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HomeMy WebLinkAbout15610 (20) , ^ 1� _ CITY OF DIAMOND BA1T / � ' ` � DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES r 216C�E.Copley Drive Suite 190 (909)860-3195 Fax(909)861-3117 PRESS '��^'� BUILDING PERMIT APPLICATION FIRMLY o DDRIESS`�•.�SJ ��:MM.1T'��t�5��� . : DATEICATION U��NUMBER� �/C $ ISSUE TYPE OCC APN LOT TRACT DATE p OWNER S'AA� 4S'1-l�k� _CONST. GROUP LL ADDR�SS SW.�i ZONING SETBACKS 0 Z CITY ���1a.� � ZIP �T6S TEL. �-v� FRONT RW C g APPLICANT TEL. REAR � zQ SIDE/SIQE STREE'f RW G � CONTRACTOR_ �A�('.� iAtLe.�S SIDE p ADDR SS 3�:L3"���/ � ClTY ZIPSG`'r2. TEL. 5�S–�'-�i� PROPOSEDUSE o ARCWENG/ z DESIGNER — � ADDRESS NO.D1NEL. IJO. NO. � CITY ZIP TEL. UNITS ;iTORIES BEDROOMS � cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION Q OWNER-BUIIDER DECLARATION SFR/ADDlREM O p I HEREBY AFFIRM UNDER PENALN OF PERIURY THAT I AM EXEMPT FROM THE CONTRACTOqS LI� G8f8J0/CefP011 ISl CENSEUWFORTHEFOLLOWINGAEASON(SEC.7031,5BUSINESS/WDPROFESSIONSCOOE:ANYCITYOF (n V COUNTYWHICHREOUIRESAPERMRTOGONSTP.UCT,PLTER,IMPqOVE.OEMOLISH,ORflEPAIRANYSTRUC- W PdtiO/OBCk z TURE,PRIOR TO ITS ISSUANCE.ALSO RE�UIRES THE APPLICANT FOA SUCH PEHMIT TO FILE A SIGNE� W STATEMENT THAT HE OR SHE IS LICENSED PURSUAM 70 THE PROVISIONS OF THE CON7RACTORS Lb W '�� CENSELAW�CHAPTER9(COMMENCINGIMTHSECTION7000�OFDIVISION30FTHEBUSINESSANDPRO- �'L' POOUSPB FESSIONSCODE�ORTHATHEORSHEISEXEMPTTIEREFAOMANDTHEBASISFORTHEALLEGEDEXEMP� (� V TKKJ.ANVVIOLA710NOFSECTION7031.SBYMIYAPPLICANTFORAPERMITSUBJECTSTHEAPPLICANTTO z qe-Roof � ACIVILPEKALTYOFNOTMORETHANFIVEF4JNDREDDOLlARS�¢5oo).�: — Z ❑I,ASOWNEROFTHEPROPERTY,ORMYEMPLOYEESWIiHWAGESAST1iEIR50i.ECOMPENSATION, ❑ Commercial - YYILL OO7HE WORK,AND THE SYflUCTURE IS NOT IN7ENDED Op OFFERED FOR SALE(SEC.7044,BUSI� J � NE55 AND 7ROFESSIONS COOE.THE COMRACTORS LICENSE LAW DOES NOT APPLV TO AN OWNER OF PROPERTVWHOBl11LD50RIAAPROVESTHEREON,ANOVlNODOESSUCHWORNHIMSELFORHERSELFOH = w7HNOUGHHISORHERONRdENPLOYEES,PROVDE�THATSUCHIMPR04EMENT6ARENOTINTEN�EDOR m Q OFFEREDFORSALEIF,HOWE4ER�EBUIIDINGOqIMPqOVEMENTIS50LDWITHINONEYEAPOFCAMPLE z TION,iHE OWNER-BUILDER WILL HAVE THE�URDEN oF ppOVING TNAT HE OR SME�DID NO7 BUILD OR � IMPROVEFORT}1EPURPOSEOFSALE�. W ❑I,AS ONTIERDF THE PROPEHfY,0.M EXCLIJSIVELV CANTRACTING Wlhl LICENSED CON'RACTORS - � TO CONSTRUCT THE PRQIFC7(SEC.7014,BUSINESS ANO PROFESSIONS CODE:h1E COYTRACTORS�I• ValUation ADJ.AREA CENSELlFYDOESNOTAPPLVTOPNONMEHOFAPROPERTYYhiOBUIIDSORIMPROVcSTHEREON,ANO -- -- � WHOCONTMCTSFORSUCHPRQIECTSNATHACONI'RACTOR�SjLICENSEDOURSUANTTOTHECONTiUC- QUANTITY DESCRIPTiON FEE Y TORSIICENSEUW.). g ❑I AM E%EMPT UNDER SEC. 8.6 P.0 FOR THIS FEASON J Q � a I � DA7E 06YNER �— 0 W F LICENSED CONTRACTORS DECLAFIATION W � 1 HEREBY AFFIRM UNDER PENALTY OF PE9.IURV THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER � . � 9(COMMENCING WITH SECTION 7�00)Or DNI510N 3 CF TY.E BUSINE55 AN�PROF'c5510N5 CODE.AND Z X MY LICENSE IS IN FULL FOACEAND EFFEC7. � � rr� � UCENSE CLA(S�S e�C(�3^w. � LIC.NO._ ���Ca� � � • U DATE 7 — L7—"�° CONTRACTOR__� a W � WORKERS'COMPFNSA710N DECLARATION Q � 1 HEFcOY AFFIRM UNCEF PENALTV OF PERIUriY ON'c OF THE FOLIOWING DECLARATIONS: �� C� _IHIWEANDNlILLMAINTAINACERTIFICATEOFCONSENTTOSELG�ItvSUR'eFORWORKERS' y Q COMPENSATION,ASPROVIDEOBYSECT(N137000FTHELABORCODE.FORTHEPERFORMANCE UI Q OF TNE WORK FOR WH!CH THIS PEWdIT.IS ISSUED. � F __IMAVEANDWI�LMAIMAINWOFKERS'CAMPENSATIONINSURANCE,ASREQU�RED9�SECTION Q 370o OF THE�ABOR CODE,FOR iHE PERNRN.PNCE OFTHE WOFK FOR WHICH THIS PERMI i IS ISSUEC.F1Y WOflKERS'bOM?ENSATOM INSUflANCE�C�A1R,.F_I�ER,AN�POl!CY td'JM9ERARE� CONSTRUCTION j CARRIER � �L�d°J"`�U�aE LI�IR1'C�`/�C PLAN REVIEW ---_ � POLICYNUk&ER C��U lG 5�,�O__ I ELECTRIC __ Q 0 (iHISSECf3�JNEmNDTBEWA�.EiEDOFiHEPERPVfISFORONEHUWRE�DOLIMS�S!00)ORLESSA PLUMBING _ ^T. Z I CERTIFY THAT IN 7HE PEHFOAASANCE OF THE WORK FOR WHICH 7H!S PERMIT IS ISSUED.I MECHANICAL (} SHALLNOT EMPLOYANY PERSON IN M'Y MANNER SOAS TO BECOME SUBJEGT TO THE %�s`. '� ;i `a (/� WORKERS'COPIPENSATION 1AW50F CALIFORNIA AND AGREE TNFT IF 1 SHOL'LO 6c`COIdE INSPECTION FEE � SU&IECTTOTHCWOflKERS'COMPENS �'PROVISION FSECTION37000FTHELABOR -'� ' "��I""""' ^ . � CADE,IaSHALLFORTHWiTHCAMPLY T}ITHOSEPROVISION. ISSUANCE __ _��� � �''2'(^C� ' SMIP «ra»s DATE: r APPLICANT: _____ - : [ r. � ENERGYP/C :,t"��"- /� 'v 'J-�'�`" � WARNING:FAIIURE TO SECURE WORKERS'COMPEhSA710N COVEP.AGE IS UNLAWFUL,MD SHALLBE — �,y SUBJECTANEMPLAYERTOCRIMINALPENALTIESANDCIVILFlNESUP700NEHUNDRED7HOUSAN� "'• y,j;y,_f� DOLLARS(Si00.000).�NADOI�IOYTOTHECOSTOFCOMVENSATbN,DAM.AGESASPROVIDEOFORIN ENERGYPERMIT ^��;� .' :.; E'•=,P�`•':; :I'•J i. J SECT70N37080FTHElABORCO'JE,INTEREST,ANDATTOANEV'SFEES. �`"���� �' ��� p� RETENTION FEE: •• - -� ��• :y'� LJJ L.D t.�-'-d'..::`.: ..._ ..� -- O CONSTRUCTION LENDING AGENCY pqE-ALT FEE: � I HEREBV AFFIRM UNDER PENALTV OF PE{UURV THATTHERE IS A CONSTHUCTION LENDING AGENCY _ FORTHE PERFORMANC'c OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.3097,CIV.C.). W -- — � LENDER'SNAME_ ,_ F- LENDER'S ADORESS_ /� wI CEftTIFY TNAT I HAVE REAO THiS APPLICATION AND STATE hIAT THE ABOYE INfORMATION IS CORRECT. TOTRL F�ES /��� � IAGREE TO COMPLV WITH ALL dTY AND COUNN ORDINANCES AND STATE LAWS RELATING TO BUIIAING J � CANSTRUCTION,ANDMEREBYAUTkORIZERePRESENTATN[SOFTHISCOUNTYTOENTERUPONTHc � A60VE-MENTIONeD PqOPE�FOR INSPcCTION PURPOSES. 0 ��� �`` _��� COMMENTS__ J v � m PEM4ITTE NAME(PRINT) "`�.� � • __ �2,�i�C:k.� � � SIGNpTURE OF PEPMITTE� UATE = RECPT.NO. 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