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HomeMy WebLinkAbout13485 (29) ___� CITY OF DIAMOND BAB /� DEPARTMENT OF COMMUNITY dc DEVELOPMENT SERYICES ` . � . 21660 E.Coplcy Drive Suite 190 (909)860�3195 Fax(909)861-3117 PRESS �'^�'�� BUQ.DING PERMIT APPLICATION FIRMLY � JOBSITE APPLICATION PERMIT �(, P/C o ADDRESS I S�� Sap�hire La"� DATE NUMBER I �l� M � ISSUE /� f ' � TYPE OCC APN l T TRACT �ATE 'T I`�"��'1� CONST. GROUP g OWNER � 'C � ADDRESS ZONING SETBACKS �6� FRONT RW ❑ APPL.ICANT � ZIP� TEL. J���! S DE/SIDE STREEf RW ❑ CONTAACTOR �. SIDE p ADDRESS PROPOSED USE � CITY �� � ZIP�y TE �I � ARCWENG! DESIGNER NO.OWEL. NO. NO. ADDRESS UNITS STORIES BEDROOMS NN CITY ZIP TEL. DESCRIPTION S�.FT. FACTOFi PSF ADJ.AREANALUATION d OWNER-BUILDER DECLAHATION SFR/AD�/RffM O I NEREBV AFFIHM UNDER P@dAITY OF PERIURV TUT I M/EXEMPT FROM TNE COMRAC70R5 U- Ge�9���M CEIVSELAWFOR7FIEFOLLOWINOREAAON�SEC.7o31.6lUSWESSANDPHOFES910N9000E:ANYCRYOH (n COl1HIYNMICFIqEGUIRESAPERIIR7�CDWSTAl1Cf.ILLTER�MPNOYE.�EMOLISH.ORREMIRNiY9THUG �W P8�101D6Ck RJRE,VAIOR TO ITS 165UANCE,AL30 REOUIRES THE MPLICAHT FOR BUCH PERIAIT TO FLE A SIONED W ETATEMENT h1AT XE OR M1E IS LJCENSED iURSUMR TO 71iE GROYISIONS OF iME CONTRACTORS L4 CENSE L�N�(CHAMEF 9(COMMENCINO WITH BEGTION 7000�OG OIVISION f OF THE BUSINE55 ANO Pq0- � POOUS{/8 FESSpNS OODE)OR THAT HE OR SHE IB E%EMPT 7HEREFqOM AN�THE 6A315 FOq 7HE HAEOED IXEMP- TqN.ANYYpLATIONOFSECTION7031.6BYNIYMPLICANTFORAPERMIT6U9.lECTSiIiEAPPLICANTTO Z pe-Roo1 F,,, ACMLPENALTYOFNOTEIOpE7HlWFNEMUNDREODOLURS�t50o).): � 01.1450WNEROFTHEPRDPFR71:OFiMYEMPLOYEE3riITNW.OGESASTNEIRSOLEOpMPENSATION, L� CORITBfC18I � "' IYILL 00 TME riOi1K.AND TME BTRIICTVRE IS NOT IMBJDEU OR OFFERE�FOR&LLE I6EC.70M,BU64 J NE55 AND PROFESSIdS CODE:TFiE CONTMCTORS IICEN3E UW OOES NOT AVPIV TO AN OWNEN OF � PRO►ERIVNIFiOWMDSORI►1P110VE8iHEREON,MIDVAIODOESSUCHWOHKHIMSELFORHERSELFOR � iHROUpFIMISOfiHEROWNENPLOYEE3.iROVIDE07741T0UG�MIPNMOVEMENTS�RENOTINTENDEDOR 'm OFFERW fORBALE IF,HOYVEVER TME BUILDINp Op MAPIIOLEMENT IS SOID WRMNONEYEAR OFCOM7L.E• ' �TIOH,7HE OWNERSUILDEH WILL HJ�VE T1E BURDEN OF PRDVINO 111AT HE OR 6NE DIU NOT BUIID pq MGRDVE FOfl TFIE PURPOSE OF 6ALE} � O 4u OWNER OF THE PROPE/T',AM IXCLUSNELV CONTRACTINO NA7H L10EN8ED CONTRACTOq3 M CONSTHUCT 7FIE►ROJECf(SEC.70�a,BU9INESS IJID PPOFESSIONS COCE:THE CONTH�CTORS LI• V91U8[IOfI ADJ.AREA CEN9E lAW DOES NOT APVLY TO AN OWNER OF A PROPERTY Yhq BUILDS OR MPHWES THEHEON,AND WFqCONTRACi6FOR8UCFlPROJECT8WITIACONTRACTpR�3)LICENSEDPURSUANTTOTHECONTMC pUAN717Y DESCRIPTION FEE � lOPS UGENSE V�W.} ❑1 AM IXEEIPT UNDER SEC. B.�P.C.FOq THIS REASON Q U LL � DATE OWNER V � UCENSED CONTRACTORS DECLARATION —� � w 1 MEREBYAFFIRW UNDER GENaLTY OF PERNi1Y 7T1AT IAM UCENSED UNDER VPOVISIONS OF CHAPTEH Vr �,,,, �(WM.IENCINO MATI9ECTqN 700%OF DIVISION 90F THE BUSINEbb AND PROFESSION3 CAOE,AN0 Z W 110EN3E I6 IN FIAl FOFlGEAND EFFECT. /� m � LICENSE CUSS LIC.NO. v V �� '� � pATE � — CONiMCTOR a WORKERS'COMPENSATION DECLARATION � � U � I XEREB�AFFlRM UNDER DENILN OF OERIURV ONE OF THE FOLL.01NiN6 DECURATIONS: Z Q _IWIVEAN�MALLLWNTAMlACEHTIFICATEOFOONSENTT08ElFINSUREFORIWHKERS' 2 � � CANPB15AipN,AS PRONDEO BY 8EC7ION 97aD OF THE L.�BOR CODE�R TNE PEPFORMMICE W OF TFIE WORK FOR NR11CH TNIS PEHMii IS ISSUEO. � � _I/IAVE AHU YYILL MIUNTAIN WORKERS'OOMPENSA7ION INSURANCE,AS REWIREO BY SECTIDN 7700 0F THE LA80R OODE.FON TNE PERFORMANCE OF 1HE WORK FOR WMICH THIS PERIdIT IS �... . .I&SUERYYW9RKER5/'�P IONWSV EGMRJ�RlJVDPOLICYNUMBERARE' , CONSTRUCTION cuwEn / ��y1°1 �Q le- PLAN REVIEW �. � ' - .-.+ � POLICV NUMBER ���—��T��O I ELECTflIC ..._. Q fnasswrqnwrIDuoreEoa.�snoFn�rewarsFor+ar€ra�onwasa+oqoat.Essa PLUMBING � s�� �� LLl [.^. /� zICERTFYTHATRlTHEFERFORMANCEOF7TIENqRKFORWHICHTXISFERMITISISSUED,1 MECHANICAL -. �,J_� �_ _��_Y _ x SMALL NOT EM7LOY ANV VERSON IN ANY 4/NNER 50 AS TO BECOME SUBJECT i0 iNE N WDRKERS'COMPENSATqNUW30FCALIFORNtA,ANDAOREETHATKI6HOULDBEGOME INSPECTION��T'� �' - � BUBJECTTOTNEWOFRERS'C01�1PENSATqNPROVIS10N50F5ECTION9�000FTHELABOFi 1'5.,�. " ' ��' � �,Ya. il :1 �j CODE,I SHAI�FOHTNWITICOM7LY WI7H TNO;E PROVISIO��NS./ ISSUANCE L•cJ.gL,�:.� ,�{T'.,, .._ . �°,i T_T�—�. � DATE:.�11�2� APPLICAM: �[G�Qr�O �/.1�e1/ SMIP � WARNPIO:FAILIIRE TO SECURE WOPo(ERS'CMAPENS�TION COVERMiE IS UNLAWFIA,AND SHALLBE ENERGY P/C �y, BUBJECTNlEMPLOV6RTOCRIMINALPENAlT1E5ANOCIVILFINESUPMONEHUWNEDTHDUSAND ENERGVPERMIT OOLURS(i100.000�,W MDITION TO TME COSTOF COMPENSATION,GAMAOES AS VROYIOED FOR IN J BECipN a7a OF THE LABOR OO�E.NTEREST,AN�ATfORNEv'S fEES. RETENTION FEE: � CONSTRUCTION LEN�ING AGENCY pRE-ALT FEE: O � IHEREBYAFFIRMUNDERPENhLTYOFPERIURYTNATiHEREISACON57Rl1CTIONLENOINGAOENCY FORTXE PERFOR6IANCE OFTHE WORK FOR VN/ICNTHIS PERMIT IS ISSUED�SEG�aB7.CIV.C.). � � IENDER'S NMIE � I,ENDER'9ADDRE55 � ICENTIFYTHATIIIAVEREAOTIISAPPL�CATpNANOSTATEiHATT1iEABOVEINFORMATqNISCOHREGT, TOTAL FEES d IA(�REETOOCA/GLVWITHALLCRYANDCOUNTVOROWANCESANOSTATEUWSREUTMI6TOBl1H.DING OONSTFUCTION,M1D HEREBY AUTHOHRE REPRESENTNTIVES OF TNI6 COUNTV TO EMEH UPON iHE S� IBOVE�AEHTqN�GflOPERTV FOR INSPECTqN VURPOSES. COMMENTS � �r'��ta rrl ,�- ,�'►.e/l.P.r m PERIAITTEENAYE y Q �'jL�-�,,,� s-_ ,� _9 9 N � 6qNATURE OF PEiq11TfEE OATE � RECPT.NO. PAI�BY YAItDATION� WHITE--Depanment Copy,YELLOW—Finance Copy,PINK—Aeaessor Copy,GOIDEN OD--FIIe Copy,GREEN—Applicant's Copy � .. , _. . , . „ ... . . . ., . � .,. , , .... . , . . .. �. _ .. . . .. 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