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HomeMy WebLinkAbout17394 (10) CITY OF DIAMO1VIy BAIt � ���' --- DEPE4R'TI�IENT OF CO & VEL PNiE ER �ES --�-- I I Z 1825 E.Copley Ihive (909)860.3195 Fax(909)861-3117 PRESS "°:v��"', Buri.D�tG�E�iTapP�.ac��io�v FIRMLY ¢ ADDRESS ���� PrX(�_�I�V�A�- ���� DATE �' �--01 NUMBER � # O_�1� y APP�ICATI q � , PERMIT P/C W DATE � � �� � TMPE OCC APN LOT TRACT p OWNER C c,. CONST. � GROUP �_ p ADDRESS 4 AE.O ZONING SETBACKS z CITY Z!P TEL. FRONT RW ❑ p APPLICANT TEL. � S DEJSIDE STREET RW ❑ z Q C�NTRACTOR SIDE ❑ ADDRESS ' � CITY ZIP TEL. PROPOSED U5E G w ARCHIENG/ ' �� ' z DESIGNER w NO.DWEL �, NO. NO. a, ApDRESS � ..►�` / � UNITS STORIES BEDROOMS �, CITY . ZIP TEL� . u� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWN�ER-BUILDER DECLAFATION SFR/ADD/REM O I HEREBY AFFlRM UN�ER PENALTY OF PERJURY THpT I AM IXEMPT FROM THE CON7RACTORS LI- GdfdJ@/Cfl�OfI '�, �W' CENSELAWFOflTHEFOLLOWING�PEA50N�SEC.7o31,5BU51NE55PNDPft�FE5510NSCO�E:ANYCITYOfl (/j '�. U'�. COUNTYWHICHREQUIRESAPERMITTOCONSIAUCT,ALTER,IMPFOVE,DEMOLISH,ORREPAIRANYSiAUC- � Z. TURE,PRIOR i0.1T5 ISSUANCE,qLSO REOUIRES THE APPLICANT FDR SUCH PERMIT TO FILE A SIGNEO W Patio/Deck w� STAiEMENT THAi HE OR�SHE.I&I�CENSED PUR5UANT TO THE PAOVISIONS OF iHE CONTRACiORS LI- W � CENSELAW(CHAPTEH9(COMMENCINGWITHSECTION7ooa)OFDIVISION30FhIEBUSME55ANDPRO- V' POOUSPB � O FESSIONS.CO�E)ORTHATHEORSHEIS�E%EMPTTHEftEFROMANDTHEBA515FORTHEALLEGE�EXEMP- (!} V TION.ANVVIOLATIONOF$ECTION,7031.59VANVApPLICANTFORAP£RMITSUBJECTSTHEAPPLICANTTO z Re-Roof 'ACIVILPENpLTYOFNOTMOPEh{ANf�VEHUNDREDDOLUIFS(55oo�J: ��, O ❑I.ASOWNEROFTHEPROPERT,Y,ORMYEMPLOYEESWITH'NAGESASTHEIRSOLECOMPENSAiION, � COmmerClel - �, Z WILL DO THE WOAK,AND THE STRUCSURE IS NDi INTENDE�OR OFFERED FOR SALE(SEC.7044,BUSI- J ^ NESSAN�PROFESSIarJSW�E:THECONTRAGTORSLICENSELAWDOESNOTAPPLVTOANOWNEflOF � PROPERTY WHO BI11L05OR IMPRqVESTHEREON,AN�WHOOOc'S SUCH WORK HIMSELFOR HERSELF OR CC THROUGHHISORHEROWNEMPLbY�ES,PROVIDEDTHATSUCHIMPROVEMENTSARENOTINTEN�EDOP m � Q ..OFFEREOFORSALE.IF,HOWEVER,THE�,6UILDINGOqIMPROVEMENTI550lDWITMINONEYEAFOFCOMPLE- z TION,THE OWNER-BUIL�ER WILLHAVE THE'BURDEN OF PpOVING THAT HE Oa SHE�ID NOT BUILD OR IMPROYE FOR THE PURPOSE OF SALE). �_ ❑I.ASOWNEROF7HEPROP�RTY,AMEXCLUSIVELYCONTRACTWGWIiHLICENSEDCONTRACTORS TO CONSTRUCT THE PAOJECT(SEC.��044,BUSIN=SS AND PROFESSIONS CO�E:THE CONTRflCTORS U- V2IUaSlOf1 ADJ.AREA W CENSELAWDOESNOYAPPLYTOANOWNEF',OFA�PROPERTYWHOBUILDSOqIMPROVESTHEREON,AND � WNOCONTRACTSFORSUCHPROJECLSWITHpCONTRACTOR(S)LICENSEOPUNSUANTTOTHECONTRAG QUANTITY DESCRIPTIDN FEE � -TORS LICENSE 4AW.). .. �) � ❑i AM EXEMPT UN�ER SEC.�� B.&P.C.FOR THIS REASON Q ' r -. S��' C{ �� � U � � �ATE OWNER U Z W �� L�CENSED CONTRACTORS DECLARATION W ¢ � I HEREBY AFFIRM UNDER pENALTY OF PEPJURYTHAT I AFA LICENSED UNDER PROVISIONS OF ChAPiEP � , p^., 9(COMMENCINa WIiH SECTION 7ao0)OF DIVISION 3 0F THE BUSINESS AND PROFESS'�ONS CODE,AND z MY LICENSE IS IN FULL FORCEAND EFFECT. o LICENSE�ClLASS�_LIC.NO.� I G � U DATE I G �3 I�'�Z CONTRACTOR.�.+•��L �- . W � WORKERS'COMPENSA710N DECLARATlON �V J Q � � IHEREBYAFFIRMUNDERPENAL'fY.OFP€RJUflYONECFTHEFOLLOW;NG�ECLARATIONS: • Z � _IHAVEAN�WILLMAMTAIN:ACEft71FICATEOFCON5ENT705ELF-WSUflEKOfiWORKERS' _ COMPENSATION,ASVROV��ED�VSECTION3�o00FTHELABOACoOE,FORTHEPEPFORMANCE U QOFTHEWOPKFORWHICHTHISpEflMITISiSSUED. � W I HAVE AN�WILLlAAMTAIN WORI(ERS'G�JMPENSAiION IN3URANCE,A3 RE�UIRED BY SECTION / ]� Q 37Do OFTHE LABOR CO�E,FOR THE PERFOFMANCE OF THE WORK FOF WHICH TH�S PERMIT IS 'n+ �/ J ISSUE�.M7 WORKEA5 COA,MPENSATION INSURANCE CARFIEflAN�POLICYNUMBERARE: CONSTRUCTION - �K v a CARRIEP.�,�!'��Er F V �O pLAN REVIEW � Z> ����- POLICY NUMBER,� �''��!�Q� �y f�O O Z�� ELECTRIC a . / � Q (IF1155EL�lONNEmNOTBE�CMAPLEiEDOFTHEPERMATISFORIXJEHUf�FiEDDOLW35($100JOflLE55). PLUMBING . __, _ __ Z I CEflTIFV THAi IN THE P�AFOFMANCE OF THE WORK FOR WHICH THIS PEFMIT I ,SU ,I -' MECHANICAL � f,� SHALLNOTEMPLOYANVPERSONINANYMANNERSOASTOBECOMESUBJEC OTH � WORKEflS'COMPENSATIQLLAWSOFC ORNIA,AN�AGR ETHATIFISHo DBEC INSPECTIONFEE SUBJECTTOTHEWORKEq'S'COMPENS NPRO IONS 710N370 PTH O � s'" ~ CODE,ISHALLFOFlTHWITHCOMPLV THOS�OVISI ISSUANCE N � Q 1 [� � p 'DATE:�S�1-{�4� APPLICAN r SMIP + d �_ J WARNMG FAILURE TO SECURE WQRKE, MPENSATION COVEqAGE IS UNLAW'rUL,ANO SHALL ENERGY P/C � SUBJECTANEMPLOYERTOCRIMINALP LTIESPNDCIVILFINESUPTOONEHUNOREDTNOUS ENERGYPEAMIT ODLLARS(yloo,a�o),IN ADDITION�O THE GOSTOF COMPENSATION.�AMAGESAS PROVI IN J SECTIONa7oeOFTHELABORCO��,INTEREST,ANDATTOqNEYSFEES. RETENTIONFEE:,,i � � CONSTflUCTION LENDING AGENCY PRE-ALT FEE: O � I HEflEBY AFFIRM UNDER PENALT�,OF PERJURY THAT iHfFE IS A CONSTRUCTION LEN�INO AaENCY FDR THE PERFORMANGE OFTHE WORK(=0R WHICH 7HIS PEflMiT IS ISSUE�(SEC.309],CIV.C.). W j LENDEWSNAME 4 rs F_ LENDER'SADDRESS , � W ICERTIFYTHATIHAVEREADTHISAPPLICA710NANDSTATETHATTHEABOVEINF�RMATIOhISCORRECi. �'TOTAL FEC�S ///'''��� ,��� � � IAGREETOCqMPLYWITHALLQTtlANOCOUNTYORDINANCESANDSTATELAWSflELATINGTO8�iL01NG �� � CONSTRUC7IDN,AN�HEREBVAU�HORIZEREPRESENTATIVESOFTHISCOUN7VTOENTERUPONTHE . � ABOVE-MENTIONED PqOPERTY FOFi INSPECTIGN PURPOSES, connMeNrs � 2�7 .O�j � � PE TTEE A (P T) � � � �D � 51 F P MITTE , �ATE " _ �� RECPt NO. PAID BY � VAIJDATION ~ � WHITE—Department Copy,YELLOW—Financ.e Copy,PWK—Assessor Copy,GOLDENROD—File Copy,GREEN—ApplicanYs Copy � . . , .... ..:......_ ... . . . . .... ... . .�,.."' .._,.,.-:.... � r <�., o-� .... � . ..�- � - - . - .t . . .. . �+�• :�'p� .;.;:,y. �, w,�'arva.ir�s ' 4�' -.. , . �� � � �,.�; . . . 3« �' ��i:�",Ci.. 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