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HomeMy WebLinkAbout10589 --�• CITY OF DIAM4ND$AR; : COMMUNITY DE`V�T:OI�`14I�NT'DE�°�R'fIGf�NT ""�.` ` : � -;.;w 21660 E.Copley Ddve Suite 190 .•,..,._,...... c9o9>a6o-3i9s FaX�9oq>s6i:3iz�. . . ,., PRESS '°"' BUII..DING PERMIT APPLICATION FIRMLY _ , ..:. , o� JOBSITE LI,eT�,�„/ !� . APPIICATION;� PEpMIT -_-/`�� P/C' "-c, ADDRES �i��� -° � DATE NUMBER ` # � ` _;�: ISSUE TYPE OCC -- APN T TRACT DATE CONST. GROUP p OWNER ,: ,...., ,. p ADDRE ZONING SETBACKS _ . z CITY ZIP��TE�. � FfiONT RW O APPLICANT' ' TEL. REAR p z ^ SIOE/SIDE STREET RW ❑ . . � ,.:,.. ,. SIDE Q CONTRACTOR '. _ , � � �, , ; ❑ o CDDRESS � Walniret f V � , PROPOSED USE . /�1�7&9 TEL o ARCH/ENG/ iz DESIGNER NO.DWEL. NO. NO. a, ADDRESS = CITY ZIP TEL. UNITS STpRIES BEDR�OMS �n _ _.... .., cn , DESCRIPTION SQ.Ff: FAGTOR PSF ADJ.AREANALUATION � OWNEH-BUILDER DECLARATION SFR/ADD/HEM O I HEREBV AFFIRA.1 UNDER PENALTY OF PEFWRY THAT I WA E%EAIPT FROM 7FIE CONTRACTOHS LL G8f899/C9fPp/( W CENSEUWFOqTHEFOLl.OWINGREASON(SEC.7o31.5BUSINE65ilNOPROFESSWNSCADE:ANYCI7YOR (J� U COUNTYWHICHRE4UIRE3APEpMITTOCONSTRUC7ALTEH,�IMPR6VE,bEMOUSN,OpflEPkIRANY57RUC- � W NRE.PRpR TO ITS ISSUANCE.AL50 REOUIRES THE APPLICANT FOp SUCH PERMIT TO-FILE A SIGNE� W Patio/Deck � .�r S7A7EMENT THAI'HE OF SHE IS UCENSEO PURSUANT 70 THE PROVISIONS OF THE CONTRACTORS ll� � CENSEGW(CHAPTER B 1CfSMMENCIN6 WITH SECTION fODO)OF DIVISION 30F THEBUSINESS AND 6R0• PQOUSpB � FESSIONSCODE)ORTHATN�ORSHEISE7IEMpTTHEREFNOMANDTNEBASISFORTHEALLEDEb�kXENP- (� . . , U TION.ANVVIULATIONOFSECTqNio31.58VANVAPPIICANT�FORAPEIiM�T'SUBJEC7�STHEAPPCICAIlTTp Z Re�Roof F ACIVIL PENALTV OF NOT Md'RE7H�N flVE HUNDAED DOCLAAS(5600).):� � � � " � � -� � Qi,!$OWNEHOFTHEPROPERTY,ORMVEMPLOVEESWITHWAGESASTHEIRSOIECAMPENSATiON, � Commercial WILL DO THE WORK,AND YflE SYFUCTUHE IS NOT INTENOED OR OF�ERED FOR SALE��SEC.70{i,BUSI- J - --- y NESS AND PROFESSIONS CADE:THE CONTRACTORS LICENSE lAW DOES NOT APPLV TO,AN OWNER OF — PROPERTYWHOBUILDSORIMPROVESTHEPEON.AN�WHODOESSUCHNKXiKHIM$ELFOqHER'$'ELFOR = � [C 7HilOUGH HIS OR HER ONM ENPLOVEES,PPOVIDEDTHATSUCH IMhRbVBAEN75 AI�6 NOT INTERDED OR � � OFFEREDFORSALE.IF,1iOWEVEi4THEBUIIAINGORIMPROVEMENTI5SbLOWRfi1NUNEYEpqOFCOMPCE• � Z TION,THE OWNER�BUICDEA`WILL�HAVE�THE BUROENbF pfSOVIN�T1iA7 HE OR SHE'DICI NOT BUILp OR . = IMPROVE FOR�711E PURPOSE OF SALE). � � ' ❑i,AS OWNER OF hiEYROPEiiTY,AM EXCLUSNELY CONTNACTING WRH LICENSED CONTRACTORS � 7o cONSiRUC7 THE PRO.IECT(SECJoa4,BUSINE55 AND PROFESSIONS CADE:THE CQNTRACTORS LI- ValUBtion RDJ.AREA W CENSELAWDOESNOTAPPLYTOANOWNEROFAPHOPER7YWHOBUiL�SORIMPqOVES7HER�fSN,AND = WHOCON7RACTSFORSUCHPRO:IECTSWITHACONTqACTOR(SjLICENSEDPURSUANTTOTHECANTRAC� � ~ TORSLICENSELAWJ. - � QUANTITY DESCRIPTION � �p� � � Y � O I AM E%EMPT UNDER SEC. B.d P.0.FOR THIS HEASON � � � V ZDATE . . . OWNER . . . . . � O � � UQENSED CONTRACTOR$pECLAHATION. W � IHEFE6YAFFlFMUNDERPENALNOF�ERJURYTHATIAML�CENSEDUNDERPqOYISION50FCHAPTER � � 9(COMMENCNJ6 WITH SECTION 7000)OF DIVISION a OF THE 9USINESS AN�PROFESSIONS CODE,AND Z . X MV UCENSE IS IN GULL FORpE AND EFFECL " � � m -�- ,�„_, h ,�,,r,� LLl y .. .^ . '� _ , � 0 LICENSE C S C LIC.NO. � V DATE �' __ CONTRACTOR d �W - ,..i.�� x .�,,��i,.n._�i, WORKERS'COMPENSATION DECCARA710N � . � I HEREBV AFFIRM UNOER PENILL.7Y OF PERJURY ONEOF THE FOLLOWING DECLARA7fqNS: z � _I HAVE AND WIIL MAMTRIN A CERTIFICATE OF CONSENT TO SELf�INSURE�OR N/pflKERS' _ �''- Q COMPENSA710N,ASPROVroEDBVSEC710Na7ooOFTNELABORCODE,fORTMEPENFORMANCE U Q OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. � QW _I HAVE AND WILL MAINTAIN WORKERS'COMPENSA710N INSURANCE,AS REOUIREO BY 9ECTION 370o OF THE LABOR CODE,FOR THE PERFOFMANCE OF THE WORK WR WHICH THIS PERMIT IS J ISSUED.NY WOFKERS'COMPENSATIDN INSURANCE CARRIER AND POLfCY NUMBER ME: CONSTRUCTION ro � CARRIER PIAN REVIEW Z Pa.ICVNUUBER ELECTRIC ¢ � (THISSECTICNNE�NOTBEOOMPLEfEDOFhIEPEPM'TISFORqJEFAN+OR�W1.LAqS�Y100)ORLFSSx PLUMBING W /� Z 1 CERTIfYTHAT IN THE PERFORMANCE OF 7HE WORK FOR WHICH THIS PERM17 iS ISSUED,I MECHANICAL �V�J C�S SHALL NOT EMPLOY ANY PERSON IN ANY hMNNER SOA$TO BECOME SUBJE6T TOTHE �.� � WORKERS'COMPENSATIONUWSOFCALIFORNIA,ANDAGREETHATIFISHOUL�BECOME INSPECTIONPEE SUBJEC770 THE WORKERS'CAMPENSATI6N PROVISIONS DP SECTION 37000P THE IABOR J+�- OCOOE,ISHALLFORTHWITHCOMPLYWITHT��,eC�,R�Ow/sioNs: ISSUANCE i� p DATE: �� APPLICANT: L.C�/�.C.GC __ SMIP J WARNWGFAILUflETOSECUREWORKERS'CAMPENSATIONC�VERAGE7SUNC14WFl1C;AN�SHALLBE ENERGYP/G � SUBJECTANEMPIOVERTOCRMAINAI.PENALTIESAN�CIVIIFlNESUPTOONEHUNOREDTHOUSAND; ENERGYPERMIT OOLIARS IS1�D,000),�N AODITI6tJ TO THE COSTOF COIAPENSATWN.DAAtIiQEfi M1S PRDYIDED FOH'IN � SECTIONS7o80FTHELABORCODE,INTEREST,AN�ATTORNEYSFEES. RETENTIONFEE:� OCONSTRUCTION LENDING�AGENCY PRE-AlT FEE: � ' � 1 HEREBY AFPIRM UN�ER PENALTY OF PERJURY TMAT7HERE IS'ACONSTRUCTION LFNDIN6 AGENCV � - ' � �� - -" FORTHE GERFORMANCE OF THE WOHK FOR WHICH THIS PERM�'f IS IS5UE0(SEC.30G),CIV.C.�. Z W � lENOER'SNAME �..a' ;�, �y:� F— LENDERSMDRESS ' ' 'a"�"a W TOTAL FEES ,s,J"` I CERTIFY THAT I HAVE READ TFIIS APPLICATION AND STATE THAT THE ABOVE iNFORMATIpN IS CORRECT. � � CONSETRUC7I�PL- IE BVAU7HORI2E�R�SENTA�ESOFT�HISCOUMYTO�ERU ONUTHE� i i M �i`� ��" eS �I� : z A80VE-ME O qNFO EC7�ONWqpOSE3 ��� COMMEN7S - � I � � '�� ' z�:�} � � � ii �ii�� i�r�' �t., irrl � m PERMITTEE NAME(PRIN� /�(�,�r. �y��j^� I ' i � �i ;�. �i � � �.KlG�.! !J'y! / i 1I '� E iw I, �If i y SI(SNATUHEOFPERMITSEE ,ppTE ." ' I•. . . .. . �.: .,. , I� ��I 16.f� . � �-, „: `�Y. 4,: �`„r, �_. ,^^"."�,h RECPT.NO. 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