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HomeMy WebLinkAbout16494 (20) `� ;'`� t 'i _�� CITY OF DIAMOND BA� � DEPARTMENT OF COMMUNITY&DEVELUPMENT SERVICES 21660 E.Copley Drive Suite 190 � .� (909)860-3195 Fax(909)861-3117 PRESS „��°,,.' BUII.DING PERMIT APPLICATY(�N� ,� FIRMLY � JOBSITE �7 �/� �� ��,�'F����,.�. � . APPUCATION PERMIT i ��� P!C �1 _ �g� o ADDRE55 < <<� DATE NUMBER �� # � APN LOT TRACT S���i'-7 ISSUE TYPE OCC � / - DATE CONST. GROUP OWNER G`� � Iw FS o ADDRESS S� G' ' /1 � � ','�ry ZONING SETBACKS � CITY �2L°IN� ZIP� TEL. I �+ FRONT RW ❑ APPLICANT TEL. REAR ❑ � SIDElSIDE STREET RW ❑ CONTRACTOR SIDE ❑ ADDRESS .- � CITY ZIP TEL. PROPOSED USE �� '- � ARCWENG/ "�� � DESIGNER �� -sS�C- ` � ADDRESS� 4 �` �- UNITS EL STORIES BEDROOMS y CITY 21P TEL.�Ri/�-7 tn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION O OWNER-BUILDER DECLARATION SFR/ADD/fiEM �I '� p I HEREBY AFFIRM UNDER PENAL�'V OF PERJURY THAT I AM EXEMPT FflOM THE CONTRACTOqS LI- Gefd e/Ca oR W CENSELAWFORTNEFOLLAWNlGREASON(SEC.7037.SBUSINESSANDPROFESSIONSCOOEANVCITYOR � 9 � � C7 COUNTYWHICHREd11qESAVERMITTOCONS7RUCT.ALTER,IMPRpVE,�EIAOLISH,ORREPAiRANVSTRUC- W P8ii0/DBCk Z iURE,PRI�R TO ITS ISSUANCE,ALSO RE-0UIRES THE APPLICANT FOR SUCH 7ERMIT TO FILE A SI6NE0 �l� STATEMENT THAT HE OR SHE IS UCENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI� W '�� CENSE UW(CHAPTER 0(COMMENCINO WITH SECTION 7000)OF�NISION 3 OF THE BUSINESS AND PHO- LL POOUSPd FESSIONSCODE)ORTHATHEORSHEISE%EMPTTHEREFROMPNDTHEBASISFORTHEALLEGEDEXEMP• (7 V TIDN.ANVVIOLATKKIOFSECTION7031.6BVANYAPPUCANTFORAPERMITSUBJECTSTHEAPGUC0.NTT0 Z Re-Roof � A CIVIL PENhLT'OF NOT MORE THAN FIVE HUNDRED DOLlARS(S5o0).): � ❑I,ASOWNEROP7HEPROPER7Y,ORMYEMPLOVEESWITHWAGESASTHEIfl50lECOMPENSATION, � COmme�Ci81 . - WIIL 00 THE WORK,AND THE STRUCtURE IS NOT INTENDEO OR OFFEFE�FOR SALE(SEC.7044.BUSI- J � NESS AND PROFESSIONS CO�E:THE CONTRACTORS LICENSE LAW DOES NOT APPLY 70 AN OWNER OF � PROPERTV WHO BUILOS OR IMPROVES THEREON,AND WHO DOES SUCH NbRK HIMSELF OR HERSELF OR � THROUGHHISORHERONMEMPLOYEES,7ROVIDEDTHATSUCHIMPROVEMENTSARENOTINTENOEDOR m OFFERED FOR SALE IF,l10WEVEi1,hIE8U1L�ING OR IMPPOVEMENT IS SOLD WITHIN ONE VEAR OFCAMPLE- � TION,hIE OWNER-BUIIDEfi WILL NAVE THE BURpEN OF PROVING TMAT HE OR SHE DI�NOT BUIID Oq IMPROVE FOHTiE PURPOSE OF SALE). W OI.ASOWNEROFiF{EPROPERTV,AME%CLUSIYEI.YCONTRACTlNGWITIiLiCENSE4fANTRACTORS [= TO CON5TRUCT TNE PR0.IECT(SEC.)0/4,BUSINESS ANO PflOFE5510N5 COOE:THE CANYRACTORS LI� V2Ill2tlOf1 ADJ.AREA W CENSEUWDOESNOTAPPLYTOANOWNEROFAPROPERTYWHOBUILDSORIMPROVESTMEFEQN,ANO -- WFIOCONTMCTSFOfiSUCHPflQ1ECTSWITHACONTRACTOR(51LICENSEDPURSUANTTOTNECONTRAG DUANTITY DES,G,`RIPTfON FEE Y TORS UCENSE LAW.;. . - � ❑I AM EXEMPT UNDER S�C. B.d P.C.FOR THIS REASON Q _`� y U � �,. LL � _ ,5. DATE _ OWNER ___________. � e. � UCENSEO CONTRACTORS DECLARATION W J � W IHEREBYAFFIRMUNDERPENALNOFPERJURYTHATIAMUCENSEDUNDERPROVISIONSOFCHAPTER � /� d B(COMMENCINO WITH SECTION 7000)OF OIVIS!OP'30F THE 8l1SINESS AN�9ROFESSIONS COOE,AND z �f MY LICENSE IS IN FULL FORCE EFFECT. m . ,�, 4. .p__� 11J �,._� / � � � LICENSE CLASS � LIC.N0. � V DATE���s,/L�/'°���ONTRACTOR. �.f.� �' � d W ,,, � Y WORKERS'CQMPENSATION DECLARATION Q 2 � I HEREBY FFIRM UNDER PENALN OF PERJURV ONE OF THE FOLLOWING DECLARATIONS: Z - � MIIVEANDWILlMA1NTAINACERTIFICATEOFCONSENTTOSELF-MSUREFORWORKERS' ¢ 2 ���� COMPENS0.TION,AS PROVIOED BV SECTION 310o pP THE LABOR CO�E,FOF 7HE.PERFORMANCE C) Q OF 7HE WOflK FOR WHlqi THIS PERMIT IS ISSUED. � y � IHAVEANOWILLMAINTAINWORKERS'COMPENSATIONINSVRANCE,ASREQUIREDBYSECTION � 37000FTNELABOflCODE,FORTNEPERFOFMANCEOFTHEWORKFOHWHICHTHISPERM1T15 (� ISSUED.MY WO�R [JS..'-COMP�NSATON INSURPNCE CARFIER AND�PO,U/�CY NUM/Bb/�ARE: CONSTflUCTION �,J � CARRIER�_('f/ �' ���_ �1P.� � _.���eS��. l"/�'� PLAN REVIEW Z POLICY NUMBER__�1gm� W � � ` � � ��,.�, ��, ELECTRIC ¢ , ��"----- � (fH�s[cTi7Nn1E�Ho76Eo�Ms'LEfE6t�il-EPEf�Y,MisWRONEHunOHEDDouaAs(Stao�orsLEss). PLUMBiNG � Y,Yr � I CERTIFV THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUE�,I MEGHANICAL .� __ I � � � ��� � SHA.L NOT EMPLOY ANV PERSON IN AtdV MANNER SOAS TO BECOME SJBJECT TO THE � WORKER5COMPENSATIONLAWSOFCAIFORNihAND0.CREETHA71FI5HOUL�BECOME INSPECTIONFEE _ � SUBJECTTOTHEWORKERS'COM�ENSATIO4PROVISIONSOFSECTION37000FTHELABOR ' �,� �ti. j f� � CODE,ISHAIJ,.FO�RyTHWITHCOMPLYWITHT SEPROVIS�ONS. ISSUANCE �� ev �l'� p �� —��t—/LL= SMIP j'"l. U i i.A � DATE: � V APPLICANT. ENERGY P(C �V � � WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNUIWFUL,AND SHALL BE i �y SUBJECTANEMPLOVERTOCRIMINALPENALTIESANDCIVILFWESUPTOONEHl1NOREDTHOUSAND ENERGYPERMIT � � OOL;ARS(E'�00.000).IN ADDITION TO THE COST Of COMPENSATION,�AMAGES AS PROVIDED FOR IN ^ (�� � SECTION3l680FTHFUBORCOOE,INTEREST,ANDATTORNEY'SFEES. RETENTIONFEE: '1�� W OCONSTRUCTION LENDING AGENCY PRE-ALT F E: � IHEREBVAFFIRMUNOEflPENAITYOFPERJUFYTHATTHEREISACONSTRUCTIONLENOWGAGENCY _ L FORTHEPERFORMANCEOFTHEWORKFOR NICHTHISPERMITIS UED(SEC.3oB7,CIV.C.). , . . W ,+1 •/�-y,��- � LENDER'S NAME_�}`Itr�� G'' L_.�"- _______._____._—._ . . . .. 1--� LENDER'SADORE55 n� � � ±V� � + � W I CER7IFV iHAT I HAVE REA�THISAPPLICATION AND STATE THAT THE ABOVE INFWilAATION IS CARFiECT. TOTAL FE ES X � IAGREETOCOMPLYWITHALLCITYANDCOUNTYORDINANCESANDSTATELAWSflELATINCaTOBUIL�ING U � CANSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OFTHIS COUNTV TO ENTER 11PON THE . Z ABOVE-MENTIONm PpOPEHTV FOq 1 PECTION PUFPOSES. COMMENTS o N��,^-� � m GERMRT E NAME(PRI ) ' ran .�..� ����C- 51 REOFPERMI E DATE '�"'�"""� � RECPT.NO. 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