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HomeMy WebLinkAbout17628 s _ ��` CITY�F DIAMOtJI?BE4R � � � � l�EPARTMEPIT OF COMMUNITY&DEVELOPMENT SERVICES 2tE25 E.CopleyDrive °'` M (909)&60•319�Faac(909)861-3117 PR ESS '��.vria BUILDING PERMIT APPLICATION FtRMLY , o ADDR SS �d�� J�1�������y � �� DATECATION ��._ i� �, NUMBER �Ds�; #!C � ISSUE 7YPE OCC APN T TFFiA�C �� DATE CONST. GROUP p OWNE r �� ls'.��7 p ADDRES � ZONWG SETBACKS z CITY P TEL. � FRONT RW ❑ p APPLICANT TEL. S DE/SIDE STREET RW ❑ z m CONTRACTOR ��� SIDE C ' � ADDRESS �' °" p � PROPOSED USE CITY ZIP��'TE - o ARCH/ENG/ i, W pESIGNER NO.DWEL NO. NO. a ADqRESS UNITS STORIES BEDROOMS � CIT`( ZIP TEL. � rn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATIdN � � OWNEp-BUILDER DECLARATiON SFR/ADD/REM O I HERE6V AFFIRM UNDER PENILLTY OF PEFJURY THAT 1 AM EXEMVT FROM THE CONTRACTOflS�I� GafB J2/C2fPOf[ �W' CENSELAWFOflTHEFOLLOWINGREASON�SEC.�031.5B115ME55AN�PROFESSIONSCo�EANYCITYOF (/� C.� CQUNTYWHICHREOUIRESAPERMITTOCONSTRUCi,ALTER,IMPROVE,�ENOUSH,ORFEPAIFiANY5TRl1G W PdSI0ID2CIC TURE,Pq10.4 TO ITS ISSl1qNCE,ALSO REOUIRES 7HE APPLICANi FOA Sl1CH PERMIT TO FlLE A S�GNE� �� 57ATEMENT THAi HE OR SHE IS LICENSED PIJRSUAN7 TCl THE PROVISIDNS OF THE CONTRACiORS LI� W . �. CENSE LAW(CHPPTER 9(CDMMENCING WITH SECTION 70�0�OF DINSION 3 OF iHE BUSINESS AND PRO� LL POOUSPd FESSIONSLODE)OflTHATNEORSHcISEXEMPTTHEREFROMAN�THEBRSiSFORTHEALLEGEDEXEMP- (� VTION.ANYVIOLATIONOr^SECTION7031.58YANYAPPLIGANiFORAPERMITSI/BJECi57HEAPPLICANTTO Z RB-ROOf A CIYIL PENALTY OF NOi MORE 7HAN FNE HUNOflED DOLLARS(SSoo)J: Z ❑I,ASOWNEROFTHEPflOPERTY,ORM7EMPLOYEESWIiH3NP.GE5A5THEIR50LEGOMPENSATION, � COfIlf110fCldl - . WILL DO iHE WORK,AND THE SiRUCTURE IS NOT INTENDED CR OFFERED FOR SALE(SEC.7044,BU51� J � NESS AN�PROFESSIONS CqDE:THE CONiRACTORS LICENSE LAW DOES NOT APPLYTO AN OWNER OF � �.PROPERTY WHO BUILUS OR IM.PROVESTHEPEON,AND WHOOOES SUCH WORK HIh15ELF OR HERSELF OR � THROUGHHISORHEROWNEMPLOYEES,PROVIDEDTHATSUCHIMPflOVEMENTSARENOTINTENDE00R � � OFFER�FOHSALEIF,HOWEVER,THEBUILDINGORIMPROVEMeNi1S5OLbWITHINONEYEAflOFCOMPLE- � �� TION,THE OWNER-BUILOER WILL HAVE iHE BUfi�C-N OF PROYING THAT HE OR SHE�ID NOT BUILD OR _'. IMPROVE FOFI7HE PURPOSE OF SALL). � ❑I,ASOWNEROFTHEPFOPERT;AMEXCLUSNELVCONiRACiINGWITHLICEN6EDCONTflACTORS a' TO CONSTRUCT THE PROJECi(SEC.7D44,BUSINESS AND PROFESSION5 CODE:THE CON7RACiORS LI- VdIUdU0I1 ADJ.AREA W. CENSELAWDOESNOTAPPLVTOANOWNEROFAPROPERiYWH�BUiLD50RIMPROVESTHc'REON,AND �, �WHOCONTRACiSFORSUCHPROJECiSWIiHACONiRqCTOR(S�LICENSEDPURSUANT70THECON7PAC- QUANTITY DESCRIPTION ' FEE � TORS LICENSE LAWJ. �� ❑I AM EXEMPT VNDER SEC. B.&P.C.GOR THIS REASON Q U � � DATE _OwNER — U Z �y '� ¢ LICENuED CONTRACTORS DECLARATION � � IHEREBYAFFIRMUNOER?ENALTYOFPERJURYTHATIAMUCENSEDUNDERPROVISIONSOFCi1APTER � C/L-S�G ' d 9(COMMENCWG WITH SECTION 7000)OF DI SION 30F iHE BUSINESS AND PROFESSIONS COaE.M10 z G�0 �X.,MY LICENSE IS IN FULI�C�AN'J.FF{E . �, m / /p � UCENSE CLASS '�� LiC.NO. C � � �,_; J V .DATE CONTFACTOR �- W � W RKERS'COMPEN5ATION DECLARATION a � � 1HEREBYArFIRMUN�ERPENALTYOFPERJURYON60FiHEFOLLOWINdDECLARATIONS: Z ZI HAVE A WILL MAINTAINA CERiIFICATE OF CONSENTTO SELFdYSURE FOR WORKERS' _ ¢ CDM 5ATION,ASPROVIOEDBYSECTION3�aoOF7HELABOACO�E,FORiHEPEflFORMANCE 'U Q HE WORK FOR WHICH THIS PEqM11171515SUED. . � Nw„ .�IHAVEANDWILLMAINTAINWOqKERS'CAMPENSATICNINSURANCE,ASREQUIFE09YSECTION Q 37aoOFiHELABORCODE,FORTHEPERFORMANCEOFTHEYlORKFORWHICHTHISPERMITIS ISSUE�.MY WORKEAS'COMPENSATION INSUR CE CAPRIER AND POLICY NUMBEfl ARE: CONSTRUCTION ¢'. ,!' �, cnRrtiER ��i-� /l � �� PLAN REVIEW 0 POLIGY NUMBER� �� a � � , — ELECTRIC 4 ,�J/J 4 (iHISSECTKKJNEmNOTBEO�MFt'cTEDOFh�:EPERMITISFORONEHUNDREDD0UAR5(S10D70flLES5F PLUM6ING �'"'� W . Z ICERTIFYTHATIN?HEPERFORMANCEOFTHEWORKFOPWHI PE I I5155UE�,1 MECHANICAL C!j SHAL4 NOT EMPLOYANY PERSON IN ANY MANNEP SOAS TO B OM_SU E TO THE � WORKERS'CO PEN TIONL4WSOFCALIFO D E HA7 IS O L�DECOME INSPECTIONFEE F; SUBJECi70 T E RKERS'COMPENSATIO PROVI 3� Of T��E IABOR . �' CODE,iSHAL FO NWITHCOMPLYWITH SE 10 : ISSUANCE Q 2 Cj; DATE: I ! ��PLICANT SMIP J WARNING�FAILURE OSECUREWDRKERS'COMPENSATI�N GEIS LAWFUL,AN�SHALLBE ENERGYP/C �y SUBJECTANEMPLOVEflTOCqIMINALP6NALilESAN�qVILFWESUPTOONEHUN�p'cO7HOU5AN� ENERGYPERMIT DOLLARS(S!Oqo00),IN A�DITION TD THE COST OF COMPENSATION,DAMAGES A5 PROVIOE�FOR IN ' J SECTION3]OPQ%THELA80RCODE,INTEREST,ANDATTORNEY'SFEES. RETENTIONFEE: � d� CONSTRUCTION LENDING AGENCY PRE-ALT FEE: ��L F9 O r �� IHEREBYAFFIRMUNDERPENALTYOFPERJURYTHAiTHEREISACONSTRUC710NLENDINGAGENGY � FOR THE PEqFORAfANCE OF THE WORK FOR WHICH THIS PERMIi IS ISSUED(SEC.3o W,CIV.C.). . Z' �.. _"--'—.— _ _ �.. -- , ��: LENDER'SNAME H LEN�ER'SADDRE55___,_.__ Q ��'� ICERTIFVTHATIHAVEREADTHISAPPUCATIONANDSTA7ETHATTHEABOVEINFORMATIONISCORRECT. TOTAL FEES � +°� W IAGREETOCOMPLVWITHALLCI�VANOCOIJNTYORDINANCESANDSTA�'ELA'NSRELATINGT00UIL�ING � CDNSTRVCTION,qNO HEREBV AUTHORIZE R ESENTAiNES 0F THiS GDUNT'f T(l ENTER UPON THE �' ABOVE-MEYTIONEpPROPERTYGORINSP 1 PIJRPOSES. J��, � f ��� COMMENTS � � PERMITTEENAM fll � �. � �� Vj� SIGNAiURE OF PE I EE � i E _� RECPT.NO. 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