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Home My WebLink About13598 (16) � CITY OF DIAMOND BAbt �'" DEPARTMENT OF COMMLTNITY dt DEVELQPMENT SERVICES � 21660 E.Copley Drive Suite 190 (904)860-319L5 Fa�c(909)861-3117 PRESS "�' BUII,DIN�PERMIT ApPLICAT�ON FIRMlY � JOBSITE \_ � ADDRESS �\�`�7 ��,\V� � pAPE��'��O ,�+�� PERMIT � � i �JC NUMBER g �ssuE rrae occ APN LOT TRACT DATE CONST. GROUP � OWNER p ADDRESS ZONING SEfBACKS �w CITY ZIP�2*TEL. ��RT RW o APPLICANT^ TEL�Z�— SIDEJSIDE STREEf RW ❑ � CONTRACTOR � SIDE ❑ ADD ESS ` g CITY ZiP�'1�.., TEL PROPOSED USE �C.�IQ� C'�� G�/ � ARCWENG! DESIGNER NO.DWEL. NO. NO. ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEI. � u� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANAIUATION ¢ OWNER-BUILpER DECUIRATION � SFR/ADDlREM 1 MEREBY AFfIM IMDEA PENAUY OF PERNqY 1/U17 1 AM EXEMV7 FflOM THE COMMCTORS LI- GefB JB/C81pOR � � CENSEIAWWRiHEFq10WIN6REA5011(SEC.7031.SBUSINESSAN�PROFESSIONSCODE:ANVCITYOR (f� tLUM�YWHIpIflEWIRESAVEfWITTOWNSTRUClPLTER�NPROVE.OEMOLI5H.OflREPRIRRNYSTRUG W pati0/DBCk 1UFIE,PRIOR TO fT8 1&SUANCE.AL50 RC-0UifiES TiE APPIICANT FOR SUCH CERMIT TO FlLE A StONED � STItiFJAENT 7MAT HE OR SHE IS LICENSEO PUR511ANT 7D THE PflOVI510N5 OF THE CONTRACT00.5 LI- � CFNSE UW(CFNPTER Y(COYMENCINf3 WITH SECTION 7o0a)OF DiVISION]Of hIE BUSME35 AND PR0- U' POOVSPB � FES8IDNS COOE)OR 7HA7 HE OR SHE IS E7�MPT THER[FROU M!D iHE 6ASIS FOR TNE ALI.EGEO EXF4N- C7 TqN.MlYVIOUTIONOFSECTION70.11.5BYANVMPUCANTFORAPERMITSU&IEC75TNEAPPLICANTTO z Fj�Rpp( F,,, A GVIL YE/417Y OF NOT/IORE 7W W FIYE HUNDREO DOLLARS�5500).)� � 04�SOMMEROF7HEPROPEflTV,ORMVEMPLOYEE5W17F1WAGE5A5THEiRSOlEC01APEN5AT10N, COl11lI7BlGI21 WILL DO TNE M'ORK MID TNE STRUCTURE IS NOT INTENDEO OR OFfERED FOR SALE(SEC.70M,BUS4 � � NE86 NAD PROFES610NS CODE:THE COHTMCTORS lIC[NSE UW�OES NOT APPLV TD AN OWNER OF VROoEHTYYMID�JIlD30fl1YPNOVES7NEREON,ANOWHODOE55UCMWORKHIMSELFOHHERSEIFOH � CC 7}1RDUGHWSORHEROVMEN7LOVEES,PROV�UEOTFIATSUQ7IMPHOVENEMSAflENOTIMENDEDOR m �� ,OFFEREDPoqSAIEIF,YpWEVERTT�E9URD�NOORNAPROVEYEM1550LOWI7HINONEYEAROFCOAIPLE Z TION,TME OMMEN-BUItDER M/ILL IMVE iHE&1ROEN OF PROYINO THAT HE OR SHE DIO NOT BUILp pf7 � AMPiqVE iOR THE PURPOSE OF SILLE). �y OI,A40WNEHOFTHEPROPERfY,AMEXCLU5N0.YCONTRACTIN6WITFiLICENSEDCONTMC70RS [y TO CONSTNUCT 7HE VRWEGT(SEC.70M,BUSINE55 AND PROiE551ON5 COOE:TNE CONTRACTORS LI- V8Il1flIlOfl ADJ.AREA W t�NBEUWDOE6lqTA0PLYTOANOWNEAOFAPflOPEHTVWFIO8UKD50RIMPFiOVESTFiEflEON,AND � WFIDCONTRACT3FORSUpiPROJEGTSWITMACONTRACTOR(5)LICENSE�PURSUIINTTOTHECONTMC- qUANTiIY DESCRIPTION �E � TORSUCENSEUW.�. .. ❑I AN IXEMPT UhbEH SEC. e.6 P.C.FOR THIS REAS(N! Q � U � � DA7E awNEa V - , . � IICENSED CONTRACTORS DECLARATION W I � IHEHfBVAFFIR4 UNDER PENFLTV OF PELiJURY THAT I AM LICENSED UNCEp P'?D`lISIO!:S OF CIiAPTER � � Y(�ENCMO WITM SECTION 7u00)OF DfVISION 30FTHE BU51NE55 ANO PROrE55lONS CACE,Ml� z X 1AY IICENSE S W FIAl FORGE�ND EFFECT. � 41 {�h � LICENSE CUSS C�LIC.NO. j � ~ DATE�$�Q Q CONTRAC G�_._ a i � �, WORKERS'COMPFNSATION DE . � Q + � IHER AFFlRAIUNDERPENN.TYOFPEAJURYQVEOFTHEi010WING0ECURATNNaS: Z � C _IFUVE/WDN'�.LLMAINTNNACERT�FlCATEOFO�NSEMTOSELFdNSUREARW�HKERS' ¢ � C011PENS�TK1N.115PROVIOFD�YSECTION37000FTNElABORCODE.FORTHEPERFORNANCE �U � Q —OFTHE WORK FORN71IG1 TMIS PEftM17131S31.�D. � W I HAVE WILL MAINTAfN WOfiKER3'COMFENSATION INSURRNCE.AS REOUIRED BY SECTIDN O 37aoOF qCOOE,iORTHEPEqWRM CEOFTHEWOR!(iCRW}11CNTVIISPEAMITiS ISSUED.M ENSATION SU CAARIERANDPOLICYNUM9ERAAE: CONSTRUCTION � } C�tiuER PtAN REVIEW � �-�Y� R ~ ` ELECTRIC +;�..��nr� O r��MOTeEa^I,RE'1EDOFTEaECM'rsFORaNEH.MIREDDQ1a4S{S�ae)oalESS�. PLUMBING :-i:3_a_.t� .. Z 1 E TIFYTHATIN?NEPERFORMANCEOFTHEWORKFOAWHICHTHISPERMITISISSUED,1 MECHANICAL /._�G I (} . t�T EMFLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SU9JECT TD TME ,. ;,j � VpRKER5COMPENSATIONUW50fC111FORNI/dRNDACilEETHATIFISHOULDBECOME INSPECTIONFEE } F `� SUBJECT TO THE VJORKER9'COMPENSATION PROVISqN50F SECTKKJ 9700 Of TME LAlOR t.' ' S GODE,15:f,1L�.fOFTHWITHCOMPIYW�TITNOSEPROVISIONS. �SSUANCE *��_� � LJd p DATE: APPLICAN7 SM)P �' . Y �� ..�., w ENERGY P/C �?'<,r'� `�` . WMNiNO:FARUPE TO SEIX1fiE WOflKEHS'COMCENSATKK!COVERAGE IS UNUWFUL.AND SHILLLBE �y„ SUBJELTANEMPLOYEflTOCRIMINALP'cNALTIESANOCIVILFINESUPTOONEHUNDR[DTHOUSANO ENEAGYPERMIT pOlURS(f 100.00D).MI MDITI�N TO THE COST OF COMPENSATKKJ.DIIMAGES AS PROVIDED FOfl IN J SECTKK1370B OF THE IABON COOE,INTEHEST,ANOATTOPNEY'S FEES. AE7ENT�ON FEE: Q d CONSTRUCTION LENDING AGENCY pRE-ALT FEE: � � � I HEREBV AFFIP/A UNDER PENALTY OF DERIURV THAThIERE IS ACOPISTRUCTION LENDINC AGENCV WR TME PERFORMANCE OFT1'1E WORK iOR WNICH 1H15 PERMIT IS ISSUED{SEC.3osf,CIV.C.). � � LENDEflSNAME �s LENDEH'SADORES3 `� ICERTIFYTHATIHAVEREADTHISAPPLICATIONAN�STAiETHATTHEABOVEINFORMATIONISCARRECT. TOTAL FEES � I AGFEE TO COMVLY WITH ALLCITY AND COUNTY ORDINANCES AND ST�TE UWS PELA7ING TO AUIIpMG � CONSTRUCTION,ANDHEREBYAUh10RIZEREPFlESENT�TNESOFTHI6WUNTVTOENTERUPONTNE . ZED PROVERTY FOR INSPECTqN PUPPOSES. 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