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HomeMy WebLinkAbout15199 . " �,����U .� CITY OF DIAMONI�BAl� �(/� (��G./ DEPARTIviENT OF COMMUNTCY&DEVELOPMENT SERVICES ' �� 21660 E.Copley Drive Suite 190 = Y (909)860-3195 Fax(909)851-3117 PRESS BUILDING PERMIT APPLICA'�'ION FIRMLY _ __. —. _�,. /��� �j� ' ' /�� '�q��. APPLICATION � PERMIT � P/C ,.� � u��� �'t rZ,�— DATE NUMBER d # ISSUE � TYPE OCC APN LO � ACT DATE � CONST. GROUP �p OWNER p ADDRESS ZONING SETBACKS Z CITY ZIP TEL•,. REART RW ❑� g APPLICANT TEL. SIDE/SIDE STREET RW ❑ � CONTRACTO SIDE ❑ � ADDRESS � CITY ZIP TEL. PROPOSED USE o ARCWENG/ � DESIGNER NO.DWEL. NO, NO. � ADDRESS UNITS STORIES BEDROOMS CITY ZIP TEL. � cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-BUILDER DECLARATION SFR/A�D/REM O p I HEHEBY AFFIRM UNDER PENALTV OF PERIIJRV THAT I AM EXEMPT FROM THE CONTRACTORS L4 Ger8g01CefpOd W CENSEUWFORTNEFOLLOWINOREASON�SEC.7037.56LISINESSANDPROFESSIONSCO�E:ANVCITYOR (n _ C) COUNTYWHICHREQUIRESAPERMITTOWNSTRUCT,AITER,IMPROVE,DEMOL�SH.ORREPAIRANVSTRUC� W PatlO/DBCk Z 7URE,PRIDR TO ITS ISSUANCE,AL50 fiEOUIRES 7HE APPLICANT FOR SUCH PERMIT TO FILE A SIpNED W S7A7EMENT h1AT ME OH SHE IS CICENSEQ PURSUANT TO THE PROVISIONS OF THE CANTRACTOfIS LI- W � GENSE UW(CHAPTER G(COMMENCINO WITH SECTION 7D00)OF DIV�SION 9 OF THE BUSINE33AND PRO- �'1' POOVSPB FESSIONSODDE)OPTHATMEORSHEISE%EMPTTMEREFROMAN�7HEBAS�SFOR7HEALlEOEOE%EMP• (� TKKi.NVYVIOLATiONOFSECTION7IXl1.68YANYAPPLICANTFORAPERMITSU&IECTSTNEAPPLICANTTO Z Re-Roof � A CML PENALiY OF NOT MORE 7HAN FNE HUNDNED DOLLARS(3500).): � ❑I,ASOWNEROFTHEPROPERTV,OFiMYEMPLOVEESWITHWAGESASTNEIR50LECAMPENSATION, � Comrtlefciel - WILL DO THE WOPoC AND THE STRUCTURE IS NOT�NTENOED OR OFFERED FOR SALE(SEC.7014,BUSI- J � NESSAND PROFESSIONS CODE THE CONTRACTOHS LICENSE LAW DOES NOT APPLV TO AN OWNER OF � PROPERTY WFiO BUILDS OR IMPROVES THEREON,AND NMO OOES SUCH WORKHIMSELF OR HERSELF OR � iHROUGHHISURIEROWNEMPLOVEES,PROVI0E0THATSUCHIMPROVEMENTSARENOTINTENDEDOR m Q ,OFFEPEDPoRSALEIFHOWEVER�EBULDINGORIMPROVEMEMISSOLDWITHINONEYEAROFCOMPLE- Z TqN,THE OWNER-0UI�DER WILL HAVE 7HE BURDEN 6F PROVING THAT HE OR SHE DID NOT BUILO OR = fMP1�VE FOR THE PURPoSE OF SAL�. � w �I,ASOWNEROFTHEPROPERiY,PMEXCWSNELYCONTRFCTINGWITHLICENSEDCONTRACTORS � TO CONSTRUCT THE PROJECT(SEC.7ou,BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI- V8luation ADJ.AREA W CENSELAWDOESNOTAPPLYTOANOWNEROFAPROPERTVWMOBUILOSORIMPROVES7HEREON,AND � WFIOCONTRACTSFORSUCHPROJECTSWITHACONTRACTOR(S)LICENSEDPURSUANTTOTHECONTRAG QUANTITY DESCRIPTION FEE � TOPS LICENSE UW.). 0 O I AM IXEMPT UNDER SEC. B.S P.C.FORTHIS REASON � 3 ¢ �'= OATE OWNER V Z W � LICENSED CONTRACTORS DECLAFATION W � I HEREBVAFFIRM 11N0ER PENALTV OF PERJURY THAT IAM LICENSED UNDER PROVISIONS OF CHAPTER �, _ � 9(COM/AENCNOWRHSECTION7000JOFONISWN30FTMEBUSINESSANOPROFESSIONSCODE,AND Z X MV LICENSE IS IN Fl1Ll FORCE AND FEC7. � LLl /1 j0 ¢y � � � LICENSEC SS LIC.NO. V �O � � � J V �ATE CONTRACTOR a W � WORKERS'COMPENSATION OECLAt9ATION ¢ = U � I HEREBYAFFIqM i1NDER PENALTV OF PERJURY ONE OF THE FOLLOWING DECLARATIONS: Z d O � _IHAVEANOWILIMAINTAINACEiiTIFICATEOFCONSENTTOSELF-WSUREFORWORKERS' _ � COMPENSA7ION,ASPROVIDEDBYSECTION37ooOFYNELABORCODE,FORTHEPERFORMANCE U � A y OF TNE WORK FOq WHICH THIS PERMIT IS ISSUED. � W �x Y` I HAVE AN�WILL MAINTAIN WORNERS'COMPENSATION INSUflANCE,A5 REOUIRED BY SECTION Q 37000FTHE LABOR CODE,FOR THE PERWRMANCE OF THE WORR FOR WHICH THIS PERMIT IS ISSUEO.MYWORi(ER5COMPENSATIONINSURANCECARRIERANDPOLICYNUMBERARE: CONSTRUCTION � CARRIER PLAN REVIEW � , POLICY NUMBER ELECTRIC y � (nissEcnoNne��vo7ee�ooF�rE�w�xr�s�orie�n�rroa�ooun�.s�a�ro)oR��. PLUMBING /l,�_- �� Z I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I MECHANICAI __ � SHALLNOTEMPIOVANYPERSONINANYNANNER50A5TOBECOMESUBJECTTOTHE � � WOFKERS'COMPENSATKKlLAWSOFCALIFORNIA,ANDAGfiEETHATIFISHOl1LD9ECOME INSPECTIONFEE SU&IECTTOTHEWORKERS'COMPENSATIONP OxISIONSOF TION3�ooOFTHELABOq ' 0/"` � CQDE✓I S A .'O .W�TN COMPLV Wl�.p NS ISSUANCE � ��� �, �ATE: l�� APPLICANT. 9l SMIP w�� WAPNING:FAILURETOSECUREWORKERS'COMPENSAT�NCOVERAGEISUNLAWFl1L,AN�SHALL9E ENERGYP/C �m � SUBJECTANEMPLOYERTOCRIMINALPENALTIESANDCIVILFINESUPTOONEHUNDREDTHOUSAN� ENERGYPERMIT n4`rl7AA/I'"�IVLB '���(5700,000).IN AD�ITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDE�FOR IN A�j.-Dyn r�� � �CT�ON370BOFTHELABORCODE,INTEREST,ANDATTORNEY'SFEES. RETENTION FEE: �'_ __ .....r. ♦i.,Sr'��'�''1 i t� CONSTRLICTION LENDING AGENCY PqE-ALT FEE: �'� 'M 9VAFFIRMUNDERPENALTVOFPERJUi7YTHATTHEREISACONSTRUCT�ONLENOINGAGENCY k 'PERFOPMANCE OFTHE WOFK FOR WHICH THIS OERIAIT IS ISSUED(SEC.3a9],CIV.C). Sr, r � � IAME ,,.�� �flE55 . �^ /'y ',,,�-''� HAVEREADTHISAPPLICATIONANOSTATEh1ATTHEA80VEINFORMATIONISCARRECT. TOTAL FEES �.,J ."7�¢ � '.Y VJITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO Bl1LDING � 1D HEREBVAUTHORI2E REPRESENTATNES OF THIS COUNTV TO ENTER UPON THE .�,, qOr RTYFORINSPECTWNPURPOSES. J ,,�-" �� ��� COMMENTS f�� �,�,- y� ,,..—.. . ,; f,� ,-' �-_ ,� .� "" DATE � RECPT.NO. 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