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HomeMy WebLinkAbout16265 (20) � �.,.- � _____ _. _ _. _ _.. � :� _ ^ � ^ 1�rt�_ CITY OF DIAMOND BAI+t � DEPARTMENT OF COMMUNITY&DEV�LbPMENT SERVICES a 21660 E.Copley Drive Suite 190 (9G9)860-3195 Fax(909)861-3117 PRESS ..�.i9Ni f ,,... . _ . . . .. . .....,.... . . BUII,DING PERMIT APPLICATION -_' FI�M�Y . .. _ . ,. _ ,..:_ , ..: ..... 4 ADDRIESS � � �. F-� APPLICATION � � � PERMIT I,� P/C I d/�� o DATE NUMBER VN # �l✓ �J'� � APN LOT TRA T ��,�_ DATEE � `J � ONST. GROUP p OWNER �� �G Lf r�11�—� � ADDRESS " , Y, ZONING SETBACKS � CITY � ZIP TE � � FRONT , Ryy ❑ APPLICANT �,_ TEL REAii p zd. SIDE/SIQE STREET Ryy �-7 � CONTRACTOR � SIDE � ADDRESS ` � � C�TY ' ' ZIP TELM PROPOSE USE i � � w ARCFUENG/ � �z DESIGNER + � NO.DWEL. NO. NO. a ADDRES � CITY 2 TEL. � � UNITS STORIES .__�Z.- BEDROOMS L_ � DESCRIP'�ION SQ.FT. FACTOR PSF ADJ.AREANALUATION O QWNER-BUIIDER DECLARATION SFR/ADDlREM j� p I HEfiEBY AFFlRM UNUEH PENAN OF PERJUHY THAT I AM EXEMPT FROM THE CONTRACTORS LI- Gdfd B1C2 OR W CENSEUWPoHTHEFOLLOWINGREASON(SEC.7031,5BUSINESSANDPROFESSIONSCODE:ANVCI7YOR (� 9 � COUNTV VN-IICH HC-0UIRESA PEBMtTTD CONSTRUCT,At,TER,IMPROVE,DEMOUSH,OR REPAIpANV S7RUC- W TUqE,PPIOq TO ITS iSSUANCE,ALSO RE�UIR6S THE AGPLICANT FOR SUCH VERMIT TO FILE A SIGNED � Patio/Deck � STATEMENT TNAT HE OR SHE IS LICENSED PURSUANT TO THE PROYI610NS OF THE CONTRACTORS L4 � � CENSE LAW(CHAPTER e(COMMENCiNO NATH SECTION 7000)OF DIVISION 30F THE BUSINE55 AND PRo- PoOVSpa FEBSION3CODE)ORTHATHEORSHEISEAEMPT7HEREFROMANDTHEBASISFORTHEALLEOEDE%EMP- (!) � 710N.ANYVKJLA7KM10FSEC710N7v37.6BYANYAPPUCANTFORAPERMITSUBJECTSTHEAPPLICANTTO Z Re-Roof � ACIVIL PENALT/OF NOT MpRE hIAN FIVE HUNDRED DOIIARS(5500).�: � ❑I,ASOWNEROFTHEPROPERTY,ORMVEMPLOYEESWITHWAOESASTHEIRSOLECOMPENSATION, � Comm91'Cidl - - WILL DO THE WORK,M10 THE STRUCTURE IS NOT INTENDED OR OFFEHED FOR SALE�SEC.7oa�,BUSb ,_I N NESS AND PROFESSIONS CODE:THE CONiRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNFA QF � PqOPERTV NM1iD BUIIAS OR IMPROVES THEREON.AND WHO DOES SUCH WOqK HIAISELF OR HERSELF OR wTHi10U(iHHISORHEROMMEMPLOVEES,PROVIDEOTHATSUCNIMPHOVEMENT&ARENOTINTENDEDOH ' m � OFFEREDfORS/LEiF,HOWEVER'�-�EBUILDING�RIMPROVEMENTISSOLDWRHINONEYEAROFCOMPLE- Z �TION,TME OWNEH�BUIIDEH NALL HAVE THE BURDEN OF PROVWG THAT HE Ofl SIiE DID NOT BUILD OR � IMiRQVE FORTHE PURPOSE OF SALE�. � � W OI,ASONMEROFiHEPpOPERTV,AMEXCLUSNEIYCANTMCTINOWI?HLICENSEDCONTRACTORS Q TO CONSTRUC7 THE PROJECT(5ECJ014,BUSINESS ANO PROFESSIONS COOE:THE CONTRACTORS LI- V21u3tion ADJ.AREA W CENSELAWDOESNOTAPPLYTOMIONMEROFAPROPERTYWHOBUILDSORIMPROVESTNEREON,AND � WFqCONTRACTSFORSUdiPRNECTSWITHACONTRACTOR�S)LICENSEDPURSUANTTO7HECONTqAG QUANTITY DESCRIPTION TORs ucENSE uw.�. FEE � ❑I AM EXEIAPTUNDER SEC. B.8 P.C.FOR THIS REASON J U � OATE OWNER � Z U � UCENSED CONTRACTORS DECLARATION W p� -- IHEREBYAFFIRMUNDERPENALNOFPERJURYTHATIAMLICENSEOUNDERPROVISIONSOFCHAPTER � � 9(CDMMENCWO WITH SECTIDN TaoO)Of DIVISION�OF TNE BUSINESS AND PROFESSIONS CODE,AND Z xx 4V UCENSE IS IN FULL FORCEAND EFFECL � u� ��/'� � UCENSE ClAgggS_ LIC.NO.��� ��l/ � -V DATE___ CONTRACTOA 1��'t���� d w ���—_ 1����-/rRT�T1� � WORKERS'COMPENSATION DECLARATICJN a � I HEPEBV AFFIRM UNDER PENALTV OF PERJURV ONE OFTf IE WLLOWIkG DECLARATIONS: Z Ca _iHAVEAN�WiLLMRINTAINACERTIFICATEOFCONSENTTOSEI.F-INSUREFORWOHKERS' _ Q COMPENSAT!OW.AS PROVIDED BY SECTION 3700 OF TNE LA80R CODE,fOR THE PERFORMANCE U Q OFTHE WOPoC FOR WHICH THIS PEFINIT IS ISSUED. � QW �INAVEAN�WILLMAINTAINWORKERS'COMP�NSATIONINSURANCE,RSREOUIREDBYSECTION �f 37ooOFiMEtA80RCQ0E,FDHTHEPERWRMANCEOFTHEWORKFORWHICHTHISPERM1T15 a �p `��' � ISSUED.MYWOR ERS' PENSATIONINSUR CECAHRIERAN�POLICVNUMBERARE: CONSTRUCTION /.� y CARNIER �"'Ll�, PLAN qEVIEW aaoLICYNUMBER � ��..f�.MLlI�_Q. _ . ELECTRIC _ � (�HISSECfqNNE�NJ78E001JFLEfIDOFiIiEPERRAfTISFOFONEMa�4NiEDDJ1IARS(b100)ORlES4� PLUMBING � 1 CERTIFY TlUT IN7HE PEHFORMANCE OFTHE WORK FOR WHICH THIS PERMIT IS ISSl1ED,1 MECHANICAL ^� � C7 SHALLNOTEMPLOYANYPERSONINANYMANNfRSOASTOBECOMES�BJECTTOTHE . � WOPoCEPS'COMPENSATIONLAVYSOFCALIFORN10.aN0AGREE7HATIFISHOULDBECAME iNSPECTIONFEE �, l SU&;ECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION a7oo OF THE LABOR /� s E, S LLFOR�HWITHCOMPLVWITHT NS. 1SSUANCE � �;� O �p DATE: �_ APPLICANT. � SMIP � � J WARNIN :FAILURE TO SECURE WOqKERS'COMPENS TION. RAGE IS UNUWFUL,AND SHALLBE ENEflGY P/C ,_ ' � Sl1BJEC ANEMPLOYERTOCPIMINALPENALTIESANDCIVILFINESUPTOONEHUNDREDTHOUSAND ENERGYPERMIT _ �.. WLURS(=100,000),IN ApDITION TOTNE COST OFCOMPENSATpN,�AMAGESAS PROVI�ED FOR IN � SECTbN 37oe OF THE LABOR CODE,INTEREST,ANDAiTORNEY'S FEES. RETENTION FEE: � OCONSTRUCTION LENDING AGENCY PRE-ALT FEE: �= � � I HEREBY AFFIRM UNDER PENALN OF PERJURV THAT THERE IS A CONSTRUCfION LENDING AGENCY ' - ' FOR THE PERFORMANCE OFTHE WORK FOR WHICH THIS PERIAIT IS ISSUED(SEC.3097,CIV.C.�. Z W _ � LENDER'S NPME____ _ - � IEN�ER'SAODRESS Y w ICERTIFYTHATIHAVEREAD7HISAPPLICATIONANDSTATE7HA77HEABOVEINFORA1AT10NISCORRECT TOTALFEES 'l, I���{�.y � ! , /,J � I AGREE TO COMPLV WITH ALL CITY AND COLINTY OPDINANCESM70 STATE IAWS RELATING TO BUILDING t`/ � f 1 � � CANSTPl1CTION,AN�NEREBY AUTI-IOflIZE REPRESENTATIVES OF THIS COUNTV TO ENTER UPON THE �1 �C, (���� . - Z ABOVEMENTIONED 7ROPERTY FOR INSVEC710N GURPOSES. 1 1� 1� • � �� � COMMENTS 1 l..s �Y J � m PERNITTEE NAME�F ) � ¢ D� I � (n SIGNATURE OF � ATE � � RECPT.NO. 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