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HomeMy WebLinkAbout13468 (14) CTTY OF DIAMOND BAA � � DEPARTMENT OF.COMMUNITY dz DEVELOPMENT SERVICES � 21660 E.Copley 1]rive Suite 190 (909)860-3195 Fax(909)861-3117 PRESS �'�' BUILDING PERMIT APPLICATION FIRMLY o ADDRESS_ l��7 �f I Vt.�' �-0.��� DATEICATION /2 q NUMB R � � N� g ISSUE TYPE OCC APN LOT TRACT � U DRTE � CONST. GROUP � OWNER � ADDRF„'SS v ZONING RO TCKS RW ❑ CITY 21P TEL. qEAR APPLICANT TEL. SIDElSIDE STREEf RW ❑ CONTRA OR D Il SIOE ❑ ADDRE S � CITY ZIP�� TEL. PROPOSED USE L � � ARCWENG/ DESIGNER NO.DWEL. NO. NO. ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. �n DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANAIUATION Q OWNER•BUILDER DECLARATION SFR/AOD/REM O 1 MEREBY AFFlRIA UlI�ER PENALTY OF IERJURY iMAT I M1 qfEMPT FtiOM TFIE CONTMCTORS 61- GefBQB/Ca1pOrt CENSE IAW FOR TYIE FOLLOWINO REASON(SEC.7031,68USINESS ANU PROFESSIONS COpE:J1NY CITV OR OOIMTYWHLCHRECWRE6APERMRNCONSIRUC7,ALTERWPqOVE,�EMOUSH,OqREMIRANYSTRUC• W pe1bNBCk IUHE�RION TO 1T8 ISSUANCE,AL80 REOUIRE9 THE APPLICANT FOR SUCN PERMIT TO Fllk A SKiNED sTATEMENT THAT NE OR!XE IS LICENSED PUi15UMlT TO 7HF PHOVISIONS OF 7HE CONTMClOR3 U• CENSEUIW(CWIVTER/(COMMENCWOMATNBECTIONIOW)OF�IVISION3OFTHEBUSINE55ANOPRO• � POOYSPB FESSqN5C00EJORTUITXEOR8HEI8pCEMPTiHEREFROMMDTMEBASISFORTHEALIEDEDE%EMP• (� T�ON.ANYVIOLATIONOFSFCtION7091.6BYANYAGPLIGNTiORAPEFlAIITSU&IECTSTHEAPPLICANTTD Z pe-Raof � A CMl iENALTY OF NOT MIORE TMIW FIVE NUNDHED DOLLARS(teoo�.). OI,ASONRJEROFhIEPROPERTV.ORMYEMFIOrEESNA151WA0E5A9THEIR30LECOMPENSATqN, GOIRrtIBfCl21 YYILL DO 7FIE WOPY(AND TNE BTRUCTURE IS NO7INTENDED OR OFFERED FOR BALE(SEC.70M,BUSI- � � MESS NIO PiWFESSION6 OODE:THE CONfMCTORS UCENSE LAW DOES NOT APPLV TO AN OYVNER OF ? ►fW VEHTY WFi�BUp„09 OR MIOROYEe THEREOV,AND WHOOOES 6 VCH VfOqKNIMSELF OR FIERSELF OR TNROUGH11150i1NEROWNEMPLOYEES,PROVIDED7HA7EUCHMPROVEMEPIBAFENOTINTENDE00R m OFFERW FORSKEIF,f10WEYERTMEBUILDINQ ORIMPFqVEMENTiSSOLO WITHM70NEYFAROFCOMRE- TqN,THE OWNEH�6ULL7ER YYILL NAVE 711E BURDEN OF PROVINO THAT HE OR 8HE DIO NOT BUIID qi 61PROVE FOR71iE WRPQSE OF SALE�. 0 4 AS ONMEROF THE GROPERIY,AY E7(CLUSNELV CONTRAC71N0 WITN IICENSED CONTRACTORS TO OONSTRUCTTNE PRO.IECT(6EC.7041,BU9INESS AND PROFESSIONS COuE:7HE COMRACTORS�I- �/eIU0IIW1 ADJ.AREA CENSE IANf OOE81qTAPVLV TO AN ONTIER OF APROPER7Y WFq BUILD6 OR IMPROVEe THEREON,AND � WFIOCON�RACTSFORSUp1GROJECT3WrtHA00NfRAC1UR(9)LICENBmPUR9UMITTOTHECONfRAG pUANT1TY DESCRIPTION �E � 7WiSUCENSEIAri.�. O I AM EXEMPT UNDER BEC. B.f P.C,FOft THIS REASON � U u' DATE OWNER U � IICENSED CONTRACTORS DECLARATION � INEREBYAFFIRMUMDEqPEN+LLT70fPEIUURYiHAT1ANLICENSEDUNDERVROVI510N50FCHAPTER � • � ��001.NIENCNJBWITNSECTpN70W)OFOIVISIONSOFTHE9USINESSANOPROFESSIONSCODE,AND Z G � � MY LICENSE 16 W FULL FORCE M!D EFFECT. m � �( �r � D � LICENSE CUSS ��W LIC.NO. � Z _ � � o�� 1'L. 4 a ca�rcnncroR a 'e t o WORKERS'COMPENSATION DECLARATION a D � I HEREBY AFFlRM UNDER PENlLLTV OF PERJIIRY ONE OFTHE FOLLOWINO DECUIRATIONS: Z � ��WIVEANDVYdLMAINTNNACERTIFlCATEOFCONSENTT06ELF-INSUflEFORWORKERS' _ OOMPENSIRION,A6 PROVIOEO BY SECTION 5700 OF iME UBOR OOOE.FOR THE PERFORMANCE W Oi illE NPDRK FOR YNiICN TNI6 PENAl1T IS ISSUE�. � � _�HAVE AND YYILL MAPIfNN WORKERS'OOMPENSATION INSURANCE,AS REWIREU BV SEGTqN ]7000FTFIE LABOfl CODE,FOR TNE PEHFORMANCE OF 7HE WORK WR WXICF7 THIS PERMR IS 0 ISSUED.MYWOqKE ' OMP IS�T/gµINSURANCECARHIERIWOPOLICYNUMBERME. CONSTRUCTION � ��� �"� PLAN REVIEW � roucv HuuBER, — b — ELECTRIC y 'F '' Q (niss[t�ta�n�rqreematE7IDOF7rerEw�i�sfaRoneruron�Dd�sR+roloqtF"�sl PLUMBING _T �i �iT•:.,� e�,��,,,,� C��L ICERTIFYTMTINTHEPERFORMANCEOF7HEWORKFORWHICHTHISPERMITISISSUE0.1 MECFIHNICAL A� �/'}�- SHALL NOT EMPLOY ANY PERSON IN ANY IAANNER SO0.5 70 BECOME Su9JEt7 TO THE � � .+. (p WORKENSCOMPENSATIONUWSOFCALIFORN1IAN���qEETNATIF19NOUL0BECOAIE INSPECTIONFEE • � �, .��%' .l.�.• SUBJECTTO7HEMADRKEA9'COYPENSATIONPROVISIONSOFSECTION370oOFTHElA80R p.� i��� � �'�' ..'✓ COOE.ISHN.LFORiHWITHCOAIPLYWITHTHO3EPqOVISIONS. ISSUANCE y..P'�1'.� � ;^`. '`� � DATE: MPLICANL SMIP ` � Y„ t`�: WMNINO�FAILUqETOSECUREM/OpKERS'COMPENSATqNCOVEHWEISUN.AWFVI,ANDSHALLBE ENERGYP/C �'r� Y (�y SUBJECTANEMPIOYERTOCqIMINALPENALTIESANOCMLFMESUPTOONEHUNDREOTHOUSAND , 1 �, DOLLMS(i100.000).M ADDITIDN TO THE COST OF COMPENSATqN,pAMAOES AS PROVIOED FOH IN ENERGY PERMIT ��L �+ J� SECTIDN97000FTIELABORCO�E,INTEREST,MI�ATTORNEY6FEES. RETENTIONFEE: V� OCONSTAUCTION LENDING AGENCY PRE•AL7 FEE: � 1 HEREBV AFFlRM UNOER PENlLLTY OF PEfUURY THATTHERE IS ACANSTRUCTION LENDINO AOENCY Z FORTHE PER�ORMANCE OF THE WORK FOR NM111CH 1HI3 PERMIT IS ISSUEO(SEC.JOW,CIY.C.�. W � LENDERS NAAIE C LENDER'SADORESS � ICERTIFYiHATIHAVEF1EADh719APPLICATIONMIDSTATETHATh1EABOVEINFORMAT10NI5CORRECT. TOTAL FEES {�Z(Q ( ��� � IAOREETOCOMPLYN7THALLGT'ANDCOIMTYON0INNICESAN�BTATElAWSREUTINOTOBULDINO � CONSTRUCTION,MI�MEREBY AUTFIORIZE HEPHESENTATIVES OF7}IIS�OUNTY TO EMER UPON THE ABOVE-MEMqNED YRDPEHT'!FOq INSPEGTION PURPOSES. COMMENTS � r ac� o a • r.n� • Q v� ruu� �rai v� z � � 91GNATVREOFPERMI 'E D � RECPT.NO. 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