REPRESENTATIVES OF TH19 LbUNTV TO EMEfl UPON THE �_Z A80VE-MENTIONED PROPEFlTY FOH INSPECTION PURPOSES. COMMENTS ; O � � -m PEHMI7TEE N RINT) p - � � /-j�-g4 n I.7 r r,� 1 r i / . � SIONATUREOFPE EE DATE � RECPT.NO. PAID BY VALIDAl70N � WHITE-0epartment Copy.YELLOW—Finence Copy.PINK—Asseuor Copy,GOLOENROD--File Copy,GREEN—Applicant's Copy � \ # -- �' ��� ����� j d n i � •-w .r q/�def�j ; i �d� i : I b '� �^k . "15 :o-�"C '�"Y �`G�CJ' �_I��7 ��t"C j21 ^l�E� ��'�;! �'i ��.�-^,Cr}� 1 ('7i""fi u. � � �. � r�,� . , � „ 1 _ i � �� �: � � � ��(�a xnk �r� �-r� rn`�,p�� "7FD�� � v-� �� �r- e ;� -.. . }^"t"�' � ( �-�. .t r- -r7 I` -a � E :*r t ,.� .`^i S." °'i'4i7 =! - I _ "g�3 y E � - i € �. 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