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HomeMy WebLinkAbout16523 (20) CITY OF DIAMOND BAFt - i F`� DEPARTMENT OF COIvIMUNITY&bEVELOPMENT SERVICES � 21660 B.Copley Drive Suite 190 (909)860-3195 Fax(909)861-3117 PRES$ �»�'� BUILDING PERMIT APPTJICATION .. ,,, , FIRMLY � JOBSITE , ` APPLICATION L�iI ..('�l PERMIT �''� � P/C Q ADDRESS Y DATE_ ...J I � `-� I NUMBER,��L��� ,r�TJ N--��C�. g �„2� issuE TVPe oc APN_ LOT TRACT �� DATE CONST. GROUP � OWNER "' ADDRESS (� �1 ZONING SETBACKS " ` ```� � CITY�.y�t�y�ZIP� TEL. REART k RW O APPUCANT �; � TEL SIDElSIDE STREET RW O � CONTRACTOR SIDE ❑ � ADDRESS PROPOSED USE Q CIN IP E . w ARCHlENGJ ��-t�. Q DESIGNER ��5, NO.DWEL. NO. NO. ADDRESS k UNITS STORIES BEDROOMS � CITY_�{Y�. � �� ZIP�,TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-SUII.DER DECLARATION SFRIADD/REM � 1 HEREBY AFFIRM UNDER PENAL7Y OF PEIYJURV THAT I AM EXEMPT FRCkA THE CONTRACTORS Li. � Garage/Carport CENSE lAW FORTHE FOLLOW ING REASON(SEC.7D31.5 BUSINESS AND PROFESSIONS COOE:ANY CITY OR COUNTYVNiICHREWIIRESAPERMRTOCONSTFlUCT,ALTEP,IMPROVE,DEMOLiSH,ORREPAIRANYSTRUC- W pat�Ol�OCk 7URE,PRI�R 70 I75 ISSUANC�ALSO REQUIRES THE APPLICANT FOR SUCH pERMIT TO FILE A SIGNE� � STATEMENT TFIAT HE OR SHE IS LICENSEO PURSUANT TO THE PROVISIONS OF TFIE CONTRACTORS U- � CENSE LAW(CHAVTER B(COMMENCINa WITH SECTION 7000)OF OIVISION 30F THE 81151NE55 ANO PRO� u" PoOI/Sp3 FE33pN5CO0E}ORTH�THEOFlSHEISEXEMPT7NEREFROMANDTHEBASISFORTFIEALLEGEDEXEMP- (� v TpN.ANYVIOUiIONOFSECTION�031.5B�ANVAPPLICANTFOR�PERMITSUBJECTSTHEAPPLICANTTO � Re-Roof Y A GIVIL PENALTV OF NOT MORETHAN FIVE HUN�RED�oLIARS(SGD�).1: � ❑t,ASOVMEHOFTHEPROPERTY,ORAIVEMPLOYEESWITHWAGESASTHEIRSOLc'COMPENSATION, ❑ COf77tT8fC10I - WILL DO THE WORK,AND THE STFUCTUiiE�S NOT INTEND�OR OFPEREO FOR SALE(SEC.7ala,BU51- J NESS P!D GAOFESSIONS CODE:TF1E CONfRACTOflS LICENSE LAW C10ES NOT APPLV TO AN OWNER OF � PROPERTVWF108ULL1JSOflIMPROVESTHEREON,PNDNMODOESSUCHWORKHIMSELFOHHERSELFOR � � 71Gi0UpH HIS OR HER ONTI EMPLOVEES,OROVIDED THA?SUCH IMPROVEMENTS ARE NOT INTENDE�oq m � OFFEREDFORSALEIF,HOWEVERtMEBUILDINGORIMPROVEMEMISSOLDWI7HINONEYEAfiDFCOMPLE- � �TpN,TFiE OWNEN�BUfLDER WILL HAVE THE BURDEN OF PROVINa THA7 HE OR SHE DID NOT BUILD OR � 161Pf�VE FOR THE PURPosE OF SALE). W ❑I,ASONTlEROFTHEPROPERTY,AMEXCLUSNELYCONTRACTINGWfTHLICENSEDCONTRACTORS � TO CONSTRUCi THE VR0.IECT(SEC.7044.BUSINE55 IWD PROFESSIONS CODE:THE CONTRACTOPS 41� VBIlId110f1 P�J.AREA W CEtiSEUWDOESNOTAPPLYTOANOWNEHOFAPFiOPERTYWHOBUILOSCRIMPPOVESTHEREON,AND � WFpCONTMC75WRSUGHPRqIECiSWITMACONTRACTOfl(5)UCENSEDPURSUM1T70TNECONTRAG QUANTITY DESCRIPTION FEE � 70RSLICENSELAW.). ❑I AM EXEMPTUNDEA SEC. 6.a P.C.FOA THIS REASON Q �'i , — U � u' DATE OWNER � � W � UCENSED CONTRACTOAS DECLARATION W � i HEREBYAFFIRM UNDER PENALTY OF PEtUURY THAT I AM UCENSED UN�'eR PROVI6IONS OF CHAPTER � p� 9 tCOMMENCIN(3 WITH SECTION 7000J OF DIVISION 3 OF7ViE BUSINESSAND PflOFESSYJNS CODE,AND Z _ }C MY LIGENSE IS IN NLL FORCE D EFFECT. !1J m � LICENSEC S LIC.N0.-�JM�-++.V"_'_-'+."-.7 = F- - U �AT ' CONTPACTOP n- W ayy� � �n` WQRKERS'COMPENSATION OECLARA710N -� ¢ � U � IHE FIFMUNDERPENALTYOF7ERJURYONEOFTHEFOLLOWINGOF.CLARATIONS: Z � HAVEANOWILLMAINTAINACERiIFICATEOFO�N5ENTTOSELF-INSUqEFOFYIORKERS' r WMPEYSATION,AS PROVIOED BV SECTION 37000F THE LABOR COOE,FOfl THE PERFORMANCE W 7NE W4RN FOR WHICH THIS PERMIi IS ISSU6D. � � :I HRYE AND NALI MAIN'fAIN WORKEAS'CAMPENSaTlO�INSUFANCE,AS REW IRED 9V SECTION ///��� 6 37000FTYELPHORCO�E,FORTHEPERFORAAANCEOFTHEWORKFOqWHICHTH!SPEPMITIS �a�,.I A1G/� � ISSUE�.MY OP.KERS;. PENSATION INSURANCE CARqIER AND POLIGY NUMBER ARE'. CONSTRUCTION -�i'N T w/1.�� 5"'�,, ciwRiEa. �� 7 �q ��a�� PLAN REVIEW � POLICYNy►±eea^ ���E�6�� ELECTRIC ` � �mu.s�S�NFmNbreEc�.�nocn�vEar.vr�swaaaEt{urnaE�oatnas�s�co)oaiEssl PLUMBING ��J� Z I CENTIFI'TNAT IN THE PERFORMANCE OF YVIE WORK FOR WHICH THIS?ERMIT IS ISSUED,I ; MECHANICAL ^`__ �_ (,� SMALLNOTEMPLOYANYPENSONINANYMANNEfl50A5TOBECAMESUBJECTTOTHE � � WpRKEFS'COMPENSATION LAWS OF CAUFORNIA,ANO AGHEE TNA71F I SHOULD BECOME INSPECTION FEE �/1-� � SUBJECTTOTHEWORKERS'COMPENSRTIONPFOVISIONSOFSECTION3'/OOOFTHELABOR I ISSUANCE _ �f'.''����"''� 'r �'~� �`,��✓� E,I SHALL.FOyR+T�H�WiTHCOMPLY WIT�y7'-IOSE PROIVISIONS. � `���''_.3.rj ��^-1"'.p �/^p� { � SMIP �ATE: � APPLIGANT; ( +�1_`=._I/ 1M� pENERGY P/C �� +. I J WAHNING FAILUftE TO SECl1RE WOFKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SMALL BE LL SU9JECTANEMPLOYERTOCRIMINALPENALTIESANDCIVILFINESUPTOONEHUNDRE�THDUSAND ESJERGYPERMIT DOLLARS(L����)�INACDITION TOTHE COS70F GOM7ENSATION,DAMAGES AS PROVI�ED FOR IN � SECTION37080fTMELA00ftCODE.INTEREST,ANDATTORNEI^SFEES. RETENTIONFEE' � � CpNSTRUCTION LENDING AGENCY PRE-ALT FEE: ��'"'"�""—'_-'�-��----�--�!�— ... ._._'-.._ .__._.. � 1 HEREBV AFFIRld UNDER PENALTV OF GERJURY THAT THERE IS ACONSTRUCTION LENDING AGENCV FOR 7HE PERFORMANGE OF THE WOflNf FOR WHICH THIS PERMIT IS ISSUE_D�(5\ 3087,CIV.C.�. � LENDER'SNAME�..�..�`��'� ���— F- LEM�ER'SADDRESS_ � ICERTIFYTHATIHAVEREADTHISAPPUCATIONANOSTATETHATTHEABOVEINFORMATIONISCARRECi 70TAL FEES •�� W I AGREE TO Cf]MPLV VATH ALL CITY AND COUNTY OR�INANCES ANO STATE fAWu RELATING TO BUILD�NG � CANSTRUCTIIXJ,AND HEflEbYAUTNORIZE REPRESENTATIVES OF�HIS COJNTV TO ENTER UPON THE ABOVE�MENTIONE�PflOPERTV FOR INSPECTION PIIRPOSES Z COMMENTS___ � � _ -� �- m PERlAITTEE E(�RINT) Q � � SIGNATU PERMITTEE ' �ATE = RECPT.NO. 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