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HomeMy WebLinkAbout15468 G� � ' � CITY OF DIAMOND BA8 DEPARTMENT OF COMMUHITY&DEVELOPMENI'SERVICES 21660 E.Copley Drive Suite 190 (909)860-3195 Faz(909)861-3117 PRESS �"�^� BUQ.DING PERMIT APPLICATION FIRMLY �� JOBSITE �� T �y APPLICATIONQ� � � NUMB R�✓ �J �� ADDRESS� O 1�I_(������f //Q._, DATE l7 � ISSUE TYPE OCC APN L T TRACT DA7E CONST. GROUP p OWNER o ADDRESS �C— ZONING SETBACKS � CIl'1�� R.AeL ZIP TEL. RE�RT RW � APPLICANT TEL. SIDEISIDE STREET RW ❑ CONTRRCTO SIDE ❑ � ADORE S P USE — o C ' l� ZIP TEL �7 �� � • t w ARCH/ENG/ (�O � DESIGNER NO.DWEL. NO. NO. AODRESS UNITS STOR(ES BEDROOMS � CITY ZIP TEL � rn DESCRIPTION SQ.FT. FACTOR PSF AW.AREANALUATION Q OWNER-BUILDER DECURATION SFR/ADD/REM e O 4 p 1 HEflEBY AFFlRM UNER PENK7Y OF PERIURY TMAT 1 MI E%EMPT FROM TNE CONTMCTOR5 LI- G819ye/C8lpOA Y.� CEN6EUWFOR7MEtOLLOWWOPEASON(SEC.7037.6BUSWESSNrDPFbFESS10NSCODE:ANYCItYOq (n C.) f�IMrtVWWGiREOWi65�PEHYRTOCOt13Ti1UC[ALTE0.�NOVE.DEMOLISH.ORPEWJRMIYSTRUC. W t Z 7URE,PRqii TO RS ISSUANCE,�L50 itEW IRES THE A7PLICANT FOR SUpi PER417 TO flLE A StGNEp Pa�Wl�9Ck ( ��� STA7FJlEM THAT NE Oq S7lE IS LCENSED PURSUANT TO THE PR041SION8 OF THE CON7RACTORb U- W � � CENSE UW(CHAPTER i(CQAANENCRV�3 WI7H SECTION 70W)OF DIVISION 3 OF THE BUSMESS ANO Pfl0- �" POOVS�3 I FE&4qN9GOD�Oq1HATHEORSFiE15EXE41PTTiEREFROMANDTiEBA915fORTNEALLEOEDE%EMP. (� TION.ANVVIOLATIONOFSECTION7tti1.68Y�NY�PPLICANTFORAFERYITSUBJECTBTHEAPPIICANTTO Z Re-Roof � AG�M YENALTY OF NOt MORE M4f FIVE NIMDRED DOL1RR51f.5oo1.): � � 04�OM�NEROFTHEPROPERiY,OPMVEMPLOVEES4/ITHWAGESA8hIEIR80LECOMPENSATION, C� Comifl0fei81 � MIII�UO THE WOW(M�THE STRl1GTlIRE IS NOT INTE�q6D pq OFFERED FOR SALE(SEC.70M,BUSI� J � tE68 NW PiiOFE5910NS CODE THE CONTRAGTORS LICENSE tAW DOE9 NOT APPLY TO AN OWNER OF = VROPENTV VMO BUNDS OR M/PA04E3 THEREOk,AND 1M10 DOES SUCNNbRK HiN5ELF ON HERSELF Oq (� TMRq/OHH150qNEflOWNEMPLOYEES,iROV1DED1fU1TSUp1WPROVEMENTSMENOTIMENDEDOp m W� OFFEN�FORSKE�F.HOWkVERTMEBURDINOOSiNiPqOVELLEMISSOLDWITHINONEYEAROFC011PLE- � T1ON,THE OWNER�9URDER YALL liAVE THE BURDEN OF PROVMO THI1T HE OR SME DIO NOT Pll1lD Oq IA1PFi0YE FOA TME PUqPOSE OF SKEG ❑411S OMIlEROFTHE PROPEHIV,AM IXCLUSIVELv CONTRACTMI(i WrtH LiCEN5E0 CONTRI.CTOR8 � TO CONSTHUCT 1NE PRO.1ECt(SEC.7oN,BU31NE55 MIO PRQFESSIONS OODE:TNE COPI7RACTORS l.l- V31U8t10f1 ADJ.AREA W CHi6EUWD�ESNOiMPLVTOMlOWNEROFAPROPFRT'WF109U0.DSORMAPROVEBTHEREON,AND � WkiOCONTRACfSfORSI)CMVR0.IECTSWI7H!{COHfRAClOP{S�tICENSEOPUliSUANTTOTHECONTRAp pUANTITY DESCRIPTION FEE � ions ucerue uw.�. ❑t AN E%EMP�UAER SEG B.6 P.C.WR THIS REASON q C.1 � � DATE OWNER U W � LICENSED CONTRACTORS DECLARATION W . � 111EHEBYAFFIRMUNDERPEWI7YOFPERNin'T1uT1AMLICENSEDUNDEqPROVISION30fCHAPTER � S 0(C0IYAENCp�WM7MSEC710N700o)OFOIVISION30FTHEBUSINESSMAPROFESSKKJSCODE,/ND z � W 110ENSE IS N FtA1 PDRCE AND EFFECT. m � LICENSE 5 LK..NO. � � � � J o� cor+rrucTo a �I = WORKERS'COMPENSAT70NDECLARATION � i � . � IMEREBYAFFlRMtMDERPEWI7YOFPEiWRYONEOFTHEFOLLON'iN60ECUM710N9: Z I � _IIUVEAlAWIILM�MIT�MACEFf�FlGTEOFCONSEMTOSELF-INSUREFORVpRKERS' _ I � CqIPEN5AT10N,ASPRDVIOE�BYSECTION37000FTMELABORCWEFORTHEPEflfORMANCE w I O OF 7F1E V/ORN FOR WHICH THIS iERM1T IS 139UE0. � I ,�_IIUVEANDWILLMAIMAINWORKERS'COMPEN9AT�ONINSUMNCE,ASNEOUIREDBYSECTION � Q 3f000FTiEUPORCODE.FOHTHEPERFORNMICEOFTHEWORKiORWMICHTHISPERMRIS � � (SSUED.MYNLJFiKERS'CaAfAENSATlONINSURWCEGIRRIEHANDPOLICVNUMBEPME: CONSTRUCTION � CARRIER � PLAN PEVIEW Z �-�y�ER 1S� ELECTRIC � a � (fF#6SECIpNNE�NOTBEo�mEtEDOF1fE�+EWNfBRXiaNEMM%iEDWLV�AS�Etoo)ORLESs�. PLUMBING � ICERTIfTTHATNITHEPERFORMANCEOFTFfEtM)RKPOqWHICHT1n5vERMITI5tS5UE�.l MECHANICAL () SHN.L NOT EMW,OY IllY PERSON IN ANY MANNER 50 AS TO 9ECOME SU&IECt TO THE � �/j WONKER5C011PENSATIONUWSOFCALIWflN1AANDAGREETHAiff�SMIX1LDBECOME INSPECTIONFEE S SUBJECTTOTlIEWORKERSCOMPENSATpNCPOVISIONSOFSECTION37aoOFTHELABOp .i s FOFlhNA7N COMPIV WITH THOSE P swr+s. 1SSUANCE ,t� -�- 1 � SMIP I ` p DA AP%.ICANT, � ENEAGYP/C �II� � '�i 7���, J WAqN1 .FI.tURE TO SECURE wOHKERS'CdAPENSATION COVEMGE IS UNLAWFUL,AND 5NI1Ll BE v �-Z p LL SURIE ANEMPIOYERTO(3i1MWALPENALTIESANDGMLFMESUPTOONEMUNUREOTHOU5AN0 ENERGYPERM�T , pOLLAp3(ita0,000),IN MDITION TO7}tE COST OF COMPENSATqN,DAMAGES AS PROVIDED FOR IN ���( �, � �y� � SECTION 370!Of TifE U80N COOE,MTEREST,ANO ATTORNEY'3 FEES. RETENTION FEE: � � ' - "d '�TD BL-1lt a CONSTRUCTION LENDING AGENCY PRE-ALT FEE: ` " ���T A..�ID SAF"� O � 1 HEREBV AFFlRAI UNDER PENPLiY OF PERJURV THAThIERE IS ACOPISTRUCTION LENOING AGENCY � iOR 7HE PERPORMANCE Of TME C�R WM�CH IS PERMIT IS ISSI)ED(SEC.30BT,CIY.C.). Z W � LENDER'S W.ME F-- �EtqEH'S�DDRES � ICERTIFVTHATIHMEREAOTHI511PPLICATIONAN�STATETHATTIEABOVEINFOibAATpNISCORRECT. TOTML F�ES l W 1 AQpEE TO COAIPLY WITH ALL CITY AND COt1NTY ORDIN�NCES ANO STRTE LANS RELATttia 70 BUIL�ING � CON3TRUCTION,ANDHEflEBYAUiHOHIZEREPRESEHTATIVESOFTH15CW1RVTOEMERUPONTHE � ABOY6MENTk7N�PROPE TY FOR NJSPfCTION PUAPOSES. 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