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HomeMy WebLinkAbout13052 (14) ���� i CITY OF DIAMOND BAhT 7`"� j —� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES �'� _ _ � 21660 E.Copley Drive Suite 190 PRE$$ � (909)860-3195 Fax(909)86]-3117 ''�"�� BUILDING PERMTP APPLICATION FIRMLY � JOBSITE APPLICATION PERMIT P/C o ADDRESS � �'�� • � DATE NUMBER��-# c� ISSUE � .��„� �" TYPE. OCC APN lOT TRAC7 DATE CONST. GROUP p OWNER �' " ADDRESS n n�.'+ ZONING SETBACKS � CITY ZIP TEL. REART RW O❑ APPLICANT TEI. SIDEISIQE STREET RW ❑ n. CONTRACTOR SIDE ❑ �, AODRESS � CITY •. a,.;�i,�_ ZIP' TEL��,Ih�"r� PROPOSEDUSE � ARCH/E�4"u'+d �— v � �t. _ Z DESIGNER NO.DWEL. NO. NO. � ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION Q� OWNER-BUILDER DECLARATION SFR/ADD/REM - p i HEREBV AFFlRM UNDER PENALTV OF PERJUNV THAT I M1 EXEMPT FROIA YHE CONTRACTORS LI- Ga�ege/C8(POIi W. CENSELAWWRiHEFOLLOWWGREASON(SEC.7037.66USINES5PN�PROFESSIONSCO�E:ANYCI7YOfl (n . �J COUMVWHICHREOUIRESAPERMtTTOCONSTRUCT.ALTER,IMPROVE,DEMOLISH,ORAEPAIRANYSTRUC- W P1ti0/DBCk W TIIRE,PRIOR TO ITS ISSUANCE,ALSO REQUIRES THE AVPLICANT FOR SUCH PERMIT TO FILE A SIGNEO � � STATEMEM THAT HE OR 9HE IS IICENSED PURSUANT TO iHE PROVISION3 OF THE CONTMCTORS LI- c. CENSE LAW(CHAVTEfl D(COMMENCINO WITH SECTION 7000)OF DIVISION 30F THE 9USINESSAN�PRO- � POOUSp7 1 FESSpNSCODE)ORiHATMEORSNEISEXEMPTTHEREFPOMANDTHEBASISfOiiTHEALLEGEDEXEMR V TION.ANYVpUTWNOFSECTION7o31.68VANYAPPLICANTFORAPEHAIITSU&IECTS7NEAPPUCANTTO Z p¢-FOof r, A CML PENALTY OF NOT MORE THAN PIVE MUNDRED OOLLAqS(S600).): . � ❑1,ASONMEROFTHEPROPERN,ORMYEMPLOYEESWITHWA6ESASTHEIRSOLECOMPENSATION, � CommB�Cl01 .. - N9Ll.DO THfi WOFifC,M'0 THE 57RUC7URE IS NOT INTENDE�OR OfFERED FOR SALE(SEG.7044,Bt1Sl� �1 - NE33 AND PROFE9910N3 CWE:THE CONTRACTOHS IICENSE LAW DOES N01 APPLY TO AN OWNEq OF - � PfiOPERTYNM1lOBU1lDSORiA/PROVESTHEREON,pNONMODOESSl1CHWORKHIMSELFORHERSELFOR = �. .THHOUfiMHI50flNEROWNEMPIOYEES,PROVIDEDTHA73UCHIMPROVEMENTSAqENO71NTEt�EDOR m � - 0 ,OFFBiED�ORSALEIF,HOWEVER7ME6UILDINGORIMPROVEMENTISSOLOWtTHINONEYEAfiOFCOMPLE- '-- 'TION,THE OWNEF4BUItDEH V17LL MAVE THE BURDEN OF PROVING'lt1AT ME OR 3HE DID NOT BUILD OK � � -UAPROVE FOR THE PURPOSE OF SALE). � � ❑I,ASOYYNEROFIHE PflOPERTY.AM EXClU51VELYCONTMCTIN411�THLICENSED CONTRAGTORS �� 70 CONSTld1CT THE PROJECT(SEC.7ou,BUSINE55 M!D PPOFESSIONS CODE THE CONTRACTOqS LI- V8IU0tiOn ADJ.AFlEA - 111. CENSEIAWOOESNOTAPPLYTOANOWNEflOFAPftOPERTYWMO8UILDSOflIRSPflOVESTNEREON,AND i WHOCONTMCTSFOHSUCHPROJECTSWITHACONTRACYOR�S�LICENSEDPURSUANTTOTHECONTi7AG QUANTITY OESCRIPTION FEE � F- TORS LICENSE LAW.). � o ❑IAMEXElAP'fUNDERSEC. 8.&P.C.FORTHISREASON U ' � �► � LL"� DATE OWNER V Q W .F UCENSED CONTRACTORS DECIARATION –� � w IHEREBYAFFIRAIUNDERPENAIttOFAERJl1RYTHATIAMLICENSE0UN0EHPROVI5lON50FCHAPTER � �,/ d D(COMMENCWOWITHSECTIONT�O)OfDIV�510N30FTHE8U51NES5AN�PPOFES510NSCO�E,AN� Z ?C_ MV UCENSE IS IN OflCE AND EFFECT. � m S i31 l -� �UCEN3ECLA9S��C". � IIC.NO. � , a . � _ j � H -� DATE CONTRACTOR d - W . _ .�. WORKERS'COMPENSATION DECLARATION - �- - � Q - - - - � � � � 1 HEH AFFliUA UNDER PENALT'OF PER�URV ONEOFTHE FOLIAWING�ECLARATIONS U � Z G'2 _INAVEANDWILLMAINTAINACERTIFICATEOFCONSEKiTOSELF-WSUREFORWOPKERS' � � COMPENSATION,AS PiiOV�EO BY SECTION 37000FTHE LABOR CooE,FOft TXE PERFORMANCE W � OF THE WORK FOfl WHICH iH13 PEFMIT IS ISSUE�. � 0 W _I HAVEAND WiLLMl.�MAW WORKERS'COMGENSATION INSURANCE,AS REQUIflED BY SECTION O . 37W OF'IHE LABOfl CODE,FOR THE PERWRMANCE OF THE WOflN FOR WHICH TMIS PEflMIT IS ...� . ISSUED.MY 5' PEN ION IN CE CARRI D POLICV NUMBERARE: CONSTRUCTION _ C OM � - CnnR1EN �- _ PLAN REVIEW _ � POLICYNUMBER ' E C O_ . .. (IHLSs[crKxuNEa)NoreEmP.�LFrEocFTFiEVEahttlSrbHor�EttJWIiEODauas(Sioa)ortt.E55� LUMBIN �� . z 1 CEPTIFV THAT INTHE PERFOR�NCE OF THE WORK FOR WHICH TNIS PERMIi IS ISSUED,1 MECHANICAL . - _ .. ('J' �. �SHILLLNOTEMPLOYANYPEHSONINANYMANNERSOAST08EGOMESU&IECTTOTHE � - � � � . . � . WORKERS'COMPENSATION LAWS Of CALIFORNIA,AN�AGREETHAT IF I SHOULD BECOlAE 1 CTION FEE _._—�,i��� �'y F 'SUBJEC7TOTHEWORKEfiS'COMPENSATIONPflOVISIONSOFSECTION370oOFTHEUBOR ISSUAN E �� � ( -+ C�E,I SHALL F RMWITH COMPLV WI SE PROVISIONS. p DATE•�� APPIICANT:��-- _ ..;�'„ "� . � ENERGY P/C -�. J' WAflNINO:FA��URETOSECUREWORKERS'COMPENSATIONCAVERAGEISUNLAWGULANDSHALLBE '�y-' SUBJECTANEMPLOYERTOCRIMINALPENALTIESAN�CIVILFMESUPTOONENUNDR DTMOUSANU ENEflGYPERMIT � �" ¢w DOLLAH5(i100,000).IN pODIT10N TO THE COST OF COMPENSATION,OAMAGES AS PROVI�ED FOR W ,� -� SECTION37080FTHELABORCODE,INTEftEST,ANOATTORNEI"SFEES. ' RETENTIONFEE: �- CONSTRUCTION LENDING AGENCY PRE-ALT FEE: �� IHEREBYAFFIRMUNDERPENALTYOFPERJURY7HATTHEBEISACONSTFUCTIONLENDINGAGENGY d fORTMEPERWflMANCEOFTHEWORKFORWHICHTHISPERMRISI55UED(SEC.3097,CIKC.). - Z W ,�. LENDEWS NAME �'� ' - 1— LENDER'SADDftESS . -�: ICERTIFYTHATIHAVEREADTHISAPP4ICNTIONMIDSTATETHATTHEABOYEINFORMATIONISCORRECT. TOTAL FEES � -_�� I AGREE TO COMPLY WITH ALLCIT'AND COUN7Y ORDINPNCES AND STATE LAWS REIATING TO BUILDING _ �; CONSTPUCTION,ANOHEflEBYAUTHOflIZEflEPRESENTqTIVESO�THISCAUNTVTOENTERUPONTHE - .Z- N80 �MEMIONED PROPERTY FOR INSPECTION PURPOSES!� COMMENTS S F� m�� PE EE NAME(PRINn � � ��� - y� SION URE PERMIITEE DATE s ._. RECPT.NO. 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