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HomeMy WebLinkAbout12728 (11) CITYOFDIAMONDBAIt " ' ° E�CPIRED ^----�� DEPARTMENT OF COMMCUNITY&DEVELOPMENT SERVICES � � �, ai�oE.coPieynri�es�c�i90 , , 0CT 1 Q 2�D0 (9�9)860-3195 Fax(9t19)861 3117 PRESS �.., sUltLrirNG PERMrY'Ar'PIL��A'Tl[o1v , :_ ",' z} , < . FIRMLY �.:; r.u,�;; ,; . . �_ ,; � :a�,c ,a..., r�a;�a.a �,,,:r. , i,.. ��•_ m�r � JOBSITE ��f � �'�� �DATECA't1�5N �� p_.q � NUMB�R I`� #/C'�, �. o ADORESS .� � APN LOT TRACT DA EE ���'� � '-` C�� ONST. GROUP p OWNER `�_` � ��` '��- Y� � ADDRESS �"�.�'i �i�i::l`� � � r, ZONING SETBACKS � CITY �,C.r+���. �+� ZIP���,�� "'C' °��ii�� FRONT RW C APPLICANT TEC. REAR [ � SIDE(SIQE STREET RW C � CONTRAbTOR � ' �R� � �."� � � : C SIDE ❑ — ADORESS^� �`� 1 � � � � CITY —�����^�� ZIP "j�`�� � TEL.�= �-"�� ' , PROPOSED U8E w ARCH/E_NG/ �z DESIGNER � ' � --- ' NO.DWEL. NO. NO. m. ADDRESS �• �'+ • � CITY �?'�ir i� 21P �' q 1 TEL.f �i " „:.+�,'t� UNITS STORIES BEDROOMS � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER DECLARATION SFR/ADD/REM O 0 I HER�V AFFIR9A UNOER PENALN OF GERJURY THAT I AM EXFMPT FAOM THE CONTRACTORS�L4 � Garage/Carpo�t W CENSEUIWFORTHEFOLLOWINORE4SON�SEC.7031.6BUSINESS�,4NDPP.OFESSb11SO�0E:ANYCITVbR C.) COUNTYVYHICNREtll1iRESAPERMITTOCONSTRUCT,ALiER,IMPROVE,DEMOLISH,ORREPAIRANVSTRUG W patio/Deok � 7URE,PRIOp TO ITS ISSUANCE;ALSO iiEQUIHES 1HE APPlICANT FOR SUCH PERMIT TO FILE A SIGNED -- � -- - W STATEMENT THAT HE OR SHE IS IJCENSED PURSUANT TO'THE PROVISIONS OF 7HE C2JNTflAC7tSR5�U- W � GENSE UW(CHAVlER 8(COMMENCINO WITH SECTION 7000)OF�IVISION 3 Of THE BUSME55 AIVp�PRO- U' POOVSp"d FESSIONSCODE)ORTH,CTHEORSHEISEXEMPTTHEREFROMANOTHEBASISFORTHEALLEGEDEXE6MP- (� �. TqN.ANYVIOLATIONOFSECTION7031.6BYANYAPPLICANTFORAPERMITSU&IECTSYHEAPPLIQANT'TO Z• Fle-R00 � � ACMLPENALTYOFNOTMORETHANFNEHl1NDREDOOLLARS(f500J.)� '�" ^"' � ❑�,ASOWNEROFTHEPROPERT/,ORMVEMPLOVEESWITHWAGESASTHEIHSOLECAMPENSATION, COfn11101'Cidl - MALL 00 7HE WORN,AND THE STqUCIUHE IS NOT INTEN6ED OR OFFERE�POR SALE(SECJ044;9U61- nJ � NE3S AND PROfE3310NS CODE:THE CONTRACTORS LICENSE LAW DOES NOTAPPLY TO�AN OWN ER OF = PROPERTY WHO BUILDS OH IMPROVES THEREON,MJD NMb DOES SUCH WORK HIMSEIKOR HERSEh:F OR � THHWOHHISORHEROWNBAPLOYEES,-PROVI�EDTHATSUCHIfa1PROVEMENTSAqENOYINTENp'E'OOq � Q ,OFFEREDFORSILLEIF,HOWEVER,7}iE8U0..DINGORIMPROVEMEMI5501DWfTHINONEYEAROFCOMPLE Z TION,THE OWNER-BUILDEF WILL NAVE TNE BURDEN OF f'RqVINC,THAT HE OR SNE DID NQT BUIID IJR = IMPROVE FORTHE PURPCISE OF SALEI- . ':' .....'.. ' . ❑I,ASOWNEROFTHE PROPER?V,AM EXCLUSIVELV CONTRACTING VdITH LICENSED CA�NTRA�TO�I$ �. TO CONS7RUCT T1iE PROJEC7(SEC.�osd.BUSINESS PND"PROFcSSiONS CoOE:THE QONTk1ACTOAS'LI-. VelUdtiCf7 ADJ.AREA W CENSELAWDDESNOTAPPLYTOr1NOWNEROFAPROPERTYWHOelItL0.40HIMPFOVE9THER�4N,AN� S NAIOCONTRACTSFORSUCHPROJECTSWITHACONTRACTOR(5)GICENSEDPURSUAkTTOTHECdNYRAC- QUANTITY DESCRIPTION FEE Y TORSLICENSEtAW.). , ' � ❑I AM EXFMPT UNDEH SEC. B.&P.C.FOPTHIS REASON Q � --.—____ � � . DATE OWNER U W � LICENSED CONTRACTORS DEGLARATiON � ' � � w � I HEREBVAFFIRLI UNOER PEkALTV OF PEFLIURY THAT I AIA LICENSE�UNDER PROVISIONS OF CHAPTER � d, D(COMMENCIN(3 WITH SEC710N�o0oi Of ONISbN 3 OF THE BUSINESSAND PROFESSIONS CODE,AN'� 2 X MY UCENSE IS MI FULL FORCE AND EFfECT. m Q LICENSE�AA SS ���'"-��� LIC.NO.,_ ' '�-+ - S` � �� ,, J U DATE_�. �o�� CONTRACTOR � �- W � WORKERS'COMPENSATION DECLARATION a � IHEflE6YAFFlRMUNDEflPENAI.iYOPPERNRYONEOFTHEFOLLOWINGDECLARATIONS: V C� a � �i HAVEAND WILL 0.10.1NTAIN 0.CERTIfICATE OF CONSENY TO SELF�INSLIRE FOR WORKERS' _ COMPENSATION,ASPROVIDEDBYSECTION9�o00FTHELABORCOD[,FORTHEPERFORMAVCE W OFTNE WORK FOR WHICH TI11S PERMIT IS ISSUED. � � � _I HAVE AND WILL MAItdTAIN WORKERS'COMPENSATION INSl1RANCE,AS PE�U�RE�6V SEGTION � ' `y �d 37000FTHELABOACOGE,FORTHEPERFORMANCEOFTHEWOqNFORWHICHTH�SPEpM1TiS � �b/� /"� e ISSUED.MYWO�R.,K, RS' MPENSAcTIONINS FANCECARRIERANDPOLICYNUMBERARE: CONSTRUCTION / Z��V' yJ t]���+� T"\�'SOC.� . .. PLAN _F�I W CARRIER "� �d � . . .. .. _ . .- . Z POIICVNUAABER_ay,q�"�� ��'i��y�Z'3�.04-1f� ELECTRIC Q Q (IHI3SECMMINE�NOTBEf�f'I.EfEDOF7HEPEFNNfSFOaONEI-IIMDREODOLLARi�yloo)ORLESS�. PWMBING Z �CERTIFY THAT IN THE PERFORNANCE OF THE WORK FOR WHICH THIS PFRMI7 IS ISSUED,I MECHANICAI C'} SHALL NOT EMPLOY ANY PERSON W ANY MANNER SO AS TO BECAME SUBJECT TO THE � WORKERS'COMPENSATION LAWS OF CA!IFORNIA,AN�AGREETHATIF I SHOULD BECOME INSP CTION FEE __ � SUBJECTTOTHEWORKERS'COMPENSATIONPROVISION$OFSECTION3'1000FTHELABDR 6"''r p.ypy CODE,I SHALL FOPTHWITH COMPLY W!TH THOSE PROVISIONS. 1SSUANCE `•� i�K..1� a (�,��. P C t � p �ATE:�+',�� APPI:ICANT: _y���`,.`. --- MIP . J WARNIN�:fA1LURE TD SECVRE WORKERS'COMPENSATIDN COVERAGE:S U lA IIL,AND SHALL BE RGY P/G � SU&IECTANEMPLOYERiOCRIMINAI,PENALTIESANOCNIlFME6U�TOONE NDREOTHOUSAND ENERGYPERMIT OOLIARS(5700,000),IN ADDITION TO THE COST OF COMPENSATION,OAMAGES AS PROVIDED FOR!N ¢ EECTiON 3708 OF 7HE LABOR CODE,INTEREST,ANO ATTORNEY'S FEES. RETENTION FEE: d CONSTRUCTION LENDING AGENCY PRE-ALT FEE: O ��� � I HEREBV AFFIftM UNDER PENAITY OF PERJURY THATTHERE IS A CONSTRUCTION LENDING AGENCY, a.�,/^(` (� � FOR THE PERFORMANCE OF THE WORK FOR WNICH TMIS PEFMIT IS ISSUED(SEC.3097,CIV.G). ,. Z W � LENOER'S NAME � . . � .� F_ LENDER'SADORESS .�.���(( _ , , „ , � �,),W � ICERTI{-l'TMATIHAVEREADTHISAPPLICATIONANDSTATE7HATTHEA60VEINFOHMATIONISCORRECT. TOTAL FEL�J �. � � tAaREETOCOMPLVWiTHALLCINANDCOUNTYORDINANCESANDS7ATELAW5PEUITING708UIL01NG � � CONSTRUCTION,ANONEREBVAUTHORIZEREPRESENTATIVESOFTHISCOUNTYTOEMERUPON7HE � / ZA90VE-MEMIONED PROPERTY FOF INSPECTION PURPOSES. COMMENTS •� � �S�� � p � � 1�1�� � !_ . � PERMITTEE (PFitNn . ,. . . � �����1�� � ��b�� � SIUNATUREOFPERMITTEE ,�„ � DAT '-� ��j � � � ���`� �- �-�` _. RECPT.NO. 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