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HomeMy WebLinkAbout12953 (11) _ _.1� CITY OF DIAMOND BAIt R �`� � DEPARTMENT OF COMMUMTY&DEVELOPMENT SERVICES � 21660 E.Copley Drive Suite 190 (909)860-3195 Fax(909)861-3117 PRESS ro»�... BUII.DING PERMIT AP�'LICA1'ION _ , --- ;. . ,,. _FIRMLY JOBSITE ��p�- - APPLICATION. � C� PERMff � P/C o AD�RESS I�✓�7 c��lZr�. L/�"N'�a DATE NUMBER # c� ISSUE TYPE OCC ApN I.OT�t� TRACT ��ti�S DATE CONST. GROUP p OWNER TC'�`� � � �°'� ZONING SETBACKS ADDRESS �� L�C.) �`"�`�J�-t<C- � CIIY t'J�� ZIP�t� TEL.��fo"yS��- FRONT RW Cl APPUCANT �— TEL. SIDE/SIaE STREET RW ❑ � CONTRACTOR C���✓�G/Q, SIDE ❑ p� ApDRESS PROPOSEDUSE KCs� .�'^'�'l�t�v%� t/Cfls��inp�' � CITY ZIP TEL. o ARCH/ENG/ � DESIGNER NO.DWEL. N�. NO. ApDRESS UNITS � STORIES BEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION c� � OWNER•BUILDER DECLARATION SFR/ADD/FIEM O 0 1 HEIi�Y AFFlRM UNDER PENALTV OF PERJURV THAT I AM E%EM1PT FROM THE CONTRACTORS LI- � Garage/Carport W CENSELAWFORTHEFOLLOWINGREASON(SEC.7o31.58U51NESSANDPROFE5510N5CODE:ANYCINOR U COUMYWFdCHREQUIRE6APEHMITTOCONSTRUCT,AL7ER,IM7POVE,OEMOLISH.OqREPAIRANVSTRUC. W PellO/DBCk WiUftE,PRIOH TO ITS�SSUPNCE,ALSO PE�UIRES THE APVUCANT FOR 5UCH PERMIT TO FILE A SIGNED W � STATEMENT THAT HE OR SHE IS UCENSEO PURSUAN7 TO THE PROVISIONS Of THE CONTRACTOR9 LI• C CENSE LAW(CNAPTER B(COMMENCINO WI7H SECTION 7000)OF DIYISION 3 OF THE BUSINESSAND PRO- u" PooU5p8 7E FESSIONSCODEJOHTHA7NEORSHEISEXEMPTTHEREFROMANOTF�BASISFORTHEALLEOEDE7(EMP• (,�} � TqN.ANYVIOLATIONOFSEGTION7031.6BYANVAPPLICANTFOFIAPERMITSUBJECTSTHEAPAUCAN7T0 Z Re-Roof �, A CML PENALTV OF NOT A6'JiiE THAN FNE HUNDRED DOLlARS(35D0).); Q � ❑I,ASONMEROFTHEPROPERTY,ORMYEMP40YEESWITNWAGESASTHEIRSOLECOMPENSATION, COfTt(I16fC18I - NALL 00 THE WORK,ANO THE S7RUC7URE I5 NO71N7EN�ED OR OFFEPED FOR SALE(SEC.7D44,BU51� „�I NE39 AND PqOFES910NS CODE:THE CONTMCTORe UCENSE LAW DOES NOT APPLY TO AN OWNER OF � PPOPENTYNh10BUILD50PIMPROVEST1iEREON.ANDWHODOESSUqiWORKHIMSELFORHERSELFOR � � TNfiOU[#IHIS OR HEROMM EMPIOVEES,PROVIDED THATSUCH iMPROVEMENTSAqE NOT INTEN�EDOR � QOFFEREDWRSALEIF,HOWEVER.TMEBUILOINGORIMPROVEMENTI550LDWIhIINONEVEAROFCOMPLE Z �TION,THE OWNER-BUILOEq WILL HAVE THE BURDEN OF PROVINO THAT HE aR SHE�ID NOT 6UILD OR = IMFROVE FOR TME PURPOSE OF SALE�. W ❑I,ASOWNEROF7HEPROPEHTY,AAAEXCWSNELYCANTRACTINGNAlHUCENSEDCONTRACTOftS � TO CONSTRUC'r THE PpOJECT(SEC.7044.BU9WESS AND PROFESSIONS CODE:THE CONTPACTOqS ll- VBIlldll0(1 � ADJ.AREA CENSE LAW DOES NOTAPPLYTO AN OWNER OF A PROPERTY WHO BUILDS OR IM7ROVE5 THEflEON,AN� � WFIOCONTMCTSFORSUCHPpQ1ECTSWITHACONTRACTOR(S)LICENSEDPURSUANTTOTHECONTHAG QUANTITY DESCRIPTION FEE � TDRSLICENSELAW.). o G I AM EXEMPT UNDER SEC. B.&P.C.FOR THIS REASON � 3 � u" DATE OWNEfl < < V Z W � UCENSED CONTRACTORS 6CLARATION �j OC I HEREBYAFFIRM UNOER PENALTV OF PEFiJURV THA7 I AM LICENSEO UNDEfl PROVISIONS OF CHAP7ER � d Y(COMMENCINU WITH SECTION 7a00)OF DIYISION 3 OF TNE B451NESSAND PROFESSIONS CA�E,AND z X MY LICENSE IS IN FULL FOHCE AND EFFECT. m lli � � LICENSE CLASS IIC.NO. � V pqTE CONTRACTOR � W � WOFiKERS'COMPENSATION DECLARATION 4 � U � I HEREBVAFFIRM UNDER PENALTV OF VERIURY ONE OF THE FOLIOWIN6�ECLARATIONS: Z 6 � _IHAVEANDWILLMAINTAINACE�IFICATEOFCONSENTTOSELF-INSVREFOHWOftKERS' S COMPENSATION,ASPRON�EDBYSECTION370oOFTNELABORCOpE,FORTHEPERFORMANCE w OF THE WORK FOR WHICH hIIS PERMIT IS ISSUED. � � W _I NAVE M�WILL MAINTAIN WOPKERS'COMPENSATION INSUHANCE.AS FEOUIRED BY SECTION � Q 37oa OFTHE LABOfl CODE,FOR THE PERFORMANCE OFTHE WORK FOR WHICH 7H15 PERMIT IS ISSUED.MYWORKERS'COMPENSATIONINSURANCECARRIERANDPOLICYNl11ABEFARE: CONSTRUCTION � � � CARRIER PLAN REVIEW � POLIGYNUMBER ELECTRIC Q 0 (n�ilSSEcfaPINE�No78EO01.R.E7moFlNEF'EaNRFFORONEHUNDREDWLWiS(Eto]1aR�E�..`1. PLUMBING W MECHANICAI. Z 1 CERTIFV THAT IN THE PERFOR�ANCE OFTHE WORK FOR WHICH THIS PERMIT IS ISSUEO,I C,j' SHALLNOTEMPLOYANVPEPSONINANYMANNERSOASTOBECOMESUBJECT70TNE � WORKERS'COMPENSATIONLAWSOFCALIFORNIA,AN�PGflEETMATIFISHOUlDBECOME INSPECTIONFEE SUBJECI'TOTHE W�RKERS'CDMPENSqTION PROVISIONS OF SECTION 3'!0o OF THE IABOR � CODE,�SHALL FORTHWITH CAMPLY WITH THOSE PROVISIONS. �SSUANCE � 0 SMIP � p DATE: APPLICANT: _ _� s . J ENERGV P/C J WMNIN6:FAILURE TO SECURE N'ORKERS'COMPENSATION COVERAGE IS UNLAWFUL,0.ND SHALL BE 4 A � SU&IECTANEMPLOYERTOCRIMINALPENALTIESANDCIVILFME3UPTOONEHUNDREDTHOUSAND ENERGVPERMIT DOLLARS(f100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGFS AS PROVIOED FOR IN � SECTION37080FTHELABORCODE,INTEREST,ANDATTORNEY'SFEES. RETENTIONFEE: u '� � � '� + � d CONSTRUCTION LENDING AGENCY PRE-AlT FEE: � I HERE9V AFFliiM t1N0ER PENAITV OF PERJURY THAT THERE IS A CONSTRUCTION LEN�ING AGENCY FOR THE PERWRMANCE OFTHE WORK FOR WHICH THIS FERMIT IS ISSUED(SEC.3097,CIV.G.�. Z W � LENDER5 NAME —.—__. F- LENOER'SA�DAE55 �_//( � ICEHTIFYTHATIHAVEREPATHISAPPL�GAl1IXJANOSTATETHATTHEABOVEINFORMATIONISCORRECT. TOTAL FEES � P 1 � IAGqEETOCOMPIYWITHALLCfTYANOCOl1NTYOR0INANCESANOSTATElAWSREUTINGTOBUILDINO - . CONSTRUCTION,AND HEREBV AUTHORI2E REPRESENTATNES OF THIS COUNTV TO ENTER U70N THE ZABOVE-MENTIONE�PROPERTYFORINSPECTIONPUHPOSES. COMMEN7S � _,s� �+ �r _' �t1`!' lY�l�-`t_�U.'1�'h� � m PERMITTEENAME(PRI Cn �Zt Q � � � SK'�NATUREOFPE `EE DATE x RECPT.NO. PAID BY VAU�ATION ' ��'� ~ WHITE—Department Copy,YELLOW—Fnance Copy,PINK—Assessor Copy.GOLDENROD--File Copy.GREEN—ApplicanCs Copy .. ,... -•.A,��:f a...,yn._....�.,,.,....�. s..� . -.. ^•;��.'r". .•.;..j,�.� .,..-: .. . T.y�.: . . i. „�sl' � . �f�. . .�j..s,. 9 , . . ... . � ' , - e:........ . .:�:...:. ..�i. ,..':. 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