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HomeMy WebLinkAbout12990 _1� CITY OF DIAMOND BAK �`"` DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES a 21660 E.Copley Drive Suite 140 (909)860-3195 Fax(909)861-3117 PRESS ��°;'• BUILDING PERMIT APPLiCATION -_,_ FIRMLY ¢ DDRESS l��{f �/(!�'�`I� �^�t� � , DATEIGATIO� " �,�) NUMB R �'� #�� p ''ISSUE TYPE OCC � APN LOT', TRACT Z �� DATE ' CONST. GROUP p OWNER �a.2t�3P,��fif-t�`• � Gi�iC_ ` �p ADDRES ,�.a�b��" %�I¢: 1^�"f3W f. ZONING F ONTCKS RW , . ❑ n APPLlCAN"f �IP��TEL. ��� ' REAR ❑ Z ciTv �' TEL. SI�EISIaE STREET RW ❑ � CONTRACTOR , � ��+ ' r✓Va ,�i'�.4 � SIDE , ❑ � C DRESS � �,�5�d� �� ZIP,�� TEL ,. Q PROPOSED USE w A . A irr o RC,H(ENG/ w GNER " UNITS STORIES BEDRO z DESI NO.DWEL. NO. NO. a ADDRESS OMS � CIIY ZIP TEL. � � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATIOM �,: �, , f�VVNER-BUILDER DECL4RATION, . -SFR/ADD/REM� � � �� �' � 0 i I HEREBY AFFIRM UNDER 7ENALTV OF PERJURV THAT I AM IXEMPT FROM THE CONTRACTORS LI- G8ffl98/C2fPOfF ' � W CENSELAWFORTHEFOLLOWINQRE4SON(SEC.7o31.5BUSINESSANDPROFESSIONSCODE:ANYCITYOR ,(n � _ , . � �. �.COUNTYWHICHREQUIRESAPERMITTOCONSTRUCT,ALTER,IMPFtOVE,DEMOLI9H2ORREPAIRANYSTflUC- ��J,J Pat10/�BCk W ' 7URE,PRIOR TO ITS ISSOANCE,�;ALSO-REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNEO� �w - , � �� STATEWENT THAT HE OR SHE IS�LICENSED PUR5UANT'f0 THE PROVISIONS OF THE WNTRAGTORS LI• � CENSE LAW(CNAPTER 9(COMM�NCINO WITH SECTION 7000)OP DNISION 3 OFTHE BUSINESS AN�PRO- � 'u' POOVSpB �! FESSIONSCODE�ORTHATHEOF{SHEISEXEMPTTHEREFRDMANDTHEBASISFORTHEALLEGEDEXEMP- .� ��,. V, TION.AM'VIOL4TIONOFSECTION7031.6BVANVqPPLICANTFOPAPERMIT5UBJECTSTHEAPPLICANTTO. . �Z RB-ROOT � � � � '�' 'A CML pENALTY OF 40T MORE t`HAN FtVE HUNDRED DOLLARS(SSoa).): ❑I,ASOWNEROFTHEPRO�'ERTY,ORMYEMPLOYEESWI7HWAdESASTHEIRSOLECOMPENSA710N, �.�� Commercial . �',. .,WILL.00 THE.WORK M1�THE STFiUCTURE IS NOT IN7EN05D OR OFFERED FOR SALE(SEC.7044,BU51- ..J , �I NESS AND PROFESSIONS COOEri THE CONTPACTORS LICENSE lAW OOES NOT APPLY TO AN OWNER OF � � � . � �� PPOPER7YWH08UILDSORIMPROVESTHEREON,ANDWHODOESSUCHWORKHIMSELFORHERSELPOR �m �". 'THHd1GHHISORHEHONMEM(jIOVEES,PROVI�E�THATSUtl�iIMPHOVEMENTSARENOTINTENDEDOR � �- � ' �W� ,OFFEREDWRSALEIF,HOWEVERTNEBUIIDINGONIMPROVEMENTISSOLDWITHiNO1�YE4ROFCOMPLE- ' I �TION,THE OWtiER�OUIIOFA WILL HAVE THE BI1flDEN OF PROVING THAT HE OR SHE�IO NOT BUILD OR � � ='i '��MPROVEFORTMEPURPOSEOF�i3ALE}. ' . � � W� ❑I.ASOMMEROFTHEPROPERTY,AMEXCLUSIVELYCANTRACPINGtlVITHLIGENSEDCONTRACTOR3 �li TO CONSTRUCT THE PfiQ1ECT(�EC.70M3,BUSINESS AN�PROFESSION$CODE:THE CONTRAGTORS.LI- ' V81118SIOfl ADJ.AREA � ����� 'Wi .CENSELAWDOESNOTAPPLYTC}ANOWNEROFAPHOPER7YWHOBUILOSORIMPNOVESTHEREON,AND �� �,��,�'WHOCONTRACTSFORSUCHPRQJECTSWITkACONTRACiDR(5)�hICENSEDPURSiIANTTOTHECONTRAC- QUANTITY DESCRIPTiON '� � FEE " . � ��TORSIJCENSE!AW.�. . ' .. . J ,�� ❑I AM E7(�APT UNDER 5�4�. B.8 P.C.FORTNI6 REASON �., � . , �'�,. _ . � . . . � . �'=' DATE � OWNER �� . . � o�� LICENSED CONTRACTORS DECLARATION W . �'. 1HEREBVAFF'IRMUNDERPENAL�iYOFPERIURYTHAP'AMLICENSE�UNDERPflOVISIONSOFCHAPTER �� ��^�� �p .,y.�° � �; � D(COMMENCINO WITM SEGTIONh000)DF DIVISION 30F THE BUSINESS AND PRDFESSIONS CO�E,AN� Z �`"'V'�°�'� I!� �Z"� r�'''� � ' �XW AAV L16ENSE IS IN FULL FORCE AND EFFECT. � W �� '] ol UCENSEGIASS L1C.N0. � �'�f�'��J7` � . �' � � DATE � � � CONTRACT04i � � � 0- � � � W � WORKERS'COMPENSATION DECLARATION Q � , � 1 HEFEBYRFFIRM UN�ER PENALTY OF PERIUHV ONE OFTHE FOLIAWING DECUFA710NS: '- U ,,. � � . vj Z Q � _IHAVEANDWILLMAINlRINACEWTIFICATEOFCDNSENTTOSELF-INSUREFORWORKERS = � -`�'� COMPENSATION,ASPROVI�EUBYSEC710N37ooOFTHEi.ABORCODE,FORTHEPERFORMANCE 4W OF THE WORK W R WHICH THIS PERMIT IS ISSl1ED. � d �F,�,,,�� '�I HAYEAND WILL MAIiVTNN WOPoCERS'GOMPENSATION MSURANCE,AS RE�UIRED BY SECTION ' � S 37�oOFTHELABORCODE,FGRTHEPERFORMANCEOFTHEWORKFORYJHICHTMISPEP.M1T15 A ISSUED.MVN'ORKERS°CO NSATIONINSl1RA CARRIERANOPOLICYNUhS6ERARE: CONSTflUCT10N ¢ cpnaiEa - � Q����� - � PLANREVIEW � � PouCYNUMBER �J� i- � ELECTRIC ' �,-� (IFIISSEC110NNE�NOTBEWx�PLEfEDOFhIEPERMfTISFOROPIEMJWREDCOLLAHS(5700)ORLESS). PLIJMBING c� Z' I CERTIFV THAT IN THE�EFIFORMANCE OF YHE WORK FOA WHICH THIS PERMIT IS ISSUED,I MECHANICAL �- - � SHALL NOY EMPLOYANY PERSON IN ANY MpNPJER SOAS TO BECOME SUBJECTTOTHE (n WORKERS'COMPENSA'TlION LAWS OF CAI.IFORNIq AND AGpEE1MAT IF I SHOUL�BECOME INSPECTION FEE � �' SUBJEGTTOTHEWORryERS'COMPENSATIONPflOVISIONSOF5ECTIDN37ooOFTMELABOR - ���' � � CAD:,1 SHAI.L FO THWITH COMPLV WfTHTHOSE PROVISIONS. ISSUANCE � ponrE: �" m,PaicArar. ���:C�I �� SMIP � �y.i .. , a �- � ENERGY P/C � � p '����, WARNINGFAILURETOSECURE'WOFiKEAS'COMPENSATIONCOVERAGEISUNLAWFUL,ANDSHALLBE ' �y �„�}'�� .�. ;�y�- Slf&IECTANEMPLOYER-iOCRIM�NA4PENALTIESANDCIVILFINESUPTOONEHUNDREDTHOUSAND ENERGYPERMIT � OOLLARS(510o,000J.M A�DITION 70 THE COST OF COMPENSATIDN,DAMAGESAS PROdI�ED FOH 1N � SECTION 3708 OF THE LABOR CbDE,INTEREST,AND ATTORNENS FEES. RETENTION FEE: Q,,, Q CbNSTRUGTION LENDING AGENGY PRE-ALT FEE: �..�'n'�.. 1 HEFEBV AFFIRM UNOER PENAI.TY OF PERJURV THATTHERE IS A CONSTRUCTION LENDING AGENCV aF' FORTHE PEPf-0RMANCE OF THE WORK FOR WHICH THIS PEHMIT IS ISSVE�(SEC.3091,CIV.C.�. . i , . �'.Z' �� . ... . .LL�I' . ., �- . I .���'..�� LEN�ER'SNAME � ' ' F:-�. LEN�ERSA�ORESS C �✓�,.� "/'������ �� ICEFTIFYTHATINAYEREADTHISdPPLICATIONAIJ�STATE7HATTHEABOVEINFORMATIONISCARRECT. TOTAL rEES �� � J(p��-✓"' '� IA(3REETOCOMPLVWITHALLCRYANDCOUN7YOR�INANCESAN�STATELAWSRELATINGTOBUILOING ` � , ���, CON57AVCTION,AN�HEREBYAUTHOflREREPRESENTAT7VE50FTHI5COUNTYTDEh'TERUPONTHE � ' . . . . ��� ABOVEMENTIONED PROPERN FOR MSPECTION PURPOSES. COMMENTS ' �� �G�'.L`� ., .�� PERMITTE (PRI - - � . . en c� � °� �, SIGNATUR OF PERPAIiTEE DATE ' ' � ....,—y. � RECPT.NO. - PAID BY - '��VALIDATION "~ IMiITE�e artment Co YELLOW—Finance Co PINK—Assessor Co �GOLDENROD—Fife Co GREEN— liranCs Co � � - P PY. 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