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HomeMy WebLinkAbout10361 la i *'f: � � � CITY OF DIAMOIYD BAR � ��� COMMUNI'I'Y DEVF,LOPMENT DEPARTMENT � � i� 21660 E.Copley Drive Suite 190 (909)860-3195 Fax(909)R61-3117 PRESS �'""'� BUiLDING PERMiT APPLICATION FIRMLY � JOBSITE -�p��6 ���An,-n ��`�' qPPLICATION "z, r NUMBER ` #/C d ADDRESS �6/ ��il� 1 p OATE � ISSUE ` TYPE OCC APN LOT TRACT __ DATE CONST. GROUP p OWNER p ADDRES ZONING SETBACKS y CITY ZIP TEL. - FRONT RW [._1_ _ S APPLICANT TEL. REAR Ll_._ Z p SIDEJSIDE STREET RW ❑ m CONTRACTOR �.67. . I�C. SIDE f] _ a ADDRESS ' 0 CITY �I�.�_ TEL. PROPOSED USE a ARCH/ENG/ " W DESIGNER NO.DWEL. NO. NO. � ADDRESS UNITS _ STORIES BEDROOMS � CITY ZIP TEL. �i DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION pC OWNER-BI:ILDER DECLARATION 5FR/AD�/REM O p I HEREBY AfFIRM UNDER PENALiY OF PERJURY THAi I AM EXEMPT FROM THE CONTMCTORS U� GB(899/C81POfI W CENSEIAWFOi#THEFOLLOWINGREASON(SEC.7037.58USINE5SANDPROFESSIDNSCODE:ANVCRYOR (n U CWNT'NR11CMflE�IlIqESAPERMITTOCONSTflUCT.ALTER,IMPROVE,DEMOUSH.OflREPAIRPNYSTHUP W P0f10ID8CiC Z TURE,PRIO(2 TO ITS ISSUANCE,AL50 REQUIRES THE AVVUCANT FOR SUp1 PERMIT TO FILE A SIGNED � STATEMEN7 THAY HE OR SHE IS LICENSE�PUFSUANT TO THE PROVISIONS OF THE CO�TRpCTORS LI- W � CENSE LAW(CHAPTER 9(CAMMENCING WITH SECTION 7000)OF DIVISION 30F THE BUSINESS AND Pq0- � PODUSPB FESSIONS fAOE)OR THAT HE OH SHE IS EXEMPT THEREFFOM ANO THE BA515 FOR TME 0.LLEGEO E%EMP• 0 TION.ANYVIOI�TIONOFSECTION7a31.5BYANYAPPLICANTFORAPERMITSU&IECTSTHEAPPUCAMTO � Re-9oof g � ACIVILPENALT'OFNOTMORETHANFIVEHUNDREDDOLLARS�SSDO).�: R o [71,ASOWNEROF7HEPROPERTY,OftMYEA1PLOYEESWITHWAGESASTr;EIR50tECOMPENSATION, 0 COmmefCi81 Z WILL DO THE WOPK,AND THE STRUCTUfiE IS NOT INTENDED OR OFFERED FOR SALE(SEC.'/040,BUSI- J NE55 AND PflOFESSIONS CODE:THE CONTflACTORS LICENSE LAW DDE5 NOT APPLV TO AN OWNEH OF N PflOPERTYWIi06UILD50RIMPROVES7HENEON,ANDWHODOESSUCHWORKHIMSELFOpHERSELFOR = 2 THflOUGHHISORHENOWNEMPLOYEES,PROVIDEDTHATSt1CHIMPROVEMENTSARENOTIN7ENDEDOR m W OFFEREDfORSN.E.IF,HOWEVER11iEBUILDINGORIMPROVEMENTI550LDWITHINONEVEAROFCOMPLE� 0� TION,7HE OWNER�6UIlDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BIIILD Oii � Z' IMPflOYEFORTMEPURPO5EOF5ALF). �= f71,ASOWNEROFTHEPROPERTI;AME%CLUSIVFLYCON7RACTINGWITHIICENSEDCONTMCTOR6 , 70 CONSTFUC7 THE PRQIEC7(SEC.70a4.BUSINE55 AND PROFESSIONS CO�E:iHE CONTRACTORS LL • ValU2f10� ADJ.AREA W CENSEIAWDOESNOTMPLYTOANONRlEROFAPROPERTYWHOBUILOSORIMPROVESTHEREON.AND' — �� WHOCONTRACTSFORSUCHPROJECTSWITHACOPJTRACTOR(S)LICENSEPPURSt1ANTTOTHECONTRAQ QUANTITY DESCRIPTION FEE 70A5 4�CENSE LAW.). Q ❑I IIM EXEMPT UN�ER SEC._______ ___B.8 P.G fOR7HIS HEASON , � —__. — '_ lL OATE__' OWNER___'_ __.., Z � LICENSED CONTRACTORS DECLARATION W � I HEREBY AfFIFM UNDER PENALTV OF PERJURY THAT I AM LICENSED UNDEF PROVISIONS OF CHAPTER � d 9(COMMENCINGWITHSECTION7000)OFDIVISION30FTHEBUSINESSAN�PROFESSIONSCODE,ANO z X MY UCENSE IS M FULI FORCE AND EFFECT. �� ,�pri � LICENSE SS Y`°' LIC.NO.�! � O _� j j� DA� CONTRACTOR / 3 a LLi -1��;�M���_� � � WORKERS'COMPENSATIONDECLARATION `'�._ �� � � � i HEflEBV AFFIflM 11NDER PENALTY OF PEFiJURY ONE OF iHE FOLLONANG DECLpRATIONS: C� 0'� IHAVEANOWRLMAINTAINACERTIFICATEOFCANSENYTOSELFdNSUREFORWORKER5 ; �' fqMPENSATION,AS PPOVIOED BYSECiION 3�aoOFiNE UBOR COOE,FORTHE PERFORMANCE OF THG WORK FOR WHICH THIS PERMIT IS ISSUED. 1 � � W _I HAVE AND ri1Ll MAINTAIN WOHKERS'COMPENSATION INSURANCE.AS REOUIRED BY SECiIUN ¢ �700 OF THE LABOR CODE,FOR THE PERFOHMANCE OF THE WORN FOR WHICHTHIS PERMI7IS � ISSUED.MYWORKERS'COMPENSATIONINSURANCECARRIERANDPOLICYNUMBERARE: CONSTRUCTION ___ J j caaAiEa ---.--- ----- PLANREVIEW _.`----- -- ZVOLICY NUMOER __� ELECTRIC ¢ -�'� 0 (fHISSECTUNNE�NOTf3E00MPLEfE�OFTHEPEFWl715(ORQVEFRNaDfiE00IX1PAS(6100)ORLE534 PLUMBING��° �.. W 1 CERTIFV THAT INTHE PERFORA�MICE OFTHE WORK FOR WHICN THIS PERMii IS ISSUEO,I �CAA�ICAL � SHAILNOTEMPLOYANYPER50NINANYMANNER50A5T08ECOMESUBJECTTOTHE y g�!��,�'��� Uj WORKER3'COMPENSATqN LAWS D�CPLIFORNIA,ANDAGREE THAT IF I SHOULD BECAME INSPECTION FEE . i � SU&IECT TO THE WORKERS'COMPENSAT OVISIONS OF SECTION 37000F THE LABOR Y'��ti.;�2�; ��cy�jT � fADE,I SHALL FOflTHWITM COMPLV WI THO Pfl VISIONS. ISSUANCE � �4 �7' 0 �� p DATEc��� APPLICANL��� SMIP .__ W WqflNING:FAILUfiE TO SECURE WORKERS'COMPENSATION COYEflAGE IS UNLAWFUL,PND SHALL BE ENERGY P/C r• � !. f^,� "' _ J SU&IECTAN EMPLOVER TO CRIMINAL PENAL71E5 ANO GVIL FINES UP TOIXJE Hl1NDRE�THOUSAN� �4� � DOLLANS(5100.000),INADOITIONTOTHECOSTOFCOMPENSPTION,DAMAGESASPROV�DEDFOFiIN ENERGYPERMIT ..___—_ J SECTION3�OBOFTHELABORCODE,INTEFEST,ANDATfORNEY'6fEES. RETENTIONFEE: � — � CONSTRUCTION LENOING AGENCY pRE-ALT FEE: O � IHEREBYAFFIRMUNDERPENALTYOFPER1UflVTHAT7HERE15ACONSTRUCTIONLEN0INCAGENCV ^_ FOfi THE PERFORMANCE OF THE WORK FOti WHICH7NIS PERMIT IS ISSUED(SEC.JOB7.CIV.C.). r Z W --" � LENOERSNAME _�—_ � �ENDER'SA��RE55_____ _.__�_. � ICEflTIFYTHATIHAYEREADTHISAPPIICATIONANDSTATETHATTHEABOVEINFOflMATIONISCOPRECT TOTAL FEES �./� � nL IAGREETOCOMPLVWITHALLCITYANDCOUNTYOROINANCESANOS7a7ElAWSRELATINGTOBIi�L�INr. � CONSTRUCTION,ANDt7EREBYAUTHORIZEREPRESF.NTATIVE50FTHI5COUNTYTOENTERUPONTHE Z ABOYE�MENTIONEA PROPEflT'�FOR INSPECTION PUPPOSES. COMMENTS 0 J —_'_ � _ __ . ' m PERMITTEENAME(VflMT) � ¢ � _ \ _ � � � SIONATl/HEOFPERMITfEE �AT ��l � RECPT.NO._ PAID BY G. 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