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HomeMy WebLinkAbout15412 (35) � r,--�... � � � � � �`� ^ _�� CITY OF DIAMOND BAB �� DEPARTMENT OF'COMMUNTTY&DEVELOPMENT SERVICES �r�`� 9 y >`�"s' :;:�,a�,� w 21660 E.Copley Drive Suite 190 " ' , I (909)860,3195Fax(909)861-3117 '�+ / PRESS ' ��''��' ' BUILDING PERMIT APPLICATION FIRMLY Q� JOBSITE ll APPLICATION - � �(}' NUMBER�� �"" #� a� l ADDREBS ff DATE ` ', � � ISSUE TYPE OCC r- APN OT'� TRA T DATE CONST. GROUP p OWNER .+ �` ADDFl SS ZONING SETBACKS ' , �W CITY 4P ZIP,�C�'�TEl��u�a����./"� REART RW ❑. APPLICANT TEL. SIDE/SIQE STREET RW � z � COIVTRACTOR ' SIDE ❑ , � ADDRESS I PROPOSED USE u t/ �. , Q GITY i ZIP TEL. w ARCN/ENG/ ' z DESIGNER � W � NO.DWEL. NO. NO. a ADDRESS UNITS STORIES BEDRO�MS �' CITY ZIP TEL. us' rn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AR�ANALUATION � ClWNER-BUILDER DECLARATION SF ADD EM O I HEflEBY AFFlRM UNDER ENPLTY OF PER1U'AY THAT i AM E7(EMPT FROM THE CONTRACTORS LI- GdfBJ 2f�JOf[ ��, O .. ..,. W GENSELAWFOflTHEFOLLOWIN�REA50N�SEC.7o95.56U5ME5SANDPR6FES510N5CODE:AN7CITYOR (n U�� COUN7YWH{CHpEWIRESAPERMITTO�NSTRUCT,ALTER,IMPROVE,DEMOLiSH,ORREPAIRAFlYSTRUC- W patl0/DBCk . W TURE,PpIOR TO ITS ISSUANCE,rLSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED w . ' " STATEMENT THAT HE OP SHE IS LICENSED PUidSUANT TO THE PROVISIONS OF THE CONTRACTORS Lb - I �' CENSELAW(CHAPTERe(COFAMENCINOWITHSECTION70a0)OFDIVISION30FTHEBUSINESSANDPR6 � POOUSP2 ' � � � S FE5910NS CODE)OR THAT HE O SHE 19 E%EMPTTHEflEFROM AND THE BA3I3 FOR 7HE ALLEGEU EXEMP- � V TION.ANYVpLATKKJOF5fCT10�17031.5BYANYAPPLIGANTFORAPERMITSU&IECTSTHEAPPLIGlNTTO Z Re-ROOf � � � �� � A CML PENALTI OF NqT MORE TiHAN FIVE HUNDREO ODLLARS�S5u6),): �, � ❑I,ASOVMEROFTHEPROPPPEATY,ORMYEMPLOVEESWITHWAC+ESASTHEfflSOLECOMPENSATION, C� COn1RlerCidi � ' � . WILL 0�FHE WtlRK,AND THE S�Rl1CTURE:S NOT INTEN�ED OR OFGERED FOR SALE(SEC.7046,Bl1Sl- J �. �� NESS AND PWOFESSIONS COD6:THE CQNTRACTOFS LICENSE lAW DOES NOTAPpLV TO AN OWNEfi OF � , �� ' � � PflOPERNYVFpBUILDSOflIMP OVE$THEREON,M7DKMODOESSUCHWORKNIMSELFORHERSELFOR ' ' CC THFiOUdiH190RHEflOWNEMPOYEE3,PHOVID�THAT3UCHIMPROYEMENTSpRENOTINTENDE�OR � , Q, ,OFFEREDFORSAI.EIFHONIEVEF�,h1EBUILDINGORIMPfiOYEMEN�I550LDWITHINONEYFRFOFCOMPLE• � � Z 'TfON,THE OWNER�BUIL�ER WILL HAVE THE BUR�EN OP PRQVING THAT HE OR SHE DID NOT BUILD OR . �, IMPROVEf-0RTHEPURPpSEOFSALE). � ❑I,ASOWNEROFTHEP ERTV,AMEXCLL751VELYCONTRACTINGWITHLICENSE6:ANTRACTORS , � TO CONSTRUCT THE PRQIECT�(EC.7DA4,BUSlNESS ANO PpO�E5510N5 CODE:THE CONTRACTORS�I- VdIU8f10f1 ADJ.AREA �� L�'J' CEN&EIAWDOE5NOTAPPLYTQANOVMlEROFhPROPER?YWH09UIL�SORIMPFOVESTHEREON,AND ��� NhIOCONiRACTSFOR3UGiPRfkIECTa'WITHACDNTPACTOR(5)LICEMSEDPUR9l1ANTTOTHECONTRAG qUAP1TITY DESCRIP310N � FEE - 'Y. TORSLICENSELAWJ. '� ' � ❑i AM EXEMPT UNDER SEO. /B. P.C.fOR THIS REp50N Q �� L�• �/y��. � ' � � �� `—' <h/7"�6�f a ��. DATE I oWNBR U � Z' i � �, UCErySED CONTRACTOAS DEC F! � �� IHEAEBYAFFIRMUNDERPENAl.II'YOFPERIURYTHATIAMLICENSEDUNDEflPROViSIONStlFCHAPTER �, ' !�'/�JS G�,.� � � - (1,'. 4(COMMENCINO WITH SECTION y000)OF�lVISION 3 OF7HE BUSINESSAND PROFESSIONS CO�E,ANG � ?��', MtlUCENSEISItVFULLFOflCEA�7DEFFECT. m / G.1, c . Q� LICENSE CLASS I L9C.NO. �j �� / . /a A � �L J I C.-- �L �� DA7E '��. CON7R.ACTOR �d � ���. WQRFf�RS"COMPENSATION DECLAr7ATICiN - —! • G.` /�� �Lv� � y�G � Q Z�C1 L' c�1�2'4�+v �'j/f� �-�.f` E ��% �� I HEREBYAFFIRM UNDER PENAL7Y OF PER1t1RV ONE CF THE FOLLOWING DECLARA7IONS: Z I F'1_^,N r` Y�i �' _iHAVEANOl�716L0.fA1N7AINACERTIFICATE6FCAHSENiTOSELF-INSVPEFOi1WORKERS' �-Z �. � ' '� � . - . GOMAEN9A7fON,ASPpOVIDE00Y9EC7lON9'loO.OFTHELA80RCODE,FORTklEPERFORMANCE w OF Tt;E WORK FOR WHi(�H THIS FERMtT IS ISSUED. . C']� . � . . � . Q� �14iAVEANO WILLMAIMA�N WORKEPS'COMPENSATICN INSURANCE,AS RcQUIfiED BV SECTION � 37COOFTHE tA50R CAdE.FQP THE PERFORMANCE OF THE WORY.FOR WHICH THIS PERMIT IS 7 J,, ISSUED.MYWUNKF.RS'�(7MPEF19AT10NINSURANCECARfiIERAN�POLICYPiUMBERARE: CONSTRUC�ON ,/,_ i � � J...��T� a t j caaR�ER----,--.-- -- ----- PLAN REVIEW L� �. POLICY NtiMBER � — FLEL'TAIC Q °� (TH6°,SEC4pWNE�Nb76EC0i�/33EfmOFiF�PEFP.9TISFORIXJEHUPDfiEDWIIPAS($900)ORLE55�. PLUMBING i./�'*��� �.�'. I CEflTIFYTHAT INTHE FIERFORMANCE OP THE WORK FOR WHIQH THIS PERMIT IS ISSUE�,I MECHANICAL ___ ��� Cg SHALLN6TEMPLOYAN'�PEHSONINANYNANNERSOA5T08ECAMESUBJECTT07HE . � -- �%y WOFKEAS'COMPENSAT�LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME INSPECTION FEE � S SUBJECTTOTHEN/0R1C AS'COMPENSATIONPROVISIONSOFSECTION37aoOFhiELA80R ,'.� CADE,I SHAIiFORTHWIIfH COMPLY WITHTHOSE PROVISIONS. ISSUANCE ��� SMIP '+���� '�.e�� p DATE: APPL:ICAPIT. n _ � WARNiNO:FAILURE TO SECVRE f"dOfi14EH5'COMPENSATION COVEftAGE IS UNLAWFUL,AND 3HALL fiE ENERGY P/C ` �'. SU&IECTANEMPLOYERTOCRiM�NAIPENALTdESANDCiVILFINESUPTOONEHUNDflE�THOUSAND ENEFGYPERMIT —������y�� � ���� DOLLARS(S1 W,000),IN ADDITiOf�TO THE COSTOF COMPENSATION,DAMAGES AS PFOVIDED FOR IN y��ry+�7� � SECTION 37080F THE L460R DE.INTEREST.AND ATTOP.NEY'S FEES. � gq°�6 � � RETENT�ON FEE: �a V�✓�"'_ o C�NSTRUCTION LENDING AGENCY � ��B_�_ Q PflE-A FEE: �� I HEREBV AFFIRM UNDER PENA OF PERJURV iHATTHERE IS A CONSTRUCTION LEN�ING AGENCY « � �'''��I � FOR THE PERFOHMAkCc OFTH�WORK FOR WHICH 7HI5 PEftMiT IS ISSUED(SEC.3097,CIV.C.�. . LL! � LENDER'SNAME - � 1-- LENDER'SAD�RESS � L TOTAL FEES s � A I�, � I CERTIFY iHAT I HAVE READ THi�APPLICATION AND STATETHATTHEABOVE INFORMATION IS CORRECL I �y. I AGREE TO COMPLV WITH ALL C AND COUNTY ORDINANCES AND STATE UIWS RELATINGTO BUILDING ZCANSTP.UCTION,ANDHEFiEBVAITHOqIZEREPRESENTA7IVESOF7HISCDUNTVTOENTERUPONTHE �� � ^` �� � � �' ��"i 0.BOVE-M NPIONED ORCPERTV�OR 7NSP TIOM PURPOSE. CO�uSMENTS Q m –��_ ¢ PERMI E N E INn � C!) 0^�, � SI P MITTEE DATE ,y RECPT.N0. PAID BY VALIDATION � , WHITE--Department Capy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN--AppiicanPs Copy � . i,�'�`'�`v .;..r' .3`,.� �k".� € s r� j,,, � ,� ,.nq'":" .., .[ w� k a�.� $.,�f�;��`?�. m'w.X'".�: . . � �'. �«,;��.� ��fr..:i r x�,,� n��a':`�', . � _ . k;��� . ,.,?,� ,J�w'> � � .�.� �,� � � ��,'.,:.. a �' ��a� m.,�.v .� ¢ i� ��'.�����,p ,� "�"' i t ' y„.r•�'§1'�'"� . 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