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HomeMy WebLinkAbout16387 (23) _ --.._...,..,_.,, .. .,�__ _.. �, s .v_ �.- . �R� CITY OF DIAMOND BAI� -- DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES w 21660 E.Copley Drive Suite 190 (909)8603195 Fax(909)861-3117 � PRESS ._�..---- ` A�"��, BUILDING PERMIT APPLICATION _ � FIRMLY . � JOBSITE �.� / �� ��,��/��/ -[ APPLICATION (�C� PERMIT I��� P/C p� .,�l, Q ADDRESS «' � � DATE ��` '�✓ v, NUMBER �` # �� � ISSUE ' TYPE OCC � APN �OT TRACT �ZZC+s 7 '� °C OWNER tr/' � DATE CONST. GROUP O Q ADDRESS O ° ,� ZONING SETBACKS � CITY.�j�s</�.-- ZIP��rZ TEL 9�g 7g 7 S'� REART RW p APPUCANT TEL. SIDElSIDE STREET RW p � CONTRACTOR SIDE ❑ ADDRESS � CITY I TEL. PROPOSED USE � ARCH/ENG! DESIGNER IZ'I7�� �,�5 �--�,.r�G- �i �� .�n,�,�J NO.DWEL. NO. NO. = C�TM E —t'�"�Z���� w � UNITS STORIES BEDROOMS � �TEL. v� DESCRIPTION SQ.FT. F CTOR PSF ADJ.AREANA UATION Q OWNER-BUILDER�ECLARATION SFR/ADDlREM �� �� , � i HEREBV AFFIRM UNDER VENAL7Y OF PERJURV 7HA7 I AM EXEMPT FAOM THE CONTRACTORS LI- � GaragelCarport � � � W CENSEUWFORTHEFOLIOWINOREASON(SEC.7031.68USINESSANDPROFESSION5CODE:ANVCITYOR � COUNTYWHICHREWIRESAPERMITTOCON5TRUCT.AI.TER.IMPROVE,DEMOLISH.ORREPAIRANVS7FIUC- PeilO/DBCk �,� �— '� � TURE,PRIOR TO ITS ISSUANCE,AL50 REOt11HE5 THE APPLICAN7 FOR SUCH PERMIT TO FILE A SIGNED w � � STATEIAENT THAT HE OR SHE IS LICENSE�PURSUANT TO TNE PROVISIONS OF THE CONTRACTORS LI- W CENSE UW(CHAPTER B(COMMENCINO WITFi SECTION�ODo)OF OIYISION 3 OF THE BUSINESS AND PRO- � Pool/Spa FESSbNSCOOEJOqTHATHEORSHEISEXEMPTTHEPEFROMANOTNEBASISFORTHEALLEOEDEXEMP- (� TKKi.ANYVI0LAT10NOF3ECTION7a47.5BVANYAPPUCANTFORAPERMITSUBJECTSTHEAPPUCANTTo Z R8-ROOf � A GYVILPENALTY OF NOT MORE TFiAN FIVE HUN�RE�DOLLARS(S5ao).�: � ❑I,ASOWNEROfTHEVHOPERTV,ORMYEMPLOYEESWITHWAGESASTHEIR50LECOMPENSA710N, � COmf1101Ci81 - ri7LL 00 TNE WOFU(,AND THE STRUCTURE IS NOT IN7ENpED OR OFFERED FOR SAI.E(SEC.70M,BU51� J N NESS AND PHOFESSIONS WOE:THE CONTRACTORS UCENSE lAW DOES NOT APPLV TO AN OWNER OF PROPERTYVhiOBVILD50RMPROYESTHEREON,MIDWHDDOESSUCHWOHKHIMSELFORHERSELFON � � THROUGH HIS OR HEROWN EMPLOVEES,PPOVIDEO THATSUCH IMPROV9�IENTS APE NOT INTEN�ED OR LT� � OFFEpEOFORSALEIF,HOWEVERTMEBUILDINGORIMPROVEMEN715SOlDWrtHINONEYEAROFCOAIPLE- Z TION,THE OWNER-BUILDER NALL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILp DA � IMPROVEFORTHEPURPOSEOF5�ILE). W ❑I,ASOWNEROFTHEPROPERTY,AMEXCWSIVELYCONTHACTINGWI?F!l.ICENSEDCONTRACTOp3 � TO CONSTAUCT THE PRQIECT(SEG.70M,BUSINE55 ANO PROFESSIONS CODE:THE CONTRACTORS LI- V8IU8t1011 ADJ.AREA W CENSELAWDOESNOTAPPLYTOPNOWNEROFAPRQPERTYWHOBUILDSORIMPROVESTHEREON,AN� � YhpCON7RACTSFORSUCMPRQIECTSWITHACONTRACTOR�S)LICENSE�PURSUANTTOiHE(:ONTRAG QUANTITY DESCRIPTION '� - FEE � roasucENSEuw.�. ❑I M1 EXEMPTUNDER SEC. B.8 P.G FOR THIS RFASON Q � �` J .� 3 � � — r� i�4.-1 l° DATE � OWNER F— � W � LICENSED CONTRACTORS DECLARATION W � � I HEREBY AFFIRM UFOER PENALN OF PERJURV THAT I AM LICENSED UNDER PPOVISIONS OF CHAPTER V, � � Y(COMMENCINO WI7H SECTION 7000)OF OIYISION 30F T4E BUSINE53 AN�PROFESSIONS CODE.AND Z , ��� MY LICENSE IS IN FLLL FOitCE D EFFECL m � LICENSECLASS LIC.NO. ����I � r.~ � �� a V DATE CONTRACTOR -�_ a � r WORKERS'COMPENSATION DECLARATION � � � � � � � I HERE AFFIRAI UNDER PENALN OF PE0.JUM ONE OF THE FOLLOWING�ECLARATIONS: Z tl � Q � � - IHAVEANOWILLMANTAINACEHTIFICATEOFCONSENTTOSELF-INSUREFORWORKERS = j�' ( � CCNIPENSAifON,AS PRONOED BV SECiION 3700 OF THE UBOii COOE,FOfi THE PERFORMAN(:F. `U � , �+ / O d�FTHE WORK FOR WHICH 1H15 PEPMIT IS ISSUED. � ' t W I HAVE AND WILL MANTWN WORKERS'CQMPENSAiION INSURANCE,AS RE�UIRE�BY SECTIDN /� /� / Q 97000F THE LABOR CODE,FOR THE PERFORMPNCE OFTHE WORK FOR WHICH THIS PERMIT 15 �I�'`� `-;''� 'N��GI �\ t�J ISSUE�.MY W KERS'.COMPENSATION INSURANCE CAR IER AMD POLICY NUMBERARE: /(� CONSTRUCTION t a � q J�� /��. j CMRIEA_ � � �'�% PLAN REVIEW �� v�ic>r�MSEA � ELECTRIC a �N�ssEcrar�N�raof`��uoFi�rE.�vrt�scaaor�NUNoaEvoauSaslasoa}oa�Ess� PLUMBING � � � Z l CEflTIFY THAT IN THE PERFORMANGE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I y/ ) QS SHALLNOTEMPLOYANYPERSONINANYPAANNERSOA570BECOMESUBJECTTOTHE (�/ � WORKEHS'CAMPENSATION LAWS OP CALIFORNIA,AND AGREE THAT IF I SHOUIp BECOME . - N � 7�y SU&IECT70 THE WORKERS'COMPEt15ATqN PROVISIONS OF SE 710N 370o OF THE L480R {'� B � O COOE,ISNALLFORTHWITHCAFIPLYWITHT OS ROVISpN I S AN�.E ,__ _ �,/U t� v� P�� � � ?.Oo�- � � p DATE:y��!� APPLICANT: � s.' /L��f � � WARNIN6:FMLURE TO SECURE WORKERS'COMPENSATION CAVERAGE IS UNLAWFUL,AND SHAIL BE ENERGY P/C � SU&IECTANEMPLOYERTOCRIMINALPENALTIESANOCIVIIFINESUPTOONEHU4DRE�THOUSANO �� DOLLARS�5700.000),IN ADDITION TOTHE COST OF COMPENSATION.DAMAGES AS PROVIDED POR IN ',�NERGY PERMIT . .. JSECTION 3708 OF THE LABOfl CODE.INTEREST,ANO ATTORNEV'S FEES. ^r'�-"^'��'��'–'"`��� � � 'aer�rrno�ee: � � V�J j a CONSTRUCTION LENDING AGENCY PRE-ALT FEE: V� O � IHEREBVAFFIRMUNDEHPENALTYOFPERJUflYTHATTHEREISACONSTPUCTIONLENDINGAGENCV � FORTHEPERFORMANCEOFTHEWORKFOR HICHTHISPERMITISISSU D(SEC.3097,CIV.C.), .�Z LEN�ER'S NAME / `��."''� � / I''�AT""_� T �/ ������ � F— LEN�ER'SADORESS W TOTAL FEES ��� , �J � I CERTIFV THAT I HAVE FiEAO 7HI5 APPUCATION AND STATE THATTHE ABOVE INFORMATION IS CORRECT. � 1 AGREE TO COMPLY WITH ALL CITV AND CAUNTY ORDINANCES AN�STATE LAWS RELATING TO BUI�OING a � CONSTtiUCTItlN,ANDHEREBYAUiHORIZEflEPRESENTATIVESOFTHiSCOUNTYTOENTEflUPONTHE Z ABOVE-MENTIONEDPROPERTVFORINSPEC IONPURPOSES. COMMENTS o ��, s,. � QPERAIITTEE N E(PRINT � ,u�-r --G`�--�� Uj SIGNAT OF PERMITfEE DATE � RECPT.NO. 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