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HomeMy WebLinkAbout13466 (27) CITY OF DIAMOND BA� �'�� --1�� DEPARTMENT OF COMMUNITY da DEVELOPIVIENT SERVICES { � 21660 E.Copley Drive Suite 190 � PRESS v� � BU)ILDING'PE (RM1T AP'PLICATION FIRMI-Y � JOB5ITE �/ ° ��.� DATE CATION - �� C�/� NU B R � P/C o ADDflESS ��� 1 �+ �V�C'r # $ iSSUE TYPE OCC APN _LOT TRACT . `�-- C'� DATE_�� �Y��CONST. GROUP p OWNER ^ 63,Lr" "� "' ADDRESS o ZONING SETBACKS gCITY 21P��� TEL. F' � � �� REART RW C7 APPLICANT TEL. SIDE/SIDE STREET RW ❑ � CONTRACTQR �I �,. �� SIDE ❑�' � ADDRE S "�' ` • ' PROPOSED USE t" ���� _ � CI7Y ` i`e6 r , ZIP � TEL. � � o ARCHJENG/ � z DESIGNER NO.DWEL. NO. NO. a, 'ADDRESS ' UNITS STORIES BEDROOMS ' � C9TY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION' ti � � � .� QWNER•BUILDERDECLARATPOId . SER/ADD/REM '� � I HEflEBY AFFIRM UIVDER FENALTY OF PERIURY THA7 I AM E%EMPT FROM THE CONTRACTORS LI- �-� G2f2 JB/C8l�OfL � � ' li,i , CENSEUWPoRTHEF4LLON7NGPEASON(SEG.7D31.5BUSINESSANDPROFESSIONSCADE:ANYCITYOR - ' C.� :CpUNTYWHICFlFEOUIRESAPEflMITTOCONSTRU�T,ALTER,IMPftOVE,r7EMOLISH,ORREPAIRANYSTRUC- W pa�IOID@CIC " ' ' " ' ' W' ,TUHE,PRIOH TO ITS ISSUANCE.14L50 RE�UIRES THE APPLBCANT WR SUCF{PEFMIT TO FILE A SIGNEO ,� .STATEMENT THAT HE OR SHE IS�ICENSEO PURSUANT TO TNE PROViSIONS DF THE CANTRACTORS L7- . � 'C£NSE LAW(CHA7TEd 9(COMPAENCIfJG W�TH SECTION 70ou)OF�IVISIOtd 30F THE BUSINESS AND PRO� - � POOI/SP3 'FESSIONSCODE)ORTHATHEOR$HEISE%EMP7THEREFROMANDTH'cOASISFOFTHEALLEGEDIXEMP� '�TION.ANYVICLATIONOFSECTION7031.SBYANYAPPLICANTPoRAPERMITSU&IECTSTHEAPPLICANTTO � Re-Roof � .A qVIL PENALTY OF NOT P.10RE THAN FIVE MUIdDftED DOLLARS�S5aa).�: ��i ❑I,ASOWNEROfiHEPROP,�cRN,ORMYEMPLOYEESWITHNe'AGESASTHEIRSOLECAMPEN5ATION, 0 Commerciai . �.N7LL DO THE WORK,AND'HE STRUCTURE IS NOT INTEN�E�OR OFFERED POfl SALE(SEC.70A4,eUSF� �4 �,NESS AND PqOFE5Si0N5 CODE:7tIE CONTRACTOPS LICENSE LAW DOES NOT APPLV TO AN OWNER OF . �� �.PROPERTVNhWBUILD50RIMPR(1VESTHEREON,ANDWHO�OESSUCHWORKHlMSELFORHERS:LFOR � �.,�' ',THROUGHHISORHER04iNEMPLOVEES,VROVIDEDTiiATSUCHIMPRDVEMEPoTSARENOTIPlTENOE�OP � � . . �,�;, ',OFFEREDFORSALEIF,HOWEVER,��THEBUILDIPIGORIMPROVEhSENTISSOLDWITHiNONEYEAROFCOMpE ' �� ''�TIGJ,THE OWNEfi-BUILDER Wfl1',�HAVE TFtE BURDEN OF PPOVItdG THAT HE OR SHE DID NOT BURD OR , �; ' IMPROYEFOHTHEPURPOSEOFSALE). ❑I,�5 ON71ER OFTHE PROPERiY,AM E%CLUSINELY CONTRACTItdG bVITH LIvENSED CONTRACTORS �'. ��, TD CtlNSTRUCT THE PRQIECT($EC.7o4b,BUSINESS AfdD PROFESSIONS CDDE:THE CONTRACTORS LI- V81U0Y1Of1 _ ADJ.AFEA_ �,� I CENSELAWDOESNOTAGPLYTOAPIOWNEROFAPROPERTYWHOBUILGSORIMPROVESTHEREON,AND , . � KNOCON7RACiSFORSUCHPROJECTSINITHACDNTHACTOR(S)lICEN5EDPLIRSUAWTT6TNECDNTRAP Q�qNTI'iY DESCRIPTION FEE� � �„ 70RS LICENSE 1.AW.). � ,, �� ❑1 AM EXEMPT UNDEH SEC� B.&P.G.FOfi THIS R'cP50N � � . �.�. � � . ... � �. �` . OATE OWNER U. . . .. L1S �,� � - LICEN�ED CONTRACTORS DECLASiAT10IV g j . � � � '� � 'i � .�"' I HEFEBV AFFIRM UNDER PENRL'f�I DF PERJURy 7'HAT I AM LIGENSED UNDER PROViSIONSCF CHAP7ER ' , 000)OF DIVISlON 3 OF THE BUSINESS AND PROFESSIOMS G�E,AND z � �m ��" �' � ���, 9(COMMENCING WITH SECTKIN 7� �� ?S.,' MYIICENSEISINFULLFORCEAt�DEFFEC?. —a.� � f _ � . Q �!,3 � LIC.NO. •�d�t'-s" . .. j � �f �'y �i � � 5� �}� � . Y—.� LICENSE C�S /p . J V ' 1„P��' r `('�..�, � � DATE � C�I�'7 I COPBTFiACTOR �'� �'d- �- �i .�. ' ��o ��� ��, � WGRK�RS'COMPEIVSATI0�9 DECLP+RATIO�P � . ' � IHEREBYAFFIWi.1UNDEfiPENALNOFPERJURYONEOFTH6FOLLOWiNGDECIARATtONS: � f/3 z Q j C1 _IHAVEAND'dYiLLMAIldTAMFUERTIFlCATEDFCONSIENTTOSELF-INSUREFORWORKERS' � �� �� � COOAPENSA710N,AS?pOi�iDEOSYSECTION37ooOF?HELABORCO�E.FOB7HEPERFORMANCE W OFTHE WORK FOR WHlC}i THIS PERR5IT IS iSSUED. � W �I HAVEAN�WILLMAIh'TAI�Pd WORKERS'COPEPENSA7iON INSUriANCE,AS FtEQUIRED BY SEGTION 0 37a00F7HELABOACOD�.FORTHEPERWRMM"CEDFTHEWORKFORWHICHTHISPERMITIS ISSUED.MY WORK S'CQ�M?EN�.TION IPISURANCE CARFIER AND POUCV Nl1MBER ARE: COIJSTRUCTIO�`I _ � AAflflIER I�'''C � PBANREVIEW � � POLICYNUMBER � ELFCTRIC `�' ¢ �p �*� J Q. (fH55EC@71VNE�FAT��MPLEfEDO'FT!'�PEFi�ATISFORaJENUPDr�EDD0.LA9S(590D)ORLESSI. PLUMBBNG �` � �CS'e s7 `��'��� . w ' � MECHANICAL .�,�';`�'.`�.�' � Z 1 CERTIFY THAT IN THc?EFFOHMr44CE OFYHE WORK FOR WHICH THIS FERMIT IS ISSUED,i p (�' SHALLNOTENIPLOYANrPEflSONINANYMANNERSOA9T00ECOMESUBJECTT07HE f t�,�'�— �Uj WORKEHS'COMPESVSATI N LAWS OF CALIFOflNf.4,HND AGREETHAT IF I SHOUL�BECOME � WSPECTION FEE _ '� ��'' � `°�'k� ' SU&iECT TOTHE WORK�RS'COMPENSATION FPOVISIONS OF SECTION 37oa OF THE LABOR 9SSUAN°�vE i �� . ''�� � � ���� a�����' jCOUE,ISHALLFORTHWII�HCOMPLYWITHTNOSEPROVISIONS. s -".y-'- : � , �j'J•.—�--:�v A. xb p� DATE: ARPLICAPlT: �SfV11P �' .,.�u5 �"ry � '`".r�"� . � � ENERGYPlC _. `� ��p .'s.'"`�l� . � WARNING FAILURE TO SECURE�OHKEHS'COMPENSATION COVESAGE IS UNLAWFV�,AND SHALL et" 'i,�� , , yy� Sll&fECTANEMPLOYERTOCRIMINALPENALTlESANDCNILFINESUPTOONEHUNDREDTHOUSAND ENEflGYPERMIT � Sk�r � " DOLLARS(S1o0.o00).IN PDDITIOI�TO THE COST OF COMPENSATION,�RMAGES AS FHOVI�ED FOFi IN a.�j:,.-� �,'� SECTION37080FTHELABORC�DE,INTEREST,ANDATTORNEY'SFEES, - � RETEPlTION FEE: . � CONSTRUCTION LENOING AGENCY pRE-ALT FEE: '� �'� I HEilEBYAFFIRM UNDER PEN�OF PERJURV THATTHERE IS ACONSTRUCTION LENDING AGENCY ' ' ' �' ' � � FOR THE PERF-0RMANCE OFTHE WORK FOR W WCH THIS PEFMIT IS ISSUED(SEC.3o9],dV.C.). . . Z � � 1.1:1, . � � , S� LEN�ER'S NAME � ' F-� LENDER'SA�DRE55 ' . '� w, 1 CERTIFV THAT I HAVE REA�TH�S APPLICATION AND STATETHATTHE ABOVE INFORMATION IS CARRECT. T�Tti� F�CS ���'� 47 �' _ ', �. �. IAGREETOCOMPLYWITHALICITYANOCOUNTYORDINANCESANDSTATELAWSF1ElAT�hGTOBUtLDING �� , , �, CONSTHUGTION,ANDHEPEBYAUTHORIZEFEPRESEN7ATIVESOFTHISCOUNTYTOENTFRUPONTHE . � ABOVEMEPlrIONEDPflOPERTYFORItdSPECTIONPURPO5E5. COMMENTS -� 0 " _ –&'�"` � �5 L� a � m. PERMITT NAME(P INt) . . . � �' ,e�,_ � ��-�y - � � ��s�, �j SIGNATUREOFPERMI / �AT _ � RECPT.NO. PAID BY �VALIDATION� ~ � WHITE—�e artmant Co YELLOW—Finance Co PINK—Assessor Co GOLDENROD—File Co GREEN—A IiranPs Co � P PY. PY. PY� PY. 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