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HomeMy WebLinkAbout16484 � � 1 � �� CITY OF DIAMOND BA& ��-� DEPARTMENT OF COMMUNITY dz DEVELOPMENT SERVICES , � , Zi�o E.c.�i�y n�;�s�u i90 PRESS (909)86a3195 Fax(909)861-3117 ^�°��� BUII.DING PERMIT APPLICATION FIRMLY oADDR SS�1�� � 1 � 1►e�.�� DATE CAnON SJ�'� O` NUMBER n� M,C � tSSUE TYPE OCC APN OT TRACT DATE CONST. GROUP � OWNER � 1 C,� � C ADDRESS ZONING SETBACKS CITY 21P TEL. FRONT RW ❑ APPLICANT �` 4. - REAR ❑ SIDElSIOE STREET RW ❑ CONTRACTOR SIDE ❑ � ADDR S � PROPOSED USE e �✓ CITY . ZI TEL���.�.j,-.(� � ,aac c,� Z4 sr�,s ` DESIGNER NO.DW�L. NO. NO. ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL.� � DESCRIPTION SO.FT. FACTOR PSF ADJ.AREANALUATION Q OWNER-BUILDER DECLARATION SFR/ADO/REM O I 11EREBY AFFlRAi UN�ER PENAL7Y OF PERM1INY 7'NA7 I 11M E]fEMPT FROM TNE ODNTIUGTOpS LI• G8f80B/C9�pOR CENSEUWiOR1HEFIXLOWINONEA80N(9EC.�0.11.6BUSINE59ANOPRO�SSIONSCOUE:ANYGiYDR (n COU1(7VV,M1iKJIREDUWESAPEMAtiTOCOliSTRUCT,KTER.4APi10NE,DE40U5H.ORREPAIRMIYSTRUG `W pAt101D6Ck TUqE PRIOIS TO iT3 N'SUANCE.AL90 REOLIIHES 7HE ADPLN`.�M fOR SUCH PERMIT TO FILE A 610NED 87ATEMEM 1}MT HE OR dHE IS UCENSED WRSUAN7 M 1HE GROVISpN3 OF 1HE CONTRACTOtIS U• CENSE lAW(CFU�PfER 0(COMMENCINO WITH SECTIDN 7000�OF DMSION 7 OF TFiE BUSINESS ANO PRO- � POOUSP9 FESSIONS CODE)ORTFNT NE OR SHE t8 E%EMPT h1ENEFRON AND iHE BASIS FOR THE ALLEOED FXEMP- iqN,11NYYqLAT10NOF8EGTON7WI.OBY11NYhPPUGN7FORAPERMITSU&IECi9THEMPLIG.NTTO Z RB•ROO( � ACML7ENALTYOFNDTMOFiET/MNFiVEHUNORE�OOLLARS�isoo�.): ❑1,11SOMJNEROFTHE►ROPER7Y.ORYYEMPLDYEESVYIITIWAGESASTHEIRSOLECOMPENSI1iqN, Q COrt1111BfCl� MIILL DO T11E W�RIC.AN�THE STRUCTURE IS NOT NTENDED OR OFFEREO FOR SALE(SEC.70�I.BUSI- J NESS AW PIiDFE5910NS CADE:IHE OONTRACTORS LICENSE LAW DDES ND7 APVLY TO JUI dHNER OF = � PROPERTYYYFIOBU0.DSORMAPROVE47FIEREON.ANDYMODOES8UCHV/ORKMIMSELFORHERSELFOR � 711ROUGHWSORHERONMEMPI.OYEEB.VHOVDED7HA73UGiWPROVEMENTSMEN�TiNTFNDEDOR m OFFERED PDA SALE IF,IIOWEYER 1NE BUYDWOOR MPFlOYEMEM 19 5WD WITMNONEYEMOF COM0.E- � �TION.TME O'NNERBULDER YALL h1AYE 7TIE BUHDEN OF PROVWO hIA7 HE OH SHE DIO NOT BUIID OR BdPRDVE FOR iME RJRPOSE OF 9/LLE} W ❑I,ASOWNEROFTHEPROPEHTI;JIME%CLUSIVELYCONTRACTINOYYITNLICENSEDCONTMCTORS � TOCONBTRUCT THE PROJECT(SE0.7DN.BIISINES3 AND PROFESSIONS ODDE:THE CONTMC70N5 LI- V81UYf10f1 ADJ.AREA CEt19E UW OOES NOTMPLY TO AN OWNER OFA PflOPEfl7V NRiO BUILDS OR qAPF�`/E9 THEREON,AND WVqCOMRACT6FOR8UCHVR6IECTSMnTHACONTRACTOR(S�LICEN5EDPURSUMRTOTHEOONTFUG QUANTITY DESCRIPTION FEE � TORS LICENSE tAW.). Q ❑I AM EXEMPT UlDER BEC. B.8 P.G FOR THIb REIISON U = pATE OWNER � � W UCENSED CONTRACTORS DECLAfiAT10N -� � w 1 FIEREBYAFFIRFI UNOER VEN,LLTY OF PE0.1UqY THATI AM LICENSED UN�ER PROVISIDN CHAPT R � � Y(OOEIMENCMlGWITMSECTION7000)OFD�'/ISIONJOFTiEBU31NE5S.WDPROFESSI Z X W UCENSE IS IN FULL FORCE AND EFFEGL � LL! 0 UCENSE CUSS��_UC.NO._��/y J F' pATE � �_CONTMCTOH (�/j� d CCC5�,,,��� CQ_ •.� ' _ � I I' WO�KEFiS'CAN1PENSATION DECLARATION � y I MEREBYAFFIRAI IIN�EP PENN.7Y OF iERJURY ONE OF THE FOLIAWM��ECLARATIONS: V � Z Q C� _I/NVEINDWIILMANTNNACERTIFICATEOFCOM5ENT703ELF-INSUREFOFWORKER3' _ CqIPEpSATqN,A9 PROVIDED BV SECTION d7000F THE UBOA CODE,FOR�HE PERWRMANCE U � pF TiE YVORK FOR MV111pi T7115 PENMIT IB ISSUED. � ��I X_AVE AND WILL MAIMAW WORKERS'COMPENSA710N INSURANCE AS REOUIRED BY BECTION � � ''�^ � 37000FTHE LABOR OOOE, OR TIE PERFORMANCE OF THE WORK iOR WHICH THIS PEN.�I715 U ISSUED.M1'NC/RKERS'CO PENS . INS RRIE OPOLICYNUMBERARE: CONSTRUCTION � CARRIER � PLAN REVIEW � ra�crNuweea � ELECTRIC � (I}16gC�IK.M1NE�rqrBEad�IPLEr�oFnEVEpxrsinRan�EFl1�J�o0oluR5R+�M��} PWMBING � 1 CERTIFY711AT IN THE PERFORMNVCE OF TNE WDNK FOR WHICM 7}AS PERMIT IS IS9UED,I MECHANICAL 511ALL NOT ENPLOY AHY VERSON IN MIY MIWNEH SO AS 70 BECOME SUBJECT 70 TME � WORKERS'CONPENSATqNLAWSDFCALIFORNIA,/JJ�AOREETHATIFISHOULOBECOME INSPECTIONFEE � w���� • SUBJEC7T0 THE WORKERS'COMPENSATION PROVISIONS OF SECTqN 970oOF THE LABON �"'�' L ( � CODE,ISHMI.FOfiTNWITHCOM7lYW�TMTMOSEPROVISIONS. /��� (�Ln ISSUANCE /� /� -Q/� u� p pATE:� APPLICANT. L�/�/l��(��-Y� SMIP � � V � �x' ENERGY P/C WARNINO:FALURETO SECIIRE WORKEFS'COMPENSATpN COVERAOE IS UNLAWFUL,AND SHiW,BE � BUB.IECfANEMPLOYENTOCRIMINALVENAL11E5AN�CIVILFWESUVTOONENUNDiiEDTHOUSAND ENERGYPERMIT r DOLIaHS�itoo,000).NADOITONTOTHEfASTOFWMPEN5�710N.DMU4E5ASVROVIOEDFOqIN .J 6ECfION 970�OFT1E U1BOR CODE,INTEREST,ANDA7TORNEYS FEES. RETENTION FEE: ' Q � CONSTRUC710N LENDING AGENCY PRE-ALT FEE: � I HEREBV AFFIRM 11NOER PENALTV OC PEFUURY TNA7 THEHE IS A CDNSTRUCTION LENUW�AGENCY FOR TME PERFORNANCE OF THE WORK FOR VMNICH TMIS YEpM1T IS ISSUE��SEG.faYl,CIV.G�. � � LEI'IDERS NAME LENOER'S ADDRE55 / ICEPTIFYTlMTIHMIEREADTHISAPPLICATIONAND9TATETUTTNEABOVENFONYATqNISCORRECT. TOTAL FEES I 1 �� � � IAOREETOCOMPLYWITNALLGTY/NDCWIN7YOROINhNCES/NDBTATElAW5REUITINOTOBULDINO ��i CONSTRUCTION,ANU HEREBV AUh1ORRE REPRESENTATIVES OF iHIS COUNTV TO EMER UPON TiE S�. ABOVEJAENfN7NE0PROPERTY WSPEGT rwoses. COMMENTS � ,�r Z*� r��v►� _ � PERMITTEE NAME(VRIN'f)1 � �/�,� r 7� I ��vl� I y SNiNA REOFPERMI DA � RECPT:NO. 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