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HomeMy WebLinkAbout12847 (11) � .��';>� �_� CYTY OF DIAMOND BAI� ( �./ DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES �' 21660 E.Copley Drive 5uite 190 � (909)860-3195 Fax(909)861-3119 PRE$5 ' 9�°•'... BUII.DING PERMIT APPLICATION ;, -- ; FIRMLY � � _._ __ - o� JOB8ITE �. �+ APPLICATION^'1 ��...�i NUMBEE��� #/C ADDRESS �2 1 ���--�'Q- ��i DATE r� � � DATE C PE OCC � ISSUE TY APN LOT T � - ONST. ' GROUP � OWNER.� i i � CppR g , � . �, T ZONING SETBACKS . W � ZIP. „L�!TEL. ' FRONT RW ❑ � .APPLICANT., • 'TEL. REAR , ❑ SIDE/SIDE STREET RW Cl � CONTRACTOR �. �� SIDE ❑ � ADDRESS h� � O � � � , PROPOSED USE � CITY ZIP TEL. n , , ,�4 z A DIGN SR� Pj�`�S�a1.�I�l� L✓�(�'�� ,,;�y � Y7 � ;� NO.DWEL. NO. " NO. w ARCH/ UNITS STORI�S BEDROOM$ � � . . DESCRIPTION SQ:FT} `F'ACTO'R PSF ADJ.A � CITY ZIP TEL REANALUATIQ.N ' , , WNER-BUILDERD�CLARATION � , GaraAe/D/REM ` x �,;I" � � � '` ����� � � ��� O .. . ... ' 1 HEREBV AFRRM UNDER PENALTV OF PERIURV THAT 1 AM EXEMPT FROM THE CONTRACTORS LI- }j} �; ' '� ��W� CENSEIAWFORTHEfOLLOWPJGREASON(SEC.7031.6BUSINESSANDPROPESSIONSCODE:ANYCITYOR (/� 9,C�� �"�� � , ,_ '�, �,Z ,'COUNTYWHICHREWIRESAPERMITTOCONSTRUCT,ALTER,IMPROVE,DEMOLISH,ORREPAIRANYSTFiUF , W �k ' ' ��.:�� 7�;'� �' , � TURE,PRIOR TO�ITS ISSUANCE,Iq�Sp.pEpU�RES THE APPLICANT FOR 9UCH PERMIT TO FILE A SIONED W�� ��y"�; ' �'. �. � �STATEMENT THAT HE OR SHE IS UCENSED PUflSUANi TO THE PROVISIOPIS OF THE CONTPACiORS�LI- ,UI .TION.ANVVIOLATIONOFSECTIQN703t.5BVANVAPPLICAMFORAPERMITSIi&IECTSTHEAPPLICANTTO , Z POOVSPd .CENSE LAW(QHAVTE9 8(COMM�NCINO WITH SECTION 7000�OF DIYISION 3 OF THE 9USINESS I1ND�PRO- FESSIONSCODE)ORTHATHEORSHE7SEXEMPTTHEREFROMANOTHEBASISFORTHEALLEGEDEXEMP- (� �.��� .'A�CMCPENALiVOFNOTMORE'rHANFNEHUN�REDDOLLARS(55oo).): � - RB•ROOf i I�Oi �, ❑A�^OWNEROFTHEPRO,PERTY,ORMVENPLOYEE6WITHWAGESASTHEIRSOLECAMPENSA7IDN, � '�� ��'� ' . , .� Z I�,WILI DO 7HE WOAK,MlD.THE�iRUCTURE.15 NOT INTENDED OR OFFERED POR SALE(SECJo4t,eU91- �J CommBfCiel � ,'�NE55 ANO PROFESSIONS CODE.THE CON�RACTORS LICENSE LAW�OES NOTAPPLY TO AN oWNER oF �j '' �� ','PqOPERTYWFIOBUILDSORIMPIiOVESTHERC-0N,ANDWl10DOESSUCHWOHKHIMSELF0IIHERSELFOF � � . .' �. ��' ". OCI ,:,TNRdI(iHMSORHEHON7JEMP,LOYEES,PROVIDEDTHATSUCHIMPROVEMENTSARENOTINTENDEDOR 'm �� �' ,,, � W �,OFFER�FORSALEIF,HOWEVEP,THEBWLOMGORIMPROVEMENTISSOLDWITHINONEYEAROFCA4IPLE-�� �� ' ��'.�� ;^. '� ' � � � "�Z ;�'710N,THE OWNER-BUILDEq WILL NAVE THE BURDEN OF PpOVWG THAT HE OR SHE DIO NOT BUILD OR . . �,IMPROVE FORTHE PURPOSE O�j SAL�. � ..� . � ❑I,ASOWNEHOFTHEPR PERTY,AMEXCLU3NELYCANTRACTINOWITHLICENSEDCANTMCTORS� �.�,�.�� I�'�� ,TO CQNSTRUCT TFIE PRQIECT�SEC.70M,BUSINE55 ANO PROFESSIONS�CO�E:THE CONTRACTORS LI-. � V8IU8IIOf1 � ADJ.RREA� � � � W ..CENSEUW�OESNDTAPPLYTOANONMEROFAPROPERTYWH00UROSORIMPROVESIHEREON,ANO ��., .�� �WFIOCONTRACTSFORSUCHPRWECTSWlTHACONTRAG70R(S]UCENSEOPUHSUANTiOTHECONTRAG�� , QUANTITY DESCRIPTION � � � � FEE i TDiiS UCENSE LAW.�. ' ❑I AM IXEMPT UPDER SEC. B.&P.C.FOIi THIS REASON. Q' U' ', W . ¢ ,— '�DATE DWNER � V , � . .Z: .; . .� . . ~ ,I HEREBYA�IRM UNDER PENa,SED CONTRACTOR$DECLARATION –� w' �; LICE�OFPERJUflVTHATfAMLICENSEDUNDERPROVISIONSOFCHAPTER �� �e�COMMENCINOWITH5EC710N7900'�OFDIVISION30FTHEBUSINESSANDPROFESSIONSCA�E,AN� ' �� � �� .�MYIICEN5E IS BJ FULL FOP.CE �EFFECT. m ..O ��,�UCENSE S �. '. LIC.NO. .:�.�� �---'� � , � , .. .. F— ..V .�ATE�� CONTRACTOR �0���- �� a . . .. W ',,,� WORKERS'COMPENSATION DECLARATION Q - . ��� ��IHEREBVAFFiRMUNDERPENALTYOFPERIURYONEOFTNEFGLLOWINGDECLARATIONS: U ' ' y. Z .���'�'�IHAVEANDWILLMAINTAINACERTiFICATEOFCONSENTTOSELF•INSUREFORWORKEflS' _ � ����'�� COMPENSATION,AS PRpVID6D BY SECTION 37ao OF THE LABOR CODE.FORTHE PERFORMANCE �U OF THE WORIC FOH WHIGH THIS PERMiT IS ISSUEO. � � ,pp�' W""' '\�IHAYEANDWILLMAINTAINWORKERS'fAMPENSATIONINSURANGE,ASREQUIREDBYSECTION � � � � /qp� .Q 37000F iHE LABOR CODE,FORTHE PERFORMANCE OF THE WORK FOR WHICH THIS PEFM1715 ��y�»` � ISSUE4 MY WO/R��c FAS",COMtREN�SArj�ION INSURANCE CARRIERAND POLICY NUMBER ARE: CONSTRUCTION ^°� +^� v!� �� caaaiea � l.">'��/`O'e'� PLAN REVIEW 1 1'�f� / � � � � � �� POLICV NUMBER �i�� Z�� ELECTRIC ��/�L� � (MISSECfK)NNE�NOTi�9E00�PLEfmOFTF�PERMffISFORONEHUMREDDd.IARS(5100)ORLE55). PLUMBING L �L� W. . � z I CERTIFV THAT INTHE bERFbRMANCE OF THE WORK FOR WHICH THIS PERMIi IS ISSUED,1 MECHANICAL �4�Q Y�C� (;� SHALL NPT EMPLOY AP{Y PEfjSQN W ANY MANNEH 50 AS TO BECOME SUBJECT TO iHE Vj, WORKERS'CdMPENSAtIONL�AW50FCALIFORNIA,ANDAGREETMATIFISFiOULOBECOME INSPECTIONFEE SUBJECTTOiHEWORf�ERS'iWMPENSATiONPROVI510NSOFSECTtON37naOfTHELABOR � � � � � CODE.I ALI.FORTHWITHCAMPLYWITHTHOSEPR IS!O I ISSUANGE "Ly�� �OATE: APPLICANT. . � I .SMIP �S����y �J� ��WARNING FAI UpETO SECUNE WORKERS'COMPENSATION COVERAGE IS IINLAWFUL,AND SFWLLBE ENERGY P/C $ f �. �✓ ;'�;�y������Sl1BJECTANEMPLOVEHTtl�CRIMINALPENAL7IESANDCIVILFINESUPTOONEHUNDRED7HOU5AN� ENERGYPERMIT � 1 DOLLARS(S1o0,q0a�.IN ADDITICIN TO rHE COSTOF COMPENSATION,DAMAGES AS PROVI�E�FOR IN ' .�.��, SECTION 3708OF THE LABOR G�iODE,'PITEREST,AND ATTORNEY'S FEES. RETENTION FEE: �' Q CONSTRUCTION LENDING AGENCY PRE-ALT FEE: 1 S�L�Ly �.�+,�...I HEqEBYAFF'IRM UN�ER PENPLTV OF PERJURY THAT THEflE IS ACONSTRUCTION LEN�ING AGENCV ' , �.4;. FORTHEPERF-0RMANCEOFTHEWQRKW�ICH7HISPERMITISISSUEO(SEC.309�,CIV.C.). . � I� ..�.'..�'LENDER'S NAIa� � �. . . �F-� LENOEfi'SAODRE55 '��I ICEflTIFY7HATIHAVEREADTMISAPPLiCATIONANDSTATETHATTHEABOVEINFOi3MATIONiSCORRECT. TOTAL FEES ���C1(�� �. - �'�!��I'6� ''�'�, .qy,'�, �IAGAEETOCOMPLVWITHALLCIiYMNDCOUNTYORDINANCESAN�STATELAWSRELATINGTOBUILDING � � � . GONSTRUCTION,AND HEREBYAUTHORIZE FlEPRESENTATIVES OFTHIS CAUNTYTO ENTER UPON THE 'i �'. � �ABDYE-MENTIONED PROPERTY WR MNSPECTION PURPOSES. COMMENTS � �' '�i ���', 7�.V�P7/�,l6ty `'�.✓N�� - .. �� .�I �PERIAITTEE N E(PR � ��� � �� � � ,. ��i SI6NATURE F PERMITTEE �i DAT - - ' RECPT.NO. 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