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HomeMy WebLinkAbout16043 (22) ����.=� ,, _�,F�� _ CITY OF DIAMOND BAI� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES �� �a J a 21660 E.Copley Drive Suite 190 (909)860-3195 Fax(909)861-3117 PRESS �"��°� BUII.DING PERMIT APPLICATION FIRMLY ¢ ADDRESS z Y�3 y sE���tt� �►�- c� .. �..:.., ,.. . . . .:,. ,:.,: , :: ,.: __. � JOBSITE APPLICATION _ �(,� PERMIT �` (\ P/C o DATE NUMBER ��'� # � APN LOT TRACT �SSUE TYPE pCC DATE CONST. GROUP p OWNER �s�o��+�I�+l°L��a p ADDRESS �Y"�3� SEr4(,�.�e�.�N Q.�- ZONING SETBACKS � CITY� YL ZIP �/�fraSTEI.y�S°--'3$(a-"T�S FRONT RW ❑ APPLICAN TEL. REAR ❑ � -- SIDE/SIDE STREET RW ❑ CONTRACTOR_ /r N�'B �s ,�-//,� S T/✓� SIDE ❑ � ADDRESS '_- L'. s�J.�nc.i�/,�..y�` o CITY G��u�E�cx�" ZIP ��:17�2 TEL.SL.z-�S�6SS'�/ PROPOSED USE o ARCH/ENG/ DESIGNER NO.DWEL. NO. NO. ADDRESS ur� UNITS STORIES BEDROOMS � CITY ZIP__ TEL. v� DESCRIPTION S0.Ff. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER DECLARATION p SFRlADD/REM p I HEREBY AFFlRM UNDER PENALiY OF PERJURY THAT�I,M EREMPT FROM THE CONTRACTORS L�- Garage/Carport W CENSE UW FORTHE FOILOWING REASON(SEC.703t.58USINESSAN�PROFESSIONS CODE:ANV GTVOR (n V COi/NTYVNiICHREG1L11HESAPERMtTTOCAN5TRl1CT,ALTER,IMPpOVE.�FNOLISN,OqREPA1RANYS7R'JC- W P8I10/DBCk Z NRE,PRqR TO tiS ISSUANCE,�LSO REOUIRES 74E APPLICANT FOR SUCH PERMIT TO FIIE A SIGNED �W STATEMEM THAT HE OR SHE IS UCENSED PUqSVANT TO THE PROVISIONS OF THE CONTRACTOfl6 LI- W CENSE LAW(CHAPTER e(COMMENCIN6 WITH SECTION 7000)OF DIVISION 3 OFTHE BUSINESS AND PRO- u' POOUSPB FESSpNSCOD�ORTHATHEORSHEISIXEMPTTHEREFROMANDTHEBASISFORTHEALLEGEDE%EMP- (� TqN.ANVYqLATIdJOF5ECT10N7031.5BYANYAPPLICANTFOHAP[HMITSUBJECTSTHEAPPLICANTTO Z Re-Root � A GIVIL PENALiY OF NOT MORE THAN FNE HUNOREO DOLIAFS�5500)J: � ❑I,ASOWNEROFTHEPqOPERTY,ORMYEMPLOYEESWITHWAGESASTHEIPSOLECOM7EN5ATI0N, C.� Commercial WILL DO THE WORK,ANO THE STRUCTUiiE IS NOT INTENDED OR OFFERE�FOR SALE(SEC.70l4.BUSI- J � NESS AND PROFESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES NOT APPLV TO AN OWNER OF = PROPERTV W/i0 6111D50R IMPROVES hiEREON,AND NM1iO DOES SUCH WOFK NIMSELF OR HERSELFOR � THROUGH HISOH HEfi OWN E4PLOVEES,PpOVIDED THAT SUCH iMPROVEMENTS ARE NOT INTENDED OR m Q OFFEREDFORSALEIF,HOWEVER1�iEBUIL0INGORIMPROVEMENTISSOIDWITHINONEVEAROFCOMPLE Z TKKJ,TFIE OWNER$U�LDER WILL HAVE THE BUR�EN OF PpOVING THA7 HE OR SHE DID NO7 BUIID OR � IMPROVE FORTNE PURPOSE OF SALE). Uj OI,ASDWNEflOFTY,EPRtlPERTY.AMEXCLU5IVELYGONTRAGTINGWITMLICENSEDCONTFlACTORS [t TO CONSTRUCT THE PROJECT(SEC.7os4,BUSINESS A40 PROFESSIONS CODE:TME CONTRRCTORS LI- VdIl13I10l1 A�J.AREA W CEN5EUW�OESNOTMPLVTOANOYMEROFAPROPER7VWHUBUItD50RIMPFOYE57tiEfteON,ANL1 WHO CONTRACTS FOR SUCH PRQIECTS WITH ACONTRACTOA(5)LICENSED PURSUANT TOTHE CONTRAO �E � TORSLICENSEUW.). UUANTITY DESCRIPTION � ❑IAM E%EIAPT UNpER S�C. ,_�_ _B.8 PC FOR THIS REASON J Q 3 � � � --- UATE OWNER__ � � _�.-- � � � UCENSED CONTRACTORS DECLARATION W I HEREBY AFFIRM UNDEH PENALTV OF PER1UqY hiAT i AM LICENSE�UNOER PROVISIONS OF CHAPTER V, � d 9(COMMENCINOWITH5ECTION7004)OFDIVISION30FTHE9USINESSANbP�90FES510NSCODE,AND Z �C IAY UCENSE I51N FULL FORCE AND EFFECT. m I.0 n � LICENSE ClASS. � �LIC.N0._ 7/ ��Z- Z � U DATE �� ��,_._____ CONTRACTORJ�j_i��r_� �1r�E'�r+ 2J. W � WORKERS'GOMPENSAT60N DECLARATEON Q � 1 HEREBV AFFIqM UNDER PEN9ITY OF PERIURY ONE OF THE FOLLOWING DECLARATIONS: Z Q � i I HAVE AND W11.L MNNTAIN ACERTIFICATE OF CANSFNTTO SELF-INSURE FOH WORKERS' _ — � COMPENSATION,AS PROVIOED 9Y SECTIO�Y 9700 OF THE LABOR CODE,FOR 7HE PERFOHMANCE W Q OP TME WORK FOq NM1iICH THIS PERMIT IS ISSUED. � � _ I HA'lEAND WIIL AINNTAIN WQRKERS'COMPEN5ATION IMSURFNCE,RS REOUIRED BY SECTION q 3700 OF TFIE LA90fl CODE,FCiH THE PERFORMANCE DF THE WORK FOft WHICH THIS PERMIT IS ISSUED.MY WORKERS'COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE: CONSTRUCTION �j c�aAi�p__.__T_ L.t`��� CCJ , T PLANREVIEW � PoucrvuMaEn___��,_[�±�t����.L ELECTRIC �/� .—�� � (MlSSCC'ttJNNF.�Nq7BEO�M�PiEfEDOfThEPERIJITISFORONEI-0NAREDWLtMS(Sico)ORLES:} PLUMBING ��C.i% CLJf�Ir�`J�L:a�� "`J"' I z I CERTIFVTHAT IN T}IE PERFORMANCr.OF THE WORN FOR WHICH THIS PERMIT IS ISSULD,I MECHANICAL L} SHALL NOT EMPLOY ANY PERSON IN ANY MANNEN SO AS TO 0'cCOME SUBJECT TO THE � WOflNERS'COMPENSATIONLAWSOFCALIFORNIA.ANDAGREETHA71FIuNOUL�BECAME INSPECTIONFEE ___. � SUBJECTTOTNEWORKERS'COMGENSAl70NPROVI510N50F5ECT10N37000FTHElA90R ,�'` � C:ODf,I SHA FORTtiW1TH COMPLV WITH THOS ROVISIONS. ISSUANCE �^ '_���„J � SMIP p DA7E: Z�� 4'� APPLICANT: ��� `�' � WARNINO:FAILURC-TO SECURE WORKERS'CAMPENSATION COVERAGE IS UNLAWFUL,AND SHALL BE ENERGY P1C LL SU&IECTANEMPLOVERTOCRIMWALPENALTIESANOqVILFINESUPTOONEHUNOREDTHOUSAND ENERGVPERMIT ���+� � L"� �i'�d��1 OOILARS(S1oo,o00).IN A�DITk�N TO THE COST Of COMPENSATION,OAMAGES AS PROVIOE�FOR IN ! a � SECT�ON3�a80FTMELABORCODE,INTEREST,AN�ATTORNEV'SfEES. RETENTIONFEE: —�—��� OCONSTRUCTION LENDING AGENCY PRE-ALT FEE � p�y�p7g��^va�.�`��� ��. � I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAi THERE 1S ACONSTRUCTION LENDING AGENCY _ '� 1J1.'�1�7 p+s�?��'•d''�J FOR THE PERFORMANCE OP THE WOPN FOR WHICH THiS PERMIT IS ISSUEO(SEC.3a97.CIV.C.). Z W � LENDER'S NAME _ __ _ 1— LENDER'SADDRESS Q {� W ICERTIFYTHATIHAVEREADTNISAPPUCATIONANDSTATETHAiTHEABOYEINFORMATIONISCARRECL TOTALFEES � �� V � I AGREE TO COMPLY WITH ALl q7V ANG CAUN7Y ORDINANCES AND STATE LAWS RELATING TO BWLDING � CANSiRUCTION,AN�HERE6Y AUTHORIZE HEPRESENTATIVES OF THIS CW NN TO ENTER UPON THE ABOVF-MENTIONED PROPER7V FOR INSGECTION Pt1RPO5ES- o COMMENTS � SCD� �i�-l� � m PERMITTE AME(�PINT) - A Q �D y/�J y�./'/" � �1CL�'% __!1/�I,,_����/�_�0� � SIGNATUPEOFPEPM1ITEE � D.MIE = RECPT.NO. PAID BY VALI�ATION ~ WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENROD--File Copy,GREEN—Applicant's Gopy .i ,. ,,;:. .;....-,: -;,:�.�_ � x�:N��lr. � ....,p .,�. . e .. , . , _. ;q':;,fi.:' . �. .:�,� wy:, ,�.�. .;, .,. .. . �- �`n, ,., � ;',,.-.�i _ ' . :� . � . .r' . . . 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