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HomeMy WebLinkAbout15499 I � i 1 ,� CITY OF DIAMOND BA� t i #'' DEPARTMENT OF COMMUNITY 8c DEVELOPMENT SERVICES � ��. . 21660 E.Copley Drive 5uite 190 (909)860-3195 Fax(909)861-3117 PRESS '�" BUILDING PERMIT APPLICATION FIRMLY o D RIESS� APPLICATION �� /1 PERMIT 1 L��G� I P/C DATE L� NUMBER # � ISSUE TYPE OCC APN LOT TR CT DATE CONST. GROUP p OWNER o ADDRESS�'�-"1- Q. ZONING SETBACKS �W CIN�p1,��D�� ZIP �TEL. /" ,�/7 FRONT RW U APPLICANT TEL. REAR I� � SIDE/SIDE STREET RW CJ � CONTRACTOR � �-- SIDE ❑_ ¢ ADDRESS Q CITX�����4, ZIP TE ��u�s���, g t w ARCH/ENG! `� ��� � ADDRE SR NO DWEL�. U NO. �p, �r Sy � UNITS STORIES BEDROOMS � N CITY ZIP TEL. — �n DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � Q OWNER•BUILDER DECLARATION SFR/ADD/REM O � I HEHEBY AFFlRM UNDER PENRLTY OF PERJURY THAT I AM EXEMPT FROM TNE CANiRAC70RS ll- G8f8QB/C8rpOR � W CEN9ELAWFORTHEFOILOWINCREASON(SEC.7o31.6BU51NESSAN�PROFE5510N5CADE:ANYCITVOR (n U COl1NT'/NMICHREOUIRESAPERMITTOCONSiRUCT.ALTER,IMPROVE,DEMOLISH,OFqEPAIRANY5TRUC� W Pdil0ID8CI( W TURE,PRpR TO ITS ISSUANCE,AL50 RE�UIRE5 THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNE� W STATEIAENT THAT HE OR 3HE IS LICENSEO PURSUANT TO TNE VROVISIONS OF TNE fANTRACTORS ll- CENSE UW(CHAPTER B(WMMENCIND WITH SECTpN 7000)OF DIVISIQN 90F THE BUSINESS AND PAO- � POOVSpB R FESSIONSCODEIOR7HATHEORSHEISEXEMPTTHEREFFOMANDTHEBASISFORTHEALLEGEDEXEMP- TION.ANYVIOUTIONOFSECTION7a31.58YANVAPGLICANTFORAPERMITSU&IECTSTHEAPPLICANTTO Z Re-Roof � � ACIVIIPENALT'OFNOTMORETHlJ1FIVEHUN�REDDOLLARS(E500).): � ❑I,ASOV/NEROFTHEPROPERTY,OflMYEMPLOVEESWITHWAGE5R5TNEIRSOLECOMPENSATION, � CORIRIBfCl81 � VALL00 THE WORK,ANO THE STRUCTl1RE IS NOT INTENDED OR OFiEFEO FOR SALE(SEC.7o4J.BUSI- � � NE55 ANU PHOFESSIONS CODE:7HE CONTMCTORS LICENSE LAV!DOES NOT APPLY TO pN OWNER OF j PROPEHTY WFiO BUILOS OR IMVNOVES 7MEflEON,fW 0 WMO(XJES SUCM WORK HIMSELF Oq HERSELF OF OC THROUGHHISORNERONMEMPLOYEES,PRWIDEOTHA75t1CHIMPROVEMENTSARENOTI4TENOEDOR LY� Q ,OFFEREDFORSPLEIF,HOWEVERTHEBUILDINGORIMPROVEMEIYTISSOLDWITHINONEYEAflOFCOMPLE- � TION,THE OWNER�BUIIDER WILL MAVE THE BUROEN OF PpOVING TMAT NE Ofl SHE OID NOT BUIID OF � IMPRbVE fOR TME PUNPqSE OF SW.E). W ❑I,ASOVMEiiOFTHEPROPERfV,AMEXCLLISIVELVCONTRACTINCWITHI.ICENS'c�CANTRACTOPS � TO CON9TRUCT TME PRQIECT(SEC.'lOta,Bt131NE33 AND PROFESSIONS COUE:THE CONTHACTOflS U- V8IU8110� ADJ.AREA_.______ W GENSEUWDOESNOTAPPLY70ANONNEftOFAPqOPERTVWF108UI1D50RIMPfiOVESTHEREON,AND �"---- -� --- - � QUANTITY DESCRIPTION FEE VhIOCONTRACTS FORSUGi PRQIECTS WITH ACONTRACTOR(S�LICENSED PUFSUANT lOTHE CANTRAG � TORSLICENSEIAW.). J Q ❑I AIA EXElAPTUNDER SEC.________.__._.B.8 P.C.FOR THIS REASON � }� _ _ U LL — ---'-------- [C OATE OWNER � � W � LICENSED CONTflACTORS DECLARATION W � 1 HEflEBYAFFIRM Uh9ER PENALTY OF PERJURYTHAT I AM LICEN9ED UNDER PROVISI015 CF CHAPTEfi � Q, 9(WMMENCINOWIiHSECTION7000)OFDIVISION30FTHEB�SINESSANDPROfESSIONSC,ODGAM1D Z � MYUCENSEISINFULIFORCEANDEFFECi. m � LICENSE C S LIC.NO.�!� j V DATE_�� ____ CONTRACTOR�r./lCY_S�rn��._��.�T/� -' W � VJOFKERS'COMPENSA710N DECLARA7IUN � � 1 HEREBV AFFIqM UNOEH PENN.TY Of PERJURV ONE OF THE�OLI,OWING�ECIARATIONS: Z � __IHAVEANOWILLMAIN7A�NACER7IFICATEOFCANSFNTYOSEIF-INSURFFORWORKF.RS' x COMPENSA710N,AS PqOVI�C-D 9Y SEC710N 37000F TME IABOR CnDE,FOR THE PEFFORMANCE U Q OFTHEWORKFORWHICHTHISPEFiMITI51S5UC0. � � W _IHAVEANDWILLMAR{TAINWORKEHS'COMPENSATIONINSURANCL,0.5RE�UIREDBYSECTION I'' Q 37000FTHELA60RCOUE,FORTHEPERWRMANCEOFTHEWOPKFOFWHICf{TIiISPERMITIS ��,Lf'f d ` ISSUED.MY WORKEHS'COMPENSA710N INSURANCE CARRIEH M!D POLICY NUMBER�RE: CONSTRUCTION ______ 'I t�� � ----F---- � � caaaiea_ —0 ^ PLANREVIEW ._....------ .--- �ZZ PaICY NUMBER_.,__ ELECTRIC Q (fFC33ECT10NNE�NOTBE00MPLETmOF7HEPEWMTISFORQVEIRN�OKEDDOLWiS(5100)ORLESS PlUM81NG __,_____ Z ICEflTIFYTHATINTHEPERF-0RMANCEOFTHEWOflKF�RWHICHTHISPERMITISI55UE0,1 MECHANICAL _.____,.___.. C„S' . SMFJ.LNOT F.MPIOYANY PERSON IN ANY MANNEfl SOAS TO BECOME SUBJECTTO THE � WORKERS'COIAPENSATIONLAWSOFCALIWRNIA,ANDAGFEETHATIFISHUl1L�BECOM[ INSPECTIONFEE __._., e°� SUBJECT TO THE WORKERS'COMPENbATqN PFOVISIONS OF SECTION 3700 OF THE LAE30P S COOE,1 ALLF TMWITHCOMPLYWITHTHOSEPHOVISIO 5. ISSUANCE ________ � ' "� ' V' ".,f-. p� DATE: �� APPLICANT: �,�� SMIP _._..____'.— -"' • �i " -. kl.u._:. _—_"' J WARNINO:F URE T�SECURE WOHKEfiS'COMPENSPTION CWERAGE IS UNLAWfUI.,AND SHALL BE ENEflGY P/C ____.___.___ _._.._ __ ____.._.._______ LL SUBJECTAN MPLDYERTOCRIMINALPENhLTIESANDCIVILFINESUPT00NEHUN�REDTHOUSM'D ENERGYPERMIT �„ DOLLARS(f100,000),IN ADOITION TO THE COST Of COMPENSATION,DAlAAG[S AS PfiOVIDE�FOR IN � _—.----_ � SECTqN37080FTHELABOACAOE,INT[REST,ANDATTONNEI"SFEES. FlETENTIONFEE: �� �� �_ ��_ d CONSTRUCTION LENDING AGENCY PRE-ALT FEE: �s�"1';���,� ,� p �}�y� � I HEREBVAFFIRM UNDER PENALTY OF PERlURY THATTHEHE IS ACANSTqUCTION IENDING AGFNCY s�y^i '��,����� , ��'{4"' ����f��+�1.1F � FORTHEPERFORMANCEOFTHEWO KFO WHICHTHISPLflMITISISSUEO(SEC.3o87,CIV.C.). —�+�. .„'",y'.a.I '.'� ��, y '3� ��p Z .. .b:a �l t.9C-8[��d R '__—_ W � ��� � LEN�ER'SNAME_,__ F- LENDER'SADDRESS�_�_SAL____./�o'!I/�.:r_q���:_— , � ICERTIFVThIATIHAVEREAOTHISADPLICATIONANDSTATETHATTHEA90VE1NFORMATIONISCORRECT. TOTAL FEES ��J� t W IAGREETOCOMPLYWITHALICITYAN�CUUNTVOflDINANCESANDSTATEIAWSRELA7INGTOBUILDING � CONSTRUCTION,AND FIEREBV�UTHORIYE HEPRESENTATIVES OF THIS COUNTY TO ENT[fi UPONTHE Z ABovE•MEN7IONED PNOPERN FOti INSPECTION PURPOSES. COMMENTS � � �'Y' ' � "' _ '_ m PERAIITTEENAAIE(PRI / a � - r � -�----a y SIGNA7UREOFPERMITTEE OATE �/ = RECPT.NO.,_� PAIDBY ______ VALIDATION ~ WNITE-0epartment Copy,YELLOW�inance Copy,PINK—Assessor Copy,GOLDENROD—File Capy,GREEN—Applicanl's Copy . . ,... _. ..._ ..� i .. .. . ,. � � � _ -� - ' ���. E 'C ' i .��'� � y4 � ' � - �. ; ��t � � t - � �i ��,�; .. � _ E � ' � , � . � r -- � '� � i � �'�i � �� . _ i - . 3 r , I i � . � , � � . - } $ 5 .. I � . i ' ; I - . � � � � � � -� ; � k� �. � � .. .. . . ' i � �- .... .. ... - : , . ' �.e�,.-�`,.� � i . _ V . � � � t � + . �I � � � . ay�.., s � I � ! . ' � ' � � � � I �` � � � � . , , . . I • + . . � .�. � 1 I . k.a . � � i � ', � � , , ,- . - � � � . � � � ta.�` ' ' • ! • i ' i , . j ' ; � , . � (� i i'' � i �� ; I ��_� � , . � � ' � � , , � . ' , ' ' ' � � � • � ' � 'i i i � . 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