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HomeMy WebLinkAbout13481 (22) � , CITY OF DIAMOND BAx �-1 DEPARTMENT OF COMMUNITY ISc DEVELOPMENT SERVICES /� f j 21660 E.Copley Ikive Suite 190 (909)B60-3195 Fax(909)861-3117 `� PRESS ���*"�� BUII.DIIYG PERMIT APPLICATION FlRMLY �� JOBSITE I S�� �R��7!/f 1"� La n e APPLICATION PERMIT I ��.G f P/C ADORESS ._ DATE NUMBER 0 N � APN OT TRACT �' 0� DATE ✓� ���`r ONST. GROUP � OWNER G ` :� ADDRES r N ZONING SETBACKS CITY ZIP� TEL. � FRONT RW ❑ APPLICANT TEL. REAR ❑ SIDE/SIDE STREET RW � CONTRACTOR L(i . C• SIDE ❑ g ADDRESS PROPOSED USE CITY 21P TE �O D � ARCWENG/ DESIGNER NO.DWEL. NO. NO. N ADDRESS UNITS STORIES BEDROOMS y CITY ZIP TEL. c�e DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANA�UATION ¢ OWNER�BUIIDER pEClJ1RATION SFR/ADD/REM O 1 HEREBY AFFlRM IINDEP PQIALTY OF PEfWRY THAT 1 MI EXEMPT fAOM THE CONfRACTORS LI. 08f896/C9�pOR CQ15ElAWFORTHE�OILONfiNOFEAB�N(8EC.7081.6BUSINESBANDPROFFSSIONSDODE:M1YCtTYOA (n COIAffYMh11CJ11tE0U1RES�trERMRTO00N8TRUCLALTER,MI7R�YE,DEMOIASH,011REPNRAHYBTRUG- � �W PeliaDeck � TURE,/RI00.TO ITS 189UANCE.ALSO AEd11RES TME MPLICANT FON 81kii PERYIT TO FlLE A BIONED W STATEMEM THAT HE OR SHE�UCENSED iUH6UAN7 TO iHE PIiOVI310N3 OF TFIE OON7MCfpp9 U� CQISE WN(Ll1AVTEFI Y�COMMENCW�M7TH SECTpN 7000J OF�NISION 9 OF TIIE BI131NESS AN�Pfq� u' �OU$Pfl iE95qN5 OO�E)di TNATHE OR SViE IS pCE4PT 7HEREFROM AND7HE BASIS FOq 1NEALLEOED E%EMP• TION.ANYVIOIATIONOFBECT10N70]1.iBYANYMPIICANTFOHl1PEHNITSUBJECT8THEMPLIC4WTT0 Z Re•Root � AqNL 7BilLL7Y OF NOT MORE TIM!FNE HUNORE�DOLLARS({60q.�: O4�OMMEROFTNEPIpPEA1Y.ORMYEMPIAYFESWITNWAOESA5THEIRSOLECOMPENSATION, 0 ��mBlCiel MALL DO THE YlORK,AND TIIE BTHUGTURE IS NOT MITENDEU OR OFFERED FOR SALE(SEG.70N,BU51� J NESS Ml�PFOFESSIONS OD�E:TME CONTii�CT00.S UCENSE LAW DOES NOTAPPLY TO AN OWNER OF ? � PqOPEFRYWFiOBUpASORRIPROVESiMEREON,AND5MiD00ESSUCHWORNMIMSELFORHERSELFOR � iTIR0U0HKSORMEfiOWNEMPLOYEES.PROVIDECTURBUCMYPROYEMENT9AilEN071MTFNDE00R m � OFFEiiEDibRSALE�F,HONIEVER�BL1L01NGORIMOHDVEY0NTI8SOLOWIfHINONEYEAROFOOUIPLE• 110N,TNE OWNER-BUILDER VALL MAVE h1E BUH�EN OF PROVINO TIA7 NE OR SHE GD NOT BNIC OR wlvnOVE PWt iNE vuflPosE oF SA1.E1. � 04�OMMEROF7HEPROVERTY,AME7ICLUSNELYCONTRACTINOWRMUCENS�CONiPAGTORS TO CONSTR{JCT THE VRQIECT(9EC.70M,BUSINE39 AND PFOFESSIONS COOE:THE CONiRACTOFIS LI- V91Ueti0ll ADJ.AREA CENSE lAVlf DOES MOTMPLYTDAN OWNEfl OF 11 PROPEFITY WIIO W ILU9 OR W PHOVE9 THEREON,MID YYFqOOMRACT8FOR8UCMiROJECTSWITiA00NiRACiOR(�LICENSEDPUNSUANfTOhiEC01lfRAG OUANTITY DESCRIPTION FEE � TORSIJCENSEUW.�. � O I AM EXEYPT UNDER BEC. B.L P.C.fOP TH16 RFJ150N � U k ¢ OIUE OWNER V � LICENSED CONTRACTORS DECLARATION � � w � INERE6YAFFIRIAUNDEFCENlLLTVOFFERtt1RYTNAT1AAlUCENSEDUNOEHGROVIS10NSOFCHAPTER � �(COMMENCWO WITM BECTIqV 7oao)OF DNi810N�OF THE B�SINESS AND CROFES9tON5 CODE,AND W LICENSE 16 N FULL FORCE AND EFFECi. m L N_� 0 LICENSE C1A53 LIC.NO. v >�_ J �j UATE '� CONTMCTOR a � WORKERS'COMPENSATION OECLARATION a � IHERE6YAFFlRMUNDERPENALTVOFPERIURYONEOFTFIEFOLLONANODECLARAiDNS: Z � _IIUVENiDN7LLWINThM1ACERTIFICATE�CONSEHTTOBEIF-INSUREFORWORNER6• _ OOIAVEMSA7I�N,AS PHOVDED BY SECTON J7ao OF 7HE U180R OOOE,POR iME PERFOFMANCE �U OFTFIE WORK FORNMICIITMIS PERMR 191SSUEA. � Q K �tiIAVEAND WILLMAWTAW YlORKERS'COMPENSATION INSURANCE,AS REOUIRmBYSECTION a7aoOFTV1EUBORWDE,fORTNEPENFORMANGEOFhIEWOPoCFORNMIq17N19PERMITl9 � ISSUEU.W WORNE ' �SATION INSl1MNCE CA IERAND POLICY NUMBER ME� CONSTRUCT�ON ? CIINRIER Z- PLAN REVIEW _� � Pd.ICYNUAgER ELECTRIC 0 (nissECIpNNE�r+orBEaol�tET�OF7IEPE�M1'6PDRa�EM1N]REDD0.W79lf+U%OpLEss} PLUMBING � .. �m._�'yy.� � I CEIITIFYTHA7 NTHE PERFORMMICE OF hiE WORK FOR WHtCH TNIS PERMR IS ISSUED,I MECHANICAL �; '. �- �- ("`''`� (�'� SM�1LL NOT B+IPlOY ANY PERSON N ANY AAIWNER SO AS TO 9EC041E SU&IECT TO TNE ',:.�,. . 1 � . � � WOPoCERS'COMPEN9ATIONLAWSOFCALIFORNIA,AN�M3REETHATIF19MOlROBECOME INSPECTIONIFEEI "�: S 6UgIECT TO THE WORKERS'CdAPENSA710N PROVISIONS OF 6ECTpN a70o OF THE IABOR ... ..`... . . . .a'e; ' OODE.ISHALLPoRTIIY/ITHCOMPLYWI7HhqSEPNOYISIONS. ` ISSUANC:E ' : i:L=,i•��`-ie k.'L'1� • � p /, � JEA1 SMIP p DA7E:s-rr-���. APPLICANi: I�c�c-ha rd �T' ���I � WMNINO:FAILURE 7D SECURE WORKERS'COMPENSATION COVERAOE IS UNIAWFUL,IVW SHALL BE ENERGY P/C Sl1BJECTANEMPLOYEN7DCRIMINALPENALTESANOqVILFINESUPTOONENUN�RED7F1oUSANO ENERGYPERMIT DOLURS(tloo.000�.IN�DDRION T07F1E COST Oi COMPENSA710N,DAMAOES AS PROVIDED PDR IN � BECTIONs70sOFTHELABORCODE,INTEREST,lWDATTORNEYBFEES. RETENTIONFEE: CONSTRUCTION LENDING AGENCY PRE-ALT FEE: � IHEREBYAFFIRAIUNDERPENALNOFPERIUMTHATTHEREISACON&THUC710NLENDNOAOENCV z FOR THE PERfOPMANCE OF TTIE WORK FOR WHICH TNIS iERMiT IS ISSUED(8EC.70Y7,dY.C.). W � LFTDER'f NM1E �S LQJDEN'BADOiiESS w ICERTIFYTii�711MVEREADTMISMPIICATION/�NDBTATEl/MT7HEABOVEINFORMIITIONISCORRECT. TOTAL FEES d IWHEETOCOMPLYW7IHALLGiYMlDCOUN7YORDWWCESMI�STATELAWSREL11iWPTOBINLDINO � CONSTIIUCTIOlLANDFIEREBVMITNORREREPPESEMATIVESOFTTtl5CO11N7YTOEMENUPONiHE ABOVEJAENiqNED PNOPEnTY FOR INSPECTION PUHPO6E5. 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