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HomeMy WebLinkAbout16377 (666) � �-���.��'' F CITY OF DIAMOND BAx �����''�� � -�� DEPARTMENT OF COMMUrTITY dt DEVELOPMENT SERVICES ✓L���� � 21660 E.Copley Drive Suitc 190 (909)860-3195 Fax(909)861-3117 PRESS ��`��°�� BL1II..DIIVG PERMIT APPLICATIUN FIRMI.Y . t,..,.. .,. � JOBSITE ���� � �!4-` DATE CATION ..-� �-�� NUMBER A��� #/C o ADDRESS � ISSUE TYPE OCC r APN , 9 LO,�-T.�_-�- TRA-CTn DATE CONST. GROUP p OWNE�L0.�V ��� I�./ WADDRESS , i. �' � _. ZONING SETBACKS CITY .I}E f�'- ZIP '��TEL. '��"J""US��. REART RW p � APPLICANT TEL.�,�r-�f�� SIDFJSIOE STREET RW ❑ � CONTRACTOR SIDE ❑ � ADDRESS 1 � CITY ' ZIP TEL.' "L PROPOSED USE o ARCHlENG! ' - ��,, DESIGNER NO.DWEL. NO. NO. � ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � v� DESCRIPTION SQ.Ff FACTOR PSF ADJ.AREANALUATION � OWNER-BUILDER DECLARATION SFR/ADDlREM O I HEHEBV AFFIRM UNDER PENALTY OF PERJURY 7HAT I AM E%EMPT FROM THE CONTRAC70RS LI- G8f8gB/CBfPOh W CENSELAWFORTHEFOGLOWINGPEASON(SECJo37.58U51NESSANDPROFES510NSCODE:ANYQ7YOR (n U COUNTYWHICHREWIRESAPERMRTOCONSTRUGT,ALTER,IMPROVE,DEMOLISH,ORREPAIRANYSTRUC- W PgtiO/DeCk Z 7UHE.PRIOP TO ITS ISSUANCE,QSO REQUIRES TME APPLICMI7 FOR SUCH PERMIT TO FILE A SIGNE� W STATEMENT hIAT HE OR SHE�5 LICENSED PURSUANT TO tHE PROVISIONS OF THE CANTRACTORS LI- W � CENSE LAW ICHAPTEfl 9(COMMENGN�WITH SEC710N�a00)OF OIVISION 30F THE BUSINESS AN�PFO- �'l' POOUSp2 FESSIONSOOOEJORTHATHEORSHEISEXEMPTTHEREFROMANDTHEBASISFORTHEALLEGEDEXEMP• (�J TION.PNYVIOLATIONOFSECTION7031.SBVANVAPPLICANTFORAPERA7ITSU&IECTSTNEAPPLICANTTO Z Re-Roof F ACIVIL PENALTV OF NOT MORE THAN FIVE HUNDRED�OLLARS�Ss�),I: � ❑I,ASOWNEROFTHEVFtOPERTY,ORMVEMPLOVEESWITHWAGESASTHEIRSOLECOMPENSATION, � C0111fI1BfCl81 - WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENOED OR OFFEflED FOR SALE(SEC.70C�,BU51- J � NE55 AND PROFESSiONS COUE:TME CONTRACTORS LICENSE LAW DOES NOT APPLV TD AN OWN61 OF = PROPEftTY WFIO BUILDS OR IMVROVES h1EREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR � THfiOUGHNI50RHERONMEMPLOYE£S,PROVIDEDTHATSUCHIMPROVEMENTSARENOTINTENOEDOR m aOFFEREDFORSPLEIF,HOWEVEiLTHEBUILDINGORIMPROVEMQJTISSOIDWfTHINONEYEAROFCOMPLE- Z TIOtd,7HE OWNEH�BUILDFR NALL HAVE THE 9l1RDEN oF PROVING THAT HE OR SHE DID NOT BUIfD ON = IMPROVE FOR THE PURVOSE OF S!.LE). W ❑I,ASOWNEROFTHEPROPER'TV,AMEXCLUSIVELVCANTRACTINGWITHLICENSEDCONTRAC70R5 � TO CONSTRUCT THE Pi1Q1ECT(SEC.7oN,BUSINESS ANO PROFESSIONS CAOE:iHE CONTRACTORS LI- V81118SI0lI ADJ.AREA W CENSELAWDOESNOTAPPLYTOANOYJNEROFA�flOPERTYWFiOBUIlD30RIMPROYESTHEREON,AND -�— — F WFqCOMRACTSFOFlSUCHPR0.IECTSWITHACONTRACTOR�SjLICENSEDPURSUANTTOiHECONTRAG pUANTITY DESCRIPTION FEE Y TORSLICENSEUW.�. 0 ❑I MA E%EAIPT UNDER SEC. 8.8 P.0.FOR THIS REASON Q 3 U � — � DATE OWNER � Z U � LICENSED CONTRACTqRS DECLARATION W ., � _ l 1 HEREBYAFFIflM UNDER PENA�TV OF PEFUUFY TMAT I AM LICENSEO UNDeR PROVISIONS OF CHAPTEfi � _ i � Y(COMMENCINO WITH SECTION 7tl00)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS Cb�,AND Z MY UCENSE IS IN NLL FORCE D E FECL ������ � liJ � -�"' � � LICENSE CLA _ LIG.NO._ � " � J V �ATE C�NTRACTOR _ a W � WORKERS'COM?ENSATION DEClhRATION Q � I HEREBV AFFlRAI UNDEH PENALTV OF PE0.IURY ONE OF THE FOLLOWMG DECL0.RATIONS: Z � IIiIWEANDWILLMAMTAINACERTIFIGATEOFGONSENTTOSELF-INSUREFORVYOFKERS' _ COMP TION.AS PflOVIOED 07 SECTION'9700 OF THE LFBOR CODE,FOP THE PERFOHMANCE U E WORK FOH WNICH THIS PERMIT IS ISSVEO. � W � _I HAVEAND WILL MAItdTA1N WORKER3'COMPENSATION INSURANCE,AS REQUIREO BV SECTION Q� 3700pFTHEI.ABORCOOE,FORTHEPERFORMANCEOFTHEWORKFOftWHICHTHISPERMITIS ISSUED.M�YW�D^,R,,�K�E-A�S/'COMPENSATI NINSURANCE RRIERANOPOUCYNl1M8ERARE: CONSTRUCTION jCARRIER�.� "� � PUeNREVIEW � PouCVNUMeEA ELECTRIC 0 (ifassEc.•raNr�raiee�moF'n-�aEw�rr�swaon'E�{uwnEooa.i.t�astE�aoyoFt�Ess� PLUMBING � � Z I CERTIFYTHA7INTHE PEfiFORMANCE OFTHE WORK FOR WHICHTHIS 7ERAl1T IS ISSUED,I MECHANICAL C�S SHA:L NOT EMPLOYANY PERSON IN ANY MANNER SOAS TO BECOFAE SUBJECT To THE y WORKERS COM,ENSATION LAWS OF CALIFORN10.AND AGREE THAT If I SHOULb BECO, INSPECTION FEE SU61 TTOT WORKERS'COMPENS IO4PROVISIONSOFSECTION37000FTH OR z S CODE 1 SNALL FlTHWITH COMPLV WI aaovis:ous. ISSLIANCE ��� '�7 � J { p DATE: � � r APPL.ICANT. SMlP _ _ I � ENERGY P/C �! � WARNING:FAILURE 70 SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFU�,AND SHALL BE �y SU&IECTANEMPLOVERTOCRIMINALPENALTIESANDCMLFINESUPTOONEHUN�REDiHOUSAND ENERGYPERMIT ` ._� �OIURS(f100.000),IN ADDITION TO 7HE COST Of COMPENSATION,DAMAGES AS PROVI�ED FOR IN { � SECTION37o80FTHELA80RCA�E,INTEREST,ANDATTORNEI^SFEES. RETENTIONFEE: ,_,_ 4 d CONSTRUCTION LENDING AGENCY PRE-ALT FEE: O � IHEREBYAFFIRMUNDERPENALTYOFPERJURYiHATTHEREISACONSTNUCTIONLENDINGAGENCV FOR THE PEfiFORMANCE OFTHE WORK FOH WHICH THIS PERMIT IS ISSUEO(SEC.3D97,CIV.C.). . Z W � IENDER'SNAME F- LENDER'SADDRE55 � TOTAL FEES � I CERTIFY THAT I HAVE READ 7HIS APPLICATtON AND STATETHA77HE ABOVE INFORMATION IS CARREC7. W I AGREE 70 COMPLY WITH ALL CITV ANO CAUN OADINANCES ANO STATE LAWS RELATING 70 BUI�DING � CONSTRUCTION,A�HEREBY AUi ORIZE REP E ENTA71VE5 OF THIS COIJNTY TO ENTER UPpN THE Z RBOVE�MEMIONED PROPEfiTY FO INS7ECT URPOSES. 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