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HomeMy WebLinkAbout15436 (20) l � �. , . _!� CITY OF DIAMOND BA8 i DEPARTMENT OF COMMUWITY&DEVELOPMENT SERVICES � � 216b0 E.Copley Drive Suite 190 (909)860-3195 Fax(909)$61-3117 PR ESS ����%'�� � BUII.DING PERMIT APPLICATION FIRMLY oN JOBSITE �y g �' �J�'�J���� , APPLICATION ¢ /�,7� PERMIT r��j�I_ P/C ADDRESS � O 3 � n� � ��' DATE CJ ����J NUMBER ��� � ,P X � APN YI LOT TRACT D/,S DATE " CONST. GROUP p OWNER �(Z f 1IS,Y��AI. ADDRESJS • ZONING SETBACKS Z CITY t�ZIP LO TEL. �M REART RW ❑❑ � APPLlCANT � TEL. SIDE/SIDE STREET RW O � CONTRACTOR SIDE ❑ ADDRESS r � CITY ZIP TEL PROPOSED USE � T A� 0 a N�G--� w ARCWENG/ % ' !_ � a ��',, DESIGNER NO.DWEL. NO. O. N �DRESS Z�P TEL. UNITS STORIES BEDROOMS � v� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OYVNER-BUILDER DECLARATION SFRIADDtREM O p I HEHEBYAFFlRM UNDER PENLL7Y OF PEfWRY THAT I AM IXEMVT FROM TiE CONTRACTORS LI- G818Q9/GdfpOtl LL1 CEN9EUWfORTHEFIXI0WIN6REA90N(SEC.7n9f.58USINE33ANOPROFE5510N5CODEANYqiYOR (n C� CIXINTVNRtlpIpEqIAqESAPERWf7000NS7RUCi,ALTER,61PqqVE,pF),IpLISH,OHPFAAIRANYSTRUC- W Z TURE,PAIDR TD ITS ISSUANCE,ALSO REW IRE5 THE APPLICANT FOR SUGH PERNIT TO F�LE A&GNED PBIIO/D6Ck �L 3TATEMENT TUT HE ON SHE IS UCENSED PUqSUANT TO TNE PROVISIONS OF THE CONiRACTORS 11- W � GENSE UW(Q1APfER i(Ctl/I/ENCWO 1VITH SECfqI'170o0)OF DIVISION 3 Of TME BUSINE55 AND PRO- � POOVSpe FES9qN3CODE)qiTriATNEORSHEISEMEIWTTHEREFNd1AND7HEBA5�SFORT}IEALLEGEDEXENP- (� TION.HiYV10LAT10NOFSECTION7091.5BYMIYA�PIICAMFORAPER41T5UBJECTSTME�PPUCANTTO Z {{g-Rpp� � ACML PENAITY OF NOT MDf1E TUN FNE HUNDPED DOLIARS I�1.): � 04�SUWNEROFTMEPROPERTY.ORMYEMPLOVEESWITNWAGESASTHEIRSOIECONPENSATqN, � COrt1R18fC18I � N7LL DO TNE WORK,MID THE STiklC?URE IS NOT IMEHDED OR OFFERE�FOR SALE(SEC.7044,&1SI- J NE83 MA PRDFfi5S10Nfi COOE:THE CONTiHCTORS LICENSE UW DOES NOT APPLY TO AN OWNEfl OF � Q.4/ � OHODEqTYY�h1091JR.DSOF111APRDVESTHEfi[ON,ANDNMODOESSUCHWORKHIYBEIFORHERSELGOq CL Tli101fOXM13ORNEROMMEMPLOYEES.PNOVIDEOTH��SUCHqAPROYEYENiSAqEN6TR7�EN6EDOR m OOFFHiEDfORSKEIFHOWEVER��DNJ(10RM�PHOVEMBRISSOLDWI7MNONEVEAHOFC04PLE- � TIOH.TME OMYNEFl�9UIIDEH WILL H�VE iME BLIROEN Of PROVIN�TlUT HE OFi SME Ob NOT BI11Lp pq NPFq4E FOR 7HE PIJR!'03E OF 311LE). W ❑L ASOMR�R OF TNE PROPEHII:AM EXCLI131YELY CONTRACTM6 N?fH LICENSEO CONTMCtt10.5 [[ TO CONSTF%1CT iNE PROJECT(SEC.70M,8V31NES5�NO PPOFESSIONS CODE:TiE CONTRACiORS LI- V81U0SI A�J.AREA W CEN8EL1W/DOF.SNOTAPPLYTOMIOWNEROFAPROPEHTYWFiOBl/kD50RWPROVESTMEREON,AND - � w�+omnrwicrswasucHPno.�crsvnn��oa+Trucra��siuceHssoruruuurrTon+ecormua Qua�unnr DESCRiPTION FEE � lD0.S t�CFtLSE uvL7. O I1W EXE/APT UNDE11 S�G B.8 P.C.PoR THIS REASON Q U u. ¢ o�h ovn+� r V � LICENSED CQNTRACTORS DECURATION W � IHEAEBY�FFIWIUNDERPENIILTYOFPERJURVTHA71A4LICENSEDUNDEPPPOVISIONSOFCHMTER � � 9(C0IWENCMOYATf15ECTION7000)OFDIVISION90fTHEBU51NE35Ml�PROFE5510NSCODE,ANO Z X MYIICEN4E IS W FUTA FORCEANO EFFECL m ui � ucE�cxass uc.rm. j � J V DATE GONTMCTOR a Gi WORKERS'COMPENSATION DECLARATION Q � � I HEREBV AFFIfiM UNDER PENALN OF VERJURY ONE OF 7HE FOLLOWING DECtARATIDN3: Z O _IHAVEMIDWILLYAMTNNACEi1TIFlCATEDFCONSENTTOSELFINSUREFORWORKERS' a 2 Z CONPENSATION,ASPROVIDEDBYSECTION37000FTHEUBORCODE,FOqTHEPERWRMANCE C,) 4 OF THE WOHK FOR WHIGH TMIS iERM1T IS ISSUED. � 0 _I HAVE MID WILL 4ARlTAIN M�ORKERS'LbM7EN5ATION INSUR/UJCE,AS REOUIRED BV SECTION Q 370o OF THE UBOR CODE.fOR THE PERPoRMMlCE OF T1E WORK FOR WXIGH 7HI3 PERMR IS _�(p. Lb ISSUED.MY WOFlN(ERS'COiIPENSAT10N INSURANCE CAqR1ER MiD POLICV NUMBER ARE: CONSTRUCTION jCARRIER PLAN REVIEW , Z aa�cr nweEa ELECTRIC ct � (Mqgccr4�IrlEIDrqree07►nlEfEDOFn+EaEa�is�ortaJEttALlrmOa.Was(t�ao�ontFss? PLUMBING � I CERTIF'/THAT IN TT1E PERF�PJdM10E OF T/E WORK FOR WNIp1 Ti15 PERMIT I5155UEU,1 MECHANICAL �j' SH/�LL NOT EMPIOV M1Y PEHSON IN ANY MANNER SO AS TO pECOME SUBlECT TO iNE � NOfiKERS COMPENS�T70N UWS OF CAI,IFORNU,PNDAOREE hUT IF I SHOULD BECOME INSPECTION FEE S SUBJECTT07HEWOPoCEHS'CQMPENSATIONPROVISIONSOFSEC7pN3]OOOFTNEUBOR cooE.i stuu wann�nn�coua�r w�tH nwse rrrowsaws. ISSUANCE S OG � SMiP + p DATE: APPLiCANT: � WARNNKi:FAILURE TO SECURE wORKEP5 COMPENSATION COVEMOE IS UtBAWFUI.,�ND SHN1 BE ENERGY P/C � � SUBJECT�NEMPLOVERTOCHWMIALPENALTIESANOCMLFMESUDTOONEHl1NDREDTTiIX15AN0 r Od.URS(iloo.000),WADDITIONTOTHECOSTOFCAMPENSATION,OAMAOESASPROVI�EDFORIN ENERGYPERMIT �'Y �7-�� ¢ SECTION 3)0!OF THE 1A80R CODE,NTEPEST,AND ATTORNEY'S FEES. RETENTION FEE: S..I Z E � - +T'V OCONSTAUCTION LENDING AGENCY PRE-ALT FEE: RZ�T�.DINC7 f �� � 1 HEFEBYAFFIRM UNOER PENALTY OF PERJURY iMAT THERE IS�CONSTRUCTION LEN�INQ AGENCV Z FOP hIE PEP WRMANCE OF THE WDRK FOR WHICH TNIS VEFMIT IS ISSUED(SEC.3087.pV.C.]. . ll] � IENDER'S NAME F- LENDEH'SADOHE55 � ICERTIFYIHATIHAVEREADhiI3MPLICATIONANDSTATETHATTHEABOVFINFORIAATIONISCORRECT. TOTAL FEES I��,�O 4 I AGREE TO COAIPLY N7TM!LLl CITY AND CWNTY ORDINANCES AND STATE tANS REIATN(3 Tp BUI�p�NG � CONSTPUCTION,ANDHEREBVAUTVWRREREPRESENTATNESOiTHISCOUNTVTOENfERUPONTHE Z ABOVE-MEHTIONED PROPERTY FOq INSPECTIDN PUHPOSES. COMMENTS � �. F � � � _ QCERMffTEENAME(P. (( //� l'� � � Q V V y SIONANREOFPEPoAIT7E D�TE � RECPT.NO. 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