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HomeMy WebLinkAbout15920 (20) ��,�d� � � _1,� CITY OF DIAMOND$AR `���/v/ . DEPARTi�iENT OF COMMUNITY&DEVELOPMENT SERVICES �%U �,t# _ : � 21660 E.Copley Drivt Suite 190 ,� (909)860-3195 Fax(909)851-3ll7 � PRESS �����'�' BUII.DING PERMIT APPLICATION __ 5 FIRMLY . . ::.::; � JOBSITE /� APPLICATION �z 2H OO pERM1T P/C o ADDRESS ���� � �/� DATE � NUMBER �5 � # � ISSUE TYPE OCC APN LOT _ TRAC DATE CONST. GROUP � OWNE�o � O — _ p ADDRESS T L� ZONING SETBACKS W CITY IP EL. ' ���. FRONT RW ❑ � APPLICANT �EL.�;c_� REAR ❑ � SIDE/SIQE STREET RW ❑ � CONTRACTOR SIDE p � ADDRESS � � � CITY ZIP�TEL. PROPOSE�USE oARCH/ENG/ ��,, DESIGNER NO.DWEL. NO. NO. � ADDRESS UNITS STORIES BEDROOMS � CITY 21P TEL. � y DESCRIPTION SQ.FT: FACTOR PSF ADJ.AREANALUATION � OWNER-BUILDER DECLARATION SFR/ADD/REM O 1 HEREBV AFFlRM UNDER PENALT'OF PERJURV THAT I AM EXEAIGT FROM THE CONTRACTOqS LI- GefBJe/CBfpOR W CENSEUWFORTHEFOLLOWINGREASON(SEC.7o31.6BU51NESSANDPROFESSWNSCODE:ANYCITVOR (n U COUNTYWHICHREOUIRESAPERMITTOCONS7FIUCT,ALTER,IMPROVE,OEMOLFH,ORREPAIRANYSTRUG W Pe�io/D6Ck Z TURE,PRIOR TO ITS ISSUANCE,AL50 REQUIRES THE APPUCMfT FOR SUCH PERMIT TO FILE A 516NED W STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO Tt1E PROYISIONS OF THE CONTRPGTORS LI- W � CENSE LAW(CHAPTER e(COMMENCINQ WITH SECTIWV 7000)DF DIVISION 30F TF1E BUSINE55 AND PR0. u" POOUSpd FESSpNS OODE�OR 7HAT HE OR SHE IS IXEMPT THEREFROM AN�THE BASIS FOR THE ALLEGED EXEMP- TpN.ANYVI0LAT10NOFSECTI0N7031.6BYANYAPPLICANiFORAVERMITSUBJECTSTHEAPPLICANTTO Z Re•Roof r, ACMI PENALTY OF NOT MORE THAN FNE HUNDPEO DOLLARS(;500)): Q O ❑4�OWN6tOfTNEPqOPERN,OHMVEMPLOYEESWITHWAGESASTHEIRSOLECAMCENSATION, CORIR10fGi0I - ' Z WIIL DO THE WORK..4ND THE STRUCTURE IS NOT INTENDED OR OFFEREO FOR SALE(SEC.701d.BU51- J � NESS ANC PROFESSIONS CODE:7HE CONTMCTOFS LICENSE LAW DOES NOT APPLY TO AN OWNER OF ? PROPERiY VMO BUI.DS OR IMPROVES THEREON,AND NM1iO OOES SUCH WORK HIMSELF OR HERSELF OR � THROUl3FIHISORHEPOWNEMPLOYEES,PROVIDEDTHATSUCHIMPROVEMENTSARENOTINTENDEDOR m 0 ,OFFEREDFORSALEIFFIOVJEVER711EBUILOINGORIMPROVEMENTISSOLDWITHINaNEYEAROFCOMPLE- Z TION,THE OWNER�BUILDER WILL HAVE THE BURDEN OF PROVING THAT ME OR SHE DID NOT BUILD OR � ddPROVEFOq7HEPURPO5EOF5ALE). w ❑I,ASONMEROFTHEPROPEflTY,AMEXCLUSIVELYCON7MCTINGWIiHIICEN5E000MMCTORS Q TO COPISTRUCTTHE PFWECT(SEC.1044,BUSMESSAND PqOFES510N5 CODE:THE CONTRACTORS LI- ValUetlOn ADJ.AREA W CENSEUWDOESNOTAPPLYTOANOYVNEROFAPROPERTYWMOBUttASORIMPROVESTHEREON.AND � W/qCONTRACTSFORSl1CHPROJECTSWITHACONTRAC70fi(5)LICENSEDPURSUPNTTOTHECONTRAG QUANTITY DESCRIPTION FEE � TORSIJCENSELAW.�. ❑IAM EXEMP?UNDEF S�C. B.8 P.C.FOR TNIS REASON J � ¢ V W ¢ DATE OWNER __ ___ V � LICENSED CONTRACTORS DECLARATION � � W I HEREBYAFF6IM UNOER PEN/LLtt OF PERAIRY THAT 1 MI LICENSED UN�ER PROVISIONS Of CHAPTER a, 9(COMAAENCWOWIIHSECTION7o00)OFDIVISION30FTHEBUSINESSANDPROFESSIONSCAOE,A!JD Z � ✓' MY LICENSE IS IN FULL FORCE A D EF ECT. 1 m � LICENSE CLASS �✓'��.,���� LIC.N0. � � � V �ATE L �'�+' CONTRACTOR � a. W � � WORKERS'COMPENSATION DECLARATION Q = U � I HEREBY AFFlAM UNDER PENALTV OF PERJURY ONE OF THE FOLLOWING OECLARATIONS: Z � IHAVEPN�WILLMAINTAINACERTIFICATEOFCONSENTTOSELFNSUREFOPWORKEflS' _ �pENSATION,AS PROVIDED BV SECTION 37o00F 7HE UBOR CODE,FOR THE PERFORMANCE U Q THE WOFK FOR WHICH TNIS PERMIT IS ISSUED. � � w _IHAVEANDWILLMAINTAINWORKERSCOAAPENSATIONINSURANCE,A9REOUIREDBYSECTION Q 3700OFTHEUIBORCODE,FORTHEP6IWRMANCEOFTHEWORKFORWHICHTHISPERMITIS ISSUED.MY WORNERS'COMPENSATION SURANCE CARRIER AND POLICV NUMBER ARE: CONSTRUCTION � CARRIER ��� �-C- '�'� PLAN REVIEW Z PouCYNUMBEa /�, �._� �� - f �_ ELECTRIC s� 0 �rnss[ciioraNe�ra7seeot.s�EiE�oFiriE�ra.ursra3avEtauroWEooawas�5ioo�oa:Ess). PLUMBING C1Cf° �') t' ��UUU DW w t Z I CERTIFV THAT IN THE PERFOFB.IANCE OF THE WORK FOF WHICH THIS PERMIT IS ISSUED,I MECHANICAL ('S SHALL NOT EMPIOY ANV PERSON IN ANY MANNER SO AS TO BECOME SUBJEC7TO THE y'�yy.A��( p�7y ��9 � WORNERS'COMPENSATION LAWS OF CALIFORNIA,ANDAGREE THAT IF I SHOULD BECOME INSPECTION FEE OI�'YJ1f]1V1. 1'VL Bi*]I` SUBJE 77oT RKERS'COM PROVISIONSOFSECTION37o00FTHELABOR TT .�.�s✓��" 5 CADE, SHALL RTNYIITHCOMPLv ITHT 10 aovisioNs. ISSUANCE � U'i"DIIOTCi AIOTT,fiS�FF 1 Y=J� � O r� � Q�+�! DATE: y��'7 APPLICANT. °, SMIP � WARNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL, SH ENERGY P/C � SUBJECTqNEMPLOVENTOGWIMINRLPENALTIESANDCIVILFINESUPTOONEHUNDqEDT ANU ENERGYPERMIT DOLURS(f1 ro.oa0).IN AOOITION TO THE COST OF COMPENSATION,�AMAGES AS PROVIDED FOR IN � &ECT'pN37aeOFTHELABORCODE,INTEREST,ANDATTORNEYSFEES FETENTIONFEE: d CONSTRUCTION LENDING AGENCY PRE-ALT FEE: O � t HEREBYAFFIRM UNDEFi PENALtt OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY FOR THE PERfoRlAANCE OFTHE WORK FOP WHICH THIS PERMIT IS ISSUED(SEC.3oB7,CIV.C.). . Z W � LENDER'S NAME _ F= LENOER'SADDRESS W I CERTIFYTHAT I HAVE READ iH15 APPLICATION AND STAT THATTHEABOVE INFOPMATpN IS CARqECL TOTAL FEES �� d IAOREETOCAMOLYWITHALICIT'ANOCOUNTYORDIN CESANDSTAiEIAWSREIATINOTOBUILDING 14,� CONSTFUCTION,ANO HEFEBY AUTHORRE REPFESENT NES OF THIS COUNTY TO ENTER UPON THE e ) � A80VE•MENTIONEO PROPER?V FOR INS CT�ON PURP s. COMMENTS ' � �/ o �,+� C _ _ � m FERMI EE PRIN� � � � � SN3NATU OFPERMfTTEE DATE ' = RECPT.NO. PAIO BY VALIDATION ~ WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENflOD—File Copy,GREEN—ApplicanPs Copy , ., -, .. �r .,.,.. ;..., . r y..„ . .. . .... . i....:.�„ •�..�._.,, ....'i .' ,.� ?}.:_;..;i �:'�' � .q4'.,x'v ��+. . . -. ��� � �: ��� ` � . . .. . . . . , , . .� . .. _:. ,. ��:: . ��.�"� „ ;, .;.... . .,,. �...:..::..: �� ��� � � � �� � :� �,,;. p � � . � ,. . , � , � � � . ��� ,. . ��;� � �. � w. � .�_.. -• p�m N_m:A..: _. e. _ ,.:. ffi ��` � :J�'' `� � f. ...:.. ��T �-3�. �; i . � FLC7C�F; °�. � , :a ,. , � ' �q,a"�I.-[;p �i _—_. : �r`°;� �-�,��,q"q c�,»�-P�'S _.__.� ...__._ _.._._�._� . ....„,i';�t� � 9VEa'3fv'€T;.'C I. ; . � ..' 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