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HomeMy WebLinkAbout13591 (14) . . --'�-. . .� i ., .� . . . . .� . , .� .. . . �: ... . . . . .- . �. .. . . . ,� ._ . � _�� CITY OF DIAMOIeTD BAR DEPARTMENT OF COIViMTJNITY 8c DEVELOPMENT SERVICES � 21660 E Gopley Drive Smte 140 ,.. � (�>86o-3igs Fa�(909�s4i-si i7 -, � PRESS 9�'. BUILDING PER1VIfIT'r11�'f"LICATIbN ' ' _ � ,� FIRMLY � JOBSITE� � � (,�, f. APPLICATION PERMIT �2 c��s � P/C o ADDRES P i,� ��' DATE NUMBER J-��r # � APN L TR l` pp7'EE r,�} �-f���C-"� CONST. GROUP p OWNER T�— " ADDR ZONING SETBACK3 �W CITY ZI TEL. �� REART RW ❑ APPLICANT TEL.�_�,„—�r�� SIDE/SIDESTREET RW ❑ � CONTRAC SIDE ❑ p� ADDR S� PROPOSED USE � C IP TEL. w ARCH/ENG/� � A ,, � " ��' ,�+...�, � z DESIGNER �9+F��1�����s,7 �`.���C� � � ADDRESS NO.DWEL. tJO. NO. � CITY ZIP TEL. UtJ1T5 STORIES BEDROOMS cn u� DESCRIPTION SQ.FT. FACTpR PSF ADJ.AREA/VALUATION � OWNER-BUILDER DECLAAATION ��� �� SFR/AD�/REM O p I HEflEBY AFFIfUA UNOER PENRLTY OF PERJURY iHR I AM E7(EMPT FROM THE CpNTRACTORS LI� G2IdgB/C01'pOfl W CENSEUWFORTHEFIX.L0IMNOREIISON(SEC.7037.SBUSINESSANDPROFESSIONSCADE:AN1'�CI7YOP (f) CWNTYWF#CHREIXIIFlESAPERMITTOCONSTHl/CT,ALiERIMPFOVE,DEMOLiSH,ORREPAIRANVSTRUC� W PahO/DBCk TURE,PRIOR TO ITS ISSUANCE,-AS6�REQUIRES THE APGIIC?NT FOR SUCH PERlAITY2i kILE A�SIGNEp � STATEMENT THAT HE OR 6HE IS IJCENSEP PURSUANT TO TNE PROVISIONS OF TNE 60NY�FiACTORS U� � � CENSE UW(CHAPTER e(COMMENCINCa YJ�TH SECTION i000)OF DIVISION 3 OFTHE 9U51N'E'55'i(N�PRO� POOUSpa FESSpNS CODE)OR TFIAT HE OR SHE IS EXEMPT THEREFAOM AN�THE BASIS FOR iHE'ALLEGEp EXEMP� TION.ANYVIOLATIDNOFSEC710N7031.SBVANVAPPIICANTFORkPERM1TSUEJECTSTHEApPLI�ANTTO Z Re-RoOf � ACINLPENALTYOFNO7MOfiETHANFIVEHUNDREDDOLLARS(5500)J: f� "q��;i. � ❑I,ASOWNEROF7HEPROPERN,oRMYEMPLOY£ESWITHWAGESASTHEIPSOLECAIU�PENSATION, � COmrnerCi81 - MALL DO THE WORK,AND THE STRUCTUR6 IS NOT INTENDED�OR OFFERED FOR SALE'tSEC:7CA4,�8UBL �1 � NESS ANU PqOFE&SIONS C(ME:THE CONTRACTORS LIC'cN3E LAW DOES NOTAPPLV T0��:41J'CWNER Of � PROPERTY WFIO BUIL09 OR IMPROVES TH£REON,AND NMO bOES SUCH WOHK HIMSEI.F OR'li�i�§ELF OPo OC THRWOM/950RHEROYMEMPIOYEES,PROVIDE�THATSUCHIMPROVEMEN?SA%EN6TINiENDE00F m Q OFFEREDWRSALEIF,HOWEVERTNE9UILDINGORIMPR04EpAENTIS50LAWITHINONEYEAR'pFCQMPIE- Z TION,THE OWNER-BUILOER WILL HAVE THE BURDEN OF PRO�ING THAT HE OR SHE L110 Nf17 9111LD OR � �MP0.0YE FORTNE Pt1RPASE OF SALE). -�� ��.-�i���il � W ❑t,ASOVJNEFOFTHEPROFERTY,AMEXClU51VELYCON7RACTINGW:THUCETISEDCONTRACTOR5 � TO CONSYRUC7THE PRQIF.CT(SEC.�W4,BUSIh'ESE AIdD PPOfESGIOHS CODE:THE CC1NTqAbTqpS ti� V81U&4i ADJ.AREA W CENSEUWDOESNOTAPPIYTOANO`NNEROFAPROPERTVYdHOBUILDSORIYAPROVESI'HER�OL,�ANO —, Y�MO COPIfMCTSFOR 5UCN PRDJECTS WITPIACONTRACTOq(5)LICENSE�PUf2uUANT70'FNIE(�NTRAF � roasucensEuw.>. ,. , QUANTITY DESCRIPTION FEE � �I AM E%EMPT UNDER S�G� &&P.C.FOii 1'NIS f'.EASOIV � Y � V � — — � DATE QWNER_._________� �'- Z � � UCENSED CONTRACTORS DECLARaTION - � � I HEREBY AFFIpM UN�ER PENRl.TY OF FEFiJURV 7NAT I Al.1 UCENS(_'�UNDER PRCVISIONS OF CHAPTEP, � ! d 9(COMMENCIN(3 WITH SECT�OF DI4ISION HE 6��A�R�S510N5 COD(,ANp Z 9G MY UCEfdSE IS�N FUII FOPCE EFFECT. �P���/ � LIJ � LICENSE CLASS LIG.NO. "�""1 � V DATE� GONTRRC70R _ �. W � WOR%ERS COMPENSATIpN DECE.AAATI�N a � IHEREBYAFFIRMUNDERPEPIALTY�fPE2URYONEOFTHEFOLLOWMGD[CLJtRkTIpNS: Z � _IIfAVEFNDUdItLMR.INTAINACERTIFICATFOFCONSEMTTOSELF-INSUREWAWORKF.RS' x — , � C9IAPENSA710f�,AS PflOVIDED BY SEC7�ION:7o00F TNE LABOR CODF.,FOR TH�PEiiFORMANCE �U � OF'�FdE bVD�21<FOR WNICH THIS PERMIT IS ISSUEO. � � ^I HAVE AMD WILL MAINTAIN WORKEAS'COtvIPENS,�TION INSURANCF„AS REQVIRED 9V SECTION � 37o00FTHE LABOR CODE,FOR THE PcRFORMANCE OF THE WORK FOq WNICH THIS PERh9iTIS 1-�-� 155UE0.MY WORKERS'CaMPENSATION INSURANCE CARRIER At�A PCLICY Nt1.UBER ARE: CONSTAUCTION ��%��,�� j CARRIER� `!_ flLAN REVIEW - �.� Zvoucvr+unasEa _�_._. EIECTRiC •�. � .�_. 'Q �:ti.��,1.�.s:,;,.,,,ry � (f}{SSECTON+IE�MOTBE0C1.pLL-1IDOFTF�PE{,'�ATISFCRGYJEMJtD.7ED[YJi.LMs(51oo)ORLESS). Pl_UMBING � 1 CER'IFYTHATIN YHE PERFOFlMANCE OFTHE NVOFK FOa WHIGH 7Hi5 PERMI715155VED,I RRECHANICAL Lj SHALLNOTEMPLOVANVPERSONINM'YMANNEft5DA5TCJ8ECOA5E5UBJECTT(?THE (/� WOHKERS'COMPENSATIONLAWSOFCRUFORNlR,ANDAGREETHATIFISHOULUBECOME ONSPECYIONFEE _ �+' �.�. ^a � � SU&IECTTO 7HE WdRKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR —�� p �(, � � !� °'� -�J- f:ODE,ISHALIFOflTHWITNCOMPLYWITHTHOSEPRnVI510NS. �SSUANCE A � . "'*' L-� �� � ~f � DATE:__ APPLICANT: _ SMIP t. � .. 6„"� 4��'�Z� a �"�!�F��ar �-7( � WARNING FAILURE Tt�SECUR[N'ORKERS'COMPENSATION COVEFAGE IS UNLAWftll_,ANp SHAIL BE ENERGY P/C ����d��'"'��' � -' a��'y^� �y SU&IECTAN EMPLOYER TO CFIM!NAL PENAITIES PNO CIVII FINE5 UP TOONE HUNDGIE�THOUSANO ENERGY PERMIT DOIURS(E700.000).1N A�DITION TO THE COSTOF COMPENSA7:ON,OAMAGES AS PROVID[D FOR IN � SECTION 37DB OF TTiE LABOR CODE,INTEREST,AND ATTGftNEY'S FEES. RETENTION FEE: oW.. CONSTRUCTION LENDING AGENCY pRE-ALT FEE: / 4 O �17. I HEREBY AFFIRM UNpEF P[NAL7V OF PERJVRV THAT THERE IS A CONSTRUCTION LFNDING AGENCY FOR THE PERFORMANCE OF TNE WQRK FOR WNIGM THIS PERMIT iS ISSUEU(SEC.309�,CIV.CJ. . Z W � LENDER'SWiME__,___ �— LENDER'SA�DRESS � ICERTIFYTHATIHAV EAD HISAPPLICATIONANDSTATE7HATTHEA90 FO A7IONISCORRECT. 1�dTAL f S � f� �� � IAGREETOCOMP WITH LCITYANOCOUNTVORDINANCESANDS WS ELA71NG7D�UILOWG � CONSTRUCTI 'D. 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