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HomeMy WebLinkAbout11957 (5) � _!� _ CITY OF DIAMOND BA� DEPARTMENT OF COMMLT1vITY&DEVELOPMENT SERVICES " '`S� � w 21660 E.Copley Drive Suite 19b (909)860-3195 Fax(909)861-3117 PRESS AtP:� BUII,DING PERMIT AF�PLICA"tION �_ , _ _,� . . FIRMLY ,.., ..�..:.. .. ... . .... . . ... . ... ...�. JOBSITE � /� " APPUCATION PERMIT P/C o ADDRESS��7.J_.7 ���G (�-yc:RH�`C� OATE �J(��� NUMBER # � APN LOT TRACT S ISSUE TYPE QCC DATE CONST. GROUP p OWNER � �Y� .cJ p ADDRESS �'-F!'C-L ZONING SETBACKS � CITYGT ti,idr) ZIP 9'EL. ` REART RW ❑❑ APPLICANT TEL. SIDE/SIDE STREET RW ❑ � CONTRACTOR�""9C�e'aBIJ'`E/� SIDE ❑ Q ADDRESS �� � � CITY ZIP TE�. PROPOSED U5E o ARCH/ENG/ �z,, OESIGNER NO.DWEL. NO. NO. y ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANAWATION Q OWNEH•BUILDER D�CLARATION SFR/ADDlREM O p I HEREBY AFFlRM UNOER PENALiV OF PERNflY THAT I PM E%EMPT FROM THE CONTRACTDRS LI- GdIdJB/CdlPOf1 W CENSELl1WWRTHEFOLLOWINOf1EASON(SEC.7o31.68USINESSAN�PROFESSIONSCODE:ANYCffVOR (n COUHTYNM1IICHREOUIRESAPERAlI7TOCONSTAUCT,ALTER,IMGROVE,OEA�LISH,OPREPAIRANY5TRUG W P3tio/DBCk W TURE,PRIOR TO ITS ISSUANCE,ALSO REGUIRES THE APPLICANT FOR SUCH PERMIT 70 FILE A SIGNED w STATEMEM THAT HE OR SHE IS LICENSEO PURSUAN7 TO tHE PROVISIONS OF THE CONTRACTORS LF � CENSE UWlCHAPTER 9(COMMENCINO WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS ANO PRO. �'L' Po0VSp8 fESSIONSCODE�OATHATHEORSHEISEXEMPT7HEREFROMANDTFIEBHSiSFORTHEALLEOEDEXEMR � 7KKJ.ANYYIOLR710NOFSEC710N7031.69VANYAPPLICANTFOHAPERMRSl1alECTSTHEAPPLICANTTO � RB-ROOf � ACIVILPENALTYOFNOTMOREIHANFNEHUNDREDDOLUIRS(SSoo).): � ❑I,ASONMEitOFTHEPROPERT/,ORMVEMFLOVEESWITHWAGESASTHEIRSOLECOMPENSATION, C] CommefCial -� WILL DO TNE WORI(,!WD THE SiAUCNRE IS NOT INTENp6D ON OFFERED FOR SALE(SEC.7044,BU51- _I � NESSMD PROFESSIONS COOE:THE CONfMCTOi1S LICENSE L1W DOES N07 APF4�T0 AN OWNER OF PROPEfi�YYV1iOBUtlD50RIMPROVESTHEREON,ANOWHO00ES5IICHWOFlKHIMSELFOpHERSELFOR � � 7NROUGHHISORHEflOWNEMPLOYEES,PflDVIDE�TI-IATSUCHIMPROVEMENTSARENOTINTEN�EDOq m 0 OiFEREDFORSALEIF,HOWEVER.THEBIHLDiNGORIMPROVEMEMISSOIAWITHINONEVEAROFCOUPIE Z TION.TrE OWNEH$UILOER WILL HAVE THE BUROEN OF PROVING THAT HE OH SNE DID NOT BUI4D OH = IMPROVEFORTHEPURPOSEOFSALE�. W ❑I,ASOVMEROFTiEPROVEHfV,AMEXCLU5IVELYCAMRACTINOWRHLICEN5E000NTHACTORS , � TO CONSTRUCT h1E PROJECT(SEC.7oI4,BUSINESS AND PROFESSIONS COOE:7HE CON7RACTORS LI� Valuelion ADJ.AREA LL� CENSEUW�OESNOTAPPLYTOANOWNEROFAPROPERTVWHOBUILDSORIMPROVESTHEREON,AND � WMOCONTMCTSFORSUCMPROJECTSWITHACONTRACTOR(5)LICENSEpPUR5UANTT07HEGOAffMG QUANTITY DESCFIPTION FEE � 70RSl10ENSEUW.�. ❑IAM EXEMPT UNDER S�C. B.8 P.C.FORTNIS REASON J � U LL ¢. DATE � ONMER U Z W � LICEN3ED CONTRACTORS CLARATIO W � 1 HEREBV AFFIRM UNDER PENALTY OF PEfUI/pV TNAT I AM LICENSFD UNDER PROVISIONS OF CHAPTER U.. � 9(LOMAENCMIOWITHSECTION7000)OFD�VISION30FTHEBUSINESSANDPROFESSIONSCADE,AND Z ��� MY UCENSE�5 W FUIL FORCE AND EFFEC7. � � LICENSE CLASS LIC.NO. � � V DATE CONTRACTOR d W � WORKEfiS'COMPENSATION DECIARATION Q � IHEREBYAFFIRMUNDERPENPLTYOFPER1l1RYDNEOFTHEFOLLOWINGDECLARATIONS: z � _INAVEANDWILLMAINTAINACER'TIFlCATEOFCONSENTTOSELF-INSUREFORWORKERS' a 2 COMPENSATION,ASPROVIDEDBYSECTION37ooOFTHELAB00.CODE,FORTHEPERFORMANCE U Q OFTME WORK FOR WHICM 1T115 PERMIT IS ISSUm. � O � ,IHAVEANDN7LLMAINTAINWORNERS'COMPENSATIONINSURANCE,ASREQUIREDBYSECTION - ' I _ ^ O 370o OF THE LA60R CODE,LOR THE 7ERFORMRNCE OF THE WORK FOR WHICHTHIS PEAMIT IS �j t I ISSUED.MV WORKEFLS'GOMPB�ISPTION INSURANCE CARRIER ANO POUCYNUMBER ARE: CONSTRUCTION J � CARRIER PLAN REVIEW 0 POUCYNUMBER ELECTRIC 0 (iFi16sEClIGJhE�NOTBEOJAREfEDOFTHEPEaAtlfiSFoaoNEHUnDRED00LtARs(S1ao)OqLESS� PLUM6ING Z ICERTIFYTHATNTHEPERFORMANCEOF7NEWORKFORWHICNTHISPERMI715155UED,1 MECHANICAL �„� SHALL NOT EMPIOV ANV PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE (p WORKERS'COMPENSATKKJ UWS OF CALIFORNIa,ANDAGREE TXA71F I SHOULD BECOME INSPECTION FEE S SUBJECTTOTHEW6RKERS'COMPENSATIONPROVISIONSOFSEC710N37oaOFTHELABOR — � CODE,i SHALL FORhIW ITH CAMPLY WRH THOSE PROVISIONS. ISSUANGE � s� p DATE: APPLICANT. SMIP W � WARNBdG�FAIWRETOSECUREWORKERS'COMPENSATIONCOVERAGEISUNLAWFUL.ANOSHALLBE ENERGYP/C LL SU&IECTqNEMPLOYERTOCRIMINALFENAL7IESANDCIVILFINESUPTOONEHUNDREDTHOUSAND ENERGYPERMIT DOLLAFiS(f100,o00).IN PDDITION TO THE COST Of COMPENSATION.DAMAGES AS PFlOVIDE�iOR IN � SECTION 9108 OF THE LA80fl CODE,INYEREST,ANDA?TORNE'/'S FEES. RETENTION FEE: � a CONSTRUCTION LENDING AGENCY PRE-ALT FEE: �' - O � I MEREBV AFFIRM UNDER PENALTY OF PERJURY TMAT THERE IS A CONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE OF THE N�ORK W R WFIICH THIS PERMIT IS ISSUED�SEC.3097.CIV C). . . Z '� w � _ � LENDER'S NMIE ' � !–' LENDER'S ADDHESS W ICERTIFYTHATIHAVEREADTHISAVPLICAl10NAN�5TATETHATTHEABOVEWFORMATIONISCARRECT. TOTAL FEES ��� � IACREETOCAMGLYWITHALLCfTYANOCOl1NTYOR�INANCESANDSTATELAWSRELATINGTOBUIL�ING � GONSTRUCTION.AND HEREBVAUTHOHIZE REPRESENTATIYES OF THIS CWNTV TO ENTER 11PON THE � � Z pBOVE�MENTIONEO PROPERTY LOR INSPECTION PURPOSES. 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