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HomeMy WebLinkAbout12992 (13) ^ ;, CITY OF DIAMOND BAFC � DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES ai66o E.coP�y n�;�e s,�r�r90 ' PR ESS w (909)860-3195 Fax(909)861-3117 9lfs _ BUII.DING PERh�IIT APPLICATION FIRMLY a- `�'�'p /� -q, �( � . . .T o ADDRIESS `!.S�C�'� �I I��� c..�✓i I'°i�4..°'- DATE CATION ���-��NUMBER � "r' " � �lC o � ISSUE � TYPE OCC °�° APN - LOT', TRACT � �� DATE " CONST. GROUP p OWNER. �r�WFIt�,�C' ` °C p ADDRESS � � �^- ZONING SEfBACKS z CITY �. ZIP� TEL�l����i--I/�a� FRONT RW ❑ p APPiICAN"f i TEL. S DElSIaE STREET RW ❑---� ¢ � CONTRACTOR F�E i ¢Y!� �e.e SIDE p ADDRESS . , PROROSED USE O CITY ` ` " `x� ZIP��.�:2. TEL �` �tS/� a ARCH/ENG/ i W DESIGNER i ' NO:DWEL. NO. NO. a ADDRESS � CITY i ZIP TEL. OOMS � i `, UN1TS STQRIES BEDR � c�wwEa•sUi�oER DE DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� . _ , CLAAATION, SFR/ADD/REM � O �' Q, I NEH�Y AFFIRM UNDER qENALTY OF PERJUFV TH.qT I AA1 EXEMPT FROM THE CONTRACTORS LI- � ,� Garage/Carport � � � �� W �CEN9EUVIFOflTHEFOLIOWIN�iFEASON(SfiC.1W1.5BUSINESSANDPROFESSIONSCODE:ANYCITI'OF U. COUNTYWHICHFiEW�RESAPERM1TTdWNSTRUCT,ALTER,IMPROVE,OEMOUSH,OflREPAIRANYSTfiUC- _ LLE _pa!i0/OeCk IURE,PRIDR TO ITS ISSUANCE,IALSp:qE�UiRES.T4E AAPLICANT FOF SUCH PERMI7 TO FILEA SIGNE� g� STATEMENT THAT HE Ofl SHE IS�LICE�iSED PURSUpNT TO THE PROYISIONS OF THE CONiflAC70R5 LI- �' � .C�NSELAW(CHAPTEF79(COMMENCIN(`z,WITHSECTIDN7000)OF!]IVISION30FTHEBUSMESSANOPRO- ' POOI/SP8 � � FESSpNS CODE)OR THAT HE OF�SHE IS EXEMPTTH'cREFROM AN�THE BA515 FOR THE ALL�GED EXEMP- � TION.ANYVIq.AT10NOFSECTlO{i7031'.SBYANYAPPLICANTFORAPERMITSU&IECTS7HEAPPLICANTTO � . � RB•ROOf � I . ' " 'ACMLPENALTYOFNOTMOftET�HAN'F�IVE'HUNDREOOOLiARS(f500).): "' ' � ~ ❑I,ASONMEPOFiHEPROPERTYyDRMYEMPLOYEESWI7HWAGESASTHEIRSOLECAMPENSATION, � � O WILL W THE N10RK,AND iHE 5 FUGT,UPE IS NOT INTENOED DR OFFERED FDR SALE(SEC.7044.BU51- � Cornme�Ciel . — � . Z, NESS AND PROFESSIONS CODE:THE CANTRACTORS LICENSE LAW DOES NOT APPLV 70 AN�,OWNEF GF � �. � PfWPERTYWHOBUIIDSORIMP OYES�THEREON,ANDWHODOESSUCHWORKHIMSELFOHHERSELFOR � �_ ' ' � ' ' ��, �'� THHOUGHFNSORHEFOWNEMPOYE�S.PROVIDEO7HpT$UCHIMPROVEMENTSARENOTINTENDEDOR �m � � � � � � OFFEqEDf-0RSALEIFHOWEVE iHEBUILDINGORIMPROVEMENTIS50LDWITHINONEVEAROFCOMPLE ' � � z. '�TION,THE OWNER•BUfLDER WILL 11AVE THE BURDEN OF PROV1NCa THAT}1E OR EliE DIO NOT BUIL�OR . . . .. . = IMPROYEFORTHEPUPPOSEOFISALFa: '�. -� . � � ❑I,ASONMEROFTHEPROpEFlT1;AMEXCLU6IVELYCANTRACTMGWITHLICENSEDCONTRACTORS �'', TO CANSTRUCT THE PROJEGT(SEG 7b4l,BUSINE55 AND i'ROFESSIONS CODE:THE CANifiACTOflS LI• � V2I112I1Of1 A�J.AREA � I W�., CENSELAWDDESNOTAPPLVTq�AN�1FMEROFAPROPER'fVWHOBUILD50RIMPROVESTHEqEON,AND . , � �N'FpCONTMCTSFOF6l1CHPp0.1ECT5WITHACON7HACTbR(5{LICENSEDPURSUANTTOTHECONTRAG ' QUANTITY DESCRiPTION � � � � FEE �'. TORS LICENSE LAW.1. I� . �'. ,'„� . . ¢? ❑tAM IXEMPTt1NDER S�C. 8.8 P.4 fOR THLS REASON ��Q � - " T C� . t� � .. ��� . . MTE OWNER � � . �. U W � LICENSEDICONTRACTORS DECLARATION W ��� I NEREBYAFFIRM UNCER PENAL#1'OF PERJURV THATI AM�ICENSED UNDER PROVISIONS Of CHAPTER �� ��� . �/�,•ys �� ���`-�� ' a �;� �'. i, p�'� 9(COMMENCINOWiTM5ECT10N7�a00)OFOIVISION30FTHEBUSINESSANDPFOFESSIONSCO�E,AND � �Ve� '�. X�, MV UCENSE IS IN FULI FORCE A D EFFECT. � m �� � . W �`,�` o, LICENSECIASS . ��. LIC.NO.'. .�0� �T�� �, �'-� . V� �ATE � CONTRACTOF �- � �'a' . L68 � WORK�RS'�.,COARPENSATION DECLAAATION a ,,, �� I HEREBY AFFIRM IDNDEH PENALIjYOP PERJL'FiY ONE OFTHE FOLLOWIfiG DECLARATIONS: � Z ' � ' �, lIHAVEANDW�LMAINTAIN ACERTIFICATEOFCDN3ENT703ELF-iNSUREFORWOHKERS' _ ¢ COMPENSATIDN,ASPRO�I�ED'�BVSECTI�IJ37000FTHELABORCODE,FORTHEPERFORtAANCE '`U I OFTHE WORK FOR WHIC '�HI$PERMIT 19135UED. ,� W � � 1 NAVE AND WBLI MAINTAIN WORKEflS'COM?ENSATION INSUFANCE,AS REOUIRED BY SFCTION � 37000F THE LABOR C0�,FOATHE PERFORMAMCE OFTHE WORK FOR WHICH THIS PERMIT IS ISSUED.MY WORKERS' E'NSATSIOnN pINSUR9/Nd(E CARqIEft AND POLICY NUMBERARE: CONSTRUCTION j cARqiER - ���G�"��6L _ PLANREVIEW Z POLICYNUMBER �', �- . � '� . . ELECTFIC � (fFdI33ECTKMJNE�NO78��.1PLEfEUOFThEPEFMTISPORONEF#JNDREDDOLW3R�S1oo)ORLESS). PLUPv1BING tx � ICERTIFYTHATINTHEP�RFORMANCEOFTHEWOflKFORWHICHTHISPERMITI5ISSUED,I MECHANICAL ���� C!S SHAI.L NOT EMPLOY AhY PERSON IN ANY MANNER SOAS TO BECOME SUBJECTTOTHE � INORKERS'COMPENSATI�NLAW�SOFCALIFOHNIA,ANDAGRE£THATIFISHOUL�BECOME INSPECTfONFEE � � SU&IECTTO THE WORK RS'CGMPENSATqN PROVISIONS OF SECTION 370o OF THE LABOR � - = CO�E,ISHAtiFD THWI HCOPAPLVWBTi/T��',j�OSEPi�VI510NS. ISSUANCE _ i pDATE: �"" �. PPf:9CAPdT:-g :.��. �����✓�� �SMIP '� , J WARN'��NG:PNLUpE TO SECURE I�ORKERS'COMPENSA710N COVERAGE IS UNLAWFUL.AND SHA�L BE ENERGY P/C - � SU&IECTANEMPLOYERTOCRIM�INALPENALTIESANDqVILFlNESUpTOONEHUNDf�DTHOUSAN� ENEAGYPERMIT DIX,lARS(5700.aoo),INAODITIONTOTHEGOSTOFCOMPENSAilON,OAMAGESASPROVIUEDFORIN � J� SECTIDN 3700 OF THE LABOR CO E,MjEPEST,ANO ATiORNEV'S FEES. ' RETENTION FEE: . _�`� �� "- � � CO�,NSTRUCTION LENDING AGENCY PRE-ALT FEE: � IHERE9YAFFIRMUNOERPENALI�FPER,IURViHATTHEREISACONSTRUCTIONLENDI4GAGENCY ' ' FORTHE PERFORMANCE OFTHE WORK FOR WHICH THIS PERMR IS ISSIIED(SEC.309�,CIV.C.). � LCJ � � LENDER'S NAME . � � !� LENDEH'SADDFiESS � w ICERT7fYTMATIHAVEREA�THI RPPLICAifONANDSTATETHATTHEA90VEINFORMAT10NI5CARRECT, TOTAL FGES �' � ..� o ��: � I AGREE 70 COMPLV WITH ALL CI AN4 CAUNTV OiiDINANCES AND STATE LAWS RELATING TO BUILDING _, . �, � CONSTflUCTION,ANDHEHEBYA�THORIZEHEPRESENTA7IVESOFTHISCDUNTYTOENTEFUPONiHE ' , . . ' � Z ABOyE-MENTIONE�PROPERTY R INSPEC710N PURPDSES. . � � Q � - � y� COMMENTS - �— �..s � . . . . . m PERAAITTEE NAME(PFINT � � �-,��- ,--- (yj SIGNAT MITTEE '. DATE -' ' � � - RECPT.NO. 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