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HomeMy WebLinkAbout17593 (23) CITY OF DIAMCIND BAR � �, -- ' DEPARTMEI�7T QF COMMUNITY&DEVELOPMENT SERVICES �� 21660 E.Copley Drive Suite 190 (904)860-3195 Fax(909)8613117 PRFS$ �ri"� �: BUII.DiNG PERNIIT APPLICATION FIRMLY o ADDRESS Z�"�L•�1� r�..�r�Cir �� DATECATION ' � �"�,""'�UMBER �� �.„�i�/C c� ISSUE TYPE OCC APN L07 TRRCT DATE CONST. C,ROUP p �WNER � � �'` ADDR SS Z tIG.�� fi"i ZONING SETBACKS � APPLICAN7���G�— f ZIP 1�J� TE .���. 77fIJ REART RW O� �' C��cF �E�.' �1,. ' .EI s���s�ne srReE-r Rw o � ,CONTRACTQ� ' e � SIDE p ADDR SS '1 ° �" ''d CIFY ' �' ZIP �� tEl�.��a ``� PROPOSEDUSE 0 w� ARCaVENG/ � CESIGME�i NO.DWEL. NO. N0. � 'ADDRESS - UNITS STORIES BEDRpOMS ITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION. cn o � � �� � � OWNER-BUILDER bEC�flATiON SFR/ADD/REM � �'� 1 HERE9Y AFFIAM UN�ER PENAl.TY'OK 7EFiJURV THAT I AAA E%EMPT FPOM THE COMRRCTOAS LI- G9.f3gE/CflfF7a[t- � � � ,� CENSELAWFOfiTH6FOLLOWINC�iREA54N(SEG7039.SBUSINE53AM�PROF65SI045CODE:ANYqTYOR (� _ COUNTY4LMICN�EQUIRESAPERAf1TTOCONSTRUCT,ALTER,IMPAOVE,DEMOLISH,OfiHEPAIRANYSTqUC- I TUpE;PPoOR TO ITS ISSUANCE,FL$O RE�UIRES THE APPLICANT FOR SUCH PERMfT TD Fl�E A SIGNE� � Paib/Deck � STATEMENT iliAT HE OH 5HE 15 LICENSE�PUN5l1ANT TD iHE PflOYIS10NS OF THE CANTRRCTORS il� � � CENSELAW(CHAP7ER9(WI61M�N,G�NGWITMSECTION7aa0)OFDIVIS!ON30FTHEBUSINESSAM1'DPFO- '�'�' POOVSPB FE55�ON5'LODE)OR7HATHE6fl511E'0.5EXEMFfTHEREFROMAN�THEBA315FORTH'cALLEGEDEXEMP- �,,(?� .�� �TION;ANYVWCATIONOFSECTdON7P18i.6'BYAYYA?PLICANTFORAPERMiTSU&IECiS7HEAPPGCANTTO ,�. R@-ROOS � � � � ACMLPENpL71'OFM1YQiAdOREr�iANFIVEHUtiDRE�DOLURS(S:W}k � � � . � ❑�I,AE�OWNEROFTNEPflOPER'PY,OAPAVEh9PLOVcESWl7HWAGESA5THEIRSOLEC�MPENSATIOPI, ���', Commercial � . – � WILL 00 THE WORK,AND THE STRUCTURE IS NOT IN7ENDE0 OR OFrEFED FOR SALe(SEC.7�k4,BU56 � J y. NESS AIVD PROFESSIONS CODE:THE CONTRACTORS LICENSE LAW�OES NOT APPLY TO AN OWNER OF ���' " � PWOPFAIYYNiOBU1l.650fi1MPRbVESTNEREON,NNOWNo�DE55UCHW�RKHIlASELFORHERSELFDR '.(Z �THpd.IGMHISORHEROWNEA/P40VEE5,VHOViDE�THATSUCHlMPqOVEMENTSARENOTINTENDEDOR �,I .Q OFFEREDFORSALElF,HOWEVERJ71HE9UILDIN60RIMPROVEMENTI59�IDWITFIIMONEYEAROFCQMALE- ' ' ,� ��SION.THE OWNER-9ULDER Wlv.HAYE THE BUR�'cN OF PAOVNO TFLiT HE OFl SHE�ID NOT BUILD OR , .,.�. � 0.1PROYE FOii?HE PUP.V oSE OF�SALE). - � � �� �6ASOWNEROFTHEPROFE�AFIEXCLUSNELYCUNTRACYINGWI7HLICENSEDCAW7RAGTOPB ;� TO C4N5TRUCT THE PflOJECT(SEC.7oC4,Bl1SIWESS APlD PROFESSIONS CODE:iHE C0IJTRACTORS LI- ' ValUfltI011 AOJ..AREA ,,� CENSELAWDOESh107APPLY70ANOWNE9.OFAPRDPERTYWHO0U6DSORIMPPCVE57NEREON,AN� � '.WF�OCONTRACTSFORSIIqiFRO'JECTSW�HAIX)NTRACTOR(SJLICEh'SEDPURSUAfuTTbTNECIX+I7FAG �Q[JANTI�FY DESCRIPTION FEE � . .,� TORS LICENSE LAW.�.. . , � ❑I AM E%EkSPd UNDER SEC.' . B.&P.C.FOR THIS REASOM Q U' LL . � PATfi �WNEF U � . . Z ' W �� � L1C.EN�Ep GQNTRACTORS DECLARATION W �� � � IHEFtEBYAFFIRMUNDERPEhRJ.TYtlFPE�RJUftYTHATIAMLIC'cNSEDUNDERPROVISION50FCNAPiER r �+ , � '. . �� �9(CBMMENCINP3 WI7F7 5ECTpN 7d0oJ'�OF�DIVISION a OF 7HE BU5INESS AND PRO�ESSIOVS CODE,AN� Z '1 ' '0 MY lICENSE f3 Ili FULI.FOl3CEAND�FFeC7. � ('� � �JZ��� � � Q'. t,ICENS6 CLAS5 _�e+' UC.NO, _�, ` � DATE�;;?^-1l��� �CONTiiACTOR�I'11�9� d . � LJJ � VVCSfiPCEF�S'COPAPENEATlON DECLRHATION � � � C� J � � INEHEBtlAFFIAMUNpERPENAL7Y'�.�PERJVP.YONEOFTHEWLLOWINGOECiAftATIDI�'S: z �� v_I NqYE AND NlILL MPikTdIW�R CERTIf{CpTE ilf CONSENT TO SELF-INStJF7E FOk WORKEAS' _ COMFENSATIOW,RSPROVl�EQBYSEC75Q+V37000FTHELAOpflCO�E,FORTHEPERWRMANCE � _. O'FTHE WORK FQFk WNipd TWIS PERMIT IS�SSUED. � � _�__I HAVE ANU WILL i4A1PlTAW,ih`ORKERS'C07dFeNSATION INSURANCE,AS RE(7t11RE�6V SECTION � 37COOFTHELABORCODE,�IF'�bTHEPERWRMANCEOFTHEWORKFOAWHICHTh'lSRERMI715 �$SUED.R9YWORKEAE�'CyA�,APEfdSAP�NSUAANC CARRIEqANOPOLICVNUMBERARE: CONSTRUCTION � CARqIER,._�-i�"•� �'�C6Ct1� PLAN FEVIEW ' z � co�,�eruur�eEa���r'J-;�?�..���� ELECTRIC Q. ��s[�cnoyNE�rarsetiot�ErEvoFrr.�pEr�qr�sFopervei-wrs�Eoccs�.nns�,soo�oq�ss). PLUMBING ,��' � � IGERTfFY7HATItdTNEPEFFOPMANCEOFTHEWOPKFOFWHICH7HISPERMITISISSUED,i MECHANiCAL (°�'/�. SHALLPJOTEMPLOYqNYP$R5GVNpNYMAPlNERSOAS7GBECAMESUBJECTTOiHE p�� , - iS�ORKERS'COMpENSATIONII,AWSOFCALIFOFlNiA,A1JDAGREETHA7IFISHOULDeECOME INSPECTIONFEE �– ' SUBJEC7T07NEW6RiSERB'COMPEN6ATiO4PROVISIONSOFSECT�W3�0oOFTHELABOfl g �, CODE,I6NALLFQRT3WITHCA}.APIYW�THOSEPROVISIONS, ISSUANCE `�M�� � DATE�,�2� .� APPL9CANT•.���4`Y� � �� €�-� �s�tiP � ;,WpRNlkO:FAILURE TO SEGURE WOI Y,ERS'COM19PENSATI�J COVERAGE IS UNLAWFUL,AND SHALL BE E(dERGY P/C LL_ .'SUBJECTP7J EMPLOVER TO CRIMIN�L�j!ENAl71E5 AND CIVIL F1NES UP 70 ONE HUNDNeD THOUSAND �NERGY PERMIT ' DOILARS(5700,000),IPiAODITif7N7C'�YHE.COSTDFCOMPENSATfON,DAMAGESASPROVI�EDFORIN ��, �'SECTION37aBOFTHEL460RCODEIN7ERE5T,AN�ATTOqNE1^SFEES. ' RETENTIONFEE: i �� � CON�T�UCTION LENDING AGENCY PRE-ALT FEE: + 4 Q��',, IHEfiEBVAFFdRM'UNOEFlPENqLNOFPEA;1t1RYTHATTHEREISACONSTqUCTIONLEN0INGAGENCV __ � '.�FOR THE PEqFORK.A�E OF7FlE WOqK FOR WHICH THIS P6qM177S ISSUED(SEC.369],CIv C)- W,"' . ���,'.�LENOE.9'S N/1ME - ' - Fy LEIJUEr7SADDAESS � � , � ICER7IFYTNATIHAVEREAD71-IISARPLICATIONANDSTAiETHATTHEABOVEMFORMA710NISCOBRCCT. TOTAL FEES = �� q�,��,',�,,I AGREE 70 COMPIV WI7H ALL CITY�ND CRUNTY OR�INANCES AND STATE IAWS FELATING TO BUILDING � �;�.;;,CONSTAUCTION,AND HEREBV AU@10p2E PEPqESEtJTA71VE9 OF T4i1S COUNTY TO EKTER UPON THE �.;, 'ABDVEMENTIONE�PAOPEPiYFOFjNSPECT��PUftPO5E5. COMMENTS � � �.a. �/� 'fi+�°���'�.� '� ffi PE, fTTE FiAM PFlENTI .. . . 4 — u7 d.�s� � {� I,., NA,REOFPEflMITTEE '' � DAT ' ' � � ' RECPT,NO. PAl�BY VALIDATION ~ ��,�WHITE—De ar4ment Copy,Y OW—Finance Co PINK—Assessor Co GOIDENROD—File Co GREEN— plicanYs Co P PY. PY. 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