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HomeMy WebLinkAbout13041 (7) �-`_"�. _�` CITY OF DIAMOND BAFt DEPARTMENT OF COMMUNITY&DEVELOPMBNT SERVICES ��� a 21660 E.Copley Drive Suite 19U = PRESS ,,,,, (909)860-3195 Fax(409)861-3117 �^ BUII.DING PERMITYAPPLICATI0I�T _, FIRMLY _ ... ,_ _ . ¢ ADDRESS� �V APPLICATION �� � PERMIT �-���, ` P/C � JOBSITE � p `'� DATE Z"2 � NUMBER �Jv�_ # c� ISSUE TYPE OCC APN LOT TRACT DATE �'�Z-Z"' CONST. GROUP p OWNER "' ADDRESS�� ° �..=�' ' a �^�' ZONING SETBACKS � CITY r�' r,. �^r" IP �� TEL. _' - RE�ART RW ❑� APPLICANT TEL. �� SIDE/SIQE STREET RW ❑ � CONTRACTOR n 51DE ❑ � ADDRESS PROPOSED USE � CITY ZIP TEL. � ARCH/ENG! � DESIGNER NO.DWEL. - NO. NO. ADDRESS UNITS STORIES BEDROOMS = CITY ZIP TEL. � y � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER DECIARATION SFR/Ap�/REAA O p I HEREBY AFFlRM UNDER PENALTY OF PERIURY THAT t AM EAEMPT FAOM THE CONTRACTORS L4 Gafdge/CBrpOrt W CENSEUIWf-0HTHEFOLIOWINGREASON�SEC.7D3t.58USMESSANOPROFES510NSCADE:ANVCITYOR (n G�7 COUNT`lVMICHREQUIRESAPERMITTOCONS7RUCT,ALTER,IMPROVE,OEMOUSH,ORREPA:RaNY3TPUG W PeiiO/DeCk 7URE.PRIOH TO ITS ISSUANCE,ALSO REqUIFiES THE APPI.ICANT FOR SUCH PERMI7 TO FlLE A SidNEO W STATEMENT THAT HE OR SHE�5 IACENSED PURSUANT TO THE PROVISIONS OF THE COPRR4CTORS LI- W � CENSE LAW(CHAPTER e(COMMENCINO WITH SECTION 7u0o)OF DtVISION 9 0F THE BU31NE33 AND PRO� �'i' PoOUS(Je FESSpNSCODEIORTHATMEOR5HEi5EXEMPTTHEREFROMAN�TtiE6A515FORh1EALlEGEDEXEMP- (?j . ,,,.�,��, V TION.ANVVIOLB.TIONOFSECilON7a37.5gVANYAPPLICANTFORAPERMIT5U8JECTSTHEAPPUCPNTTO z Re-POOf �4'7G�U �' ����� � ACML PENA4TY OF NOT MORE THAN FNE HUNOREO OOLURS(SSoo).�: � ❑I,ASOWNEROFTHEPROPERTY,ORMVEMPLOYEESWITHWAQESASTFiEIR50LECOMPEN5A710N, G1 COMroBfCial - WIl1 DO THE WORK,IWD TNE STRUCTURE IS NOT INTEN6ED OR OFFEiiED FOR SALE(SEC.7D44,BU51- J � NE55 AND PROFESSIONS CODE:THE CANTRACTORS LICENSE LAW�OE9 NOT API+LYTO AN OWNER OF � VfiOPER7Y NRiOBURDS OR INPHOVES'fHEREON,AND WHQ WES SUCH WOfiK HIMSELFOR HERSELF OR � 7HROUGHNISOFiHEROWNEMPLOYEES,PROVIDm7HAT5UCNIMPROVEMENTSARENOTNJTENDEDOR m � ,OFFEHEDFORSPLEIF,HOWEVERTMEBUII.DINOORIMPNOVEMEN715SqDWITHINONEVEARQFCOMPLE- Z �710N,THE OWNER�BUILDEfi WILL HAVE THE BUHOEN OF PROVIN6 THA7 ME OR 5HE DID NOT BUtLO OR = IMPqOVEFORTHEPURPOSEOFSALE�. - W ❑I,ASOWNEROFTHEPFOPERTY,AMIXCLU61VElVCANTRACTINCWITHLYCEN6EDCONTRACTORS � TO CONSTRUCT TME PRWECT(SEC.7aµ,BUSINESS AND PRpFESSIONS COL�E:THE CONTRACTORS LI- VflIU3Ii011 CP�� ADJ.AREA � CENSELAWDOESNOTAPPLYIOANONRJEROFAPROPERTYWHOBUILDSORIMPROVESTHEAEON,AND W/IOCONTqACTSFORSUCHPROJECTSWI?HACONTRACTOR(&)LICENSEDPUPSUANTTpTHECOMR7�0. qUANTITY DESCRIPTION FEE � TORSl1GEN5ELAW,). 0 ❑I AM E7fEMPT UNDER SEC. B.a P.C.FOR THIS HEASON Q .� � �'1' TE OWNER U 0 � W F, UCE SED CONTRACTORS DECLARATION W � 1 HEREBYAFFIHM UNDER PENALTY OF PERJURY THAT I AM LICENSEO UN�E9 PROVISIONS OF CHAPTER �i p� 9(COMMENCINO WfTH SECT�ON 7000)OF DIVISION 30FTHE BUSINESS AND PHOFESSIONS CODE,AND Z . �L� MY UCENSE IS IN FULL FORCE AND EfFECL m � LICENSE CLASS LIC.NO. 'j V DATE CONTRACTOF �1- W � WORKEFiS'COMPENSATION DECLARATIDN a � IHEREBVAFFIRMUNDEFlPENALTYOFPERJURYONEOFTHEFOLIOWINGDECLARATIONS: Z O _IHAVEANDYVILLMAINTAINACERTIFICATEOFCON9ENTTOSELFMSUREFOFWORKERS' i Q COMPENSATION,ASFi10VI�EDBYSEC?ION370oOFiHELABORCO�E.FOR7HEPEqfORMANCE W ri OFTNE WOqK FOR YlHICH TNIS PERMIT IS ISSUED. � QW _I HAVE PND 1MLL MAINTAIN WORXERS'COAIPENSATION INSllRANCE,AS REOUIRED 8Y SECTION 37000FTHELABORCODE,FORTHEPERFORMANCEOFTHEWORKFORWHICHTHISPERMITIS r`l_��� /ep�y'��� J ISSUED.MV WORKERS'COAIAENSATION INSURANCE CAFRIER AND Po�ICtl NUMBER ARE'. CONSTRUCTION L(/ ,� j cnRR�Ea� PLAN REVIEW . Z roi.ICY NUMaER_ ELECTRIC Q (fFBSSECi�ONNE�NOT8E0]@APLEfEDOFhEPEPFMiISFOAONEHI!NOREDOd..IARS(51CO�ORLESS� P�UMBING 0 ----�'-•�_ _— Z 1 CERTiFY THAT IN THE pERFOFiAAANCE OF THE WORK POF WHICH THIS PERMI7IS ISSUED.1 MECFIANICAL _�"yt>B- C3 SHALLNOTEMPLOVANVPERSONINANYMANNERSOASTOBECOMESUBJEC770THE ,='_--� �/j WORKERS'COMPENSATION LAWS UF CALIFORNIA,AND AGREE TNAT IF I SHOULO BELOME �NSPECTI ON FEE SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 37�0 OF TH'c LABOR q O CODE,ISNAL4FORTHWiTFICOMPLYWITHTHOSEPpOVISIONS. ISSUANCE ��Rig � tia p �ATE: APPLICANT: _ 5MIP _....,.....C.�Q Gu� ,- � J WARNINQ:FAIWRETOSEWRENIOi1KfiRS'COMPENSATIONCOVERAGEISUNLAWFU�,AN�SHALl6E ENERGYP/C ry. �Q�j� �°'�� Y�a� LL, SU&IECTANEMPLOYERTOCRIMINALPENALTIESANDCIVILFINESUPTOONEHUNOREDTNOUSAND ENEPGYPERMIT 9gf� '✓ 5q��� � � OOLURS(i100.000).IN ADDITION TO TNE COST OF COMPENSATION,DAMAGESAS PROVIOED FOR IN y�l �,$�' "' J SECTION 3708�F T}iE LABOR CODE,INTEREST,ANO ATTORNEV'S FEES. � RETENTION FEE: 'Rj IlI.�� OCONSTRUCTION LENDING AGENCY PpE-AlT FEE: � IHEREBYAFFIRMUNDERPENALTYOFpERJURYTMAT7HEREiSACONSTRUCTIONLENDINGAGENCY � FOR THE PERFORMANCE OFTHE WORN FOR WHICH THIS PERMI7IS ISSUED ISEC,3097,CIV.C.7. . - � � Z W � LENDER'SNAME � 1— LENDER'SADORESS � ICER7IFVTHATIHAVEREADTHISAPP4ICATIONANDSTATETHATTHEABOVEMFORMATIONISCARRECT. TOTAL FEES W I AGREE T COM%.V WITH ALLCIT'ANp COUNT'(OHDINANCES AND STATE LAWS qELATING TO BUILDING - � CONSTR CTION.ANDHEREBYAUTHORIZEREPRESENTATIVESOFTHISCOUNT'TOENTEfiUPONTHE ZABOVE- ENTIONEO PHOPERTV F SPECTION PURPOSES. � COMMENTS t m PERMI EE NAME(PRINT - ' Q +'� � � � � I NAT E OF PERMITfE - TF _ , RECPT.NO. PAILI BY VAIIDATION ~ ` WHITE—Departmant Copy,YELLOW—Finence Copy,PINK—Assessa Copy,GOLDENROD—File Copy,GREEN—Appiicanl's Copy ,._,, _. ... . ..„ . , . _ ,... ,,... _ ;, , „ . � .. . �°�� ��� ���� ���m�� ���:� ��`���:,���`����� E�� ������ ¢•� �.•����l�'��a.ti ���,� �"" �` ��'� �b hr� �: ���'�"�` �'"� �,� ' � � �e -�. ��"� n -�_ a � � x �� a°�'����� �:. � �� '��i a.� �� �A � �k - a���„ e�. ��� .. � �� � �� .� �� ��� � ..��.»� ,t�,.��m�.��. .: � .w^, �' . :, _� .rs, � ��- �•�'� � .. v ,_ °�u �c.�'" ... 5�u�a� �:.. x: �..ff � _. . . :. ...�' .:. �.�.�...y `E j - � . ; s � �t � �� €-t,�. '; I � � ' . ... ._ _�._. .__.._ -�-_____..._.__ ��. 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