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HomeMy WebLinkAbout15876 (23) . .. .,._ . ' C �!��v--2� � CITY OF DIAMOND BAI+t �3 / ----��- DEPARTivIENT OF COMMUNITY&DEVELOPMENT SERVICES � d D/ w 21660 E.Copley Drive Suite 190 ' \,�,,,. (909)860-3195 Fax(904)851-3117 PRE$$ � BLTII.DING PERMIT APPLICATI01�1 _-_ : r FIRMLY _ _ � . ,. ,.... �� JOBSITE /� �y�, ^ �^ ,�/ APPLICATION PERMIT P/C ADDRESS ��`��� ��:TAD�.s�'6"�� /C..' DATE �2I��/OO NUMBER 1 5876 # � ISSUE TYPE OCC APN LOT TRACT DATE CONST. GROUP p OWNER " ADDRESS ' ZONING SETBACKS � CIIY ZIP �!1'��c�TEL. fJ' '" — REART RW �❑ APPLICANT TEL. SIDE/SIQE STREET RW ❑ � CONTRACTOR „(,d SIDE ❑ p� ADDRESS `A r � CITY ZIP TEL. PROPOSED USE o ARCH/ENG/' W DESIGNER NO.DWEL. NO. NO. q, ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � u� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER DECLARATION SFR/ADD/REM O 0 I NEREBY AFFlRM UNOER PENILLTV OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS U- G8f89B/G8fp01S W CENSEUWFORTHEF01101MNOREASON�5EC.7031.6BUSINESSANOPROFE5510N5CODE:ANYCITVOR (/� COUNTVWHIq1R[-0UIRESAPERMITTOCONSTRUCT.ALiERIMPRDVE,�EMOI!BH,ORREPAIRANVSIAUC- W pefio/DeCk W TURE,PRpR TOITS ISSUANGE,AL50 itEOUIRES THE APPLICANT FOR SUCH PERMIT TO FILE R SIGNED w STATEMENT TMAT ME OR SHE IS LICENSED PURSVqNT TO THE PROVISIONS OF THE CONTRACTORS LI- � CENSE UW(CHMTEfl 9(CAMMENCINa WITH SECTION 70W)OF DIVISION 3 OF TFIE BVSINESS AND PRO- U' PooVSpa FESSqNS CODE)Oq TMAT HE OR SHE IS EXEMPT 7HEREFROM MD THE BASIS FOR THEALLEOED EXEMP- TION.ANYVIOLATIONOFSECTION7031.SBYANYAPPUCANTFORAPERMITSU&IEC75THEAPPUCANTTO Z Re-Foof � ACMLPENALTVOFNO'TMOHE'fHANFNEHUNDHE�DOLLARS(5600)J: � ❑I,ASOWNEROFTHEPpOPENN,ORAIVEMFLOYEESWITHWAGESASTHEIPSOLECAAIPENSATKNJ, � CORIffiOfCldl - WILL DO THE WORK AND THE STRUCTURE IS NOT IN7EN�ED OR OFFERED FOR SAIE(SEC.7o4t,BUSI- J � NESS PND PRDFESSIONS CODE:THE CONTRACTOHS UCENSE LAW DOES NOTAPPLY TO AN OWNER OF ? PROPEFiTY VJHO BUNDS 0H INPROVES iHEREON,AND WNO DOES SUCH WOPK HIMSELF OP HERSELF OR � THROU6HHI30RHEHOWNEMPLOYEES,PROVIOEDTHATSUCFiIMPROVEMENTSARENOTINTENDEDOR m Q ,OFFERWFORSALEIF,FIOWEVER7MEBUILOINGOqIMPROVEMENiL55q.OWIT111NONEYEAROFCOM%.E- Z iION,THE OWNEfl�BUILDER WILL HRVE T}IE BUR�EN OF PROVINQ THAT HE Op SME DID NOT BUILD OR � IMPHOVE FOR THE PURPOSE OF SALE). W ❑1,AS OVYNER OF THE PROPERTY,AM IXCIUSiVELYCAN7PACTING WITH LICENSEO CONTRACTORS � TO CONSiRUCT lH[PRO.IECT(SEC.104t,BUSINE55 AND PROFESSIONS CODE:THE CONTRACTpRS ll- V21Uedon ADJ.AREA � CENSEUWOOESNOTAPPLYTOANOWNEROFAPROPER7YWHOBUIIDSORIMPROVESTHEREON.AND NM1/OCONTRACTSFORSUpIPROJECTSWITHACONTRACTOR�S)LICENSEOPURSUANTTOTHECONTMG QUANTITY DESCRIPTION FEE � TORS 110ENSE UW.J. �I M1 EXEMPT UNDER SEC. B.8 P.C.FOR THIS REASON Q 3 � LL � DATE OWNER � � LICENSED CONTRACTORS DECLARATION W � 1 HEREBY�FFIpAI UNDER PENALTV OF PERIURV THAT I AM LICENSED UNDER PROVISIONS OF CNAPTER J f"� j� d 9(COIAMENCWOWITHSECTION7000)OFDNISION30FTHEBUSINESSANOPROFESSIONSCODE,ANU Z t/ �.+ B' .� X MY LICENSE IS IN FULL FOqCE AND EFFECT. m 0 LICENSE CLA � _ IIC.NQ„_ ���� � j V DATE �- CONTRACTOR a W � WORKERS'COMPENSATION DECLARATION � Q � i HEREBYAFFlRM UNDER PENAITY OF PER,IURV ONE OF THE FOLLOWING DECLAfiATIONS: z � IHAVEANDWILLMAINTAINACERTIFICATEOFCONSENTTOSELF-INSUREFORWORKERS' _ PENSATION,AS PRONDED BY SECTION 37a00F THE UBOR COOE,FOR THE PERFORMANCE 'U F THE WORK FOR WHICH THIS PERMIT IS ISSUED. � � w _I HAVE Ml�WILL MAINTIUN WOHNEH9'COMPENSATION INSURANCE,AS REOUIRED BV SECTION Q 370oOFTHELA80RCODE,FOPTHEPERFOfS�/ANCEOFiHEWORKFOflWMICHiHISPERMITIS ISSUED.MVWORKERS'CO ENSATIOI INSURANC C RIE P MBSRARE: CONSTRUCTION � CARRIER '� PLAN REVIEW � aOLICYNUMBER _ �� -� ELECTRIC � (iF153ECT10NNE�NOTBECOMPLEfEDOFhEPEPMfTISFORONEFIUFA(iE�00LLARS(StDD�ORL6SS� PLUMBING c � w 1�20Q0 Z ICERTIFY7HATINTHEPERFOPMANCEOFTHEWOfiKFORWHICHTHISPERMITI51S5VED,l MECHANICAL C7 SHALLNOTEMPLOYANYPERSONINANYMANNERSOASTOBECOlAESUBJECTTOTHE vj WORKERS' ENSATIONIAWSOFCALIFORNIA,ANDAGREETHATIFISHOULDBE ME INSPECTIONFEE SUBJE TO i WdRKEAS'COAIPENSAT ROVISIONS OF SECTION 370D OF T BOR /� WDE, SHALL pOR NWITHCOIAPLY WITH OVISIONS. ISSUANCE ry�� ,� � V� � � � L�� �' SMIP �u�� p DATE: APPLICANT: J WARNINO:FAILURETO SECURE WORKERS'COMPENSATION CAVERAGE IS UNLAWFUL,AND SHALLBE ENERGY P/C LL SUBJECTAN EMPLOYEFl TO CRIMINAI.PENAL71E5 AN�GVIL FINES UP TOONE HUNDRE�THOUSAND ENERGY PERMIT DOI.L0.RS(ft 00,000).W ADOIT�ON TO 7HE CO57 OF CAMPENSATION,�AMAGES AS PROVIDEO FOR IN � SECTION370BOFTHEUBORCODE,INTEREST,/WDATTORNEV'SFEES. RETENTIONFEE: W4 CONSTRUCTION LENDING AGENCY PRE-ALT FEE: O � t HEREBV AFFIRM UNDER PENALT/OF PERJURV THAT THERE IS A CONSTRUCTION LENDMG AGENCY FOR THE PEFlFORM�ANCE OF THE WORK FOR WHICH 7HIS 7ERMIT IS ISSUED(SEC.3087.CIV.CJ. Z W � LENOER'S NAME F- LENOER'SA�DRESS � TC)TAL FEES ` 1 CERTIFY THAT I HAVE READ THIS APPLICATION AND STATETHATTHEABOVE INFORMATION IS CORRECT. W I AGREE TO CAMPLY WRH ALL CITV AND COUNTY OfiDINANCESAND STATE LAWS REUTINd TO BUILOIN6 � CONSTRl1CTION,ANDHEHEBV�UTNOFlIZEREPRESENTATIVE50FTHI5COUNTVTOENTERUPONTHE (/�"/e�'_ � r 1y ZABOVE�MENTIONED DROPERTV FOR I SPECTION PURPOSES. COMMENTS V i,7 t•�/� �v(�� �'���_ � J � m PE ITT E(P INT) � . - / � � _ Uj SIONATURE OF PERMITTEE DA E � � RECPT.NO. 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