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HomeMy WebLinkAbout11617 _ _��` CITY OF DIAMOND BAIt �-';�-"��� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVIC�S ' �—= � 21660 E.Copley Drive Suite 190 (409)860-3195 Fax(909)861-311? � PRESS ��'A�' BUII.DING PERMIT APPLICATION FIRMLY � JOBSITE � + � � � f� APPLICATION � t� PERMIT P!C �� J '�' o ADDRESS l�-���-- l�°'Q�'�`v t'{ �,� �4.� f'� DATE �_ � � NUMBER I�r # � � �� �� ISSUE TYPE . / OCC � APN LOT �-- l'RACT `�C DATE CONST. �Lf �U GROUP p OWNER ti� LL'�\.i � ADDRESS -� ' U ' l.s , ZONING SETBACKS g� Ca . _ � ' FRONT RW � CITY�� � ;� � . ZIP ' TEL�, REAR ;� APPLI�ANT TEL. SIDEISIOE STRE�T RW ❑ � CONTRAC'TOR SIDE ❑ � ADDRESS PROPOSED USE 7 ���J�Y1 � CITY ZIP TEL. w ARCH/ENG/ �, Z DESIGNER — � � � W NO.DWEL. N . NO. a ADDRESS � CITY ZIP TEL. UNITS _ STORIES BEDROOMS CI� cn DESCRIPTION SQ.Ff. FACTOR PSF ADJ.AREANALUATION � OWNER-BUILDER D�CLARATION SFRlADD/HEM O p I HEREBY AFFIRM UNDER PENALTV OF PERIURV THAT I AM EXEMPT FROM THE CONTfiACTOqS L:� Caa�ag0/Carpoll W CENSEWWiOR7HEFOLI..OWINGqFASON(SEC.7o3t56USME55AN�PAOFESSIONSCODE:ANYCITYOR (n U COUNTYNMICHREWIRESAPERAfITTOCONSTRUCT,ALTER,IM7ROVE,DEMOLISH,ORREPAIRANVSTRUC LLI PatiolDeck Z lUPF,PRIOR TO ITS ISSUANCE.ALSO REIX11flE5 THE MPLICANT FOR SUCH PERAAIT N FILE A SIGNEO W STATEMENT THAT HE OR SHE IS LICENSEO PUiLSUANT TO hiE PHOVISIONS OF THE CONTRACTOflS Li� W � GENSE UW(CHAPiER e(COMMENCINO WfTH SECTION laob)OF D!NSION 3 0F THE BUSINESS AND�PRO- � POoUSpa FESSpNSCODEJORTMATNEOR5HEISEXB.IPTTNEFlEFROMAh�TNEBA515FORTHEALLEGEOEXEMP• �TION.ANYVIOLHTIONOFSECTION7031.SBVANVAPPLICAMFOFAPERMRSU&IECTSTHEAPPLICANTTO z R8-Roaf F ACMLPENALTYOFNOTMOHEhIANF�VENUNDRE000LlARS(S5aa).1: � ❑I.ASOWNEROFTHEPROPERT/,ORAAVEMPLOVEESWITNWAGESASTHEIRSOLeCOMPENSATION. � COR11118fGidl tlYILL DO 7NE WORK,AND THE STRUCTURE IS NO7 IN7ENDED OR OFFERFD FOR SALE(SEC.7044,BU51- J � NE55 M1D PROFESSIONS CODE:THE CONTMCTORS LICENSE UW OOES NOT APPLV TD AN OWNER OF � PROPERTYN'FIO BU0.D3OR IMPROVES THEFEON,AND WHo DOES SUCH WORK HIMSE:F oR HERSEIf OR � TMNOUGNFIISORNEROWNEMPLOYEES,GROVIDWTNATSUCHIMPROYEMEMSARENOTINTENDEDOfi m QOFFERmFORSALEIFHOWEVER,THEBUILOINGORIMPROVEMENTI550lDWI7HINONEVEAROFCOhAPLE � TpN,THE DWNER�BUILDER WILL HAVE THE BUNDEN OF PROVI4G THAT HE OR SHE DID NOT BUIL�OR = IMPROVEFORTHEPURPDSEOFSALEI. W ❑I,AS OVMER OFTHE PFOPERTY,AM E%CL1151VELY CAMNACTING WI7H LICENSEO CANTRRCTORS � TO CONSTRUC7 THE PROJEC7(SEC.1041,OUSINESS AND PROFESSIONS COOE:THE CONTRACTORS LI- VeluBtlOn _ ADJ.AFEA W CENSELAWDOESNOTAPPLYTOANOWNEROFAPROPERTYWFIOBUIL0.50RIMPAOVESTiEHEON,AN� � WFpODNTRACT3FORSUCHPRQlECTSWITHACONiRACTOH(S)LICENSEDPl1R5UMlTTOTHECONTfiAG QUANTITY DESCRIPTION FEE � TORSIJCENSEUW.). � ❑I AM EXEMPT UNDER SEC. B.6 P.C.FOR THIS REASON � � DATE ' {� oWNER_ .k' -� f , Z / r � Q¢ LICENSED CONTRACTORS DECLARATION ' ¢ I HEflEBY AFFIHM UNDER PENALTY OF PERJURY THA71 M1 LICENS'c0 UNDER PROVISIONS OF CHAPTER � ` P'` �^ ` d BICOMMENCIN(3WITHSECTIDN7a00)OFDIVtSION30F7HE8USINESSANDPROFES510Y5CODE,Ah'D Z C . MY UCENSE IS IN NLL FORCE AND EFFECT � u� � � j� , � LICENSE CLASS LIQ NO. � / �� , ' r ��� � 1� V �ATE CONTAACTOR a , t � WOFKERS'COMPENSATION DECLARATION ' C �� C - ¢ I' i2 IG i►3 (,�14 � 1 HEREBV pFFIRM UNDER PENALTV OF PERJURV ONE OFTHE FOLLOWING DECLARATIOYS: Z `: /L � � ��` L G°�^ `� a ^T y� O IHAVEANDWILLMAIN?AINACERTIFICATEOFCANSENTTOSEIF-INSUREFOflWORKERS' 2 �r �� �✓[ �s/-, � Z COMPENSATION,AS PHOVIDED BYSECTION 370o OFTHE LABOR CODE,FORTHE PERfORMANCE U � / � OF THE WORK FOR WHICH THI6 PERMIT IS ISSUED. � , /��_ ! � W -�zqa Q _I HAVE AND WILL MAINTAIN WORKERS'CAMPENSPT!DN INSURANCE,AS REOUIRED BY SECTION s7ooOF THE LABOR CODE.FOR THE PERFORMPNCE OF THE WORK FOR WNICH THIS PERMIT IS � 4SUE0.MV WORKERS'COMPENSATION INSURANCE CARRIEH AND POUCY NUIU85R ARE: CONSTRUCTION _____ J � CARRIER PLAN REVIEW Z PouCVNUMeER — ELECTRIC __ _, � (fHL55ECf10NNE�N0T8E00AAETEDOF7YEPERMfflSFORONEHUMRED�q!ARS(5:ao)oa�F.55). PLUMBING -- -- (FJ.�� �„ Sy . Z ICERTIFYTHAT INTHE PERFOHMPNCE Or THE WORK FOR WHICHTHIS PERMIT IS ISSI:ED,l OAECHANICAL _._..____ _ � (j SHALLNOTEMPLOYANYPERSONINANYMANNERSOASTOBECOMESU&IECTTOh1E (n WORKERS COMPENSATION LAWS OF CALIFORNIA,PN'J AGREE TMHT IF I SHOULO BELOME INSPECTION FEE _ � SUBJECT TO THE WORKERS'COMPENSATqN PROVISIONS OF SECTION 37D0 OF THE 1A20F — __---- — � � CODE.I SHALL FORTHW ITH COMPLV WITH THOSE PROVISIONS. �SSUANCE � � SMIP Q DATE: APPLICANT: " __'__ • � FNERGV P!C _ J WARN!NG:FAIIURE TO SECURE WORKERS'COMPENSATAN COVERAGE IS UNUIWFUL AND SHALLBE _---��-., �y SU9JEC7ANEMPLOVEFTOCRIMINALPENAL7IESANDCNILFINESUPTOONEHUNOREOT40USAkD ii!I DOLLARS(51maDo),INAO�IilON707HECO5TOFCOMPENSA:ION,DAMAGESASPROVIDEDFORIN ENERGYPERMIT ___ __;S-J J SECTION 37080F THE LA80R CODE,MTEREST,ANDATTORNEY'S FEES. , u � RETENTION FEE: ___._ OCONSTRUCTION LENDING AGENCY PRE-ALT FEE: �A.V�'I� aIHERE9YAFFIRMUNDERP'cNpLTVOFPERJURYTHATTHEREISACONSTRUCTIONLENDINGAGENCY ��'�� FOR THE PERFORIAANCE OF hIE WORK FOR WNICH THIS PERMITIS ISSUED(SEC.3o97.CIV C.). Z W � I.ENDEfYSNAME ___ F- LEN�ERSA�RE55 � TOTAL FEES IZ '�.$ wI CERTIFYTHAi I HAVE HEAD THIS APPLICATION AND STATE THAT iHE ABOVE INFORMATION IS CORqECT. � IA6HEETOCOMPLYVA7}IALLCRYANDCWNTYORD!NANCESAN�fTATEIAWSREUTINGT00UILDING � CONSTRUCTION,M:D HEREBYA'JTHOR¢E REPRESENTATIVES OFTHIS COUNTYTO ENTER UPON THE ABOVE-MEMIONED PROPEflTY FOR INSPEGTION PURPOSES. ? CONMENTS_ � ���'� '�,L��..1 _ � m PERMITTEENAl�E(PRINTI.. Q cn r�''t �f`�� ""�.� -- � S:GNATUREOFPERM�TTEE DATE F � � � RECPT.NO. � PAID BY�, r VALIDATION WHITE—Oepartment Copy,YELLOW—Finance Copy,PINK—Auossor Copy,GOLDENR06—File Copy,GREEN—ApplicanPs Copy . ... . .. . 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