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HomeMy WebLinkAbout13437 _ _ _ _ � ��� ^ �.� CITY OF DIAMOND BA& ,r-'� DEPARTMENT OF CUMMUNITY&DEYELOPMENT SERVICE$ w 21660E.CopleyDriveSuitei90 PRE$$ � (9D9)860-3195 Fac(909)861-3117 _....,�, , •y� - BUILDI1wiG PERMTT APPLICATION ' FIRMLY , _—.. - ,, ., � � JOBSITE ^�' ��� : APPLICATION PERMIT t2� (I P/C o ADDRESS ' ' � � 14J' '' ' DATE NUMBER t J`T�� �Y o� , ' ISSUE TYPE OCC APN LOT 'r T CT ` DATE ��I�� CONST. GROUP. p. _OWNE�' �.. � e, Q ADD F � .v ZONING SETBACKS z CITY _ZIP , TEL, � �, FRONT. .., . RW ❑ p 'APPUCANT I TE " 5 DEJSIQE STREET RW ❑. z ¢ CONTRACT Z , , � SiDE ❑ � ADDR � �'�� ''� -• PROPOSED USE � � C��'� �� Z� ,���TEL. � W ARCM/E G! � ��'� � ' �z DESIGNER � NO.DWEL. NO: NO. a PDDRESS � UNITS STORIES BEDROOMS _= CITY � ZIP TEL. , ' � ' � DESCRIPTION SQ,FT.`" FACTOR,PSF ADJ.AREANA�UATION' ' ..,d.� .._ OWNER-BUILDER DECLARA710N � . � SFR/ADQ/REM ���� �� �� O � I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FpOM THE COMRACTOqS 1.1-� . G8f8ge/CefpOfl. � �W� ��GENSELAWFORTHEFOLLOWINCa�REA50N(SEC.7o97,5BU51NE55ANDPPOFE5510NSCODE:ANYCITYOR (� v.W� �STATEMEN7 THAT HE OR SHG I5�ENSEO PURSUrWT TO TH'e pqpy EMOLISH,OR REPAIRANYSTRUC�. .W pgtio/DBCk ' � CRJSE LAW(.CHA 7EH 9uCOMM ,C NO WITH SECTI�N 7au0!OF q�y q SUCH PERMIT TO FILE A SIGNEO � . ' COUNiYYVFiICHREWIRESAPER ITTOCON6TRUCT.ALTEP,IMPROV ISIONS OF THE CaJTFlACTORS LI- ,�, .. ( Q ) I$ION30FTHEBUSINESSANDPRO� 'V" �POoUSpB � � FESSIONSGOOEjORTHATHEOR�$HE15E%EMPTTHEREFROMAN�TMEBASISFOR7HEALLEGEDEXEMP� � (] ,V� TION.ANYVIOLATIONOFSECTIOWI'7031,SBVqNVAPPLICANTFORAPEAAlITSUBJECTS4NEAPPLICANTTO Z R0-ROOf '� - � ��'AGIVILPENAIiY OF NOT MOqET�+AN FIVE HUNDRED�OLLAPS(5500)J: � ' Q, ❑I,A60WNEROFTHEPROpERTY,OPMYEMPLOVEE6;WITHWAGESA5iHE1R50lECOMPENSATION,� �� COfI"tt17BfC181 - - ' .� Z. ,WILL DO THE WOHK,ANO THE S RUCNHE IS NOT INTEN0�0 OFl OFFERED FOR SALE(SEC.7�bq,B1156 J � �NE55 AND PROFESSIONS COOE:THE CONTRACTORS LICEMSE LAW DOES NOT APPIY TO AN OWNER OF ,� � . PFiOPERTYWHOBUILOSORIMP OVES�THEREON,ANDWH600ESSUCHWORKHIMSELFORHERSELFOR� " "� ��TNROUGFIH150RHEAOWNEMP'�O'YE�,PROVIDED.TNATSUGHIMPROVEMENTSAREN0TINTENOEDOR 'm ' ' ,� �,OFFER�DFORSALEIFFiOWEV THE6UILOINGORIMPROVEMENTiSSOLDWI7HINONEYE4ROFCOMPLE- �:T�ON,THE OWNEfl-BUILDEH WI �HAVE TME BUROEN OF PROVMG THAT HE OR SHE DID NOT BUIID OR IMPROVE FOR iHE PURPoSE OFtSALE)�, - � ❑I,AS OWNEfl OF THE PFidiPERTY,AM EXCWSIVELY CONTRACTING WITH LICENSEO CONTRACTORS . ��� .��TO CONSTRUCT 7HE PROJEC7(SEC.7014,BUSINE55 AN��PfiOFESSIONS CODE:TFIE CONfRACTORS LI-� VdlUflll017 ADJ.AREA� i � � 'W ��CENSEAWDOESNOTAPPLYTC�ANOWNEROFAPROPEHTYWH06UILDSOFIMPROVESTHEREON,AN� �' ''WHOCONTRACTSFORSUCHPq�,�ECTSWITF!ACONTRACTOR(5)LICENSEDPUFiSUAN7TOTHECANIAAG QUANTITY DESCF3IPTION " " ' . FEE �,� .TORSUCENSELANA). ���T� � ^ �.,Q.,. ❑IAM EXEMPTUtd�ERSE�. .. . .. B.&P.C.FOR THIS REASON � � � -, - ' ~" �. . "" � � � ' „ ;'. LL � L�Z- � 6 ?.�,: DATE OWNER � V W � LICEWSED CONTRACTORS DECLARATION �� - -� -� � ��� ; . . . . � . � � . ' 1 HEREdV AFFIFM UNDEFi PEN�OF PEPJUfiY THAT IAM LICENSEO UN�ER PFOVISIONS OF CHAPTER - � $;,�� 9(COMMENCINp WITH SECTIONh000j OF.DIY1910N 3 OF THE BUSINE33 AND PROFESSIONS COOE,AND Z ' . a, MY LICEMSE IS IN FULL F �l�FJO EFFECL � � . � F_ UCENSE p55� �.��. LIC.NO. "'^� � ���. DATE � �+�� � CONTRACTOR , d �- W eit WORI�ERS'COMPENSATfON�ECL4RATION -� ¢ ��� I HEpEBY AFFIRM UNDER PENAL7Y O'r PERJURY ONE OF7HE FOLLOWING DECLARATIONS: ' Z � ' , � �' _IHAUEAN�WiLLMAINTIUPIACESiTIFICATEOFCANSENTT�SELF-INSUREF�RWORKERS' _ -Z'�'"', CAMPENSA71tlN.AS PROYIDED 6Y&ECTION 370o OFTHE LABOR CODE,FORTHE PERFORMANCE U � OFTHE WORK FOR WHICHTI{IS PERMIT IS ISSVEU, � �W�' �.I HAVE ANO WILL MAINTAIN WOqKEHS'COMPENSATI�N INSURANCE,-AS FEDUIRE�BY SECTION , 37000FTHELABOR E,FpATHEPERFORMANCE 7HEWORKFOflWHICH7HI5PERM1715 y. ISSUED.MY WOR MPENSATION INSl1RA CE CARRIERAND POLICY NUMBEFARE: CONSTRUCTION CARRIER F ?LAN HEVIEW �� POIiCYNUMeER I, �, . . . . ELECTRIC s''�'' .�,.,. , a � ,�,.. v �a (iH'SSE(.'IpNNEIDf�SiBEQ�R'LEfEDOFTriEPEMiA9f(ISFORONEHUNDREDb01�AR5(SIOOIORLE55). RJC-- LLl.. Z I CERTIFYTHAT IN THE IPERFORMANCE OF7HE WORK FOR WHICH THIS P6RMR IS iSSUEO,I MECHANICAL .*.,�� C�!S SHALLPIOTEMPLOYAryYPEp50�NiNANYMANNER50A5TO8ECAMESUBJECTTOTHE q y r, ",�.`�g� � WORNERS'COMPENSP�TIONLAWS.CFCAU;ORNIA,ANDAGREEYHATIFISHOULOBECOME INSPECTIONFEE ' : � f �� . ��� SU&IECTTOTHEWORKERS'COMPENSATIONPflOVI510N5DF5ECTl0 OOFTHELA90F �FfiLF" E . '�. \, "��� CADE,1 SHALL iOqTHWITM GOMPLV WI E PqIW1910N9. SUANCE q q �t � p�� OATE: li APPLlCANTf�� � � � SMIP `��,� Ysr ��`3 �fi}z �^�. -�ySrF a : ,3. �' WARNING FAILUAE TO SECUR WORKEfl$'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALLBE ENERGY P/C �t�&„y��.'�S.%�i.�4�°�"'�� } `y" -SUBJECT AN EMPLOYERTO C IMINAL PENALTIES RWD CIVIL FlNES UP TOONE HUNDflEO THOUSAN� ' ENERGY PERMIT DOLLARS($100,Oo0),INADDITI NTOTHECOSTOFCOMPENSATION,DAh9A0ESASPpOVfDEDFORiN � SECTION37080FTHELABOR� DE,INTEqEST,ANDATTORNEY'SFEES. RETENTIONFEE: � O �ONSTRUCYION LENDING AGENCY PRE-ALT FEE: �, IHEREBYAFFIR�AUNDERPEN�L?YpFPEPJIJRVTHATTHERE�ACONSTRUCTION�ENDINGAGENCY � ' FOfl THE PERFQRMANCE OF TrIE WORK FOR WHICH THIS PERMIT IS I55UE�(SEC.309],CIV.C.). � . � ��', LENDER'S NAME I. . . . ��. � ' ' .. . 1-� LENOERSA��RESS �, ICEflTIFYTHATIHAVEREAD IHISpPPLICA710NAND5TATEhiATSHEA90VEINFORMATIONISCAPRECT. TOTAL FEEV � ' � ' ��" � I AGREE TO CAMPLY WIFH AL CITY AN�COUN7V ORDINANCES ANO STATE LAWS RELATING TO BUIL�INO � � - � ' CONSTRUCTION,AND HEFtEB�AUIHORIZE flEPR�SENTATIVES OFTHIS COUNTYTO ENTER UPON THE � A80VE-M6 _ NEDPROPER FOAINSPEC7¢IO"PURPOSES. COMMENTS � � - � '�� :•-.- � PERM,R/i�EE N,AME(P�I �^ /�,v ' - 'CY) / �`.. "� J !/ � � i .... , .. . ' �jj SIG TUREOF7 ITiEE ' DATE ,; �, - '. .� i .. RECPT.NO. PAIDBY i VALIDATION �� - � � ' NiFiITE—De aAment Co YELLOW—Financa Co AINK—Assessor Co GOLDENROD—File Ca GREEN P UY� PY. PY. PY, —APGlicanPs CopY . _. _.._____._. _ . .._... ... . ���� �� ��; � . ���� ����_ ,��� � �� �: t $ a � � � . � � � ,% �,. �, � � a � � � :���`���� _ , . 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