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HomeMy WebLinkAbout16986 (37) J� CITY OF DIAMOND IIAR � DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES ��� � 21825 E.Copley Drive (909)860-3195 Fax(909)861-3117 PRESS BUILDING PERMIT APPLICATION FIRMLY } JOBSITE • APPLICATION �_��\,.�I PERMIT I �(�j p/C o ADDRESS DATE— �� NUMBER `f d So # � APN LOT TRACT �SSUE TyPE p�C DATE CONST. GROUP p OWNER o ADDRESS ZONING SETEiACKS gCITY Q=��� ZIP �TEL.��,�,�-Z/� FRONT RW O APPLICANT 7EL, REAR � � SIDFJSIDE STREET RW ❑ � CONTRACT R _ ,�"� SIDE � � ADDRESS . � CITY/�G. ZIP� TEL � PROPOSED USE . o ARCH,'ENGI � ' � I z� �ESIGNER NO.DWEL NO. NO. a ADDRESS � CITY ZIP TEL. UNITS STORIES BEDROOMS � � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION Q OWNER-BUILDER DECLARATION p SFR/ADDIREM I HfREBY AFFIqAI UNDER PENALTY OF PEfiM11RY THAT 1 AM E%f14PT FROM THE LONTMCTORS LF Garego/Carport W CENSEUWFOHTMEFOILOWWCREASON�5EC.7WI.SBU5WE53AVDPROFE55lOI:5C00E:ANYCITYOR (f� C� COUNiYVhiICMREWIPESAVERMITTOCON57AUCT,ALiERiM7ROYE,DC1.!OLISM,ORREPAIq114Y5TRUG (L w TUHL iniOR TO ITS ISSUtivCE,AL50 REOUIRES iME�Pvl�CM1T FOR SUdi VEW.��T TO FIIE A S:GNCD W PdtiO/DOCk � S7ATEMENT TMAT ME OR SHE IS LICENSEO MIRSUANT TO THE VROVISIONS OF iME CONTMCTORS lb � GENSE UW(CHAPTER Y(COMMENCINQ WITH SECTIOY)D00)OF DIV1510N 7 OF THE B'JSiNE55IWO PHO u- PooUSpa � FESSIDNSODDE�DNTUTHEOR5NEI5EXEUPTTMEREFROUANDTNEBA515FORTHEALLECEDExEMP- (� TION_�IJYVIOLATiONOFSECTION70]1.SBYANYAPVIICANTfOR�PERMITSV&JECTSTNEAPPLICANTiO Z Fle•Roof F, ACMLVENALTVOFNOTMORETIIANFNEHUhDREDDOLLAHS�75oC�.�: 0 ❑�ASOWNEROFTHEPROPERTV,ORMYEMPLOYEESWITMWAGESASTHEIRSOLECOMPENSATqN, O COTfifBftl2l Z 1MLL DO THE WORK AND iNE STRUCNR[IS NO7INTENDE�OR OFfEREO FOR SALE(SEC.70��,6USI� �J � NESS AND VROFE5510NS COOE:TNE CANTRACTORS IICENSE UW DOES NOTAPPLY TO AN OWN[R OF FROPERTYWMOBUIIDSORIIAPROVESTHCREON,ANOWMO00E55UCHWOqKMIMSELFORHcRSELFOq � � THHWGHHISORHEROK?lEMPLOVEES.VRONOEDTNATSl1C/11MPROVEUENT5A37ENOTINTEN�EDOR m � OiFERCDFONSALEIF,NOWEVERTM[BURDINGOR/dPRO�EIAEMI550lDVYITMINONEYFAROF�qAP�E- Z iION,ME OWNEN-BUILDER WILL II�VE TME BUROEN OF PROVMO TMAT NE OR SNG C��NOT BVIID OR = W VROVE FON h1E PURPOSE OF SALER uJ �l�aN�EROFTHEPROGEHTY,AMEXCLU5IKLYCON7R�CTWGW11NlICENSEDCONTMCTORS � TO CONSTRUCT TM@ PRQIEGT(SEG 7W�,BUS�NE55 NrD PROFESSpNS CADE:TNE CONTRACTORS LI� Va1i121i0(1 �D ADJ.AREA W LENSEUwDOESNO7AP�LYTOI�NOwNEROFAPnOPEf1TYWMDBUilD50A1MPROVESTMEREON.AND T�- N?qCONTMCTSFORSUCHVRQ1ECf5VA7HACONTMCTOi1(S�UCCNSEDPURSUANTTOTHECONTMG QUANTITY DESCRIPTION Y TORSUCENSEIAWJ. FEE � 0 I IA1 EXEUCT UNDER SEC. 8.10.G FOR THiS REASON Q � U LL DA7E OWNER F��- Z U � LICENSED CONTRACTORS DECLAFATION W � I HEREBY AF�IRIA UNpER PENAI,TY OF 7ERJURY THAT 1AAl UCENSED UN�FR PpON510NS OF CHAPTER � p„ 9�CdAlAENqNOYATH5ECT10N700o�OFDIVI510N70FTHEBU5INE55AN�PROFE55iON5C00E,AYD Z X MY IILENSE IS N FULL FORCE AND EiFECT. m � LICENSE CUSS��_�LIC.NO.j� `� � � w��.�Q� corrrruc��� .-- s� a w � WORKERS'COMPENSATION OECUTAATION Q NI NCRE9Y�FFIRM UNDER VENALTY OF CERJUFi`I ON[DF T11E FOLLOWING DECLAMTqNS. Z � _IHAVEMIDWILLMAiNTAMACERTIFICATEOFCONSENTTOSE.F-INSUREFOAWORKERS' a l��� C061PENSATION,AS PROVIDED BY SECTION 710o OF TME L�BOR CODE,iOR 7NE PERFORMMICE CJ �j Q OF TME WORK FOH WNlpl iNiS PERMIT IS ISSUE�. � . _ `�_ w _IHAVEMI�WILLIAAINTAINWORKERS'fAMVENSATIDNINSURANCE.A5RE0UIREDBVSECTION J Q 7�00 OF THE Ut30R COOE.FORTHE FERFORMANCE OF 7M�WpW(FOfl WHiqi iHl$PERNIT IS Q �U ISSUED.MY � iN T -VRANCE CAR .R MIO POLICY NVMOER I1RE: GONSTRUCTION O J j uRaiEp_., PU1N REVIEW � � voucrNuuoea� ELECTRIC ¢ � (11iSSECTICNhLmNOTB[WMiLEfEDOFMPERMTISiOfiOrv[HU�OREDDOl1/UYi(Stoo;OfiLE55j. PLUMDING W Z ICERTIFYTNA7NTHEPERFORMANCEOFTHEWORKFORNT1:dITM15iERUITI51S5t1ED,l MECHANICAL C7 SIIALL NOT EMPLOY ANY GERSON IN AYY A/ANNEH 50 AS TO BELOME SU&:EC770 7HE y 1MURKERS'CdA�ENSATIONLAW50FGLIFORNIA,ANDAGR[ETHAiIFISNOULDBECOIAF INSPECTIONFEE -• - ��r "�'�—"�- SU0.1ECi TO TNE WORKERS'CCMPFNSATqN PROVi510N5 OF SECTqN 7]0o OF THE UBOR � r—"'j�''�.� � � . � 7� �j COOE,ISHALLFORTMw1THC01.1PLYWITNTHOSEGROV1510N5 ISSU/WCE �� .�V 0 n w OATE: APPLICANT. SMIP �y,y„��._[\ �}fi(11 � V � WARNING:i1,0.UR[TOSECUFEN+DRNERS'COA�PENSATpNCOVfRACEISUNUWFULANDSHµyBE ENERGYP/C ^ H��l � ti' �y bIAIECTANEIAPLOYERTOCRIIAINALPENKTIES/�N�CNILFWESUPTOONEHUNDREOiNOU5AN0 ENERGYPERMIT 1" JDOlLARS�SIoo.000),H ADOITON TO TH[C0.5TOF�pMPENSATION,DAMAGES A$PROVIDED FOR IN SECT10N710lOF7HELABORCOD[,WTEREST,/wOATfORNE1"SFEES. CL RETENTION FEE: ��1 T' _ pCOUSTRUCTION LENDING AGENCY PRE•ALT FEE: � � � IHEREBYAFFIHUUNOERPENALTVOFiERAlRYT11ATTMERE1511CON5TRUGTIONlENOINGAGENCY FOR ME PERiORMANCE OF iME WORr(FON WH1p1 TMIS VEW.+IT IS ISSUEO(SEC.7oY1,CIV.C.�. Z w � LENOER'SNAMC S � LENDER'SADDRE55 w 1 CERTIF`/TMAT I MNVE REM TMIS APPLICATION AN�STATE THAT THE A30VE INiOR1AATqN IS CORRECT, TOTAL FEES �3. 1� � IAGREETOCOAIPLYYATHALLCITY�NOCOUNTYOR�INANCESnNDSTATEUWSRCUTINCTOBUILDING � CONSTRUCTION,AM1DHEFEBYAUTHOF2ENEPHESENTATIVESOFTHISCOUNTYTOENTERUPONTHE Z ABOVE-AIEMIDNEDVROFEHTYfORINSPECTIONGUFPO5E5. COMIAENTS 0 J � m 7. E NAME(PRINT) Q _�'-2 d- � (A �.+• .. UF PLHMIT7EE DATE � RECPT�0. PAID 6Y VALIDATION � WHITE—Depariment CaOY.YELLOW—Finance Capy.PINK—Assessor Copy.GOLDENROD—File Copy.GAEEN—Applicanl's Copy , .. .r."..-• ;���....• :-,,,..,,,-,•a+.t.•,�� ..., - . . 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