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HomeMy WebLinkAbout16392 (20) � J "` � �� CITY OF DIAMOND BAB i� - DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES w 21660 E.Copley Drive Suite 190 (909)860-3195 Fax(909)861-3117 PRES$ �`'^�'� BUILDING PERMIT APPLICATION � FIRMLY . . ,.:. , . a.. :.. . .:,, ., o DDRESS � '�' �� �1� Fi' L•� � � C.:- DATECATION �- ��'�,}I NU BER �� ��/C $ ISSUE TYPE OCC APN LOT TRACT .fj�-��'7 DATE CONST. GROUP p OWNER r! I�t�"t' p ADDRESS rl� � 9 L �Q ZONING SETBACKS � CITX.�,�itllo� ZIP�j��[/ 2--TEL. � REAR RW ❑ APPLiCANT TEL. SIDE/SIQE STREET RW ❑ � CONTRACTOR � SI�E ❑ ¢ ADORESS Q CITY ZIP TEI. PROPOSED USE w ARCWENG! 9r � DESIGNER_.��%��� �SS�� �.S^Cy'C9- ° NO.DWEL. NO. NO. = CITY E� � �ZIP �'�L UNITS STORIES BEDROOMS � � tn � DESCRIPTION SQ.Ff. FACTOR PSF ADJ.AREANALUATION � OWNER-BUILDER DECLARATION SFRlADDlREM O p I HEREBY AfFIFW UNDER PENALTY OF PERJURY iHAi I AM E%EMPT fROM THE CONTRACTORS U- GafagOlCHfpOR W CENSEUWFOiiTHEFOLLOWINOREASON(SEC.7031.58USINESSANDPROFESSIONSCODE:ANYCITVOR (n 5� COUNTYNMICHR�UIRESAPERMITTOCONSTHUCT.PLTER,IMPROVE,�EMOUSH,ORREPAIRPNYSiRUC- W Patio/Deck Z TURE,PRIOR TO ITS ISSUANCE,ALSO REWIRES 7HE APPUCAN7 fOR SUCN PERMIT TO FILE A SIGNED LL� BTATEMENT T}1AT HE OR SHE IS LICENSED PURSUANT TO THE PROYISIONS OF THE CONTRACTORS LI- W � CENSE lAW(CHAPTER Y(COMMENCINp WI7H SECTIDN TaDa�OF DIVISION 30F THE BUSINESS AND PRO- � POOVSpfl FE33qN3CODE)ORTFIATHEOPSNEISE%EMP'lTHEREFROMANOTHEBA3ISFORTHEALLEGEDE%EMP- (� TION.ANYVKKATIONOFSECTION7031.5BYANYAPPLICANTFORAPERMITSUBJECTSTHEAPPLICANTTO Z Re-Roof � ACIVIL PENK7Y OF NOTMORE THAN FNE HUNDRED UOLURS(5500).i: � ❑I,ASOWNEROFTHEPROPERTY,ORMVEMPLOYEESWITHWA4ESASTHEIRSOLECOMPENSAiION, � C011'IO10fCiel � WILL DO THE WORK,ANO THE STRUCTURE IS NOT INTENDED OR OFFERED GOR SALE ISEC.7044,BUSI- J � NESS AND PqOFES510N5 COOE 7HE WNTRACTOfiS LICENSE UW DOES NO7 APPLY TO AN OWNER OF = PpOPERTY Vhq 9UILOS OR IMPROVES THEREON,ANO VMO DOES SUCH WOPK HIMSELF OR HERSELF OR fL THROU6H HIS OR HER ONM EMPLOVEES,7ROVIDE�THATSUCH IMPROVEMENTS ARE NOT INTENDED OR m . � OFFERED�ORSILLEIF,HOWEVER,7HEBUIIAINGORIMPROVEMEMISSOLDWITHINONEVEAROFCOMPLE- � • � TION,THE OWNEH-BUIL�ER WILL HAVE THE BUROEN OF PROVINO TNAT HE OR SHE DID NOT BUI��OR IMPROVEFORTHEPUHPOSEOFSALE�. W ❑I,ASONMEROFTHEPROPERTV,AMExCW51VELYCONTRACTINGWITHUCENSEDCOMRAC70R5 Q TO CON5TRUCT THE PR0.IECT(SECJDOs,BUSINESS PND PROFESSIONS CODE:THE CONTRACTORS U- VflIU2I100 __ ADJ.AREA W CENSEUWDOESNO7APPLVTOANONMEROFAPROPER7YWH08UIL�5ORIMPROVESTHEREON,pN� WFiO CONTRACTS FOA SUCH PR0.1ECT5 Wlhi ACONTRACTOR�S)LICENSEO PURSUANT TO THE CONTRAG 7oFlSUCEn�SEUW.� QUANTITY DESCRIPTION FEE � ❑i AM IXEMPT UNDER SEC.i 9.8 P.C.FOR THIS REASON Q 3 v � - -- a� DATE OWNER _ V � LICENSED CONTRACTORS DECLARATION W J � 1 HEflEBV AFFIRM UNDER PENALN OF PERJURV THAT I AM UCENSED UNDER PROVISIONS OF CHAPTER �, ^ .�-r� (i 0(COMMENCINO WITH SECTION 7a00)OF DIVISION 3 OF THE OUSINESS AND PROFESSIONS CODE,AN� z V X MV UCENSE IS IN FULL FORCE ANO EFFECT m LLI _�_ s/�S�'t 3 � UCENSE CLASS LIQ NO. j ^ J V DATE�����r~� CONiRACTOR�Y✓P�6/� a. W � � WORKEFiS'COMPENSA7iON DECLARAT{ON Q � IHEREB AFFIRAIUNDERPENALTYOFPERJURYONEOFTHEFOLLOWINGDECL4RATIONS: Z � I HAVEAND WlI1 MA�NTRIN A CERTIFICATE OF CONSENTTO SELF-INSl1RE FOR WOPKERS' _ COMPENSATION,AS PROVI�ED BY SECTION 3700 OF THE I.ABOH CODE,POR THE PERFORMANCE W Q OF THE WOHK FOR WHICH THIS PERMIT IS ISSUED. � � I HAVE AND WILI MAINTAIN WCFiCEPS'COMPFNSATIpN INSURANCE,AS fiEOUIREO BY SECTION Q37000FTHELAHORCOOE,FORTHEPERf-0RMANCEOFTHEWORNFORWHICMTHISPERMITIS t55UEA.MV WO��S,'.C�O�MP/@�NSATION INSURANCE CARRIER AND PO�LICrY YN+UMBER CONSTRUCTION � CARRIER__._��' /���_ r .�fv.+- -�I PLAN REVIEW -- Js-. � � POLICV NUMBER___��.���_Z?�����r+ e��_ ELECTRIC �` ¢ 0 (n+s�cipr+N�no'reEoxna_etmaF���:tM�swaon�EtrtxartE�oa.t.uis(E�oo)oA�Essa PLUMBING _ V W z I CERTIFY THAT INTHE PERFORMANCE OF hfE W�RK FOR WHICH THIS PERMIT IS ISSUE�,I MECHANICAL � (3 SHA:L N07 EMPLOY ANY PERSON IN ANY MANNER SOAS TO BECOME SUBJECTTO THE uy WORKERS'COMPENSATION LAWS OF CAUFORNIA,AND AGAEE THAT IF I SHOUID BECOME INSPECTION FEE = SUBJECTTOTHEN/ORKERS'COMPENSATIONPROVISIONSOFSECTION37000FTHEUBOR ' CAOE,ISHALLFOfiTH//WITHCOMPLYWITHTJHJ9#EPflOVISIONS. ISSUANCE � O „���,�"� APPLICANT: ✓�(.I/� SMIP � .. '______� p DATE: J WARNING FAIIURE TO SECURE WORKERS'COMPENSATION CAVERAGE IS UNLAWFUL,AND SHALL BE ENERGY P/C �y, SU&IECTANEMPLOYERTOCRIMINALPENALTIESANOCIVILFINESUPTOONEHUN�REDTHOUSAND ENERGYPERMIT DOLLARS(S1ao.o0a�.IN ADDITION TO THE COST Of COMPENSAT�IXJ.DAMAGES AS PROVIDED POR IN � SECTION37080FTHEL4BORCODE,INTEREST,ANOATTOPNEY'SFEES. RETENTIONFEE: � CONSTRUCTION LENDlNG AGENCY PRE-ALT FEE: i O C= I HEREBYAFFIRM UNOER PENALTV OF PERJU(iY ATTHERE IS A STRUCiION LENDINGAGENCY n- FORTHEPERFORMANCEOFTHEWORKFOR ICHTHISPEFMITI ISSUE�(SEC.3D97.CIV.C.�. � LENDER'SNAME f✓�Pi'" ��I/�'� ' F— LENDER'SADORE55 � I CERTIFY7HAT I HAVE READ THIS APPLICATION AN�STATE THAT THE ABOVE INFORMATION IS CORRECL TOTAL FE ES � �„ ` L,5 � I AGREE TO COMPLV W1TH ALL CITY RNO COUNT/ORDINANCES ANO STATE LAWS FiELATING TO BUItDING e \U +LJ � CONSTRUCTION.AND HEREBY AU7HORIZE REPRESENTATNES OF THIS COUN7YT0 ENTEH UPON THE . 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