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HomeMy WebLinkAbout16515 (20) _ �,�_ CITY OF DIAMOND BAbt DEPARTMENT OF COMMUNITY d�D�VELOPMENT SERVICES 21660 E.Copley Drive Suite 190 w (909)860-3195 Fax(909)861-3117 PR ESS A,�'`�' FIRMLY BUII,DING PERMIT AP1'LICATIbN ; _. . ,,_ _a . . . .., , ,,_. � JOBSITE >- �ij��`L� �G��,�Ln PJL ,�-- Cg APPLICATION ��� ��(�} PERMIT � � , � P/C a ADDRESS l°�-Ft c� DATE NUMBER # � APN LOT 3 TRACT �Z?GsY ISSUE TYPE OCC � DATE CONST. GROUP p OWNER � .�df,�S'.� , ,p ADDRESS ��/J/ [9rt/ �r'T� ZONING SETBACKS �W CIN.�,�/N� ZIP� TEL.�� �y FRONT RW O � REAR APPLICANT TEL. SIDE/SIDE STREET RW ❑ � CONTRACTOR_ SIDE ❑ ADDRESS � CITY v ZIP s TEL. PROPOSED USE ,,� w ARCH/ENG! z DESIGNER J�O�-' ^ rS..(n � . ���-- w - NO.DWEL. NO. NO. � CDDRESS�� E�.j��c/� UNITS STORIES BEDROOMS � � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-BUILDEA DECLAFiATION SFR/ADDlREM O p I MEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI- G1f&90/Cef(JOti W CENSEUWPoRiHEFOIIOWINGREA50N(SEC.7037.58USMESSANOPFIOFESSIONSCODE:ANVCITVOR (� couNivNMICHREIX11RE5APERMITTOCONSTRUCT,AL7ER,IMPHOVE,DEMOLISH,DRREPAIRANY5TRUG W Patio/Deck W TURE,PRIOR TO ITS ISSUANCE,ALSO AEDUIRES THE APPLICANT FOR SUCH PERMIT 70 FILE A SIGNED W � STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS ll- CENSE LAW(CHM7ER 9(COMMENCIN6 Vu1TH 5EC710N 7000)OF DIVISION 30F THE BUSINESS AND PR0- V' PoOI/Spa FESSIONS CODE)ORTHATFIE OR SHE IS EXEMPTTHEREFHOMANO THE 9ASIS FOP THEALLEGE�E7(EMP- (� TION.ANVVIOUTIOtJOF6ECTION7o31.5BVANYAPPIICNlTFORAPERMITSUBJECTS7HEAPPUCANTTO Z Re-Roof F, ACIVIL PENALT'OF NOT MORE THAN FIVE HUNORED DOLLARS(SSoo).): � ❑I,ASOWNEROFTHEPROPERTY,ORMYEMPLOYEESWITHWAGESASTHEIRSOLECOMPENSATION, � COfI1RIBfCiBI . - WILL DO TNE WOFi1C,AND THE STRUCTUqE IS NOT INTENDED OR OFFERED FOR SALE(SEC.70l4,BUSI- J � NE55 ANO PROFESSIONS COOE:TfiE CONTMC70F5 LICENSE LAW DOES NOi APPLY TO AN OWNER OF = PROPERTY WFp BUILOS OR IMPROVES THEflEON,ANO VMO DOES SUCH WORK NIMSELF OR HERSELP OR � THROUOM HIS ON HEROWN FMPLOYEES.PROVIDEO THATSUCH IMPfiOVEMENTS ARE NOT INTENDEb Oq CO � OFFEREDWRS/LEIF,HOWEVE0.tNE8111lDINGORIMPROVEMENTIS50LDWITHINONEVEAROFCOMPLE- � Z TION,THE OWNER-BUfLOER WILL HAVE TME BURDEN OF pqOViNG THAT HE OR SHE Dlb NOT BUIL�OR � IMVi�VE FOR THE PURPOSE oF SALE�. W ❑I,ASOWNEROFTHEPFlOPERTV,AMEXCLUSNELYCANTMCTINGWITHLICENSEDCONTRACTORS � TO WNSTRUCT THE PROJEC7(SEC.704�,BU3INE93 AN�PROFESSIONS CADE:THE CON'RACTORS Li- V0lU0[I00 ADJ.AREA W CENSELAWDOESNOTMPLYTOANONMEflOFAPHOVEflTYWHOBUILC50RIMPROVC-STHEREON.AND –"– � WHOCONTMCTSFORSUCHPROJECTSWITNACONiRACTOq(S)UCENSEDPURSUANTTOTHECANTMG ��JANTITY DESCRIPTION FEE TORS IICENSE UW.). � ❑I MI E%EMPTUNOER SEC. B.8 P.C.FOR THIS REASON Q +y U � � DATE OWNER F ' Q W �s[ IICENSED CONTRACTORS DECIARATION w K I HEREBY AFFIRM UNDER PENALTY OF PERJURV?MAT I AM LICENSED UNDER PROVISIONS OF CNAPTER � j� �y Y(COMMENCINO NATH SECTION 7000)OF DIVISION 3 OF 7HE BUSINESS AND PROFESSIONS CODF,ANO Z V �X� MYIICENSE 1511J FULL FORCE D EfFECT. � I� rG � UCENSE CLA/S�S_�,_ LIG NO. l J g V �ATE��c�k�v.. / �� GONiRACTOR f���"'_,�- d — W � , lR'ORt<ERS'COMPENSATION DECLARATION Q � I HER Y AFFIRM UNDER PENAITV OF PERIURV ONE OF THE f-0LLOWING DECLARATIONS, Z L� IHAVEANOWI:LMARITAINACERTIFICATEOFCONSENTTOSEIF-MSUREFORWORKERS' ¢ z = Q WMPENSATION,ASPROV!DEOBYSEC710N3looOFTHEUBORCODE,FORTFIEPERFORMANCE U OFTHE WORK FOR WFfICH THIS PfF4.11T I5155UE0. w � � w I HPN[ANO WILL MAYJTAIN WORKERS'CAMPENSATION INSURANCE,AS REOUIRED EY SECTIDN /T_9�, Q 37000FTHElA00HCODE,FORTHEPERFORMANCEOF?HEWORKFORWHICHTHISPERMITIS \ __ / .C/.I I55UE0.MV YlOR ti'CAMPENSATION INSU�RAN,G,rE�CARRIERAND POLIGY NUMB AflE: CONSTRUCTION +�T�z^� ��'�—• � CARRIER���__[_� �7'+7�_��5� �C,'�� PLAN REVIEW _ a ���NUM�ER, '�������%� d�� ELECTAiC � �„���. � 7��-7- � Q (tH SECflOfJNEFD 8E(.Y�.4�f_EfF.DOFh�PFRI�NTlSFOR[XJEFIUI�C7REDOIXIARS(E10D)ORLESS� PLUMBING 1 � . �l..✓ Z 1 CER11fY TNAT IN THE?ERFCRMPNCE OF THE WOAK FOq WHICH THIS PERMIT IS ISSUED,i MECHANICAL (3 SHALLNbT EMPLOYANY PEft50N INANY MANNEfl SOAS T08EGOME SUBJECTT07HE (�j WORKEHS'COMPENSATIONLAWSOFGALIFORNIA,ANDAGFEETHATIFISHOUIDBECOME INSPECT�ONFEE SU&lEC f TO THE WORKERS'COFIPENSATION PRO`J1510N5 OF SECTION 3700 OF THE LABOR �j COOE,I SHALLFORhiWITH CAMPLY WI7H7H E�'ROVISIONS. ISSUANCE �� a ��i"�.��IAPPt_1CANT: SMIP p DATE:�_�C_ '�f,L+� _ J WMNING:FAILUFE TO SECUFE WOflKER5'COMPENSATION COVERAGE IS UNLAWFUL,ANO SMALL BE ENERGY PIC � SU&IECTANEMPLOYERTOCRIMINALPENALTIESANOGIVILFINESUPTOONEHUNDREOTHOUSANO ENERGYPERMIT DOLLAiiS(5700.000).IN ADDITION TO THE COST OF COMPENSA710N.DAMAGES AS PROVIDED FOR IN ¢ SECTION 3708 OF THE LABOR CODE,INTEREST,AND ATTORNEV'S FEES. RETENTI ON FEE: OCONSTRUCTION LENDING AGENCY PRE-ALT FEE: � IHEREBVAFFIRMUNDERPENALTYOFPERJURV ATTHEfiEISACONSTRUCTiONLENDINGAGENCV _ _ FORTHEPERWRMANCE FTHEWOPKFORW ICHTHISPERMITIS�SUE�(SEC.309l,CIV.C.). W � IENDER'SNAME � L'��� F-- LEN�ER'SADDRESS _ ,/ w� TOTAL FEES ` 1 CEHTIFY THAi I HAVE REAO THIS APPLICATION nND STATE THATTHE ABOVE MFORMATION IS CARRECT. � � <J� � IAGREETOLOMPIVWITHALLCITVANOCOUNTYORDINANCE50.NDSTATELAWSREUTINGTOBUILDING � �� � CON5TRUCTION,ANDHEREBYAUTH RIZEREPRESENTATNESOFiHISCOVNTYTOENTERUPONTHE Z ABOVE-MENTIONED PROPERTV FO NSPECTION PUFPOSES, COMMENTS � -_.�i���c. — ' ..f' . � -- m PEFiMITTEE NAME INT) - � � � ._z��.v l. vj SIG URE Of PERIAI E DATE �r' � RECPT.NO. 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