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HomeMy WebLinkAbout14687 (19) .. . _. . � .� / ��--��r _ �rr� CITY OF DIAMOND BA8 l'Q�jd/G/ � .� � DEPARTT<4ENT OF COMMUNITY&DEVELOPMENT SERVICES �l'C�' w Z16GO�.Copley DCivC Suite 1 JO (909)860-3195 Fax(909)8b1-3117 PRESS '�"��� BUII.DII�TG PERMIT APPLICATION __._ FIRMLY - .. ,.. _ _.,_..._ ., .. � JOBSITE ? � APPLICATION � PERMIT �I�'J��f P/C o ADDRESS J DATE NUMBER % # � ISSUE � � �n )TYPE � OCC APN LOT TRACT DATE (/ f/ CONST. GROUP p OWNER.t RE L I�ll C''�J�. � ADDRESS ZONING SETBACKS Z CITY��AKV➢.I� � ZIP � TE�.��`�oO-��I9� REART RW ❑ g APPUCANT �TEL. � � SIDElSIQE STREET RW O � CONTRACTOR C� �_ SIDE ❑ A�DRESS�(<yl�I 1 � _ � cir��rYr►+�u- Rr,,,�ziP� TEL. 'Z PROPOSEDUSE o ARCH/ENG/ DESIGNER � NO.DWEL. NO. NO. q. ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEI. � cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDEFI DECLARATION SFFUADp1REM � Q I HEREBY�FFlRM UNDER PENAL7Y OF PERJURV THA71 AM EXEMPT FROM THE CONTRACTORS�I- Gefe9BIC21FlOit CLI CENSELAWFONTHEFOLL0ININGREASON(SEC.7031.58USINESSANDPROFESSIONSCA�E:ANVq"fYOR (/� U COUMYWHICNpEpUIRE6APERMRTOCON6TAUCT,ALTER,IM7ROVE,DEMOLISH,ORREPAIRANYSTRUC- W Patio/DeCk � 7URE,PRqR TO IT$ISSUNJCE,ALSO REWIRES THE APPLICANT FOR SUCH PERMfi TO FILE A S�RNED W STATEMENT THA7 HE OR SHE IS LICENSED 7URSUANT TO THE PROVISIONS OF THE CANTRACTORS LI- � CENSE lAW(CNAPTER 9(COMMENCIN4 NA7H SEC710N 7000)OF DIVI9ION 3 OF THE BU3INESS AND PRO- �'�' PooUSpa FESSqNSCODE)ORTHA7HEORSHEISEXEMPTTHEREFROMANDTHEBASISFORTHEALLEOEDEXFMV- (� TION.ANVYPOLATIONOFSECTION7031.68VANVAPPLICANTFORAPERMITSU&IECTSTHEAPPUCANTTO Z qe-Raof � ACMIPENALTY OF NOT MORE TiAN FNE HUNDREO DOLUqS(iwo).): p1,IfSOWNEROFh1EPROPERTY,ORMYEMPIOYEESWITHWAGESASTHEIRSOLECOMPENSATION, � CommefCiel � � WILL 00 THE N'ORK,AND THE STRUCTURE IS NOT INTENDED OR OFFEREO FOR SALE(3EC.7044.BUSI- J N NE55MID PROFESSIONS OODE:THE COMfiACTORS LICENSE LAW�OES N�T APPLV TO AN OWNER DF � PROPERTY WFW BV ILDS OR IMPROVESTHEREON,AND VMO DOES SUCH WOFiK HIMSELf OR HERSELF OR � THROUGHHISORHEROWNEMPLOYEES,PROVIDEDTHATSUCHIMPROVEMENTSAFENOTINiENOE�OFi m / OFFEAEIYFORSALEIF;HOWEVER,THEBU��INGORIMPpOVENiQJTIS50LDWRHINONEYEAROfCOA1Pl.E- Z 'TION.TfIE�OWN6i�BUILDER WILL HAVE THE BURDEN OF PROVM�TNAT HF OR SHE�IO NOT BUIID OR � MPROVE FOR THE R1FiPO5E OF SALE). ly,� ❑I,ASONTIEROFT/iE7ROPERTY,AMEXCLL151VELVCONfMCTINGWITHUCENSEDCONTRACTOR$ � TO CqNSTRUCT 7HE PRQIECT(3EG.70H,BUSINE55 AND PROFESSIONS CODE:THE CONTRACTORS LI- V8I118t1011 ADJ.AREA tJ.J CENSEUWDOESN�TAPPLYTOANOWNEROFAPROPERTVYJFIOBUIIDSOFINPROVESTNEREON,AND Z WlIDCONTRACTSWRSUCHPRQIECTS'MTHACONTMCTOR(6)UCENSEOPURSUAN7TOTHECONTMP QUANTITY DESCRIPTION FEE � TORS IICENSE UWJ. Q ❑i AM IXEMPT UNDER SEC. B.e P.0.FOR THIS REASON q � U 1=. � � DATE OWNER U Z W s�[ LICENSED CONTRACTORS DECLARATION W (r IHEREBV�fFIRMUNDERPENAITYOFPEHJURYTNATIAMUCENSEDUNDEflPROVI510NSOFCHAPTER � � B(CCNMAENCIN(1 N7TH SECTION)000�OF OIVISIpN 30F THE BUSINESS AND�ROFESSIONS CODE,AND Z �y� MY UCENSE IS IN FUI.L FORCEAND EFFECT. m � � UCENSE CLASS �•��.1/ LIC.NO. S � S` �j DA'fE �-��—�� CONTRACTOR d W � WORKERS'COMPENSATION DECIAR � � 1 HE BYAFFIRM UNDER PENALN OF PERJURY ONE OFhIE FO WING DECLARA 10 : "—' a � IHAVEANOWILLMAINTAINACERTIFICATEOF MTOSELF-INSUPEF�ESWORKE 5' _ COMPENSATION,AS PROVIUEO BV SECTION 37 FTHE LABOR COOE,FOR THE PERF CE 'U Q OF THE WORK FOR WHIC,H THIS PERMIT IS ISS D. � IHAVElWDWILLMAINTAINWORKERS'COMP CE.ASRE�UIREDBVSECTIDN Q 7o00F 7HE LABOR CODE.FOR iHE PERWRMANCE OFTHE WORK FOR WHICH THIS PERMIT I SSUED.MY WORKERS'COMPENSATION INSUNANCE CARRIER'A^ND POLICV NUMBER ARE: CO UCTION � CARRIER S ,l REVIEW � POLICV NUMBER_ ` CTRIC Q (INISSECiCXJNE�NDT9EQ7bPLEfIDOFTHEPEFiAYTiSFDRONEHIN�DfiED o� �. PLUMBING Z ICEFirIFYTMATINTHEPERFORMANCEOFTHEWORKFORWMICMTNIS MIT ISSUE�,I MECHANICAL _, � SHALL NOT EMPLOV ANY PERSON�N ANV MANNER SO AS TO 9ECAME SUBJECT TO I � WORKER3'COMPENSATIONLAWSOFGALIFORNIA,ANDAGREETNA7IFISHWLDBECOME INSPECTIONFEE i./� / j SUBJECttO THE WORKERS'COMPENSATION PROVISIONS OF SECTON 37ooOFTHE LABOR �` �fT CAUE,I SHALL FOFRHWITH COMPI.V HOSE PROVIS�° ,.-�/� ISSUANCE � 4 Te�LI�D SMIP C'�11'� o � DATE: 'I�'�� APPLICANT T�(� �,MJ� y, �+�1 AM7y e,�., � WARNINO;FAILURETOSECUREWORKERS'COMPENSATIONCOVEMGEISUNLAWFUI,ANDSHALLBE ENERGYPlC ]7-�TT���SJSF�+�'� �y„ SUBJECT RN EMPLOVER TO CRIMINAL PENALTIESµ0 CIVIt,FINES UP TO ONE NUNDREb THOUSAHO ��'u"�L� DOLLAHS(Si00.a00),IN Ap�ITION iOTHE COSTOF COMPENSATION.DAMAGES AS PROVIDED FOR IN ENEFlGY PERMIT ¢ SECTION 370a OF THE LABOR COOE,INTEHE5f,ANDATTORNEI"S FEES. RETENTION FEE: a CONSTRUC7ION LENDING AGENCY PRE-AlT FEE: O � INEREBYAFFIRMUNDERPENAL7YOFPERJURYTHATTHEqEiSACONSTFUCTIONLEN0INGAGENCY FOR THE PEFWRIAANCE OF THE WOPo(WR WHICH THIS PELLNIT IS ISSUE�(SEC.3097,CIV.CJ. Z W �Z LENDER'S NAME i 1— IENDER5A0URE55 /� A � ICERTIFYTMATIHAVEREAOTHISAPPLICATIONANDSTATETHATTHEA80VEINFOPMATIONiSCORRECT. TOTAL FEES J S`� :� � �AQREETOCOMPLYWITHALICITYANDCOUNTYORDINPNCESANDSTATEUWSREUTINOTOBUIlAINO � CONSTRUCTION,AND HEREBV AUTHORIZE REPRESEN7ATIVES OF THIS COUNTV TO ENTER UPON THE Z ABOVE-MENTIONEDPfiOPERTVFORiNSPECTqNPURPO5E5. � ��h( �.D 6�`�z�C �b� � COMMENTS _ ¢ PER AME(PRINn � �' ����C� ��no,�v1 3• ��1'G� _ N SIONA F DATE � RECPT.NO. 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