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HomeMy WebLinkAbout15816 � _ �� CITY OF DIAMOND BAA a DEPARTA4ENT OF COMMUNITY&DEVELOPMENT SERVICES � r ,� . 21660 E.Copley Drive Suite 190 � (909)860-3195 Fax(909)851-3117 PRESS ; �, ���9�°�� BUILDING PERMTT APPLICATION FIRMLY ,� JOBSITE f� r1 � / � ! �n APPLICATION � PERMIT ( � P/C o ADDRESS / D'� � � ���� � +"�'' DATE '� NUMBER I�..1��� � $ ISSUE TYPE OCG � APN LOT���R CT DATE_ CONST. GROUP p OWNER r o ADDRESS . � � %�3� �-- � ZONING SETBACKS w � FRONT RW fl_ � CITY ZIP���TEL.(����� REAR L� APPI_ICANT ``' "7 TEL. '7 SIDE/SIDE STREET RW fl � CONTRACTOR �aC> � Ll' ,� SIDE _ __ ❑ ___ � c ADDRESS �� 6 '� PROPOSED USE o CITY_r�• �s • ZIP�f TEL. 5 I - wo ARCHlENG/ � �� DESIGNER NO.DWEL. NO. NO. � ADDRESS UNITS STORIES � BEDROOMS,__ � CITY _ ZIP TEL. v� DESCRIPTION SQ.Ff. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER DECLARATION SFR/ADD/REM O Q I HEREBYAFflAM UNDER PENAITV OF PERIURY THAT I AM EXEMPi FROM THE CONTRqCTORS LI- G3f2Q8/C8f(Wfl W CENSEUWFORiHEFOLLOWIN6HEA5IXJ(SEC.7031.SBUSINESSANDPFOFESSIONSCODE:PNVCITYOF (n U COUNIYWHICHRC-0UIRESAPERMR7000NSTRUCT,ALTER�MPROVE,DEMOL!FH,ORREPAIpANYSTRUG W P3fi0/DBCk Z TUHE,PRqq TO ITS ISSUANCE,AL50 RC-0UIRES THE APPLICANT(OR SI1CH PEHMIT TO FILE A SIGNED w STATEMENT THAT HE OR SHE IS LICENSED PURSl1ANT TO THE PROVISIONS OF iHE WNTMCTORS LI- W � CEN5E LAW(CHAPTER 9(COMMENC�NG WITH SECTION 7000)OF�IVISION 3 OF THE BUSINESS pND PRO� u" POOUS(18 FESSIONSCODE�ORIMATFIEOR5NEIBEXEMPTTHEREFflOMANDTHE8A515FORiHEALLEGEDEXEMP- (!} V TION,ANYVIOLqTIONOFSECTION7031.5BVANVAPPLICANTFOqAPERMITSU&IEC7STFIEAPPUCANTTO Z Re-Roof � ACMLPENpLTYOFNOTMORETHFWFIVEHUNDHEODOLLARS(i5oD)J: � ❑I,ASOWNEROFTHEPROPER7Y,ORMVEMPLOVEESWITHWAGESASTHEIRSOLECOMPENSATION, O Commercial - WILLDO7HE WOPoC,AND THE STRUC7URE IS NOT INTENDED OR OFFLRED FOR cpLE(SEC.7004,BU51- J � t�SS ANO PqOFESSIONS COOE:THE WNTRACTORS LICENSE LAW OOE6 NOT APPLV TO AN OWNER OF ? PHOPEHTY WHO BUILDS OR IMPROVESTHEREON.ANO VMO DOES SUCH WORK HIMSELFOR HERSELF OR Q iHfiWaHHISOPHENOWNEMPLOVEES,PflOVIDEDhIATSUCHIMPROVEMENTSARENOTINTENDEDOR m OOFFEAEOWflSALE.IF,FIOWEVERNE9UIL�INGORIMPFlOVEMENTI550LDWITMNONEYEAROFWMPLE- Z TIOPI,THE OWNEfiBUILDER WILL HAVE THE BURDEN OF PROVINO TNAT ME OR SHE OIU NO�BUILD OR � IMPFq1/E FOR THE 7l1HPO5E OF SA4E). W ❑I.A90WNEROFTHEPpOPERfY,AMEXCLU9IVELYCANTRACTINOWI7HLICENSEDCOMRACTORS � TOCONSTRUCTiHE PflQIECT(SEC.7o4a,BUSINESSAND PROFE5SIIXJS CODE:THF COMRACTORS LI- Valu8fi0!1 _._ ADJ.AREA__,___ W CENSEIAWDOESNOTAPP�YTOANOWNEROFAPROPERTYWHOBUIL�SORIMPHOVESTNEREON,PND ---- —'--- � NM1qCONTRACTSFORSUCNPR0.IECTSWIIHACONTqACTON(S)UCENSEOPUR5UANT70THECON7RAG pUANTITY DESCRIPTION FEE •_ 10q5LJCENSELAW.�. � 0 ❑IAMEXEMPTUNOEflSEC. _ ____9.8P.4FOHTHISREASON U 3 ------- cc u" OATE� ONMEfl __ U 0 W � LICENSED CONTRAGTORS DECLAAATION w � 1HEREBYIIFFIRMIINDERPENALTYOFPERIl1RVTHATIAMUCENSEDUNDEflPROVISIONSOFCHAPTER V. ' J / . � B(COMMENCINO WITH SECTKKJ 7000�OF DIYISION a OF THE BU51NES5 ANo PROFESSIONS CODE,AN0 z ' C ' X YV 110ENSE IS IN FULL FOFCEAND EFFEC7. .y � '1 /"1 /� � z i �.f `Q UCENSE CLASS ` LIG.NO._�`�'���� ' � V � ' -� y'9�"'_--'_ a OATE � GONTRACTOR (.9 n J W � WORKER3'COMPENSATION DECLARATION � y U � I NEflEBVAFFIRM UNDER PENAI.YY OF PERAIRV ONE OFTHE FOLLOWING DECLARATIONS: z O __IHAVEANDWIILMAINTAINACERTIFICATEOFCONSENTTOSELF-INSUREFOflWORKEfIS' a � � '—' COMPENSA'ION,ASPROVIDE09YSECTION97000F7HEtA80RCADE,FORTHEVGRFOqMANCE �U �THE WORK FOR WHICH THIS PF.HMIT IS ISSUED. � W '/ � _IHAVEANDWILIMNINTAINWOPKEHS'COMPENSATIONINSURANCE,ASRE�l11RE�BYSECTION Q37000FTHELPBDRCODF,FORTHEPERFOFMANCEOFTHEWORKFORWHICHTMISPENMITIS � ISSUED.MYWORKEflS'COMPEN511TI NINSU AN AflRIEHA�ND�POLICYNUMBEflARE: CONSTFlUCTION __„__ .___ ' CARRIER � _� �' -_��•�,�A:'= PLAN REVIEW „---- --. -- � POLICYNUMBER A�I�.�LiI� `f ����f ELECTRIC .__...- '__'_ --_-'_ p {n��ssEcriavr��noreE�rEooFn�Ereaur�sror+or+eHu'vot�moousas(stool�t.�ss). PLUMBING -�i 9 ---- --—--- Z ICERTIFYTHATINTH[PERFORAIANCEOFTHEWORKFORWHICHTHISPERMITISISSUED,1 MECHANICAL ' ' �_,_ _ C} SHALLNOTEMPLOY/WYPEfl50NINANYMPNNEfi50A5TO�ECOMESUBJECT70THE . • . � WORKEflS'COMPENSRTIONLAWSOFCALIFORNIA,ANDAGREE7HAiIFISNOULD�E00M(: WSPECTION�EE ,___ ___, ______..___ _ SU ECTTOTH WORKERS'COMPENS OVISIONSOFSECTION37000FTl1ELABOR � s ,1 SHALL Ofl7HWITH GOMPLV WI TH S ROVISIONS. �SSUANCE _____ �j/�� ��- + ' _"'_"- ""-"'__'__ � 1 �,-f SMIP �`p DATEi� I . Is�-' APPLICANP. __ -- .._.. . ., � ..--� . . __—____'.....___ ENERGYP/C ____—_ _ ____ J WApNINGFAILUflETOSECUREWORKERS'CAMPENSATIONCOVERAGEISt1hYAWFUL,AN�SMALLBE , . , ti SUBJECTAN EMPLOYER TO CRIMINPL PENAlTIES AN�CIVIL FINES UP TOOYE MUNDREO TF70USAND ENERGY PERMIT ' � ' � � DOLUflS(i100,000�,INl�D�ITIONTOTHECOSTOFCOMPENSATION,DAMAGESASPROVI�EDF�PIN - ---- — - - � SECTION37080FTHELABORCO�E.iNTEHEST,ANDATTORNEY'SFEES RETENTIONFEE: ____._—_ �_::_-._:___ pW., CONSTRUCTION LENDING AGENCY PRE-ALT FEE: _ Q ---'------' ------- � IHEflEBYAFFIRMUNDERPENALNOFPERJURYTHATTHEflEISACONSTRUCTIONLEN0INGACENCY __ _ __ __ FOR THE PERFORMANCE OF THE WORK FOR Wf IICH THIS PERMIT IS ISSUEO(SEC.3a97,CIV.C.). Z W -- --- ----- ---' � LENDER'SNAME"'__"'_ " "_"_'" _'_ __ F_ LENDEflSADDPESS ___....__--___ ¢ ICEHTIFYTHATIHAVEREADTNISAPPLICA710NANDSTAT THATTNEABOVEINFORMATIONISCORRECT. TOTAL FEES �� `�� w I AGflEE TO COMPLY WITHALL CITY AN�COUNTY OFDIN LE50.ND STATE LAWS RELATINC TO BUIL��NG d � CONSTRUCTION,AND HEREBYAUT RRE REPRES[NT IVF.S OF Th�15 CDUNTV TO ENTER UPON THE Z pBOVE�MENTIONEO PROVERTY FOR I SPECTqN PUfl E5. C M NTS � �/'� ' F � �� / � LJ�' --- m PER ITTEE PpINT) � � �� �• --- ---- --- N SIGNAiL1RE PEHMITTE D E ---T' � �- � RECPT.NO. ���._ PAID BV _o _Y VALIDATION _ WHITE�eparlmaM Copy,YELLOW—Financs Copy,PINK—Assessor Copy,GOLDENROD--File Copy,GREEN—ApplicanYs Copy . _. .... ,._. _. .. _ ...... m�.,. . ._...... ._.__ .._....__.._...i ...., _ . . , ..�,. _ .... , , � , �t � _ �, , � f� ! ' � � � �� ` � � �� - � ..�i i ; , '� , � , �4 `' � ` � � . "� � s�� 4 , €: � i �ti �� > � � �+ �.x � i � � � � i , : . � � : _ I i - y i- +' f a° � ,d7 '� i ' � . ' � i - � �.i �, 1 �i s�� � I � � I i � '_ , � � �i � i � r���� , , � :. ; rr-.3 - � � � = I �. . - . 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