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HomeMy WebLinkAbout16964 (668) �,'°'.��.� .. CITY OF D�iAMOND BAIi ^-----�°` — DEPARTMEIdT OF COMMUNITY&DEVELOPMENT SERVICES I � - 21825 E.CopleyDrive � (909)860-3195 Fax(909}861-3117 �%' PRE$S `'-.»�a'���' BUILDING PERMIT APPLICATION FI RM LY � JOBSITE Q �9 I APPLICATION PERMIT ,,+� � #/�� o ADDRESS 'Ssp �( V . "7 �' � � DATE � NUM6ER e� �- ,� � ISSUE _,,� g TYPE 0.� OCC �j �, � APN—�— LOT �Z TRACT DATE "i ^ 1 CONST. '`+V G OUP �*° � OWNER V S O � � ADDRESS�IZU (p�. ��`O ZONING SETBACKS oGTY �f^NIV1� �C� IP����TElq�l = ZZ Z � FRONT RW ❑ o APPLICANT T6V1Y G'i PP 7EL�l REAR ❑ "—� SIDE/SIQE STREET_�! RW ❑ m CON7RACTOR dPVS '�`.Ga✓1S'H� �011 SIDE ❑ � ADDRESS `�d2t� ,5-��- g0� PROPOSEDUSE !7T'"�1�� � asse� d t 5-��tm•- o cirv �rv�►✓1e� ziP a?1rIN TEL.R�f -FlL2 �+� ,,�,,��> VbGI � � o ARCHIENG/ � /�, ,�-'S�'�p �L:vl TaG►�' • z DESIGNER_ � � L.°S i w ' ti NO.DWEL. NO. NO. a ADDR�SS LG'7'�Z. QC A�V������-- UNITS STORIES BEDROOMS � � 'CITY W IHP ZIP�(�_ 7EL.R�='�__�"�u�'I � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-BUILDER DECLARATION SFR/ADO/REM � O �p I HEREBY AFFIRM UN�ER PENALTY OF PERJURY THAT 1 AM EXEMPT FROM 7HE CONTRACTORS LI- � Garage/Carport 'W� CENSEIAWFORTHEFOLLOWINGREASON(SEC.7031.58USINESSAN�PROFESSIONSCODE:ANYpTYOR � .0 COUNTVWHICHREQUIRESAPERMITTOCONSTRl1CT,ALTER,fMPROVE,DEMOLISH,ORREPAIRANVSTRUC- TURE,PRIOR TO ITS ISSUANCE,AL50 REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED W Patio/Deck �W'�� STATEAIENT THAT HE OR SHE IS LICENSED PURSUANT TO 7HE PROVISIONS OF THE COMRACTORS LI- W ,�; .CENSE lAW(CHAPTER 9(COMMENCING WITH SECiION 7000]OF ONISION 30F THE&151NESS AN�PR0- V' POOUSpB '�FESSION6CAD�ORiHATHEORSHEISEXEMPTTHEREFROMANDTHE9ASISFOPTHEALLEGE�EXEMP- (� �,�'����.TION.ANY�VIOLATIDNOFSECTION7037.56YANVAPPLICANTFORAPEFMIiSUBJECTSTHcAPPLICANiTO z pe-Roof � I� ���,'',ACIVILPENALTYOFNOTMOftETHANFIVEHUNDFEOUOLLARS(E5Co�.�: , Q. ❑I,ASOWNEROFTHEPROPERN,ORMVEMPLOYEESWITHINAGESASTHEIR50LECOMPENSATION, � COYI1117BfCIflI ���9 '�) p„ � Z,',WILLDO THE WORK,AND THE STRUCTURE IS NOT INTENOED OR OFFERED FOR SALE(SEG 7044,BUSI- J �;;�'NESS AN�PROFE551DNS CODE:THE CANTRACTORS LICENSE LAW�OES NOTAPPLY TO qN OWNEfl OF � � ' ��.;pROPERTY WHO fiUILD50fl IMPROVES THEREON,ANO WHO DOES SUCN WORK HIMSELF OR HERSELF OR j �,�� '�.;THROUGHHISORHEROWNEMPLOVEES,PROVIDEDTHATSUCNIMPROVEMENTSARENOTINTENDE�OR CO ' �, W, �,,�,OFFEREOFORSALEIF,HOWEVER,THEBUILDINGORIMPROVEMENTISSOLDWITHINONEYEAFOFCOMPLE- ','.TION,THE OWNER-Bl11LDER WILL HAVE THE BURDEN OF PFOVMG THAT HE OR SHE�ID NOT BL11L0 OR '..Z,�','',''IMPROVE FOR THE PURP09E OF SALE). 4 ❑I,AS OWNER OFTHE PROPERN,AM EXCWSIVELYCONTRACTING WITH LICENSED CONTRACTORS �;�'''�,i'TO.CONSTRUCT THE PFOJECT(SEC:�044,0U91NESS AND PROFESSIONS CODE'.THE CO�TRACTORS LI- VHII18�1011 ADJ.AREA W'r '�'�CENSELAW�OESNOTAPPLYTOANOWNEROFAPROPERiYWH�BUiL�SORIMAROVESTHEREON,ANO - — — .�'�.'�� �;'�WHOCOMRACTSFDRSUCHPqOJECTSWITHACONTRACTOil(S)LICENSEDPURSUANTTOTHECONTRAC- (]UANTITY DESCRIPTION FEE Y,.' '�TOfiSLICENSELAWj. '�" ❑I�AM EREMPTUNDER S�C. B.&P.G FORTHIS REASON Q - �' � LL � 0.4TE OWNER U � '� LICENSEDGONTRACTORSDECLARATION w ��-�=��,��.',�� �4"' "i'�""""� �� � ' �': 'IHEREBYAFFIRMUNOERPENALTYOFFERJURYTHATIAMLICENSEDUNDERPROVISIONSOFCHAPTER � { "� � ' d' 9�(COMMENCMGWITHSECTION70oa)OFDIVISION30FTHEBUSINESSANDPROFESSIONSGODE,AND Z 'X; MYUCENSEISINGULLFORCEAND�EFFECi. � ; � �;� LJCENSEGLASS p� � LIC,ND. ����3�g y � I � , �.' F"":�.'b'ATE �''�k��� d ����. GONTRACTOR�g°�"�" °'��'��"� d � . w ��1— U�.=.ti�°''�*e��°.d`�`� ��.�s . . . ��.n..6.- .--,�.. .__. __.' � . � � WORKERS'COMPENSATION DECLA ATION �-�-- - `---- f = U p'W.. �'. �HERE�BVAFFIRMUNDERPENALTVOFPERJURVONEOFTHEFOLLOWMGOECLARATIONS: z � „g� �. �IHAVEAN�WIILMAINTAINACERTIFICATEOFCONSENTTOSELF-INSUREFORWORKEPS' �_ ' � �`�� COAAPENSATION,ASPROVIDE�6VSEC710N37000FTHELA60RCO�E,FORTHEPERFORMANCE �U ,���'' � Q OFTHE WORK FOR WHICH THIS PEPMIT IS ISSUED. � ; 3�� O w -I HAVEAND WILLMAINTAIN WORKEPS'COMPENSATION INSVFANCE AS REOUIRE�9YSEGiION 4"" r Q 37o00FTHELA80FCODE,FORTHEPERFORMANCEOFTHEWOPKFORWHICHTHISPERMITIS -�.(,fJL���� �� �q �'��'�,'��, ` �il�' ISSUE�.MYWORKERSCOMPENSTIONINSURANCECAqRIERANDPOUCVNUMBERARE: CONSTRUCTION .. j�. �p,qq�EpA�lA�'��I�l^J ��sa'��.r =�.��z PLANREVIEW '' � � POLICYNUMBEH ���� 1'�''���` .'�` �fv�� ���'�_ ELECTRIC Q ,,{ �y p (1HISSECiKKJNEmNOTBECOMPLETEDOFTHE?EPMRISWRONEHUN�RED�OLLAflS(570070RLES51. PLUMBING �T�°'4 (9 ' � W Z 1 CEflTIFV THAT IN THE PEFIFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,i MECHANICAL _��� �� (� SHALLNO7EMPLOYANYPERSONINANYMANNERSOASTOBECOMES JECTTO'HE {J]� WORNERS'COMPENSATIONLAWSOFCALIFORNIA,AN�AGREETHAiI'r HOUL�BECOME INSPECTIONFEE ��� 5U8JECTTOTHEWORKERS'COMPENSAiIONPROVI510NSOFS TIO ooDFiHELABOR 'y �� GOD ISHALL ORTHWITHGCMPLYW VI o . ISSUANCE �` �� �', p�.; �ATE:� ���1 �� APPLICANT. . , SMIP _ —�' WARNING:FAILURETOSECUREWORKERS'COlAPENSATIONCOVERAGEISUNU+WFUL,ANDSHALLBE ENERGYP/G +q� J�. SUBJEC7ANEMPLOYERTOCRIMINqLPENALTIESANDCIVILFWESUPTOONEHUNDPEDTHOUSAND ` LL ENERGY PERMIT � '. DOLI.ARS(S10o,o00),IN ADOITION TO TH6 COSTOF COMPE�SATION,DAMAGES AS PAOVIDED FOR IN ;9\¢ ,��r-''- .��'����. SECTION 37oe Or'THE LHBOR COOE,INTEftEST,ANo anoRrver�s Fees. RETENTION FEE: � +�6`A' ' ���'=s �'. a��. CONSTRUCTION LENDING AGENCY PRE-ALT FEE: n '����C, �, O: '.'���:...J " ��'� IHEREBYAFFlRMUNOERPENALNOFPERJl1RYTNATTHEREiSACONSTRUCTIONLENDINGAGENCV FOF TNE PERFORMANCE OFTHE WOFK FO�WHICH THIS PERMIT IS ISSUED�SEC.3097,CIV.C.). � . �'� Z r� Ll:l., ����/ �.` �q S�,� LENDER'S NFME � � vy'`s•'�.e �'�� V+4/� � I— LENOER'SA�DRESS R h � ICERTIFY7HATIHAVEREPATHISAPPLIGA710NANDSTATETHATTHEABOVEMFORMATIONISCORRECL T�"AL FEE g � '�•_ � W IAGREEiOCOMPLVWITHALLCITVANOCOl1NTVORDINANCESANDS7ATELAWSRELATINGTO6UIL�ING �� _� � ���e � ' � � , CONSTFUCTION,ANDHEREBYAUTHORIZEflEPP.ESENTAiIVESOFTH:SCOUNTYTOEMEflUPONTHE /� ���j/ � '� Z� A80VE-MENiIONE�7flOPERTYFOR INSPECTION PURPOSES. COMMENTS fi � � ! IIf� I �, � � ��� ����1� t� �g » O f ' _ 0 ¢,.��.��dL ME P N Y n � - G{ �� ,9�`S �'' � � (�� � .f � �i�i ,. � � � �� � ��3. ��''S`,a� � ,'� � SIG ATURE 'PEFMITI'EE � 0�TE ' ��,�I �, � = RECPT.�O. 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