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HomeMy WebLinkAbout15892 � ""'�''' CITY OF DIAMOND BAI� " -�-��� DEPARTMBNT OF COIGCTvTiJNITY 8t DEVELOPMENT SERVICES *�/ .� 216b0 E.Copley Drive Suite 190 �1' ,..,A�.... (909)860-3195 Fau�(909)861-3,1,17 4 PRESS BUILDING PERMIT AP�LICATION ` ",' FIRML ` � JOBSITE � ^ < , ' APPLICATION �g� � �'�' PERMIT � `�j/'�P/C o ADORESS _� pATE NUMBER ` # � ISSUE � � TYPE C APN _ LOT TRACT DATE � CONST. GROUP p OWNER p ADDRESS ° ZQNING SETBACKS CITY . Zf. 'fEl. FRONT RW ❑ REAR ❑ APPU ANT T��-�-���'.�' SIDE/SIDE STREET RW ❑ CONTRACTOR �I t __ SIDE ❑ ADDRESS � " PROPOSED USE ?, � ` �� � � CITY—�.,� Z�'� ' TE����I--���� ,qt}�i ARCH/ENG/ — ^ � DESIGNER NO,DWEL. NO. NO. � ADDRESS UNITS_ STaRIES SEDROOMS � CiTY ZIP_ TEL. cn u� pESCRIPTION SQ.Ft FACTOR PSF ADJ.AREANALUATION � OWNER-BUiLDER DECLARATION SFR/ADDlREM O I HEREBY AFFlRM UNOER PENALTV OF PERJURY THAT I AM EXEAIPT FROM THE CqNiMCTORS LI- G9fe90/CaIpOR W CENSELAWFORTHEfOLL.OWINGFEASON(SEC.7031.68USINESSANDPROFESSIONSCpDE:ANYC:TVOq (f� ZCOLINTYWHICHqE0U1RESAPERMITTOCONSTRUCT,ALTER,IMPROVE,DEMOUSH,ORREPAtRANYSTRUP �,jJ patiO/DeCk TURE,PRIOR TO ITS ISSUANCE,ALSO REWIRES THE APPLICANTFOR 5UCH PERMIIT TO FILEA SIGNED � STATEMENT TVIAT HE OR SHE IS tJCENSED PURSUANT TO THE PROVISIONS OF THE CANTR4CTORS LI- - W CENSE LAW(CHAPTER B(COMMENCINO WITH SECTION 7oao)OF pIV1516"N 30F7HE BUSME55 ANO GR6- U" PDoVSpe FESSIQNSCODE�OHTHATHEORSHEISIXEMVThIEREFROMANpTHE8AS15FORTHEALLEGEpEXEMP- (� TION.MJYVKKATqNOFBECTION7091.5BYANYAPPUCANTFORAPEHMITSUBJECTSTHEAPPLICANTTO � �1e-ROOf � ACMIPENKiYOFNOTMO{SFTNANFVEHUNDREDDO�LpRS(S5�)J: � � � �� � ❑f,A50WNEROFTHEPROPERTY,ORMYEMOIOYEESWI7HWAGESASTHEIRSOLECOMPENSATION, C, CCmntBrCiel _ - WILL DO 7HE WORK,IW�THE STRUCTUPE IS NOT MTEN�E�OfV�OFFEqE�FOF7 SALE(SEC.7044,Bl1Sl- �J � NESS ANO PHOFESSIONS CODF.:THE CONTAACTORS LI�NSE IIiW OOES NOT APPLY TO AN pWNER OF � PROPER7YVh108UILD50RIMPHOYESTHEREON.MI�WHO00E95UCNWORKHINfSEI:FORH�RSELFOR � CC THROUOkI HISOR HER OWN EMPLOYEES,PR0410ED THATSUCH IMPROVEMENTS ARE NO7 MTENOED OR m w .OFF'EAEDFORSALEIF,HOWEVEft'MEBUIL�IN�ONIMPROVEMENTISSOLDWITHINOhIEYEAROFCOMPIE- SC+ TION.YHE OWNER-BUILDER WILL HAVE THE BUpDBd OF AROVIN6 THAT HE OR SH£DID NOi BUILD Oq � IMPROVE FOR 7HE PURPOSE OF SAL6� . .�'.�... � ❑I.ASOWNEROFTNEPROPERTY.A0.1E%CLUSIVELYCAMRACYINGWI7HUCENSEDCCNTR0.CTOR5 — TO CONSTRUGT l}7E PRqJECT(SEC.70i4,BUSINESS AND PROFESSIOIdS CODE:THE CONTRACTORS L.I- V81L7[IOfI ADJ.AREA CENSE LAW OOES NOTAPPLV TO AN ONMER OF A PROPERTV WHO BUILDS OR IMPROV�S 7'HEiiFON,AND WFIOCONTRACTSFDRSUCHPPp1ECTSWITHACONTRACTOR(S)LICENSFDPUfl9UANTTOhIECANTRA�- Q�JRiVTITY OESCRIPTION' FEE � TORS UCENSE IAWJ. O �I AM EXEMPT UNqEq SEG_____ __.___._8.&P.0.FOR THIS REASON Q � V 6L � DATE oWNER _�_ U � --•— --' W @ LICENSED CON7RACTORS DECLARATION � OC I HEREBYAFFIRM UNUER PENALTY OF PEpJURY THA7 i AM LICENSED UNDER PflOVISIONS OF CHAP7ER � , _ ., , � ' � 9(COMMENCINO WiTM SECTION 7000)OF DIVISION 3 OFTHE BUSINESSAN�PROFESSIONS COOE.AND Z _ MV UCENSE IS IF!FULL FORC AN EFF[C7. f � � � Q LICENSE CIA55_ ��� LIC.NO.����� � - � DATE__`_��',� CONTRACTOR � � , ° � I1J � � Ye'CIiKEF5'COMPENS�ITION DECIARATION " /° J � ,. � IHEFEBVAFfIRMUN�ERPEWLTVOFPEfUURYONEDFTHEFOL�OWINGD[CLARATIOh'S: Y z � IHAVEANDWILLMAMTAItdACEfiTIFICATEOFCONSENTTOSELF-INSLIP.EFORWORKER5 Z �� COMPEtdSATION,qS PROVIDEO BY SECTiCN 370o OFTHE LAfif)q CO�E,FOR TNE PEFFOPMANCE � Q OFTHE WOpK FOR WHICii THIS PF_RN,IT IS ISSUED. � � __I HAVE dND WILI,MAiIVTAIN WORKERS'COPAPENSA710N SNSUHANCE,AS REOUIRE�BY SECTION � 37000FiNEUBORGO�F,FOftTHEPERWHMqNCEOFTHEWOPKFORWHICHTFiISPERM1T15 ISSUED.MVN'ORKEFtS'WMPENSATIONINSURANCECARRIERAtJDPOLICYNUM9ERAl�E: CONSTRUCTION > c.wR�ER_—__.__ Ptah rtFwew ZPouq.r_Nu�neeR � �---_ ELE�TRIC _ � �,r. , x � .r (rwssEct�vn�.[flNoreEcoA,rci�EooFn�aEw�ar�sroaav6�n.woaeo�ws�S+m�op�Ess�. PLUMBING �^: /, cil ' �`— �,' ICERTIFYTNATINTHEPERFORMNlCEQFTHEWORKFQRWHICHTHISPFRMITISISSUcO,I MECHANIrqL � C,�„J� SHALL,NOT EMPLO7 ANY PENS'JPJ IN ANY MANNEH SOAS TO BECOME SU&IECT TO THE � WORKERS'r'OMPENSATION�.AWS4FCALIFORNIA,ANDAG6iEETHATIFISHOULOBECOME INSPECTIONFEE � SUBJECTT4THEWORKERS'COMPcNSATIONPqOViS10N50F5ECTION37090FTHEtABOR /� � CAUE,ISHAtLfOHTHWITHCOMPLYWITHT120SEPROVISIONS. � ISSUANCE j� ����,,�_� 9 �p DATE://�/�C.LJz APPUCANE _�,��,i4��G� t SMfP W /�" 7—r---- �_. WAflNING:FA1LUflETOSECUREWORKERS'COMPENSATICN. VLR ISUf�YAWFUL,qND HALLBE ENERGYPlC �y -'S17&IECt-AMEMPLOYER?OCR�MINALP�NALT.I�S,ANI1CIVILFINESU7TOONEHVJNOREU�THOUSANO ENERCyYPERMR DOI.IARS(510D.000).IN AOpITION TO THE C057 OF COMPENSATION,DAMAGES AS PROVIOED FOR IN � SECTION370BOFTHEUeORCODE,IN7EFE5T,ANDATfORNEY'SFEES. RETENTIONFEE: OCANSTRUCTION LENDING AGENCY PRE-ALT FEE: � IHEPEBYAFFIRMUNDERPENALTYOFPERJURVTHAT7HEREISACqNSTAUCTIONLENDINGAGENCY FOR THE PERFORMANCE OF THE WOftK FOR WHICH TNIS PERMIT IS ISSUED(SEC.9a97,qY C.j. � � W � LENOER'&NAME ' . ''' � F— LENDER'SADDRESS I CERTIFY THAT I HAVE FEAO THIS APPLICATION AND STATE TFiO.T THE ABOVE INFORMATION IS COPRECT. � IAGREETOCOMPLVW1THAlLCITVANpCOUNTVORDINANCESANDSTATEIAWSRELATINOTOBUIL�IN� TOTAL FEES �.;, $ �', :� � CONSTRUCTION,AND MEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTV TO� TER UPoN THE ' Z ABO �MENT70NED PRO TY FOR INSPECTIpN PURPOSES. COMMENTS 0 �� s� G m — Q PE �TfEEN FRINT) � a vj IG TUP.EOFPEflMITTEE ATE � = RECPT NO.,. PAID BY � �� - VALIDATION ~ HITE—Do artment o YELLOW--Fina�ceCo PINK—AssessaCo GOLDENROCI—FileCo GAEEN— P PY, PY. PX PY. 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