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HomeMy WebLinkAbout14665 �°����""�' _ �� CITYOFDIAMONDBA& ��j?dr�/ DEPARTMENT OF COMMUMTY&DEVELOPMENT SERVICES �f=''l/ �. �� w 21660 E.Copley Drive Suite 190 (909)860-3195 Fau(909)861-3117 PR ESS ��''� ,;m BUII.DING PERMIT APPLICATION _, FIRMLY � JOBSITE , / _ _ . _ p ��-� -�:��7�f'i9��� � DATECATIDN "1 NUMBE� #/C a ADDRESS � ISSUE TYPE OCC APN LOT TRACT DATE CONST. GROUP p OWNER __ 0 ADDRESS __�LII�� ZONING SETBACKS w CITY �- ZIP��..�,�TEL. `6'1� FRONT RW ❑ � APPLICANT TEL.��]�*� REAR ❑ � SIDFJSIDE STREET_ RW ❑ CONTRACTOR �N SIDE ❑ o CDDRESS ZIP TEL.� PROPOSED USE o ARCH/ENGI ` � '�C 7 "�"�1 S"`� � Y CD � DESIGNER NO.DWEL. NO. NO. ADDRESS UNITS STORIES BEOROOMS � CITY _ _ ZIP TEL. �n DESCRIPTION SQ.FT. FACTOR PSF ADJ.ARErWALUATION p� OWNER-BUILDER DECLARATION SFR/ADDlREM O p I HEREBY AFFlpM UNDER PENALTY OF PERJURV THAT 1 A/A EXEMPT FROM THE CONTqAC70RS LI- GdfHgB/CBfPOfI W CENSEUWfORY'HEFOLLOWINCREASON(SEC.7031.68USMESSANOPROFESSbNSCODE:ANVCITYOR (f� COUMVWHIp1RE0UME5APEFMITTOCONSTRUCT,ALTER,IMPROVE,DEMOUSH,ORREPAIRANYSTRUG W Patio/Deck W TURE,PRIOR TO IT9 ISSUANCE,ALSO qEDU1RES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED W � STA7EMENT THAT HE OR SHE IS LICENSEp PURSUANT TO TME PROVISIONS OF THE GONTRACTORS�I- � � GE!VSE LAW(CHMTER 8(COMMENCINO WI7H SECTION 7000)OF DIVISION 30F THE BUSINESS AND PRO- POOUSpa FESSpNSCODE)ORTHATHEORSHE15EXEMPTTHEREFROMANDTHEBASISFORTHFALLEG[DE%EMP- (� TqN.M1VVI0U710NOFSECTION7031.59Y11NVAPPLIC�NTFORAPERMI75U&IECTSTHEAPPLICANTTO z Re-Rp01 � A CIVIL PENALN OF NOT MORE THAN FNE HUNDRED DOLIARS(55oa1.): � ❑I.ASOWNEROF7HEPfiOPERTV,ORA1VElAPLOYEESWITHWAGESASTHEINSOLECOMPENSATION, � Commercfal � WILL DO TNE WORK,AND THE STRUCTURE IS NOT INTENOED OR OFFERED FOR SALE(SEC.7oK,BU51- J � NESS AND PROFESSIIXAS�OE:TNE CONTRACTORS LICENSE UW DOES N07 APPLV TO AN OWN[R OF = PROPERN WI10 BUIL09 OR IMPROVES THEREDM,ANC NMOOOES SUCH WOHK H IMSELF OF HERSELF oR wTHROU(1H HIS OR HER OWN EMPLOYEES,PROVIDE�TNA7SUCH IMPROVEMENTS ARE NOT INTENDED OR m �' Q OFFEREDFORSALEIF,HOWEVER,THEBUIIDINGORIMPROVEMENTIS50LOW11'HINONEYEAROFCOMPLE- _ Z TION,TF1E OWNEH�9UIIAEN WILL HAVE TH[BURDEN OF PROVING 7HAT h1f OR SHE DIO NOT BUILD OR = IMPROVEfORYHEPURPOSEOFSALE�. w ❑I.ASOWNEROFTHEPROfiERTY,AMEIICWSIVELYCANTRACTINGWITNUCENSEDCONTaAC70FS — � TO CONSTRU.T T}'.E PRQIECT(SEC.70.t4,BUSMESS RNO PROFESSIONS CODE THE CONTRACTORS LI- V31U'uUon ADJ.AREA` W CENSE LAW DOES NOTMP�V TOAN ONRdEP OFA PROPERTY WHO BUIL�S Oq Ih1PAOVES THEREON,AND � � NM1bCOMRACTSFOqSUCHPROJECTSWITHACONTRACTOR�S�LICENSEUPURSU/WTTO7NECONTRAF QUANTITY DESCRIPTION FEE � TOq5I10ENSELAW.j. ❑I AM EXEMpT UNDER SEC. B.&P.C.FOR THIS REP.SON � 3 � � U — — � — — — OC DATE _ OWNER�_� 1-- — — U � UCEN5ED CONTRACTORS DECL4RATIDN � � � 1 HEREBY AFFINM UNDER PENAl7Y OF PERJUFlV THAT I AM LICENSED UNDEFl PFiOVI510NS UF CHAPTER � /�9� � i(COMMENCINOWITFi5ECT10N7000)OFDIVISION30FYMEBUSINESSANDPROFESSIONSCODE,AN� L G.+� X MY UCENSE IS IN FULL FORCEAND EFFEGT. m � `�� �LLI � � LIC6NSE C S � LIC.NO. � �7� � � V DATE� �_,_ OONTRACTOR_ ___ n. W � WORKERS'COMPENSATION DECLAAATIC�J � I HEREBY AFFlRM UND'cH 7ENALTY OF PERJURY ONE OF THE iOLLGWING DECL0.MTIONS', Z �� _I HAVE AND WILLI/AINTAIN ACERTIFICA7E OF CANSENTTO SELF-INSURE FOR WORKERS' � r CtNAPENSATION,ASPROVIDED9YSEC710N37ooOSTHEUROR�DE,Ftl�THEPERFORMANCE U Q jiF TNE WORK FOR WMICH THIS PERMIT IS(SSUEO. � � �� IHAVEANDWILLMAINTAINWORKERS'!'AMVF.NSA710NIN5UflANCF,ASREQUIREDBYSECTION QQ 3'lOOOFTViELABURCbDE,FORTNC-?ERi{JRMANCEOFTHEWORKFOFINHICHTIiISPERMITIS ISSUEp.AFV WQftKERS'COMPENSAT N INSURANCF CAflRIERF,NO POLICY NVMOERARE: CONSTRUCTION � CARRIEN_����� "�� '�"_� PLP,NREVIEW Z POLICY NUi�ffiER.�,j�l��,._-��.���1,��_ ELECTRIC _ Q � �rr��ss[cmdNE�Nor2Fcr.�.w�_Er��or�nrv�w✓:r�.waavF�oaEoca.inas�s�m�oai.rssl. PLUMBING � (�� �' Z ICERTIFYT4IATWTHE?ERFOftMAYCEC1FTFiEIYOPKFOqWHICHThIi5PEfiMITISiSSUED,I MECHANICAL (•f SHALLNOTEMPLCYNNYPERSONINAIVYMANNEfiSOASTOBECOME�iIBJEGTTOTME [n WORK.flS' PENSATIONLAWSOFCRLIFORNIA,nNDAGREETHATIFI5410ULO8ECUME INSPECTIONFEG SUBJ CTTO HEYJORKERS'COMPENSA i510N50F5ECTION3��0UFTHELABOR 1:0�,I H FOR�HWITH COMPLY WIT THO P VISIONS. IJSUANCE � e � �f��..F �' __...������o p DAT: . APPLICANT: ..�_.. _ SMIP . J WARNING:FAILURE TO SECURE WOPKERS'COMPENSRTtON GOVERAGE I5 VNIAWFUL,AND ENERG �- � SU&IECTANEMPLOYERTOCFIMINALPENALTItSANDCIVILFINESUPTOONEIiLINORE�THOUSAN� ENERGYPERMIT DOLLARS�5100.000),IN AD�ITION TO THE COSi OF COMPENSAI'ION,O0.MAGE5 AS PftOV10ED f-Oq IN p7' ��7 � SECTION 37080FTHE IABOR CODE,INTEftEST,ANDATTORNEV'S FEES. RETENTION FEE: 11aDING t11VD S�� OCONSTRUCTION LENDING AGENCV PRE-ALT FEE: _ � I HEHEBV AFFIRM UNpER PENALTV OF PEAJURV THATTMEflE IS ACONSTPUCTION LENDMG AGENCY _ _ FOF THE PERfORMANGE OF THE WOFK FOfl W HICH THIS PERMIT IS ISSUED(SEC.303],CIV.C.). Z W � LENDEFi'S NAME__ _ _ F— LENDER'S ADORE55 _ _ _ � TOTAL FEES � � � 1 CEFTIFV THAT I HAVE REAG THISAPPUCAT,ON AND STAT THAT 7Y1E ABOVE INFORMATION IS CARRECT. � IAGPEETOfAMPLVWITHALLCI7YAN�COUNTVORDI CESANDSTATELAWSRELATINGTOBUIIDMG � CONSTRUCTION,AN�HEREBY AUTHORIZE REPRESENTA ES OFTHIS COUNTY TO ENTER UPON THE Z A60VE-MENTIONEOPflOPEFiTYFOFiINSPEGTIONPURP E5. CO TS � � r� � m PERMI77 � NT) ¢ � �ed") 1 d/ � , y SIGNATURE p RMIT7EE DATE �� = RECPL NO. _J 1 PAID BY� VALIDATION � ~ WHITE—�e artment Co YEILOW--Finance Co PINK—Assessor Co GOLDENROD—File Co GREEN— P PY, pY. PY. 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