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HomeMy WebLinkAbout12854 (13) CITY OF DIAMOND BAIi' � �—�� DEPARTIO�IENT OF COMMUNITY&DEVELOPMENT SERVICES � � . 21660 E.Copley Drive Suite 190 (909)860-3195 Fax(909)861-3117 PRESS '�``� � _ _- ` Y � BUILDING PERMIT APPLIGATION` FIRML 0 D RIESS ����I �L�–vGiG.- L�,�Q APPUCATION ,�� PERMIT '�7 �(�" C DATE � �'`' � NUMBE . '��V # $ � ISSUE T�lPE `.; OCC -- APN LOT�I,,„� TRACT � �� QATE CONST. GROUP p OWNER 5'��f�Y.0 � �r LL ADDRESS� C<� � ZONWG SETBACKS- W CITY�A� ZIP _ -TEL�-������'G�QI� FRONT RW ` ❑ � APPC:ICANT�,��'E�,i/� TEL. ' S DE/SIdE STRE � ¢ ET , RW ❑ oCONTRACTOR� � SIDE ❑ w ARCHlENG/ PROPOSED USE �i"K.. r" � � : � CDDRESS I—_ ZIP TEL. � ��..,, . , z DESIGNER, � f� I�1� �,� " ` ,:s W NO.DWEL. '�NO. NO. a ADDRE S " UNIT$ '- STORIES BEDROOMS � CITY �.•'S' ZIP TEL , ,«.. .,., , ' cn DESCRIPTION SQ.F,7". ; ���ACTOF�i P5F ADJ:AREANACUATION , � I - , � ;.. . .. . .. . �WNER-BUILDER DIECLARATION_ ���� SFR/ADD/REM- �� ��, .�� '��� � � � � ' . ,.` ,_.. ...._. . .. . . , , .. I HEREBY AFFIRM UNDER�ENALN OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI- GflfBC]e/CBf�JOf1 � �"�.' � '� W CENSEUWFORTHEFOIIOWINp RE/1SON(SEC.io31.bBU51NES5ANDPROFE5510N5CODE:ANYCITYOR (n - C.� COUMYNRIICHREQUiRESAPEFA1fTTOCbNSTflUCT,ALTER;IMPR04E,0EMOLISH,ORREPAIRANYSTRUC- � � � � W -il1RE.-PRIOR TO IT3�{SSUANCE,AL90 REQUIFES�THE APPLICANT FOR SUCH PERMI7 TO FILE A SIGNED W�'�--�� �r .;� .�j* STATEMENT TMAT HE OR SHE I LICENSED PURSUANT TO THE PROVISIONS OF THE CANTRACTOFS LI- � �' 4 . CENSE UW(CHAPTER e(COMM�NCINO NMTH SEQTION 7000)OF DIVISION 9 OFTHE BUSINESSAND PR0. PO01/Sp8 °j` �✓� �j i ��y ���� � � ' � � �.FESSqNSCOOE)ORTHATHEO SHEISEXEMPTiHEREFROMANDTHEBASISFORTHEAILEGEDEXEMP- ,� ,(�} � ; , U � TION.ANYVbI.ATIDNOFSECTI 70375BYANYAPPLICpNTGORAPERMITSU9JECTSTHEAPPLICANTTb � Z' R0-ROOf , rj,' � I��.A CINL PENALTY OF NOT MORE HAN FNE HUNDRED DOLLARS(f5oo�:j: � � , , � � ' OI,ASOWNFAOFTHEPROERN,ORMVEMPLOVEESWITHWAGESASTHEIR60LECAMPENSATIDN, CO(f1111B1'C7aI , � ,. �� '�`�� t��- �'� � , � .WILL DO THE WORK,AND THE 91�RUCTURE 13 NOT MTENDED OH OFFERED.FOR SALE(SEC.7044,BU51- �', ��NE55 AND PROFESSIONS COOENj,TC��HE CONTHACTORS LICENSE LAW DOES NOTAPPLY 70 AN OWNER OF °�, 'h Q� THNOUGFIHISORH RONMEMp VESTHEREON;ANDWHtl00E55UCNWORKHIMSELFORHEflSELFOR � ���� '4".'�J i �`� � . . LOYEES,PpOYlOEDTHATSUCHIMPROVEMENTSARENOTINTENDE�OR� � m' � � - - I � �;OFFEREDWRSALEIF,Ii�WEVER1HEBl11LDINGORIAIPHOVEMENTIS50L�WITHINONEVEAROFCOMPLE- . Z '�TfON,�THE�OWNER�BUILDER WRL HAVE 7HE BUR�EN CrF PROVING THAT HE Oq SH6�I�NOi BUIID OR� . ,. :..,;.,-,: " , _ �IMPROVE FOR THE PURPOSE OA SALE�. ' - � ' ❑I,ASOWNEflOFTHEPRdPERTY,MAEXCLUSIVELYCOMRACTINOWITHLICENSEDCONTRACTOR3 ��_TO GONS7HUCTTHE PRQIECT(�6EG 7044,BUSINE55 AND PROFESSIONS GODE:THE CONTRACTORS LI- V8IU3UOf1 � ADJ.AREA �� � W �CENSEUWOOESNOTAPPLY70ANOWNEROFAPflOPERTYWHO6U1LO50RIMPHOVE57HEREON,AND F I�.WFIOCON7RACTSFORSUCHPRbJECTSWITHACONTRACTOR(S'LICENSEUPURSUANTTOTHECONTRAO QUANTITY DESCRIPTION ��FEE Y;,�"fORS LICEN6E UW.). I �� . . � ❑I AM EXEMPT UNDER S�C,r. B.&P.G FOR THIS REASON � � �Q � - � " �' '�. � " ' . � V �.;_ .;. �i, . � .. .. '. � " ,�'' , , . � DATE � � ONMER ��- . , � LICE W � t�SED CONTRACTORS DECLARATION W I � � I HEREBYAFFIRM UNDEH PENMMM���TTTVVV OF PERIURV THAT IAM LICENSED UNDER PROVISIONS OFCHAPTER Z. . . �., , , I ,"''i ' y��. B(COMMENCINO WITH SECTION I/00U)OF DIVISION 90F THE BUSINESSAND PROFE3SION9 CA�E,AND ' " X MY 610ENSE IS IH FULI FO CE a�hdD EFFECT. �p ��:.: LICENSEC S � ��..I � . . .LIC.NQ �G' •� �4�.�V� . � � . ' � U"� DATE � � I � CONTRACTOR�.. �. . � RT�y A r � �. LLJ I .� �iV�.Y�ri1� . � WORIQEFIS'COMPENSATION DECLARATION � t���i �, I Q T � L�.�.��:ifi.t '� ���� IHEREBYAFFPGUNOERPENALTVOFPE0.IUR/ONEOFTHEFOLLOWINGOECLARATIONS: Z ' �� � '� � � � '� �,� _I HAVE AN�WILL MAINTqIN ACERTIfICATEOF CONSENT TO SELF-INSURE FOH WORKERS' y COMPENSATION,AS PRbVIDED BV SECTION 37000FTHE LABOR CODE,FOR THE PERfORMANCE W �� OPTHEWORKFORWHI�HTHISPERMITISISSUED. � , '�� .�,I HAVEAND WILL MAINfI�IN WORKER3'COMPENS47foN INSUqANGE,AS REQUIPED BY SECTIaJ � - � � ; Q, 37000FTHELABORCO E,FORTHEPEHWRMANCEOFTHEYVORKFORWHICHTHISPERMITIS qy ISSUEO.MYWORKEAfS'��O�MP,ENSATIONINSURANCECARWERANDPOLICYNUMBERARE: CONSTRUCTION 4 �2�1 i�, {�� ��� � � y,... caRaiEa—��il G��t—'��V,'�,�'. ��. g� . . � PLAN REVIEW L V / ��L,6� . � . .z',. POucv NUMBEa��I�tJ�./��^N La[J C Z - E�ECTRIC ��S���� d �p9 �. �� (IFiISSEL'i1GNNE�NDT�EwP«f�eiEooFn��wati'�5waataEHuwFlEaoalaRs(Staa)ORLESS). PLUMBING ��p+�.7�/�' r�e� � Z��. I CEA7IFYTHAT INTHE ERFORMANCE OFTNE WORK FOR WHiCH THIS PERMIT IS ISSUED,I MECHANICAL l�7 LO L�v . '� (�}, SHALLNOiEMFLOYAN'PERSONINANYMANNERSOASTOBECAMESUBJECTTOTHE . �, � WOHKERS'COMPEN3A 1AW50FCAl.IFORNIA,ANDAGflEETF1ATIFI5HOUI.DBECAME INSPECTIONFEE ', �' ' SU&IECTTOTHEVNORK RS'COMPENSATI�NPflOYIS10NSOFSECTION37o00FTFlELABOR � '�+ � � CA� 1 SHALL FORTHW TH COMPLY WI'IH THOSE PR SIONS�/�� ISSUANCE ��7��� a -�'�6��'�l>( ►� sMiP c�taf� '� p" DATE;_t� �PPLlCANT. ��� - ENERGY P/C � WARNING FAILURE TO SECUflE RKER$'COMPENSATION COVEftAGE IS UNIAWFUL,AND SHALL 8E ��i �` �y SUBJECTANEMPLOYERTOCRI INALPENALTIESAN�-CNILFINESUPTOONEHUN�RE�THOUSANO C..G DOLLARS(S7aa,ouo),IN ADDITI TO hiE COST OF COMPENSATION,DAMAGESAS PROVIDE�FOR IN ENERGY PERMIT E_� � SECTION970BOFTHcLABOR �DE,IN7EREST,ANDA7TORNE`/'SFEES. ' RETENTIONFEE: _ � L�C.d o' C NSTRUCTION LENDING AGENCY PREALT FEE: �. �.,',, i HEREBV AFFIRM UNDER PENAITV OF PERJURV THATTHEAE IS A�NSTRUCTION LENDING AGENCV ' FOR THE PERWRMANCE OFTH W RK FOR WSIICHTHIS PERIAIT IS ISSUED�SEG 3a9],CIV.CJ. . . Z W. �� LENOER'S NAME . � � � F•' LENDER'SADDRE55 ]� p w ICEHTIFYTHATIHAVEREADTHISAPPLICATIONANOSTATETHATTHEABOVEINFORMATIONISCARRECT. TOTAL FEES ���� � l� -' ��GS4..��f�.��' �' �' IAGflEETOCAMPLVWIiHALIC�TYANOC6UNTVORDINANCESANDSTATELAWSRELATINGTOBUILDINO - , �. CONSTRUCTION,ANDHEflEBY�UTHORIZEREPRESENTATIVE50FTHISCOUNTYTDENTERUPONTHE ' � ' Z�, ABOVE-MENTDNEDPROPERTY ORINSPECTIONPURPOSES. COMMENTS � � � �'��' ��-i • ��' PEHMITTEE � (PR N'� py � ' �',. . - IL� �� - . . . . ��,� SIGNATUREO PEHIAITTEE I �AT . p,, � � ' � _� �� I. - - RECPT.NO. 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