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HomeMy WebLinkAbout16378 �_ _ �� CITY OF DIAMOND BAx DEPARTMENT OF COMMUNI'j'Y dc DEVELOPMENT SERVICES 21660 E.Copley Drive Suite 190 (909)660-3195 Fax(909)861-31IT PRESS �'*"� BUII.DING PERMIT APPLICATiON FIRM � ` DDRESS 1 � � Y�S� p APPUCATION �� �� PERMIT P/C o DATE NUMBER R � APN OT TRACT DATE � CONS7. GROUP � OWNER ADDRESS �O� I /�E � . ZONING SETBACKS CITY �� O ZIP��TEL.� FRONT RW ❑ APPLICANT TEL. REAR ❑ SIDElSIDE STREET RW ❑ CONTRACTOR �/V O. NC. SIDE p g C�y ES� Z�P �` PROPOSED USE � ARCFVENG/ ��—�--5 TE �(jI �-77 DESIGNER NO.DWEL. NO. NO. ADDRESS v� UNITS' STORIES BEDROOMS � CITY ZIP TEL. --r— � OWNER-BUILDER DECUIRATION DESCRIPTION SCI.Fl:%' FACT R PSF AW.AREANALUATION g sFwnoo�eM ' 1 NER�V AfFlRAf UNDEN PENRITY OF PEiWRV TIAT 1 A1A E7(EMPT FROM TIE CONTR�C70R3 LL Gara9e/Caipon ' � - � CENSEUWFORTNEFOLLOWNOREAUON(SEC.7D3t.6BUSINE55ANDPROFE5510NSCDDE:ANYCITYOR (n CQU(INMM1IICNNEOUWESAPERA1RiOCON6iRUCT,ALTER�PROYE,DENOLISH,ORREPAIHMlYB7iN/C- W P����p� IURE.VRIDR TO R8 ISSUANCE,AL30 REOUIHES THE APPI,ICANr FOR SUCH PERMIT TO FILE�SiONED W MATEYENT TVIAi HE OR SHE IS LICENSED WRSUANT TO TNE PROVISKKYS OF THE CONiFNCTOR9 U- � CENSE LAW(CIUPTER Y(COAAMENCINO Ypf1/1$ECTION 700a)OF DIVISION]OF THE 9USINE35 Ah9 PRO- � PDOYSPB fEbSqNS CODE)OR TFU1T NE OR SHE 18 E%EMPT TNENEFROM AND TNE BA91S FOH THE ALlEOED EIIQAP- (� TION.ANVVpUT10NOFSECTION7W1.6BYANVAPVLICMlTFpqAPERM1T6l1BJECTB7HEAPPLICANTTO Z qe-Roo1 � A pNL iENKIY OF NOT MORE TIiMI FNE XUNDHED DOLLARS��Soo).�: p ❑4��EROFTNEPROPEfiTY.OHMYEM7lAYEESWITHWM3E3A5TNEIRSOLECOMVENSATqN, CpmmB�Cl81 - � MIILL 00 7NE riOR1C,M70 TIIE BTRUCNRE IB NOT INTENOED OR OFFERE�FOR 6ALE�6EC.70aa,BUSI- � � NESS M1D PROFESSIONS CODE:THE CONTRACTORS IICENSE lAw ODES NOi MPLY TO AN OWHEq di .. . . iNOPFAiYYiH09UKD80RNAPROVE9lHEREON,Af/DWFIODOES5Up1WORNNIMSELFOqHER5ELFOR � � " � 1HROUGHHISORMEROWNEMVLOYEES,PipVIDEDi}NTO�itl�PqOVEMEnT511RENDTW7EN0EDOR m OFFERED PORBALE IFlpWEYER TNEBULDINOOit IMPMOVEfAENT 19 Sq.D WI7FpN ONE YFANOFCONP�E- TI�N.TFE ONNEFi�UILDER M7LL WIVE TME BURDEN OF PPOVING iHAT NE OH SHE WD NOT BUII�Op M1iROVE FOR iH[RlRPOSE OF 811LE4 � � ❑I.ASOWNEROFTNEGROPERTY,AIAEXCLUSIVELYODNTRACTINOWITNLICEHBEOCONTRACTORS 10 CONSTRUCT TNE/R0.1ECT(9EC.7W1,BUSINE85 ANO VAOFESSIONS COOE:TNE CAHfMCTONB LI- VdIUYJIOfI ADJ.AREA CENSE UW DOES MOTMPLV TO AN OMMER OFAPflOPEHTV W1q BUILD8 OR IMPiUYE3 THEREOfL AND 1Ni00DNTRACfBFORBUCHGHO.lEC13WIhiAOONTMCTOR�9�UCENSEDPUR4UANT70THECONTMP pUANTIIY flESCpIPTIpN FEE � TORB LICENSE UW.). ❑1 AM EXEMPT WDEp SEC. B.i P.C.FON THIS REASON Q U �—'' o�re OWNER � " � U LICENSED CONTRACTORS DECLARATION � � INEREBYAFFIWAUNDEHPENALTYOFPEfUURVTNATiAMLICENSEDUNDERPqOYI510N50FCHAPTER � ' _1 ��ODMIMENCWONRTMSECTION70oD)OFONIS�ON70F'MEBUSINESSANDPROFF531ONSCO�E,AND Z /J W LICEN9E IS N NLL WRCEMID EFFECT. _J`, ��� /� !1:"�t� m � LICENSE 5S �—��V LIC.NO. t F�� j �j a+� �'l —b/ ca+rnacron �' � WORKERS'COMPENSATION pECLARATION � IMERE9VAFFlIWUNDERPENALTYOFiE0.1upYONEOfTHEFOUANnNGDECUHATIDNS; Z � _IiYWEANDWiLLMAINiNNACE1ffIFICATEOFCONSENTTOBELF-WSUREFORWORKERS' a COMPEqSATION,ASPROVIDE�6Y3EC710N77000FTHELABORCODE,FORTIEPERWRMANCE U OF7NF WORK FORMMICN TMI6 PERMIT 19155UE�. W � �IHhVEANDWILLWIMAINWORKER9'COMPENSATIONINSUMNCE,ASREIXIIREDBYSECTIDN � �C �700OF 7HELABOR COOE.FOR THE 7ERFOqMANCE OFiME WOR(FOR WHIAf TXIS PEFlMfT IS � 65UE�.IAY WOWCC�E.R�S'O_O_AAPENSAT�I)NSUp�CECARRIEHAND VOIILW NUMBEHARE CONSTRUCTION �j CARRIER /1� I �� PLAN REVIEW � pa�wwHu�q �J/�G�00 �T��— ELECTRIC � (n+seEcroNne�wrBEoohRErmaFhEren�ril6fanOraetul�AFlmOaUfiS(S+m�ontFss� PLUMBING � I CENTIFY THAT IN TFIE PERfORMM10E OF iNE NKNiN FOR Yhil HI �RMIT IS ISSIIEO,I MECHANICAL SHMINOT E1�IPLOYANY iERSON Ml ANY YANNER SOAS TO &IECT TO TNE (/� MIORK RS'COYPENSATIONLAWSOFCALAFO DA E ISHDULDBECOME INSPECTIONFEE � TO EM�OFKEHS'COMPENSAT F 77000FTHELABOR i coAnn+nTMcoMr�rwi ISSUANCE p OATE: � O� ppp� SMIP � WARNINO: AIWRETOSEWREWORKER9'COMPENSATIONCOVERAGEISUNLAWFVl,M1D8HALLDE ENERGYP/C - �y BUBJECTlWEMPIOYEHMCflIMINALPENALTIE6ANDCNILFMESUPTOONEHUNORE�THOUSANLI ENERGYPERMIT � DOLLMS(it00.000).W ADDIiqN TO THE CAST OF COMPENSATION,DAMAGE9 h4 PROVIDED FOq IH 9ECTqN]70B OF 7TIE LABOR CODE,INTEREST,AND A7TOqNEY'S FEE9. � RETENTION FEE: � CONSTRUCTION LENDINGAGENCY pRE-ALT FEE: IHEREBYAFFlRM IINDEH FENALTV OF PERIUNV THATTHERE IS�CONSTRUCTION LENDINO A(iENCY FOR THE YERFONMANCE OFiNE WORK FOR WHtCH MIS PERMIT IS ISSUED(SEC.ioG7,CIY,GJ. � LENDER'SNAM[� !'�— C IENDEH'S ADDRE55 � ICERTIFYTi1ATIHAVEflEAD7HIS�PiLICATqNANO3TATETMTTMEA80VEINFORMATpNISCORqECT, TOTAL FEES ��, �T, 1 AOREE TO COMPLV WITX�LL CITY AND OWNTY ORD W/WCES ANO ETATE UWS qELATNVO TO BVILOING V � CONSTRUCTION,ANDHERE9YAUTIiOflIZEREPRESEMATIYE50FTHI5COUNTYTOENTERUPONhiE A90VENEMqNEO VROPEPTI FOR INSPECTIDN PURPOSES. 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