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HomeMy WebLinkAbout15479 (22) ,_ � �y��l�� ^ �,�,�_ CITY OF DIAMOND BAx "r DEPARTMENT OF COMMIINITY&DEVELOPMENT SERVICES LU %os°7 ._. "" 21660 E.Copley Drive Suite 190 ,,,,,� (909)860-3195 Fax(909)861-3117 PRESS �'��". BUII.DING PERMIT APPLICe�TION _-- FIRMLY �. ,..:_ .. � JOBSITE ��j)� ��� .�� APPLICATION �-� NUMBER �-�#/C o ADDRESS L��-! DATE $ ISSUE ,�1 q TYPE OCC APN LOT RACT DATE �1t '� CONST. GROUP p OW ER � ADDR / ' ZONING SETBACKS FRONT � CITY '� ZIP " TEL. e � '� REAR RW ❑ APPLICANT TEL.�_ � � SIDE/SIQE STREET RW � CONTRACTOR ,�11 (iy'�C.., SIDE � ADDR � CITY G EL. C PROPOSED USE w ARCWENG/ � DESIGNER ` NO.DWEL. NO. NO. � CDDRESS ZIP TEL. UNITS STORIES BEDROOMS �n DESCRIPTION SQ.FT: FACTOR PSF ADJ.AREANALUATI�N Q OWNER-BUILDER DECLARATION SFR/AOD/REM O 0 I HEREBY AFFIRM UNOEp PENALTY OF PERJURV THAT I AM EXEMPT FROM THE CONTRACTORS LI- G8ffl9B/CBfpOi'I W CENSEUWFORTHEf-0LLOWINGHEil90N(SEC.70.91.68USINESSANDPPOFESSIONSCODE:ANVCINOR (n �..� COUNT`/WHICHHEQUIRESAPERMITTOCONSTRUCT,ALTER,IMPROVE,DEMOUSH,ORREMIRANYS7RUC- W P2It0/DBCIC w TURE,PRIOR TO ITS ISSUANCE,ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED w � STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PPOVISIONS OF THE CONTMCTORS ll- � � CENSE LAW(dNPTEfl Y(COMMENCINO WITH SECTION'lOOU)OF DiVI510N 3 OFTHE BUSINE55 ANO PRO- POOVSP3 FESSqNSCO�E)ORTHATHEORSHEISEXEMPTTHEREFROMANDTHEBASISFORTHEALLEOEDEXEM7- TION.ANYVIOtATpNOFSECTION7091.6BVANYAPPLICANTFOFAPERMRSU&lECTSTHEAPPLICANTTO Z Re-Foof � A CML VENALTY OF NDT MORE THAN FNE HUNDRED DOLLARS(55oD).�: O ❑IASOWNEROFh1EPHOPENTY,ORMVEMPLOYEESWITHWAGESASTHEIRSOLECOMPEN5A710N, 0 Commercial -- � WILL DO THE WORK�1D THE S7RUCTURE IS NOT INTENDED OR OFFERED f-0R SALE(SEC.7o4a,BU51- J � NESS RN�PROFESSIONS CODE:THE CONTRACTORS UCENSE UW OOES NOTAPPLY TO AN OWNER OF � PROPEAT'/VJIIO BU�DS OR IMPROVES iHEREON,ANO WHO DOES SUCH WORK HIMSELF OA HERSELF OR Q THROU6FIHISORHEHONMEMPLOVEES,PROYIOEDTHATSUCHIMPROVEMEN't3AHENOTINTENDE00R m QOFFEREDFOHSKEIF,HOWEVER'mEBUIL�MGORIMPRO�EMEN7ISSOLDWITMINONEYEAROFCOMPLE- Z TION,TT1E OWNEfl-0UILDEP WILL HAVE THE BURDEN OF PROVINQ THAT HE OR SHE DID NOT BUIID OR � IMPf�YE FOR iHE PURPOSE OF SALE). U I,AS ONMER OF THE PROPERfY,AM El(CLUSIVELYCAMqACTING WITN LICENSED CONTRACTORS i0 CONSTRUCT h1E PROJECT(SEC.7ou,BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS U• V01Uation ADJ.AREA CENSE LAW DOES NOTAPPIV TOAN OWNER Of A PROPERNWMO BU!LOS OR IMPROVESTHEREON,AND � WFIOCONTMCTSFORSUCHPRQIECTSWITHACONTRACTOR(SJLICENSE�PURSUANTTOTHECOMRAG QUANTITY DESCRIPTION FEE � TORS LICEI�LSE LAW.). ❑I AM E](EMPT UNDER 6�C. B.fl P.C.FOR THIS REASON Q � U LL � �ATE_ ._QNMER_ V � LICENSED CONTRACTORS DECLARATION W J � W I HEREBY�FFlRM UNDER PENALTY OF PERIUHY THAT�M1 LICENSED UNDER PHOVISIONS OFCHAPTER �, � �(ODMMENCINO WITH SECTION 7DOD)OF DIVi519N 3 OFTHE BUSMESS AN�PROFESSIONS CO�E,AND Z O MV LICENSE IS IN FULL F pS:E AN EFFECT. �� m � ( .� � LICENSE � ;f����_ LIC.NO. � V DATE CONTRACTOR d W � WORKERS'COMPENSATION DE ' AT a � I HEREBV AFFIRM UNDER PENALTV OF PERJURV ONE OF THE FOLLOWING DECLARATIONS: Z � _IHAVEMIDWILLMAINTAINACERTIFICATEOFCONSENTTOSELF-INSUHEFORWORKERS' a COMPENSATION,AS PROVIDED BV SECTION 97000F i NE IABOR CODE,FOR THE PEFlFORMANCE C� Q OFTHE WDRK FOR WHICH THIS PERAIR IS ISSUE�. � � _I HAVE AND WILL MAiMAIN WORKER5 COMPENSATION INSURANCE,AS RE�IJIFED BY SECTION Q 37aaOFTHELABOflCODE,FORTHEPERFORMANCEOF7HEWORKFORWMICHTHISPERMITIS ISSUE�.MY WORKERS COMPENSA JN INSURANCE CARRIER AND POLICY NUMBER ARE: CONSTRUCTION jCARAtEA �( _ _ PLAN REVIEW � POLICYNUMBER � �-i' ELECTRIC � (IHSSECiIONNE�NOT�00MF1.ETEDOFhfPER�MtSf�RONEi-tUNDf1m00LtiViS(57oo)ORLESS� PLUMBING –�yp$�( �� _ Z I CERTIFYTHAT IN THE PERFORMANCE OF THE WORK FOR HICH THIS PERMIT75 SUED.I MECHANICRL Y 1.�Y!� C3 SHAILNOTEMPLOYANVPEHSONINANYMANNERSOASTO ECAMESUBJEC7T0 E —�'�'�` � WORNERS'COMPENSATIONLAWSOFCALIFORNIA.A DAGR THATIFISHOUIOBE ME INSPECTIONFEE SU TOTHEWbRKERS'COMPENSATIONPR 1 O CTION37ooOFTHE OP p��y HALLFOR IT CAMPLVWITHTHOS P VISIO . ISSUANCE +1 -)\\Q G �p p DATE: J �PLICANT: n SMIP __���� � .T�'yl� � - ENERGY P/C r Yl" � .r�r�+� WAHNINQ: ILURE TO SECURE WORKERS'COMPENSA71 N IS UNLAWFUL,AND SHALL BE ��'�( � 1 �y SUBJECTANEMPLOYERTOCRIMINALPENALTIESANDC ILFINESUPTOONEHUNDFEDTHOUSANO ENERGYPERMIT ��f`_�y,`�4��� r DOLI_ARS(f10D,D00),IN AD�ITION TO THE COSTOF CO ENSATION,OAMAGES AS P{70VIDE�FOR IN q =�-- � SECT�ON 37oe OFTHE LABOR CODE,INTEREST,ANO ATTORNE`/'S FEES. RETENTION FEE: . �4I�� OCONSTRUCTION LENDING AGENCY PRE•ALT FEE: � I HEREBV AFFIRM UNOER PENALTY OF PERJURV THAT THERE IS ACONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED�SEG 3097,CIV.C.�. Z W � LENDER'S NAA/E F– LENDER'SADDRESS � TOTAL FEES �%� /�� � ICE THATIHAVEREADTHISAPPLICqTIONANDSTATETHAT7HEABOVEINFORMATIONISCORRECT. � I A E TO COMPLY WITH PLL CITV ANO COU O�DINPNCESANO STAtE LAWS REIATING TO BUILDING `�'/ � ST CTION.AND MEREBYAUTHORIZE R RESEMATIVES OFTHIS COUNf7 TO ENTER UPON THE ` Z VE EN EO PROPERTV F7R INSPECT PURPOSES. � - COMMENTS � ' �t- "_~' , �-�''�--'_ 4 RAAITTEENMI ( INn. �� r , f-ry, u� pf] � u, � SIGNATUREOFPE MITTEE ORT � RECPT.NO. - PAIO BY VALIDATION WHITE—Department Copy,VELLOW—Financa Copy,PINK—Asaessor Copy,GOLDENROD—File Copy,GREEN—ApplicenYs Copy ,�,..:yt,,, .�y..^^, .r.�::.,n„��'.>i-+5�'.1�..,..N a,..,��;w�! , r,;..t.,,,,.,:..v.�.a+�rv'r< , ;r=Y,�•a+a !,�r,:�Nti°" �F . ,:G:. 5��5�g!:-;e.g�. . . ..�v , , ��. . .� . :,.vn, e�.,::�.;4�, . „ vu,...s ;�.�ymny�.R.•5;;::; ��� � � � � , '. 3�'. . �:�'_ �.�... . . � . � ._ . ... . . . . . .. . . . .....,... , .....�.:. ......,,,«r -� �:.. .. . ._. .,� .. . _ : _ � ,� � � ��.. � � . : -.... �-�ro .�.; w � � • ��� m �:�. � ..�,.:.... 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