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HomeMy WebLinkAbout13174 EXPIRED CITY OF DIAMOND BAx " , DEPARTMENT OF COMMLTNITY&DEVELOPMENT SERVICES N OU 3 O ZOOO W 21660 E.Copley Drive Suite 190 (909)860-3193 Fax(909)861-3117 PRESS "�'�� BUILDING PERMIT APPLICATION FIRMLY � JOBSITE .� Fj� /f APPLICATION PERMIT p/C � AODRESS J'� 9 X.. o �A� NUMBER��I � � APN LOT TRACT DATEE__J Z'�1��1 ONST. GROUP °� OWNER � ADDRE S 6 20NING SETBACKS CITY 21P TEL.��c-Cr!� FRONT RW ❑ APPLICANT TEL. HEAR p +� SIDFJSIQE STREEf RW p CONTAACTOR SIDE p ADDRESS g CIT/ ZIP TEL PROPOSED USE • � ' �i AR � DESIGNER NO.DWEL Np. Np, ADDRESS UNITS STORIES BEDROOMS CITY ZIP TEL. � OwNER•BUILDeR DECtARA710N DESCRIPTION Sa.FT. FACTOR PSF ADJ.AREANALUATION g sFwn�o�enn I MEREBY AFFlqM UNDER PENALTY OF PERJURY TNAT I AM E%EMPT FROM THE CONTR�CTORS U- G9f&QB/C81p0A CENSEUWFORTNFFOLLOWWGREl1SON(6EC.70.77.68USMESSANOPROFESSIONSCO�E:ANYCITVOH (J� OOUNf'/WHCHIIEUNflESAPEqMRTOCIXiS7RUGT,II�TERMAPROVE.OEMOUSH,ORREMIRANYSTRUC• W P91i0/DBCk 7URE,MpR TO 1T8165UANGE,ALSO ilEQU1RE3 T1E APPIICANT FOR SUGi PERMIT TO FILE A SWNEO W fTATFMENi TIAT ME OR SHE IS 110EN3E0 PURSUANT TO IHE PROVISIONS DF 7HE CONTRACTORS ll- 4tNSE LAW(CHAPTER 0(COMMENCINO MII7H SECTION 70D0�OF DIYISION]OF THE&1SINE53 ANO Pq0- �"' POOVSpB FESSpNS OOOE7 OF{7HA7ME OR SHE IS IXEMAT THEREfROM ANO TME BASIS FOq THE ALLE�EO ExEMP- TION.MIYVIOLATIONOFS[CT10N7o91.6BVANVAPVUCAN7FOHAPERMITSUBJECT67HEACPLICRN770 z Re-Roof .Q"� '„� ACJNLIENALTYOFfqTYOREINIWFIVENUNDREDDOLURS�tSao�.): � 01./150WNEROFTHEPROPERTV,ORWEMPLOYEE9WITNWAOESASiHEIq50LECOMPENSATION, CORIfl1BfClfil tALLDO TNE WORK,AND THE BTRUCTURE S NOT WTENDED IXi OFFERED FOR SALE(BEC.7w�,pU51- � � NE65 AND P110FESSIONS CODE:THE CONTMCTOR9 LICENSE LAW DOES NOT MPLV TO AN OWNER OF ? Pi10PERTY YYIq pUqpS Dlt M7ROVE9 h1EREON,qN0 YM0 DOES 6UQ1 WORK HIAISELF OR HERSEIF OR � TIIROUGHIY601lNEROriNEGPLOYEE9,PqOVIDm7YUT8UqiMIPRDVEMENTBARENOTINTENDEpOR m OFFEREO fORSALE IF,HON�FyEi�7}IE BUILDINOOR IMPROVEMENTIS 80LD WITMIN qVE VEAR OFCOMPLE- TION,7HE OWNER�UILDER YNLL FUVE TME BURDEN OF PROVWO TNAT HE OR SHE DID NOT 94R�DR �1PROYE FOR TME PUfiPOSE OF SILLE�. {y� ❑LASONMEROFTNEPROPER7Y,IWEXCLUSNELYCONTpl1CTIHOWrtNIICEN5EDCOMMC70RS � TO CON6TRUCf THE OROJECT(SEC,7011,BUSINESS MI�PROFESSIONS CODE:THE CONTRACTOqS LI• \/gIU8II0(I ADJ.AREA CENSE UW OOES NOTMPLY TO MI OWNER OF A PNOVERTY W!q BUM.OS OR W PROVE9 THEREON,Mlp � MSpODMRACTSFORSUCHPppJECT9MnTHACONfRAC70R�5)LICENSEDPURSUANi70THECONTHAG QUANTITY DESCRIPTION FEE � 70RSlICENSELAWJ. �I M1 EXEMPT UNDER SEC. B.�P.C.FOR THIS REASON U � DATE ONMER h- Z U F LICENSED CONTRACTORS DECLARAT{ON w � INEFEBYIIFFIRMUNDEHPENALTYOFPEH.IUPYTMATIAMLICENSEDUNDERPROYISIONSOFCHAPTER � ��CAAJMEHqNG W1TH BECTIDN 1000)OF ONISION 90F 7HE BUSINE33 AND PROFESSIDNS CODE.�U10 Z MY LICENSE 6 Nl FVLL FOpCE Ml�EFFECT. m � L�CENSE CU1SS �'�� LIC.NO. �� I � � DAiE,��ZS�� CONTMCTOR d WORKERS'COMPENSATION DECLARATION U � I HEREBV AFFIPM UNDEF PEN/LTYOF PERNRV ONE OFTHE iOLLOWINO DECLIRATpNS: Z � �IMAVE�WILLIMW7NNhCEfITIFICATEOFCONSENTTOS0.F-INSUREFOFlNIORKEFiS' a 001AVENSATION,ASVfqVIDE0BY8ECTIONa7000FrHEUBORCODE,FORTHEPERFORM/JJCE U Q 9VTFE VlORK FOR VMIdITXIS VERMR 191SSUE0. � / �� IHAVEIW�WILLMARITAWWORKERS'COMPENSATIONINSUfUNGE,/SREQUIREOBVSECiqN Q �700 OF hIE UBOR COOE.FOR THE PERFORMANCE OF iN RI(FOR WHICH THIS FEHMIT IS G�•� = ISSUED.YY EA' ENSATION IN UAANCE CAR AND POLICY NLIMBER ARE. CONSTRUCTION Q > �+p��+ PLAN REVIEW � POUCY NU�ABER ELECTRIC 'Y p' (�s[cnau�rpTe�a�rIDa�n#�n�rsw�a+E��oottu�R��'i�tEssl PLUMBING w � I CEpfIfY T14.7 W hIE PEfIFOiUJANCE OF THE WOiU(FOR WHICH iNIS PERMIT I5 ISSl1ED,1 MECHANICAI � SHAIL HOT Ei1PLOV JWY PERSON N ANY MANNER SO�S TO BECOME SVBJECT TO THE (n WORKERS'C�MPENSATION LAWfi OF GILIFORNIA,AND A(3REE TMAT IF I SNOULO BECAME INSPECTION FEE ��� 6U61ECT TO THE WORKERS'COMPENSATqN PROVISIONS OF SECTION J7000F THE LABOR s 000e.i sruu Foarnvnni caeP�r hnrn rrrose rno�nsiorrs. ISSUANCE ��U � � �� � J Ip DATE:_ APPLICANT. SMIP C� � ENERGY P/C B� WARMNG:FAILUHE TO SECURE WORKERS'COMPENSATION COVERAf3E IS UNlAWF11L,ANU BHALL BE �y BUBJECTANEMPLOYERTOCRIMIN/LLPENKTIESANDCMLFINESUPTOONEMUNDREDTHOUSMA ENERGYPERMIT � DOLLARS(i100,00�,N7 ApDITiON TOTHE COST OF COMPENSA7qN,DAMAOESAS PROVIDED FOR IN BECTION97ae OF lXE U1BOR COOE,IN7ERE3T AND11TfORNEYS FEEB. RETENTION FEE: QCONSTRUCTION LEN�ING AGENCY PRE•ALT FEE: � i � I HEREBYAFFIpM Uf�ER PEHALTV OF iERIURY THAT THERE IS A CONSTRUCTION LENOINQ AGENCY Pofl TNE PERFORMANCE OF TNE WOFlK FOR WHICH TMIS GERMIT IS ISSIIED(SEC.909�,CIV.C.�. � � LENDEiFSN/WE � � LENDERSADDRESS � � W ICERTIFYTMATIINVEREADTHISAPPLICIUqNANDSTATETMTTMEABOVEINFOFMATqNISCORRECT. TOTAL FEES d I/W REE TO COMPLY WIiN ALL GTY M10 COUNTY ORDINANCES IND BTATE UWS FELATINa TO BUMING � CONSTRUCTION,ANOHENEBVAUT10pIZEREPRESENTATNE50F7H15COl1NTYTOEMERUPONTNE , /�BOVE•MEHf10NED PRDVERTY FOR INSPECTqN PURPOSES. COMMENTS 9 /,//�tJ C 1�� �.e S ti'e�.�' �. m iENMITTEE E�RINn � 3--.2g-�4. � awru o�rE � RECPT.NO. 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