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HomeMy WebLinkAbout16524 (22) ��` CITY OF DIAMOND BAI,t DEPARTMENT OF CQMMUNITY&DEVELOPMENT SERVICES ,; 2166D E.Copley Drive Suite 190 �S�r���,��-. PRESS ,,� (909)860-3195 Fax(909)8613117 ^��° BUILDING PERMIT APPLICATItJN ' � ��. � FIRMLY , QJOBSITE r �(��� ��'� DATECATION � ' 1\-..� � NUMBER� ��� #/C�� � � ¢ ADDRESS y $ ISSUE TYPE �- J- OCC APN T CT DATE CONST. GFiOUP p OWNER , . ADDR ZONING SE78ACKS Z CITY ZIP TEL RE�ART � RW �O g APPLICANT TEL. SIDE/SIDE STREET RW ❑ � CONTRAGTOR SIDE ❑ Q ADDRESS � ' � CITY A ZI T L. PROPOSED USE o ARCWENG/ r z DESIGNER NO.DWEL. NO. NO. � ADDRESS UNI7S STORIES BEDROOMS � CITY ZIP� Cf TEL. N DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � � OWNER-BUILDER DECLARATION SFR/ADD/REM � O p I HEREBY AFflRM UN�ER PENQN OF PERAIRV 7HAT I AM E%EMPT FROM THE CONTRAC70R5 LF � Garage/Carport � � �� W CENSEUWWRTHEFOILOWMGREASON(SECJ031.5B115MES5ANDPROPES510N5CODE:ANYCITYOR !�, ZOOUNTYNRIICHREOUIPESAPERMITTOCONSTRUCT,ALTEF.IMPRO'�C,DEMIOUSH,ORFlEPAIRANYSTRUC- W PdfiO/DBCIC �, � '�1 W TURE.PRIOH TO ITS ISSUANCE.A.LSO RE(1UIRE5 THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED � .� S7ATEMENT TNA7 HE OR SHE IS LICENSED PURSUANT TO iHE PqWISIONS OF THE CONTRAC70RS U- � CENSE LAW(CHAMER 91��ENCINO WITH SEC710N 7Mo)OF DIVISION a OF THE BUSINES5 AND PRO- � POOUSp2 FESSIONS GOUE)OR TliAT HE OR SHE IS E%EMPT TrIEREFROM AND THE BASIS FOR THE AlLE6E�E�CEMP- TqN,ANYVIOLATIONOFSECTION7031.68YANYAPPLICANTFORAPERMITSU&1ECi5THEAPFLICANTTO Z Re-Roof � ACML PENALTY OF NOT MORE TNAN FNE HUNDFED DMLARS(S50o�.): � ❑I,ASOWNEqOFTHEPROPERiV,ORMVEMPLOVEE$WITHWAGESASTHEIRSOLECAMPENSATbN, � COmmBfCld� � WR1 DO THE WORK,M1O THE STRUCTURE IS NOT INTETIDED tlfl OFFERED fOR SALE(SEC.7044,8U5�� J NESS AND PpOFESSIONS CODE:THE CONTRACTORS LICENSE lAW IbES NOT APP�V TO AN OWNER OF � _ (�� � I� . � PF�VERT'M/FIO BUII.US pR IMPROVES THEREON,AND NMO OOES SUCH WORK HIM3ELF OR HERSELF Ofl � � �- � THROU(Ui HIS OR NER O1VN EMPLOVEES.PROVIDEO THAT SUCH IMPROVEMENTSAqE NOT INTENDED OR m� � ', }� OFFEREDFORSALEIFNOWEVERTMEBVILDINGORIMPROVEMENTISSOLD'MTHINpNEYEAROFCOMPLE- Z � � /� 1` lN TION,THE ONMER-BUIL�ER Wll.l HAVE THE BURDEN OF PROVING hiAT NE OR SHE DIO NOT BUI�D OR . � � IMPfqVEFORTMEPURPO5EDF5ALE). ❑4��'MdEROF 7HE PAOPERTY,AM EXCLUSNE(.V CANTRACTiNC W17H LICEN5ED CONTPACTOFS ..t � TO(pftlSTPUCT THE PRWECT(SEC.70H,BUSINESS AND PROFE5310N5 fADE:THE CONTRA!:7pqS U- V81118SIOf1 J.AFEA W CEN5EUWDOESNOTAPPLY70pNOWNEROFI,PROPEKTVWH08U1LD50RIbIPROVESTHEREON,ANO � WhqCONTWICTSFORSUCHPRQIECTSWIi?1ACONTRACTC'R(5)UCEN3EDPURSUANT70THECONTRAG QUANTITY DESCRIPTION FEE TORS LICENSE LAW.�. / ! � ! J � ❑I AM E%EMPT UNDER S�C. B.&7.C.FOR THIS REASON Q �9 ` � 3 a _ 'Z S'i�s/�7�1� � D�TE oWNER__ U e ✓ � Z W � UCENSED CONTAACTORS DECLARATION W f'- 1 HEREBV AFFIRM UNDEA PENA.LN OF PERJUFYTNAT I AM LICENSED UNDER PROVISIONS OF CHAVTER 6 n�-j � 9(COMMENCING WITH SECTION 7oCo�OF 0!VISION 30F THE BUSINESS AND PROFESSIONS COOE,AND Z ___(� �� ✓�^'^-" LLl �UCENSE i5 M FULL FORC D EFFECT, m �9„ - '� ,.�^j� vi � LICENSE CLASS _ LIC.No. C ✓ � � x`.' V OATE_ __ CONTRACTOR a � � ^i � CNt'` 1 WORKERS'COMPENSATION DECLARATION U �,^�,/ , �„ � 1 HEREB AFFlRM UNDER PFNAI.TY OF PE0.1UR�ONE OF TNE F6LtDWING DECLAriATtONS: Z � ��„�.� CJ (� Q C] ' HAVEANDWILLMAMTAINAOEfi'7'lFICATEOFCONSENTTOSELF-INSUREFORWORKERS' 2 � Cl`�� � � COMPENSATION,AS 7RdVIDED 8�SFCTi(Xd 370o OF THE LABOR G��E.FOR THE PERFORMANCE � � THE woRK FOR WNICX THIS PERMiT 1315SUE0. � , �"\ � w �_IHAVEANDWILLMA�NTAINW�JRKEFS'CARIPQVSATIONINSURAkCE.ASRE�UIREDBYSECTiON 1 ,(�/� c'� � O 37o00FTHElA80RCODE,FORTHEPERFONMANCEOFTHEWORKF'ORWNICHTHISPEqMITIS —���,1�� 1 '� Ily �SSUED.MY W ERS'�M NSATION L°URANCE A`R'RIEP AN POLICY NU ER CONSTflUCTION x s �' � } jJ fJ � CJ. PLAN REVIEW (,�/ CARRIER r�1 (_�� Z c icv rvuM(g,�.�q � _ ELECTRIC � �� -7 . -. L'y @��'L+ �� a ��NEID �EOJMR.E�EDOFIHEPEFFNT6FORONEF0..TmNEDDOLIAFS($tOo;ORLESS). PLUMBING �� .+� �ii I�.� � W / /� Z i CERTIFVTHAT IN'}1E PERFOqMANCE OFTHE WORK FOR WHICHTHIS P[RMIT IS ISSUED,I MECHANICAL _��,�•L� i I 3 (.i,o� \/ � � SHAILNOTEMPLOY/V3YPERSONINANVMANNFRSOA6TOBECOMESUBJECTTOTHE INSPECTIONFEE � WORKERS'GOMPENSATiON UWS OF CALIFORNIA,ANp AOP[E THAT IF 1 SHOUlO BECOME � SUBJECT 7'O THE WORKERS COIAPENSATION PROVISIONS OF SECTION 7700 0F THE LABOR P � � CODE,Ir-S�HAj�,FO�}jHWIhI COMPLV WITN THOSE V wsov$ , .� I5SUANCE _j�.,.����.-� Q �/�j^{]' � �4'� � � SMIP � p DAT6:!���f+� APPLICANT: ,_ � � ENERGY P/C ~ . • ..:�. .. .,... � � —� WARNING:FAILURE 70 SECURE WORKERS'COMGENSATIDN CAVER.4GE IS UNLAYVFUI.AND SH/1ll BE � SU&IECTANEMPIOVEPTOCRIMINA�PENALTIESANDCIVILfWESUPTOONEHUNDREDTHOUSAND ENERGYPERMIT �,f�ff! � DOLURS(St UO.000).IN ADDI�l04 TD THE COST OF COMPEkSAT10N,�AMAGES AS PHDVIDEP FDR IN ��}f}�'�-- y � SECTION3)oBOFT1ELABORCODE.INTEREST,ANDATTOqNEY'^uFEEs. RETENTIONFEE: .. �� `' � CONSTRl1CTION LEN�ING AGENCY PRE-ALT FEE: - � I HEREBV AFFIRIA UND6R PENALTV OF PERJURV THATTHERE IS A CONSTRUCTION LENDING AGENCV �—.1- + n- fOR 7ME PERFORMANGE OF THE WORK fpR WHICH THI PERMIT IS IS UED(SEC.3097. IV.C.�. " — . .. __...._--_........_._. W �.�'1�`zz���'�''c ���1 .ffi ,� �� .....-- � LENDER'S NAME � LENDEH'SA�OHESS I�/ ^ � � ICERTIFVTHATIHAVEREADTHISAPPLICATIONANOSTATETHATTHEABOVEINFORMATpNISCARRECT TOTALFEES ./�,{�I� 1 d,J � I AGREE TO CAMPLY WITH pLL CITY AND COUNTY ORDINANCES ANO STATE iAWS REUTING TO BUILDING � CONSTRUCTION.ANDHEREBVAUTHORI2EREPRESENTATNESOFTNISCOUNTVTOEMERUPONTHE �11 Z ABOVE-MENTIONEDPR4PER7YFOflINSPECTIONPURPOSfS. 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