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HomeMy WebLinkAbout16380 (9) "��. _. ---_�� CTTY OF DIAMOND BAltt ` : DEPARTMENT OF COM1vIUNITY&.DEVEZ.CfPIvIENT SERVICES � ` _ w ' 21660 E.Copley Drive Suite 190 PRESS y�'�\' BUQ.DII�GS F�ax(909)861-3117 `�iv�r ar�LicarioN . - ` , FIRMLY , , . ... ...... . ..._ ..�E .�. . o DDRIESS��P �e"lJ�����T� � APPLICATIC>N �,..�,����1 NUMB R � �+�� #/C DATE � � APN LOT TRAGT ISSUE TYPE OCC DATE CONST. GROUP p OWNER �E1��✓� "' ApDRESS S��-r�3�' ZONING SETBACKS W CITY � ZIP TEL. REART _ RW ❑❑ � APPUCANT ' ���y �'G-f�'''J TEL.�y - SIDE/SIDE STREET RW ❑ � COMTRACTOR �-` �^�p"a SIDE ❑ � ADDRESS PROFOSED USE 4�°''�� �^� fAl�-.S �°� ..5� A''v`�e��' o CITY r� ZIP TEL. o ARCH/ENG/ 5, �fs�;L� � DESIGNER NO.DWEL. NQ. , ,�.r;- NO. ' = CDDRESS ZIP TEL. UNITS STCIRIES � BEDROOMS � DESCRIPTION SQ.FT. FACTaR PSF ADJ.AREANALUATION v� oOWNER-BUILDER DECLAFiAT10N SFR/ADDIREM Q i HEREBY AFFlRM UNDER PENALN OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI• � Garage/Carport W CEMSEUWFORTHEFOLLOWINGflEASON(SEC.7U31.58USINESSPNDPROFESSIONSCOOE:ANYCITI'OR C.� COUNTYWHICHREQUIRESAPE6iMfTTOCOtdSTRUCT,10.7ER,IMPROVE.�EMOLISH,OflREPA1flANY5TRUC- 'W patfo/Deck � 7URE,PPbR TO ITS ISSUANCE.ALSO REWIRES THE APPIICANT FOR SUCH PERMIT TO fILE A SI(iNEO � STA7EMENT iHAT HE OR SHE IS LICENSED PURSl1ANT TO THE PHOVISIONS OF THE CONTRACTORS LI• � CENSE LAW(CHAP7ER B(COMMENCIN�W17H SECTION 7000)OF DIVISION 30F THE91151NES5 AN�PRO- �'�" POOUSpa FES9bN5 CODE)OR THATHE OR SHE IS EXEMPT 7HEREfROM AND 7HE BASIS FDR iHE ALLEGED E%EMP- TION.ANYVIOUTIONOFSECTIUN7031.6BYANYAPPLICANTFORAPEflMITSUBJECTSTHEAPPLICMlT70 � Re-Roof r A CIV{L PENALTV OF NO7 MORE THAN FIVE HUNORED DOlLARS(t5oo).J: � � -� � ❑I,ASOVMEROFTHEPROPERT7,ORMYEMPLAYEESWITHWAGESASTHEIRSOLECOMPENSATION, CI COI11fIlBfCiHI � WILL DD THE WO(iC.PND THE STRUCTURE IS NOT INTEN6ED�OR OFFERE�f6R 5ALE ISEC.704a,BUSi� J NESS AND PROFESSIONS COOE:THE COMRACTOPS LICENSE LAW DOES k0T APPLY TO AN OWNER OF � PiiOPERTVVhIOBUKDSORIMVPOVESTHEREON,ANDWHODOESSUCHWORKFiIMSELFORHERSEIFOR = � THROUGH H�S OR HEHONM EMPLOVECS,PROVIDED 7'HAT SUCH IIAVROVEMEN75 AAE NOT INTENpEDOR �m �1 OFFERED FOR SALE IF HOWEVER 1'NE BUILOING OR IMPROVEMENT IS SOW WITHIN ONE VEAR OFCOAIPLE- Z �710N,THE OWNER-BUIIDER WII.L HAVE THE BURD�1 OF PROVM(i THA7 HE OR SHE DID NOT;BUILT7 OR � IMPF�YE FOq THE PURPOSE OF SALE�. �� � �' _ .. ❑1,AS OWNEROFTHE PROPERTY,AM EXCLUSIYELY CONTRACTING WilTi 410ENSEC CONTflACTORS y�� � TO CONSTRUCTTHE 6'ROJEC?(SEC.]oM,BUSINESS AND PFOFESSIONS CQpE:THE CON7RAC701�5 LI- V8W8tiOfi` �'C/ ADJ.AREA LLl CENSELAWDOESNOTAPPLV70tSJOVMEROFAPROPERTYbVH09UiLDSORIMPRbYESTNERE(NJ,/iND � WHOCONTMCTSFOfiSUCHPA0.IECTSWI?HAC6MRACTOR(S�LICENSEOPL1p5UAfVTTOTHEhAN7RAC� QUANTITY �ESCRIPTION FEE � TORS UCENSE UW.�. J y ❑�AM EREMPT VNDER SEG._ 6.&PC.FOR THIS REASIXJ U k'. '"'t 9 _ � � DA7E OVJNER__ �' � W � LiCENSED CONTRACTORS DECLARATION —� � w 1 MEREBV AFFIRM UNDcfl PENILLTY OF PERIURV 7HAT t AM LICENSED UtVOER PROVISI�IJS OF CHAPTER � � 9(COMMENCING WITH SECTKKV 7000)OF�IvtEION 3 OFTHE l3USINESSAND PROFE$SIONS COOE,AND � MY LICENSE�S IN FULL FORCE PN, FFECT. m Q UGENSE CLA55 ��LiQ NO.��Z�— ° 'Sc p ' J � pp,7E . GONTRACTOR�� �- W � WOftKERS'CO'MPENSATION DECIARATION Q � U � IHEREBYAF UNDERPEkALTYOFPEWURYONEO�?HEFOILOWINGDECIARATIONS: Z . � iNAVEANOWILLMAINTAINACEHTIFICATEOFCONSENT705"eLF�INSUREPORWORKEFS' 2 � COMPEMSATION.AS PROVIDFU BY SECTION 37000F TI1E U180fl CADF.FOA THE PERF09MANCE �U OF?HE WrJFI<FOR WNICH THIS PEPdAIT IS�SSUED. 0 2 1 4 �1 HA`7E ANO W1LL MNtdTAtIV WORKEflS'WMPENSATION INSURANCE,AS REC1L11qED BY SECTION 3700 OF 7NE IAflOA CO�E,FOR 7HE PERKOR.�IANCE OF THE WOiiK FOR WHICH THIS P�RMIT IS �� �� d tSSUED.MYWORKERS'ODMP�EfNSATIONINSURANCECARp1EpANDPOLICYNUMBERARE: CONSTRUCTION �.� � CARRIER_���T�� �t�� a PLAN REVIEW 7 � POLICVNUMBER�" " � E.LECTRIC ._ Q ti (iF0.SS�CiqNNFE1NOT8EWh OOF'ila[PEPNui�sFc:�cNE+NNaiEo0Cttlasrytoo)oa�tss} PLUMBING _ � I CERTIFV TlU9�INTHE PERFORMl�NCE OFTHE WORK FOR WNICH'HIS PERAIIT IS ISSUED,I MECHANICAI. �' SHALLNOTEMPLOYANYPERSONINANYMANNERSOASTODECOMESUBJECTTOTHE � WORKERS'COMPENSATIONLAWSOFCALIFORNIA,ANDAGREETHATIFISH4UL7BECOME INSPECTIONFEE . � SU&lEC TOTHEWORKERS'CAMS'ENSATIONPROVISIONS4FSECTION370oOFTHELABOR CADE SHA FORTHWtTHCOMPLY W�'�J T�p SE PROVISIONS. �SSUANCE q' Js /� „'' ('"�...'$..+-�� SMIP ....` _ p OATE: ^ APPLICANT.�rf"" "`��^ .�' - - . � ENERGY P!C ------'- WARNI :FAIIU ETOSEWREWORKERS'COMPENSATIONCOVERAGEISUNLAWft1L,ANOSHALLBE q LL SU&IE TANEMPLOVERTOCRIMINALPENALTIESANDCIVILFINESUPTOONEHUNdREDTHOUSAND ENERGYPERMIT � 0. OOLLARS�qt ao,o0o),IN AODITION 70 THE CosT OF COMPENSATION.�AMAGES AS pHOVIDED FOR IN j6��. J SECTION37oeOFh1ELABOPCOOE,INTEREST,ANDATTOFNEY'SFEES. RETENTIONFEE: P � � � CONSTRUCTION IENDING AGENCY PRE-AlT FEE: �Va � � . - --_.....__._.�-....__..___.._._-..__,. - . � IHEREBVAFFIRMUNDEF�ENALTYDFPERJURYTHAT7HEREISACCNSTRUCTIONLENDINGAGENCV ' ' ' ' ' "" �' n- FORTHE PER(ORMANCEOFTNE WORK FOR WNICH THIS PERMIT IS ISSUED�SEC.3097.CIV.C.�. ' ' � W � LENDER'SNAME_ 1� LENDEH'S ADARE55 ( � ICERTIFVTHATIHAVEREAO7HISAPPLICATIONANDSTATETHATTHEA80VEINFORMATIONISCARRECT. TOTAL FEES ��+s� � IA(#REETOCOMPlVW1THALlCIIYANDCOUNTYORDINANCE5AN�5TATEL4WSPElA.TINO708UILDItJG CANSTRUCTION,AND NEREBY AUTHORIZE REPRESENTATIVES OF THIS CWNTV TO ENTER UPON THE Z ABOVE-MEMIONED P/J�OPERTY FOR INSPECTION PURPOSES. COMMENTS � �C ! ie'"C(� .3 C� _ � PERMIT�EE NA�ME(P�AINT�) � �F-�."".� �,r' � S� �� ,`' — /� � SIONATURE RMITTEE `—� RECPT.NO. 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