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HomeMy WebLinkAbout13444 � � __�.� CITY OF DIAMOND EAR 9r; DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES �-" 21660 E.Copley Drive Suite 190 (909)$60-3195Fas(909)861-3117 PRESS '?�; :, BUILDING PERMIT APFLICATION FIRMLY o ADDRIESS���� �•���t�'�-�,�� DATECATION NUMBER C �'T`t�#/C o APN� LO7� + ISSUE �,} TYPE OGC CT DATE �� (_v d� CONST. GROUP ¢ OWNE A.8 '+�,�,�.���� ' ,�� _ " ADD S . ZONING SETBACKS Z CITY, - �I , TEL ` � REART RW p �¢ I y � SIDE ' ET RW ❑ g APPLICRNT T � CQNTRRCT R SIDE/SIQE STRE ❑ � _.---". � ADDR ^� ° L o' CITY ZI .. TEL: °" PROPOSED USE • w ARCH/ENG( ���`;�. � W PESIGNER � ` � UNITS STd NO. Q ADDRESS NO.DWEL. NO. a CITY ZIP TEL. RIES BE�RODMS � .,fn ._ .. . . . . � � ,. � J.AREqNALUATIOM DESCRIPTION SQ.FT. FACTOR PSF AD p I�HERE6Y AFFIpM UNDER�ENALTY OF PERJURY THA71 AM EXEMPT FROAI 7HE coNTPACT ' � "SFR/ADD/REM - ��� ���� � � dWNER-Bl1iLDER DECLARATION �� � bas u- �� � Garage/Ca�port �� ' W CENSEIAWFORTHEFQILOWIN�REASON(SEC.ia31.59t1$YNESS,4NqPROPESSIONSGODBANYqTYOq , � .GOUMYWHICHHEQUIflESAPER ITTOCONSTRUCT,ALTER,R1PflOVE,DEMOL19H,oRREPAIfjANYSTRUC- W. patio/DeCk � ;TURE,�PRIOR TO 17S kSSUANCE;� SO REQUIRES THE APPLMJ�NT FOR SUGH PERMIT To FILE A SIGNEtl � � �STATEMENT THAT HE OR&HE IS UCENSEO PURSUANT T07HE PROVISIONS OF THE CONTRACTORS LI- A CML PENi1LTV OF NOT MORE;HAN F W'TH SECTION 7000)OF ONI$IaN 3 oF THE BUSINESS AND PPO- ' � POO�SQfl � . „� CENSE.LAW(CHAPTER4(C�IMENCING , FESSIONS�E)ORTNATHE�RSNEISEXEMI+7THEFiEFRpMANDTHEBASISFORTHEALLEGEDEXEMP- (!f U TION.ANYVIOLATIONOFSECYIO{d 7031'.5BYANYAPPLICANTFORAPERMITSU&IECTSTHEAPPLICANTTO � Z Re�Roof � � Y �IVE HUNDRED DO�LARS(i500j.): � . ❑I,AS,OWNEROFTHEPRBpERTY,ORMVEMPLAVEESWfTHWAGESASTHEIR50LECOMPENSATION; � ,0 Commercial � � . ' ,2' I.�WILL W.THE.WORK,AND THE StRUGT,UFE.15 NOT INTEND'�Ll Ofi OFFEREO FOR SALE(SEC,7044,.9USI- ,J '�,NE55 AN�GFaC]FESSIONS CO�E:ITHE CONTRl1CTORS LICEN5E U1W DOES NOTAPPLY TO qPl OWNEF OF � ���PROPERTYYYFtlOBUILO50pIMPqOVES,THEREON,ANOWHO�0E9SUCH4VORKHIMSELFORHERSIELFOR ��,m .pC�� '�THFWIA(iHHISORHEH'OVMEMPZOYEES,PROVIOEDTHAT$UGiIfAPROVEMENTSAFENDTINTENOE�OF � � '� ��. �'OFFEREDFOR6ALEIF,HOWEVE}�,7HEBNLDINGORIMPROVERflENTISSOIDWITHINONEYEAROFCdMPLE- Z� �;710N,THE�OWNER$UIIAER WIL4�HAVE THE BUR�EN dF PROVWG THAT HE OR SHE DID NOT BUII.O DR . . . I�IMPHOVEFORTHEPl1flPO5EDF�',SAL�. '� ' � w , ❑I.p50WNEROFTHEPROPERfY�AMEXIX.USIVELYCONTRACYiNGWlTHLICENSEDfANTRACTOflS ' �, � � '� I TO CpNSTRUC7 h1E PROJECT($EC,1044,BUSiNE&5 AND PROfESS10N5 CODE:THE CONTRACTORS LI- � V8PU9ilOf1 ADJ,AREA � . W C�NSELAWDOESPF�tAPPLVTO'ANOWNER�FAPiiOPERTYWHOBUIL�SORIMPpOVESTHEREIXd,AND � � PF WHOCONTRACTSFORSIJCNPRC}JECTSNATNAGOfJrRAGTOR(5)IJCENSEDPURSUAN7TOTHECONTRAG QUANTITY DESCRIPTION FEE � oY T9RS IJCENSE L/.W.1. ' . 8.$P.0 FOR THIS R J ' .. � , r•���. ❑I AM EXEMPT llPIDEP S�CI' EASON � � ,� c� r�.� 1� � P+�TE. .. ' � ONR1Efl � �. .� ..... .. LICEN, , .. . . . . WU � � � .j ,�.` ' � ,�. � , SIED CpNTRACTOR5 DECLARATION � -W� ' , � - � �� � !HEREBY APFIRM UNDER PENAL,rJ�,�OP P,EFRIURYTHAT I AM UCENSED UNDEfl PROVISIONS oF CHAPTEP � �� p� e(COMMENdP7f3WITHSECTION7Po0)OFDIVISION30FTHEBUSINESSANDPROFESSIONSCO�E,R�ND Z � id j GY{ICENSE IS N FULL FOR D EFFECL � � � ,LICEidS L4S5 f �r 6JC.NO �-,'/"' .�G.' s.J � � ,j . �..�'�DAT � ' �L� � CONTRACTO � a � [��d WORK�RS'COMPENSATION DECLAAATlON Q ���IHERE91'AFFIRMUNDERPENFLT�'OFPLHJURYONEOFTHEFOLLOWINO�ECLARAilONS: Z - ' C!9. I C8 ._IHAYEANDWILLMAINTA�NACERTIFICAYEOFCANSENTTOSELFINSUREFORWORKERS' z � '�COM1IPENSATION,A9PRO,U���D�D6YSECTION37000FTNELA80RCOOE,FORTHEPCflFORMAl�E `U OFTHE W00.K FOR WHICF{7FII5 PERMIT IS ISSUE�. g � I W �'HAVEAND WRLMAINTAI`'}`WOPKERS'COMPENSATION INSl1RANCE,AS RC-0UIRED BY SECTiON �� � 37000FTHELA@ORC0�2�FORTHEPERWRMANCEOFTHEWORKFORWHICHTHISPERF91T15 J VSSUC-0,MV W/OR�ETR�C'CµLriMPEkP1�ATION.INSUflR C�CAfiFIER AND POLICY NUNIBERARE: CONSTRUCTION �j�, .CAFiRIER ''A./e��I� I � � � P W . .�^ d POucY NUMBER z�+ro "` � � ELECTRIC 3 � a�L.ery <, (IFISSECIqNNE�Pd�ieE��FnoFn�eEw�rr�sFoaavExurvae000uaas�s�w�oa�ss�. PL BING � �:... . I '� - �.. .r£ Z I CEFTIFVTHAT IN THE P6filFORPhANCE OF THE WORK FOfl WHICH THIS PERAIIT!S ISSUED,I MECHANICAL �'��" �� (�'� SHN,LNOTEMPLO7ANYp�R50NINANYMANNERSOASTO9ECAMESUBJECiTOTHE � WORNERS'COMPENSATIqCVIAWSOFCALIFOqNIA,ANDAGREETHATIFi6HOULDBECOME INSPECTIONFEE 'SU&lECT70THEWORKEpSCOdAPENSATiONPROVISION50FSECT10N37ooOFTHELABOR . F�s`f�4 �, ~ C1JOE,I SHALL FORTHWITH COMALY WIT E PROVI51oN5. ISSUANC M�" P'� 7�[t�'C� i�h'/ � -a, f ��"z� o '�:�ATE:�f_�J�'A PLICANT:��./fa�� 7 rs r `� � .WAfiNIN�i'FAILURE TO SECURE �, RKEflS'COMPENSATIIXd COVERAGE�5 UNLAYdfUL,AND SHALL BE ENERGY P/C -��'S„1,�', 3"�.�i �: 4 ��� _ � �,�SU&IECTANEMP40YEqTO�GRIMI ALPENALTIESANDGIVIL'.FINESUPTOONEHUNDREOTHOl15AND - ENERGYPEPMIT ���# � V;-.9 �� ��` �;,,,�!'DOLLAFjS(L10o,U00�,IN ADOITIONT THE.COSTOF CadPENSATION,�AMAGES AS PROVIDED FOR IN ,,k �,�- J� ��,,SECTION37o60rTHELABOpCOD,INTEREST,ANDATTORNEY'SFEES. '� ��" -' RETENTION FEE: O� � CO STRUC710N LENDINGAGENCY PREALTFEE: � �,:,�., IHERE&�'AFFIRMUN�Ei1PENALTyOFPEAJURVTHATTHER�ISACONSTqUCTIONLEN�INGAGENGY . . FOR THE PERFORMANCE OF THE'ORK FOR WH�CH THIS PERMI7IS ISSUED(SEG.3os'I,CIV.G.�. . W... I . . . . . �:` �LEN�ER'6 NRME � ' � LENOER'SMDRESS �'� � ���,.y ' W ",I CERTIF'/�THAT I HAVE READTHIS IPPLICATION AND STATE THATTHEABOVE INFORMATION IS CORPECT. 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