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HomeMy WebLinkAbout16782 CITY OF DIAMOND�AR -----���� --- DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES � 21825 E.Copley Drive , ` (909)860-3195 Fax(909)861-3117 PRESS ''%H»����' BUILDINGPERMITAPPLICATION FIR LY � JOBSITE APPLICATION � � � �� PERMIT � �`�P/C o ADDRESS�- DATE NUMBER � � L.�F � ISSUE E� TYPE CC APN LOTI TRACT DATE d � CONST. GROUP p OWNER � ADDRE� ` ZONING SETBACKS z CITY ZIP TEL ' y FRONT RW ❑ � APPL CANT ! fE�, REAR ❑ � SIDE/SIDESTREET RW ❑ ¢ 'CONTRACT S1DE ❑ � ADDRESS oCffY ZIP TEL r- ��,P4SEp USE w ARC /ENG/ I � t��/y iz D6SIGNER ' NO.DWEL. NO. NO. a ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � � DESCRIPTION SQ.FT. FAC70R PSF ADJ.AREANALUATION' p� OWNER-BUILDER DECLARA710N SFR/A�D/REM O i 0 I HEREHY AFFIRM UNDER P�NpLiY OF PERJURY THAT I AM EXEMPT FROM THE CONTFACTORS LI� G&�8g0JC2�0A W CENSELAWFORTHEFOLLOWINGRFASON(SEC.�D31.5BUSINESSAYDPROFESSIONSCO�E:A�YCITYOR (n U. COUNiYWHICHREOUIRESAPER�ITTOCONSTRUCT,ALTER,IMP.90VE,DEMOLISH,ORREPAIRANYSTRUG W patio/Deck w TUflE,PRIOR TO ITS ISSUANCE.,dL50 fiEQUIRES THE APPLICANT FOR SUCH PEFMIT i0 FILE A SIGNED STATEMENT THAi HE OR SHE IS ICENSED PUqSUANT i0 THE PFOVISIONS DF THE CONTRACTORS L6 � CENSE LAW(CHAPTER 9�COMME CING WITH SEC710N 7aoa)OF DIVISION 3 OF THE BU3INESS AN�PRO- U" POOUSpH FESSIONSCO�E�OR7HATHEOP HEISEXEMPiiHEREFROMAN�THE8ASI5FDRTHEALLEGE�E%EMP� (� �, TION.ANVVIOLAiIONOFSECTlO 7031.50VANVAPP4ICM1MFORAPERMITSUBJECTSTHEAPPLICANiTO Z Re-Roof A CIVIL PENALTV OF NOT MORE T AN FNE HUNDRED DOLL4R5(5��).)� ZOI,ASOWNEROFTHEPROP��FTY,ORMVEMPLOVEESWITHWAGESASTHEIRSOLECOMPENSATION, 0 Commercial -- WILL DO THE WORK,ANO THE STf3UGTURE IS NO7INTENDED OR OFFERED WR SALE(SEC.7049,6USI- J � NE55 AND PROFESSIONS COOE:THE CONiRACTOftS LICENSE LAW DOES NDiAPPLY i0 AN OWiVER OF ' PROP6RNWH09UILDSORIMPR�VESTHEREON,ANDWHODOESSUCHWORKHIMSELFORHERSELFOft � CL THROU6H HIS OR HEfl OWN EMP YEES,PROVIDE�iHATSUCH IMPROVEMENTSAqE NOT INTEN�ED OR m QOFFEREDFORSALE.IFHOWEVER,THE6LILDINGORIMPROYEMENTISSOIDWITHINONEYEAROFCOMPLE� �,. TION,THE OWNER-BUILDER WILL HAVE THE 6URDEN OF PROVING THAT HE OR SHE DID NOT BUILO OR = IMPROVEFORTHEPURPOSEOF ALEJ.�� ❑I,AS OWNEROFTHE Pfl0 iERTV.'AM EXCLUSIVELYCONTRACTING WITH LICENSED COMRACTOflS �, ' TO CANSTRUCTTHE PR0.IECT(SEC.7044,6USINE55 AND PROFESSIONS CODE:THE CONTRACTOPS LI� VBIUBiI ADJ.AREA W� CENSELAWDOESNOTAPPLYTOANOWNEFOFAPqOPERTYWHOBUILD50RIMPROVESTHEREON,AN� �� WHOCONTRACTSFORSl1CHPRO.�ECTSWRHACONTRACTOR[5)LICENSEDPURSUANTTOTHECONiRAG (�UANTITY DESCRIPTION FEE x TOR5410ENSELAW.). �, � ❑I AM EXEMPT UNDER SEC.��� B.&�C.FOR THIS REASON Q � U � � DATE OWNER U W � LICENSED CONTRACTORS DECLARATION W Q � IHEREBYAFFIRMUNDERPENAL7YOFPERJURYTHATIAMLICENSEDL'NDERPROVI5ION50FCHAPTER � � �, 9(COMMENCINGWITHSECTION]boo�OFDIVISION30FTHEBUSINE55ANDPROFE5510NSCO�E,AND Z `X MY UCENSE IS IN FVLL FORCE ANb EFFECT, m � UCENSECLASi_� LIC.NO.—J— � � r ��� G J U . DATE � CONTRACTO d W d_'=l WORK�RS'COMPENSATION DECLAflATION ¢ � U � IHEFEBVAFFIRMUNDERPENALT}'DFPERJURYONEOFTHEFOLLOWMG�ECLARATIONS: Z Z _I HAVE AND WILLMAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS' _ COMPENSATION,PS PRO�'IDE�BY 9ECTION 9�0o OF THE LABOR CODE,FOR THE PERFORMANCE U Q OFTHEWORKFORWHICHTHIS'.PERMITISISSUED. � W IHAVEANDWILLMAINTAINWORKERS'COMPENSATIONINSURANCE,ASREQUIREDBYSECTION � - p � �,,�\ . Q l370oOFiHELABORCOD�,FORTHEPERFORMANCEOFTHEWORKFORWH:CHTHISPEflMlT16 �I ��)�IJo +�] `� ISSUED.MY WORK S'C M�PEN+SATION INSUR E CARPoERAND PO�ICY NUMBERAPE: CONSTRUCTION �r� !B�� Q�u jcnAAie� � ���/'���.�� _ PLAN REVIEW z POLICYNUMBER � �� r � ELECTRIC Q I � (RiISSECi%7N�E�NOTBECOMPLEfE�OF7HEPERMRI5i=0RONEHUNDaED�OLLARS($100)ORLE55). PLLIMBING Z ICERTIFYTHATINTHEPErFOflMANCEOFTHEWOflKFORWHICHTHISPERMITI5ISSUE�.I MECHANICAL ('S SHALL NOT EMPLOYANY JPEfl50tJ IN ANY MAN4ER SOAS 70 BECOME SUBJECT TO THE � WORKERS'COMPENSATI�NLAWSOFCAUFORNIA,ANDAGREETHATIFISHOUL03ECOME INSPECTION FEE SUBJECTTOTHEWORKE S'C�AAPENSATIONPROVISIONSOFS'cCT10N37oaOfTHELA90R `� � COOE,I SHALLFORTHWIT COMPLY WITH THOSE PROVISIONS. �SSUANCE �-�,^�J p �ATE: ApPGCANT. SMIP `Q t f�! � ' � ENERGY P!C �y WARNING:FAILURETOSECUREWlO�RKEFIS'COMPENSATIONCOVERAGEISUNLAWFUL,ANDSHALLBE � Sl1BJECTANEMPLDYEFiTOCRIMIfV/U.PENALTIESANDCiVILFINESUPTOONEHUNDflEDTMOUSAND ENERGYPERMIT �OLLARS(Stao,000�,IN AODITIONt07HE COSTOFCOMPENSATION,OAMAGES AS PROVI�ED FOR IN g J SECTION3�OBOFTH�LABOFCODE,MTEREST,ANDATTORNEY'SFEES. 9 a t '' � RETENTION FEE: � �O CO�STRUCTION LENDING AGENCY PRE-ALT FEE: � IHEFEBYAFFIPMUNDERPENAL7 OFP�RJUflVTHATTHEREISACONSiRUCT!ONLENDMGAGENCY FOR THE pERFOflMANCE OF THE OflK'FOR WH!CH THIS PERMIT IS ISSt1ED(SEC.309],dV.G.7. Z W 2� LEN�ER'S NAME � __ � 1= LENDER'SA�OFESS '� -- — W ICERTIFYTHATIHAVEREADTHIS�IAPPLIGA710N�NDSTATETHATTHEABOVEINFORMATIONISCORRECT. TOTAL FEES ���a � d IAGREETOCOMPLVWITHALlGT�4AN�.COUNTYORDINANCESANDSTATELAWSRELATING70BUILDING � CONSTRUCTION,AN�HEREBYAU�HORI2EREPRESENTA7IVESOFTHISCOUNTYTOEN7EfiUPONTHE � ABOVE-MENTIONED P P TV FOR INSPECTION PURPOSES. 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