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HomeMy WebLinkAbout16178 (20) CITY OF DIAMOND BAbL - - -- DEPARTMENT OF COMMUNTfY&,DEVELOPMENT SERVICES ��; . � 21660 E.Copley Drive Suite 190 (909)660-3195 Fex(909)861-3117 PRESS ���M� $UII.DING PERMIT APPLICATION F7RMLY N JOBSITE APPLICATION PERMR � P!C r� o ADDRESS y j S D�� G 0� • DATE � NUMBER � # � APN LOT TRAC7 D TEE 2Z � ( TMPE � � CONST. GROUP � OWNER � /V ADDRESS� Q . YONING SESHACKS �W CITY ��� 1S � ZIP � TEL. REAR Rw ❑ APPLICANT ��.,y�.S ti TEL. - SIDFJSIQESTREET RW ❑ � CONTRACTOR l �-1T` �O.t/�S • SIDE ❑ � ADDRESS • �ti w � ' ' PROPOSED USE 1 o.C� �v �bTf OX� � CITY oPHA/E� __ ZIP�_ TEL. / " 1 � � ARCWENG✓ 9s'P�I -�-�3i�'v �' L���rT=7�/C'.F� DESIGNER NO.DWEL. NO. NO. AODRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. y DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION Q OWNER-BUILDER DECLARATION SFR/ADD/REM O � I NERE6Y AFFIAA IM�ER PENILLTY OF PERRIRY iHl1T 1 AM EXEMPT Fil01d TlIE CONfMCTORS Lb Ge�BOB/Yi81pOR CENSEIAWFOR7MEFOLLOWIN(iREA90N(SEC.70]1.6Bl/SME33ANDP110FES51ONSO00E:ANYdNON (n COJNSYWFNqlREOUIitESAPERWTTOCONSTqUCT,ALTER�PNOYE.0EMO1J5H2OflflEVWRM7'/STAVC- W PatiolDack 7UilE PRIOR TO ITS ISSU�NCE.ALSO REUUIPES TIE APPLICANT FOR SUCH PEHMI7 i0 FILE A BIGNED w lTATEMEM TUT NE OR 8HE IS UCENSED MIRCUANi 7U TNE PROYISIONS OF TME CONTqACTORB�l• � ppiSE UW(CMMTER Y(COMMENqNG YNTH BECTION 7D0o)OF DIVISION 9 OF h1E BUSINE55 ANO PFlO- � Pool/Spa FESSIONS OO�E)OR THAT ME OR SHE IS EXEYPTTMEREFROM AND THE BA515 FOR TFIE N.LE4EU EXEMP� TpH.ANYV10lATICNOFBECT1DN7077.6BVNiYMPLICANTFORAPERMIT4UBJECTSTHE�PP�ICANTTO � Re-Roof �„� ACIVIL PENALTY OF NOT MONE TMAN FNE FIUNDHEU DOLL.\RS(i500�J: � OI�OWNEROF7HEPROPEHN,ORMYENPLDYEE4W171iWA0ESA5TNEIR50LECOMPENSA7pN, A Cpmmereiel � YALL DO 1HE W�7K..\ND TNE STRUCiURC:IS NOT INTENOED OH OFFERED FOR 6ALE(SEC.7N1,6U51- �J NESS AND PIqFES510N5 GODE:T11E CON�RACTOfiS LICpl9E lAW DOES NOTAPPLY TO AH OWNER OF y WpPERTYNM1lOBU1lDSORNAPROVE9TNEREON,MWWHO00ESSlK:HIM�NKHI4SELFONNEi1SELFdi = � TFIROUGHWSORHEROWNEMPLAYEES.P110VIDED1H�i8UCNNAPqOVEMEN75ARENOTINTENOEDOR � � OFFEREDFDR9uEIF.FIOWEYERME6uRO�noORMvnovEMEE4fff�SsoLOW�1'nMorJErFMOFooMPIE• TION,711E OWNER-BNLDER WILL N11VE 7HE BUROEN OF PRWMO 1HAT HE OR SHE 010 NDT BUItD OR NAVIOOVE iOR TNE PUHPOSE OF BALE), W O4ASOWNEROFTHEPROPEfiTY,AMEXCLUBNELYCONTRACTINOWITHUCENSmCONiqACTOR3 (,'L TO CONSTRUC'T hiE PRD,IECT(SEC.70M,BUSINE33 AND PRDFESSIONS CODE:THE CONTRACMIRS ll- V81Ufi[i011 ADJ.AREA liJ CQ15E UW OOES NOTAPPLY FO AN ONMER OF A PR�PERT'NTIO BUILOS ON IMPI�YES hIEHEON,M7U � � YAqOOMMCf8FOR8UCHPR6IECTSNIIMAGI�NTHACTOR�S�LICEN3E0PUR5UAMTOIHECONrMG QUANTITY OESCRIPTION FEE � TORSLICENSEIAW.�. O I MI EXEMPTUNDER BFC. B.i P.C.iON THIS REA.CON U .�M � �O � � Lr �5 ' fl wre w+mEn U C�` 3 O � LICENSED CONTRACTORS DECURATION W �� s3 Q � IFIEREBY AFFWY UNDER PEPLLLT'OF iERJURY THAT I MA LICEHSED UNDER PROVI5IDNS OF CMAP7ER � . �' _f d� e� I� S �(001AYENCNO WITH SECTION 7000�OF DIVISION eOFTME BU5INESS AND PROFESSIONS CODE,AND Z •� ��/^ T w � 0 "u W LIGENSE IS W FU.L FORGEANO EFFECT. m � UCENSE CLASS �. C+(�`G7 3 LIC.NO. S �U ! � ,� �,� a � DATE Z— I ��� r CONTMCTOR��• kJ/T T � .. _.. WORKERS'COMPENSATION DECLARATION � N IHEREBYAFFIRMUNDERPENALTYOFPE0.IURIONEOFTHEFOLLO'NiNOOECLARA7qN5: U � cn ., �z � ��IF/�VEMlDWILLIANN7AINACERTIFlCATEOFCONSEN7TOBELF.INSUREFORWORKEfiS' _ ' ' " CqIPENSATqN,ASPIpVIDEDBYSEC710N�70oOFTMELAlORCOOEFORTiEPERFORNMICE W OF 7NE MpRK FOR VAIICH THIS VERMIT 18155UED. � � Q �I IMVE AND WILL MAIMAW WORKERS'OOMPENSATION INSURANCE,AS REOUIREU BV SECTION J70oOF TilElilBOR OODE.FOfI ME PERFORMANCE OF THE WORK FORriHICM hI1S PERMIT IS ����}� � ISSV�.MY WORKEHS' PENSI17pN�IN-S^URANCE CARRIER AND POLICY NUMBERME CONSTRUCTION � L� � v � CARRIEH �J�� i'�LC/ZJID 7 PLAN REYIEW ' � POLICYNUABER �'].o��77.L .� D� ELECTRiC � � 3� p (11i66EGRqNNE�IpTBE001.PI.ErmOFhEPERARBRAONEVMi7HEDDOlU0.S(S10mORlESS} PLUMBING I a$O Z 1 CERTIFY iHhT IN 7HE PERFOFlMANCE OF THE WORK FOR WHiCN 7H13 PERWIT IS ISSUE0.1 MECHANICAL ' (,�' SMIILLNOTEMPLAYMIYVEflSONWANVMANNER90A970BECOME6UBJECTTOiHE � NADRKERS'COMPENSATIONUWSOFCALIFORN10.AND/1GREETHJITIFISMOVlp9ECOME INSPECTIONFEE BUBJECT TO 7HE M/ORKERS'COMPENSATqN OROVISIONS OF SECTqN 7700 DF TNE LABOq D� p cooE,i sruu ForrrrrvnrncoMr�rwin�nase raowsior+s. ISSUANCE � "T{� A�S- '7• � Z•�O p ��: ,^I �O �{pp�ICANT. M W SMIP � � ENEHGY P/C WMNINO:FULUHE TO bEWRE WOHKERS'COMPENSATqN COVERAOE IS UNLAWFUL,AN�9HALLBE �y SU&�EC7ANEMPtDYENTOCRIMINALPENALTIESANDCMLFINE5UP700NEMUNOHm7MOUSANO ENERGYPERMIT OOLLAHS(i100,OD0).W WDI710N TO THE COST OF COMPENSATION.ON/ACES AS PF01/IDED FOq AY J SECTqNJ/0lOFTT7ElA80flCOOE,INTEilEST,ANDATTONNEY'SFEES. RETENTIONFEE: Q d CONSTRUCTION LENDING AGENCY PRE-ALT FEE� � IMEAEBYAFFIRMIUNDEHPEN�LTYOFPERJURYTFUTTHEREISACONSTRUCTIONIENDINOAOENCY WR THE OEHWRAIANCE OFTME WORK P�R WHICH THIS PERMIT IS ISSUE�(SEC.90D7,qV.C.). � � LENDER'S NM1E F= LEN�ER'SADDRE33 /� � ICERTIFYTMATIFUVEREA�TMI311PPLIWTqNANOSTATETMTTHE�BOVE1NfOFYMTIDNISOORREGT. TOTAL FEES SI�►S�% d IAGFlEETOWIMLYWITH�LlC1TYAN�COLWTVORDINMlCESAN�STATEUWSRELATINO70B�ILDING C� 1 � CONSTRUCiION,Ml0 HEREBY AUTFIOHIZE HEPqESENTATIVEb OF THIS ODUNT�'TO FMEH UPON iHE 1�/� ��'� ` 1190VE-MEIYIqNFDVR07ENT'FORINSPECTIONPUflP0.5E3. 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