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HomeMy WebLinkAbout15858 , ^ CITY OF DIAMOND B.4b2 DEPARTMENT OF COMMUMTY&DEVELOPMENT SERVICES f a 216b0 E.Coplcy Drive Suite 19D � (909)860-3145 F�(909)861-3117 PRES� '�"� BUILDING pERMIT APpLICATION FIRMLIfi A DORI SS / 7�U � r �(� �W'.1/ p�CATfON ��.� N MB R M� � APiV LOT TRACT_ ISSUE � ��,� TYPE OCC ! �-.--r--- �b�� DATE �� �.- � t. CONST. GROUP i p OWNER _ tr�v p ADORESS ��,�N�b7� r!n ! ZONING SETBACKS � CITY Z4P TEL. 4 FRONT RW ❑ APPUCANT lG�l�'h TEL. SI�SIpESTREET RW ❑ � CONTRACTOR �E��N j� �//�l S1DE ❑ � C�DTMDRESS Z1P e TEL .�t t PROPOSED USE t � � . � ARCt1lENGf � � DESiGNER NO.DWEL. NO. �NO. ADt/RESS UNITS STORIES HEDROOMS � GITY ZIP TEL. � �n DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUAT{ON Q OWNEFl-BUILDER DECtARAT10N �p/pDDlREM O p i HERE9Y AiFlRN U�DER PENALTV OF PERAJRY TFIAT 1 MA E%EMPT FROId TNE CONTMCipR9 LI. ����9�� � CBISEU1Y/fORTMEFOLLON�!Nf3flEA.40N(9EC.70.t1.5BU5iNE93ANDPROFE55qNSGODE:ANVU7YOp (/� OOIINTYMMCFIR60UWESAPEdWRTOfANBTilUCT,ALTER�Pf4VE.0E110L1SN,ORPEVMRANYSTRUC W P8}IO/DBCK TUHE,PfIqR TO ITS IS&IANCE.K50 fiEW4RES iHE APPUCAM FON SUCH PERidIT TO fILE A 61GNEp w STA7pdENT TH+1T HE Ofl SHE IS LICENSED PUR4UAM TO 111E PROVISION3 OF THE CON7RACTORB LL CP18E UW id1A7TER 9(CdIYENCIN[i WRH SECTION 7000)OF DIV�SION 3 OF THE BUS1tlf55 A*%l PRO• � POOVSPB FES510!!S OOOE)OATUTHE ON SHE IS EXE4VTTiEREFROM AND THE BASIS FOH THE.\LIEQE�E%EAtP� TION.ANYVIOlA7k7N�FSECT10N7N7.5BYANYAPPLICAMFOflAPERMI7SUBJECTSTHEAPCLICANTTO z R@.RODV � { F AGYIL PENALTY OF NOT NORE THAN PNE NUNORED OolUA3 156oD).): � ❑4�OM7lEROFTNEVH0�6RTY,OFMYEMVLOYEESWIRIWAGE5115THEiR50LEP7MPEN5ATIDN, (�`pmm6fCldl - WMl i10 THE WONf.NJU THE STRUCiURE�S NOT IMENDE�OR OFFEREU FOR SALE{SEC.70µ,BU51. OJ � tE53 MA PMIfES810N3 CODE:TNE CONTRACTORS LIGEN3E LAW OOES NOT�GPLY Tb AN ONMER OF � PIiDVER7V YNq BUILDSOR IMPRDYE57HEfgON,IWD WHO OOES SUCH NtlRN HIYSEif OR HENSELF Oq � TWOUpNH180RHEflONRJEYPLOYEES,PROYiOEDTHATSUCiINIMOVENEMSARENOTMTENDE00R m � OFFEP£ORkiSALEIF.HOMIEVERTHEBUILDM!(iOHNIPipVEMENT19SOtDWiMWONEY£kROFCONRE TqN,SME ONrt1ER-0URDEA NnLL H+IVE 7ME BUROEN OF PROYiNO tlMT ME Oli SHE OIO!qT BUItA Oit � rwnovE Foa n�auarosE oF suEx ! � ❑I,ABOWNEROFTMEPROPEHfY,ANIXCIUSIVKYCONTMCTMOWfiTILIGEN9EDCOHiRACTOR3 Tp CONSTRIIGTTME PqpJECi(SEC.7oM,BUSIN�55 AIA PRQFESSIONS CODE hiE LONfRAGTORS L4 Y�II101�IX1 ADJ.ALiEA CEHSE UW DOES NOTAPPLYiOAN OriMEP OFA PROPERTY W�q 6UROS OR WPROVES THEREON,Nlp NHOCONTRACTSiOftSVqiPfiOJfCTSWITNACONTMCTOR(SIUCENSEDpUR�IANTTOTHEWHTFiAG QUANTITY �ESCRIP"f10N FEE � iC)NSl1GE'NSEIAW.j. ❑1.41 E%EMPT UNDEfl SEC. 0.8 P.C.FOR TH5 R£ASON Q U LL � Q4TE ONTIER � J i �4 LIGENSED CONTRACTORS DECLARATION W ' (� 1 MEREBYAFFIPIA UNOEq PENALiY OF VE0.1UqY TH��1 MA LICENSED UNDEA PROV�SIDN5 OF GHApTER � � Y�WNYENCRqWIT/15ECTIOM7000)OFOMSION30F7HEBUSINESSMI�PROFESSIONSCO�E,AND Z � }C MY UCENSE IS M FUl fOViCE hND EFFECT. ! o G ?'`� �1 j09'L�' � � � tICENSE CU1S5 LIC.N0. � V DXTE CONT(1NCTOR a � WOHKEHS'COMPENSATION DECIA(�AT�ON Q ��� � I NEAEBY AFFIip1 UNDEW CENAL7V OF PERIURV ONE Of THE FOLLOWING DECLAMTqNS: � (/a Q ' � �IlI�YEItAYl1LlMAMTAM�tEi7TIflGTEOFCONSEMfTOSELF-INSUREFORN"OPKERS' _ C04PENSATION,/SPFq41DE0BYSECT10N37000FTHElABORCOOE,FORTHEPEFWRMANCE W �. �7HE WORK FOfl WNitli THIS PEflMIT 6153UED. � � �_I HAVE M�0 W1LL Y�IMTAIW WORKER3'CdIPENS�TION INSUPANCE,A3 ft£W�S1ED 8Y SECTIDN (� Q 97ooOFtNElABOR OOOE,FORTIEPERFORMANCE Of THE WORK FOR WHIGH TtiIS PERMI718 { � ,� � i53UED.W WOqKEAS'LOMO�EN{SiT�ON INSURANCE CgAg��I�Efl AN�VOLICY NUMBER AqE CANSTRUCTIDN ;l � CMRIEP !"' � F� � �'�"' PLAN REVIEW � ra�crtxn�eEa [� .�,.,�'-7 � - � ELECTRIC �-, _ 0 (111s5EcfCNr�NOTeEaa�F1.EIEDOFhEPEPMt6fORddEMAOR[DOCIiARSM�IORIEs31 PLUMBING ' Z itERTIfYTU7kITiEPERFBRMANCEOFTHEWORKFORWHICHTHISPERMITI51S5UED.1 MECHANICAL (� SMW,NOT EMPLOV AN1'PERSON M!INY MANNER SO RS TO BECOME 5UBJEGT TO THE - � NbFKER$'COMYEN6ATIqiUN50F�.V.IFORNi�qNDAGREETHATIiISHWL�BECOYE IN5PECT14NfEE S SU9)ECT TO THE WORKERS'COMPENSATION PflOVIS10N3 OF SECT�ON 370o OF THE L�BOR ' - � � ,1r1 cooE.�swu Farn+win�ca��r xnn�nase v�Hsbr+s. ISSUANCE vV p DATE: APPLICANT.__�� 1 � SMIA_ � . . . . � . . � ,L1A W ENEFOY P/C.� • . . < .. 7 V J W1IRNINO�FMVRE TO SECURE WORKER9'fAMDENSATpN�VEPAGE IS UNLAWfUL,AND 5HALL BE �y 8UBIECTANEMPLOVEqTOCiWNAlPENI�LTIE8PNOCMlFMESUPiO�NEHUNOREDTH0U5AN� ENEPGYPERMIT DplL1H5(t�o0.mo),W nODIT10N 70 TME COST OF COMPENSATqH,OAMAOES AS PAOVIDED FOR IN ¢ SEC7�'18T0lOF1HELABOFCODE,INTEFEST,ANDIITTORNEY'SFEES. RETENTIONFEE: d CONSTRUCTION LENDING AGENCY PREALT FEE: O Q1 MEREBV AFFIRM UNUER PENALN OF PEFUUHY 111aT THERE I5 A WNSTHUCTION tENDING AG�NCY FOR THE PER WRMANCE OG THE WOi1K FOR VMICH 7HIS PERMIT IS ISSUEO(SEC.3097,CIK C.). Z � LENDEH'S WWE � LENDEPSAtC�AE55 � TOTAL FEES � � a � ��,, I CERTIFY TF1AT I H/NE READ THIS APPLICA710NAN0 ST�TE TlUT THEABOVE INFOR/AATION IS COqRECT. � IAaREETOCDMPIYWRHNA.CRYM1000lRITYORDINANCE5AND6TA7EUWSREU�TINCtt16UlLOING � CONSTPUCTION,ANO HEREBV AUT�qR12E AEPRESENTATIYES 0F T1US GOUNTY 70 ENTER UPON THE ABOVE�MENTKKIED PROPERTY FOR INSPECTIDN WRP0.SE5. COMMENTS � f� � m PERMfTTEENMAF�V � Q N Lp S�CNATUREOFP DATE � RECPT.NO. � PAID BY � � VHLfDATION WHITE—DepartmeM Copy,YELLOW--Finance Copy,PINK—Msessor Capy,GOl6ENR0 i4a Copy,GREEN—ApplicanYs Copy .�__�__V..s.________ �� � �"'"' �"� C j ' � -� F i�-"c�Cn�[7 t�I r�1Icn k�f v � �a Kt � p i-i m G)I-n m �___ � � �� J�r� v`rzt .-�r n�� �ir �C'� C��ta ���FC3� ( � �Im � �i Ci5'0 � � � ' . r r ) c '�c C O J --�I� Cp�O � � i i� I � (" �irs . r ! jG1 �,��,if-n�> 'rt m � c� �m � c� � � ) i �`'1, iza `'I';r�- c��'.�i�Fm� � �,.- �, xr��„��� ��jo n � � . 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