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HomeMy WebLinkAbout15273 _ ;>w,�_. __._.,.._ ..___.. __ �i L✓�P�-re�'' ,» �'_�,��_ CITY OF DIAMOND BAI� `0/3��,� � � DEPARTIvIENT OF COMMUTTITY&DEVELOPMENT SERVICES ��=�� : � 21660 E.Copley Drive Suite 190 (909)860-3195 Farz(909)861-3117 PRESS ��'et^ BUILDING PERMIT APPLICATION FIRMLY — -- - o DDRIESS ���S CJ��w� �l ` DATECATIO �G � NUMBER � � #/C ISSUE ,� � APN L T TRACT DATE ��CONST. GROUP p OWNER p ADDRE ZONING SETBACKS w FRONT CITY c � ZI TEL. RW C � APPLICANT TEL. —1 REAR C � SIDE/SIDESTREET qW ❑ � CONTRACTOR � L1 � � SIDE ❑ � CITY �S ZIP TEL. � PROPOSED USE o ARCH/ENG/ z DESIGNER � AD�RESS UNITS EL STORIES B DROOMS � CITY ZIP TEL. c� cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER OECIARATION SFR/A��/REM O I HEREBV AFFlRIA UNDER PENALTV OF PERJURY iHA7 I AM EXEMPi FFOM 7HE CONTRACTORS LI- G8f8CJB/COfpOR W CENSEUWPoRTNEFOLLONANOREASON(SEC.7031.6BUSINESSANDPROGESSIONSCODE:ANYCIT'OR (n CJ COUMYWHK7IREOUIRESAPERMITTOCONSTRUCT,AITERIMPROVE,DEMOL!EH,ORREPAIRANVSTRUC- W pefi0/DOCk w TURE,PRIOR TO ITS ISSUANCE,AL30 REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIONED W � STATEMENT THAT FE OFi SHE IS LICENSED PUqSUANT TO THE PROYISIONS OF THE OONTRACTORS LI- CENSE UlW(CHRPTER e(CAMMENCINd WITH SECTION 7000)OF DIVISION 9 OFTHE BUSINESS 0.ND PR0. � PooUSpa FESSIONS COUE)OR iHAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR iHEALLEOE�EXEMP- TION.ANVVIOLATIONOFSECTION7031.5BY/WYAPPI�CANTFORAPERMITSU&IECTSTHEAPPLICANTTO Z RB-ROOf � ACMI PENALTV OFNOT MORE 7HAN FNE HUNDRED DOLLIRS(5500�J: � ❑I,ASOWNEROFTHEPROPERTV,ORL/VEMPIOVEESWITHWAGESASTHEiRSOLECAM7ENSATION, � COfflRIBfCld1 - NlILL DO 7HE WORK,AND THE STRUCTURE IS NOT INTENDED oq oFFERED FOR SALE(SEC.7oas,BUSI- J � NESS PND PqOFESSIONS CODE:THE CONTFACTOqS UCENSE LAW DOES NOTAv7LV TO AN OWNER oF � PROPEFTY NM1IO BUILUS OA IMPROVE6 THEREON,AND WHO OOES SUCH WORK HIMSELF OR HERSELF OR � THROU6HHISORHEflOWNEMPLOYEES,PROVIOEDhIATSUCHIMPROVEMENTSARENOTINTENDEDOR m QOFFEREDFORS/�EIF,FIOVIEVER,IHEBUILDMGORIMPROVEMENTI3SOIDWITHINONEYEAROFCAMPLE- Z TION,TME OWNEH�BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DI�NOT BUILD OR = IMPfiOVE FOR TME PURPOSE OF SALE). W OI,ASONMEROFTHEVROPEiRV,M7EJ(CLUSIVELYCONTMCTINOWITHLICENSEDCONTIiACTORS � TO CONSTRUCT 1HE PROJECT(SEC.7au,BUSINESS AND PROFESSIONS CODE:7HE CONTRACTORS LI- ValUation ADJ.AREA W CENSEUIWDOESNOTAPPLYTOANOWNEROFAPROPERTVWHOBUIlD50R�MPFOVESTHEREON.AND � WIIOCONTMCTSFORSUCHPFOJECTSWITHACANTRACTOP(5)LICENSEDPUFSUANTTOh1ECONTRAG QUANTITY DESCRIPTION FEE � TORSLICENSELAW.). ❑I NA EXEMPT UNDER S�C. B,d P.C.FOR THIS REASON Q � U LL � DATE ONMER U � W LICENSED CONTRACTORS DECLARATION -� � w I HEREBY AFFIWA UNDER PENALTY OF PERIUNY THAT I AM LICENSED UNOER PROVISIONS OF CHAPTER � d 9�COMMENCIN(i WITH SECTION 700D)OF OIV�SION 9 OFTHE BUSINESS AND PROFESSIONS CADE,AND Z X MY IICENSE IS IN FULI FORC ANAD EFFECT. m LLI � LICENSECLASS /� LIC.NO. j -- t V DATE �'J�''C/� CONTRACTOR J W � WORKEftS'COMPENSATION DECLARATION Q � 1 HEREBV AFFIqM UNDER PENALTV OF PERJURY ONEOFTHE FOLLOWING OECLAMTIONS: Z � _IHAVEAN�MALLMAINTAINACEFirIFICATEOFCONSENTTOSELF�IN5l1REFOFWORKERS' _ COMPENSA710N,ASPROVIUEDBYSECTION37000FTHEU80RCODE,FORTHEPERFOFMANCE W Q �F TNE WORK FOR WHICH THIS PEflM�T IS ISSUED. � � _I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION IN9URANCE,AS REQUIRED BV SECTION Q 37000FTHELABORCODE,FOHTNEPEfiFORM0.NCEOFTHEWORNFORWHICHTHISPERMITIS ISSUEO.MY WOHKERS'CWIPENSATION INSURANCE CARR�N AND POLICV NUMBERARE: CONSTRUCTION � CARRIER �'� -,`'�( PLAN REVIEW � POLICV NUMBER �f� j,� ��� ELECTRIC � (IFissECIpNNE�NOTBEmMP�EfEOOF'iNEPEt�M'sroaoNe��PNAfiEODOl.W74(Stoo�oRLFss). PLUM8ING k Z ICERTIFYTHATINTHEPERFORMANCEOFTHEWORKFORWHICHTHISPERMITISISSUED,I MECHANICAL C7 SHALI NOT EMPIOY ANY PERSON IN ANY MJINNER SOAS TO BECAME SUBJEC7 TO THE - � WORKERS'CONPENSATIONLAWSOFCALIfORNIA,ANOAGREETHATIFISHOULDBECOME INSPECTIONFEE SU&lE TO T WORKERS'CAAAPENSATION PROVISIONS�F SECTION 37aa OF THE U180R s CADE, SHA �qO,yFiT�HW17HCOMPLV SEPROVISIONS. ISSUANCE nnt111 _`,,�.Li= � DATE: / Y"V SM�P _ �I���—'• p APPI:ICANE ' -�„-..� — J WARNINGFAILURETOSECUREWORKERS'COMPENSATIONCOVERAGEISUNLAWFUL,ANDSHALLBE ENEflGYP/C � '� � �y SI)&IECTAN EMPLOYERTO CRIMINAL PENALT�ES AND CIVIL FINES UP TOONE HUN�RED THOUSAND ENERGY PERMIT D01.LARS(f10o.000�,IN ADO17ION TO THE CASTOF CONPENSATION,DAMAGES AS PROVIOED FOR IN � SECTION37080FTHELABORCOOE,INTEREST,ANDATTORNEY'SF'eES. RETENTIONFEE: � d CONSTRUGTIDN LENDING AGENCY PRE-ALT FEE: O � IHEREBVAFFIHMUNDERPENAL7YOFPERJURYTHATTHEREISACONSTRUCTIONLENDINGAGENCV FOp THE PERFORMIINCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.3087,CIV.C.j. Z W � LENDER'S NAME 1— LENDER'SADaRESS � TOTAL FEES � ` � I CERTIFV iHAT I HAYE READ THIS APPLICATION AND STA7E7HATTHEABOVE INFORMATKKJ IS CORRECT. � I AGHEE TO COMPLY W1TH ALL CIiV ANO COUNTY ORDIN ES AND STA7E LAWS REUTINO TO BUIIDING � CONSTRUCTION,ANO HEREBV AUTFIORIZE REPRESENTA VES OF THIS COUNTY TO EMER UPONTHE /yT�" �� Z ABOVE�MENTIONED PROPERTY FOR INSPEG'ION PURPO ES. �i�Y r � ;`v� COMMENTS �-•��•�•" ¢ PERMITTEEN RINn ' f � / � � SNitUTURE OF P MfTTEE D E � RECPT.NO. 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