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HomeMy WebLinkAbout14385 t _!� CITY OF DIAMOND BAIL �j � � � — DEPARTMENT OF COMMUNITY&DEVE PMENT SERVICES ^ � 21660 E.Copley Drive 5uite 19� (909)860-3195 Fax(909)861-3117 PRESS '�+�'� BUII,DING PERMIT APPLICATION FlRMLY N JOBSITE � APPLICATION � :�; f PERMIT �`�Yj. P/C o ADDRESS ���� f'�'���"�'- �• DATE r'�`- '�NUMBER �� 3i± � # c� ISSUE TYPE OCC APN LOT TRACT_ DATE CONST. GROUP p OWNE�E��+� '�Atc+�cS,c.ti �` ADDRESS��+�+1.� ZONING SETBACKS � CITY�'�fJ�.tt�T3�� ZIP�-x3'7�Z TEL.�I-9"�'}-- FRONT RW :] APPLICANT TEL. REAR � � SIDE/SIDE STREET RW � CONTRACTOR �� •�c�l��"�S;A�x. -i2.f SIDE _7 q� ADDRESS '3`�7-3 " �3.5"i'`dLJ � CITY �11�;r'x:�S 21P e�_ TEL.`��"�''4'S�'v PROPOSED USE � ARCWENG/ � DESIGNER NO.DWEL. NO. NO. ADDRESS UNITS_ STORIES BEDROOMS � CITY ZIP TEL. N DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OOWNER-BUIL�ER DECLAAATION SFR/A�DlREM p 1 NEREBY AFFlRN UNDER PENALTY OF PERJURY THAT I AM EXEMPT FflOM THE COMMCTORS LI- G9f8QB/CflfpO1L W CENSEUIWFOHTHEFOLIOWiNGiiEA50N(SEG.70.11.SBUSINESSAIVDPROFESSIONSCODE:ANVCITYOR (n C..) CpUNTYVMICHREOURESAPERMRTOCONSTRUCT,ALTER,IMPROVE,DEMOLISH,ORREPAIRANYSTRUC- LW pallolDeCk Z lURE.PRIOR TO RS ISSUANCE.ALSO RE�UIqES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED `t�' STATEMENT THAT HE OR SHE IS LICENSEO PURSl1ANT TO hIE PFlOVISIONS OF THE COMRACTORS LI� C CEP7SE LAW(CHAPTER Y(COMMENCING WITH SECTbN 7000)OF OIVISION 3 OFTHE BUSINE55 ANO�RO- �'�' POO�SpB F FESSIONSCODE)DRTHATHEORSNEISEXEMPTTHEREFROMANDTHEBASISFORTHEALLE6EDEXEMP- V TqN.ANYVIOLATIONOFSECTION7097.58VANVAPPIiCANTFORAPERMITSU&IECTSTHEAPPUCANTTO � qe-Rooi � A CML PEN�LTV OF NOT MOFE THAN FIYE MUNDRED DOLLARS(S5o0�.j: Q � ❑I,ASOWNEHOFiHEPfiOPERTY.ORMYEMPLOVEESWITHWAGESMSTFtEIfl50lECAMPENSATION, COfTIfflBl'CI�I ' MALL DO THE N/ORK,AND THE STRUCTURE IS NOT INTENOED OH OFFERED FOR SALE(SEC.70a1,Bu51- J NESS AND PROFESSIONS COOE:THE CANTFL1C70R5 LICENSE LAW DOES NO'APPLY 70 AN OWNER OF N PHOPEFl7YNM1iOBUILDSORIMPHOVESiHEREON,ANDWHODOESSUCHWORKHIMSELFORHERSEIFOR � � TMpOUGHHISORHEROWNEMPIOVEES,PROVIDEDTHATSUCHIMPPOVEMENTSARENOTINTEN0E00R m QOFFEREDFORSALEIF,HOWEVER'THEBLNLDINGORIMPROVEMEMISSOLDWffHiNONEVEAROFCOMPLE- Z TION,THE OWNER�ULLDER WILL HAVE THE BURDEN OF PROVING TiAT HE OR SHE DI�NOT BUILD OR � IMPROVEFOFTHEPURPOSEOFSAL�. ❑I,AS OWNEA OFTHE PftOPER1Y,AM E%CL�SIVELY CONTRACT!NG WITH LICENSED CONTR0.CTOR5 � TO CONSTFUCT THE PRO,IECT(SEC.7oM,BUSINESS AND PROFESSIONS COCE:7}iE CONTRACTORS ll� V81Ufl110f1 ADJ.AREA W CENSE UW�OES NOTAPPLY TOAN OWNER OFA PROPFRTV WFIO BULLDS OR IMPR04E5 THEREON,AND � NM1IOCONTRAC7SFORSUCHPROJECTSWITNACONTRACTOR(S)LICENSEDPURSUANTTOTHECONTMC- QUANTITY DESCRIPTION FEE Y roAs uca+sE uw.�. � J O �I AM EXENPT UNDEfl SEC. _8.d P.C.FOR THIS R:ASON Q 3 -- -- � ¢ � DATE OWNER ~ Z U � W LICENSED CONTRACTORS DECLAAATION � � W 1 HEREBYAFFIRM UNDER PENAL?T OF PERJURY THAT IA41 JCENSED UNDER PFlOVI£IONS OF CHAPTER � � 9(GOMMENCINGIMTMSEGTION7oa0�OFDIVISION30FlHEBUSINESSANOPROFESSIONSCODE,AND Z • MY IiGENSE iS IN FULL FORCEAND EFFECi m � l r/� `a �r� C"� :6J"" -. � UCENSE CLASS ��;��T LG� LIC.ti0. ���+�� j V DATE ���`'' —" CONTRACTOR f�' __�..� a W � WOFiFCERS'C01�IPENSATION DECIARATiON Q � U � I HEREBY AFFIR4 UNDER PENALTY OF PERI;IRY GNE OFTH�r0'_LOWING DECiAFA?IONS: 47 z Q — � iMAVEANOWILLMAINTAINACERTIFICATEOFCANSEM70SEiF-I45l:REFORWORKERS' =I � CqAPENSATION,ASPROVI�E00Y5ECTION3�oaOFTNELP80RCWE.FORTHE?ERFORMANGE W� _ OFTHE WORK FOA WHICH THIS VERMI7IS ISSUED. � � � _IHAVEANDWIIIMAIMAINWORKERS'CQMPENSATIONINSURANCE,ASR64UIREDBVSECTION Q 37000F TME LABOR CD�E,FOR TNE 7ERFORMANGE OF THE WOPK FOR WHiCH THIS PERMI'IS � ISSUED.MVWOAK�E,jFlS'COMPEIrSATIONINSURhYC�E^C:q�RRIERAN7POLICYNUMBERAflc CONSTRUCTION _ __ jCARRIER_!F'•���'C�+tiT �.�.f��.'-���+• PLAN REVIEW --------- � 70LICY NUMBER__ _�1� �52.2 l s� --- [LECTAIC __ _ d - �'I (htlSSECTqNNEH'iNDTBEOD�MLEfEDOF7MFPERAYTISFOR�NdE�iLMDREDDOLL.M5�3100;ORL'c55} PLUMBING .---- s.a��a���� l�': O ,.., t:t?.. .�'i.a"` . � 1 CERTIfi THAT Iti THE PF_RFORMAYCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I MECHANICAL _____________ (� SHALLNGTEMPICYANYPER50N:NANYMANNERSOAS'09ECOMeSUkLECTTOTHE � WOHKERS'CO#APEt+SATION U4W5 OF CALiFOPNIA,M1D AGREE THAT IF I SHOIJLD 6ECOFAE INSPECTION FEE ______ SU&IECTTOhiEWORKERS'COMPENSAT 70!JS�OFSECTION9�DOOFTHE:ABOR y (� S �S � ISSUANCE .____�� :�����j. GO�E,I SFIAL:.FORMWITH COMPIV TNOSE PROVISiCNS. �" �� 0 ,y r�' � `� p DA7E: ��'_`� APPLICANT: __�� ___ SMIP �V., ,�` {S }_ w �'— cNERGY P/C �;.�V2^�1,��.�.�.si�'!3.) �.�'..+.tRta WARNING:FAILVflE TO SECURE WORNERS'COMPENSATION COVERAGE IS UNLAWFVL,AND SHA:LBE 5yp yy 7 .�.�3-, � SU&IECTPNEMPLOYERTOCRIMINALPENAITIESANOCIVILFMESUPTOONEHUNDFEOTHOUSAND ENERGY PERMIT i9i 195.§.�����'..�R"'s>�+��'"��-��`�' DOLLARS�51ao.aoo).IN ADOITION TOTHE COST OF COMPENSATION,DAMAGES AS PROVIDED FOF 14 � SECTION37000�T/1ELABORCOOE.IN7EREST,ANDA'TDRNEI^SFEES. RETENTIONFEE: __,._,__ a CONSTRUCTION LENDING AGENCY PRE-ALT FEE: ____ � INERE9YAFFIRMUNOERPENALTVOFPeR:U�'THATTMEREISALONSTRUCTIONIENDINGAGENCY ___ _______ FOR THE PERFORSIANCE OF THE WORK FOR WHICH THIS PEFMIT IS ISSl1ED(SEC.3097,CIY.G). Z W � LENDER'SNAME_ _ _--- _ F_ LENDER'SADORESS_._ _ �� � I CERTIFYTHAT I HAVE READ THIS APPLICATON AN'�STATE THAT THE ABOVE INFORMATION IS CORRECT. 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