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HomeMy WebLinkAbout14273 (17) 1�_ CITY OF DIAMOND BAB � DEPARTMENT OF COMMiJNITY dc DEVELOPMENT SERVICES � , 21660 E.Copley Drive Suite 190 (9D9)860-3195 Fax(909)861-3117 PRESS �'�'� BUQ.DING PERMTT APPLICATTON FiRMLY � DDRESS /�"�� ��` �er ��l+rJ APPLICATION//r /U��y' PERMIT r_�a��P/C o DATE f f � NUMBER # ISSUE TypE OCC r- APN T THACT pATE CONST. GFiOUP p OWNER � ADbRESS � 20NING SETBACKS , CITY ZI T FRONT � p APPLICANT o �Q REAR p SIDFJSIQE STREET RW ❑ CON7AACT0 a II,� SIDE p ADDRESS � CITy Z� +Zp T , PROPOSED USE�_ C� . � ARCHIEN DES�GNER NO.DWEL. NO. NO. ADDRESS UNITS STORIES BEDROOMS CITY ZIP TEL. � OwNER-BUItDER DEC�AR►,noN �ESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATtON g SFR/ADDIREM 1 HEAEBY AFFliqI UNDER PENALTY OF VEFWRY THAT I AM EXEMP7 FROM THE CON7MCTOi1S U- G81H B/C8 !I CENSELAWFORTHEFOLLOWINGNEASON(SEC.7091.6BUSINE93AN�FROFESSIONSOOOE:ANYGYTYOR (n 0 � COIYli�NMCMREOInRESAVERMRTDCONSTRUC7,ALTERM/PROVE.OElAOl1SH.OHNEPAIRANY3TRUC- W Pp2iO/DBCk TUR�MtqR 10ITS ISSUANCE.AL50 REW IRE9 7HE MPLiCANT iOR BUCN PERMIT TO FR,B A 810NED 6TATEMEM THAT NE Oq SHE 19 4CENSED PURSUANT TO THE VROY1910N9 OF T1E CONTMCT0115 U• CENSE LAW(CHAPTER Y(COMMENCINO WIT115ECilON 700D)OF DIVISION J OF iNE BUSINE55 AND Pf10- �' POOUSpB FE83qN500�E�ORTMATNEOHSFIEISEXEMPTTHEREfROMAN07NEBA5ISFORTHEALIEDEDEXEMP- (� TpN.ANYV10lAT10NOFBEGTION7DJ1.69YMIYAPPIIGNTFOpAPERMITBU&IECTSTHEAPP{JCANTTO Z RB-ROOI � A CML PENALIV OF NOT MORE h4W FNE FRINDRED OOlLAR3(t600)J: � OIASOYMEROFTHEPROPERTV,ORIJYEMPLDVEE9N11THWAOESASiHEIR50LECOMPENSATqN, COR1111BrCiHI - YYILL OD TNE WOiLC AND TNE STRUCiURE IS NOT MENOED Oq OFFERED iOR SALE(SEC.7041.BU51- Q � NE65 A!O GNOFESSIdiS COOE:iHE CONTRACTOR6 LICENSE tAW DOES NOT APPLY TO AN OWNER OF = PFqPERiY YVFq BUILDS OR MIPROVE97HEHEDN,A!�WF1000E5 SUCH YNRK HIMSELF OR MERSELF OR � 1TYWUOFIipSORNEROWNEMPIAYEEB,PROWEGTiATiUpi1MPROYEMENTBMENDTINTENDWOR m OFFERED PDRSALE F IIDWEVER i11E BUIIpNOOR IMVROVEMFM IS&O�p W17MNONE YEAROF CpdPLE. TION,iNE OWNEfLBllIl71EP N7LL FY1VE THE BUf1�EN OF PROVN�TXI1T ME OR BYiE DID q�T BUILD Oq MPROVE WR iY1E PUHPOSE OF SIILEI. �yJ ❑IASOYMEROFIHEPIpPEiRY.ANEXCIUSNELYCONTRACTM10WIhILICEN5E000NiMCTORS � 70 COMSTRUGT TNE PROIECT(SEC.7ou,BUSiNESS AN�PFqFESSION3 COOE:h1E CONTRACMpS Lti V0146�1011 AW.AREA �ISE UW DOEB NOTAPPLV TO AN OWNEii OFA PpOPERTY WIIO BUX.DS OR MAPipVE3 iHEREqV,ANO IM/00DMMCfB�ORSUCNOROJECTSWITHA00MfqACTOR�S)LICENSEDMNiSUANT70TMECONTRAO QUqryn7y pESCRIPTION FEE � TORSUCENSELAW.�. ❑I AM EXEYPT UNpER SEG B.i P.C.fOq THI5 REASON � �= DATE ONMER � Z U ��[ IJCENSED CONTRACTORS DECLARATION W R IHEREBY/�FFIAMIA�WERPENALTYOFPERAIRYTHATIAMLICENSEDUNDERGROVi510N90FC11APTER � � /(COWAENCNOYYITFISECTpNfOWJOFpN1510N70FTNE8U81HESSANDPROFE5SqN5CO0E,N10 Z �� W LICENSE IS W FULL FORCE ANO EFFECT. � ucEwsE cus � 4 _uc.r+o. 7 � Z �� 1 ~ �� � �,� � v ���,�oR WORKERS'COMPENSATION DECLAR N yIMEREBYAFFlRMUNDERPENALTYOFVERJURYONEOFTHEFOLLOWWGDEClAfU7qNS: � � 1 NIUVALLYAMITNNACEflT�FICATEOFCONSEN7T08RF-INSUREFOflYNDRKERS' �FHSATION,ASVpOVIDEDBYBECTON�7000FTNElABORCODE,FOR7NEPERFORMANCE W TFIE YYORK FOR VAiICH TMIS PERMIT 19186UEU. � � ��111AVE MID MIILL WINTAM WORKERS'COMPENSATION INSUqANCE,/S REpl1IRED BY BECTqN C 97000F T1E LA60R COOE FON TIiE DERFORMANCE OF THE WORK FOfl WH�qi iT115 PERMIT IS ISSUEA.MY E PENSATION I RANCE CAqq1ER AND POLICY NUMBER ME: CONSTRUCTION ycu+RiER �� ���� PLAN REVIEW � ro�.icv nuMeER_ ELECTRIC p (n+ssEcna+�wTeE�r�oFnFrErr�ns�oaa+��noau�saiao�a+� PLUM,BING � W � 1 CERTIFY 1M11T W THE PEFFOqNANCE OF7ME WORK FOR CH THIS PERMIT tS ISSUED,I MECHANICAL 8liML NOT EMPIOY 11N`/VEq3pN N ANY IAANNER 50118 T 'COME SUBJECi TO THE (A WORKERSCOMPENSATIONUWSOFCALIFOiNIA.AND .THATIFIBHOUL�BECOME INSPECTIONFEE SU9IECTTOTMEWORKER3'COMPEN3A710NVROVIS 6E THEUBOR � caoE. sr+ui an�win�cour�r wmr nase v ISSUANCE C s p O Q }� p �ATE: � /APPLICANi: SMiP O� J �t �W A WAIWINfi:FAILUflETOSECUREIMDRKERS'C0IAPENSAT VERAdEISUNLAWFUL.ANUBFW,LBE ENERGYP/C G�}�[r,^ ]} 8U61ECTANEMPLOVERTOCRIAIWALVEN+LLTIESANDp INESLIPTOONEHUNOREDTHOUBAND i�J]��� �{.�.�' DOLLARS(5100.0001.N AODITON TOiHE CAST Of COMPE SAiqN,DAMAOES/4S PNOVIDEO FOH IN ENERGY PEFiM1T -"�y, y J oECTqN i70!OF T1E LABOH CODE.INTEHEST,AND ATfORNEY'S FEES. Oc RETENTION fEE: `��" CONSTRUCTION LENDING AGENCY ppE-ALT FEE: � 1 HEREBYAFFIRM UNDER PENILLTV OF PERIVFn'THAT7HERE IS ACCMISTRVCTION tENDING AOENCY Z FON THE PERFONA/ANCEOF 711E WORK FOR WMICH TMIS VERM�T IS ISSUED(SEC.�Oa7,CIY.0.�. W � IENDER'S NAIAE F-- LENDER'SADDflE55 � I CERTIFY h1AT 1 NAVE READ THIS APPLICATION ANC STATE htA7THE ABOVE INFORMATpN IS CORRECT. TOTAL F E ES � I MRFE TO COMPLV WI1H/�LL CRV AND COIAJTV ORDINANCES ANO STATE UV/S RELAiINO i0 BUdDINO / ` CONSTRUCTqN,AND HEHEBY lW7HORI2E REPRESENTATIVES OF iT115 COUNTY 7D EMER UPON THE � ABOVE�MENTpy��TY F NSPECTpN PURPOSQE9� �� � COMMENTS � �.� �tJ' � PERMITTEE NMIE(P�n /, /� G v� G ('� y 81�NATIIRE OF PER111 7� �� p� J� � RECPT.NO. 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