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HomeMy WebLinkAbout13846 (17) � � CITY OF DIAMOND$AB � � I� DSPARTMENT OF COMMUNITY 8c DEYELOPMBNT SBRVICES 216C0 E.CoQley Drive Suite 140 � �� (909)860-3195 Fa�c(909)861-3117 PRES� '�'�� BUII.DING PERMTI'APP�.ICATION FIRML'1�' � JOBSITE �2 Q^� ' L APPIICATION� �' ""'�," ' PERMIT �P/C ADDRESS � h DATE � � NUMBER � # � ISSUE TYPE OCC APN T TRACT DATE CONST. LiROUP � OWNER 1.SS � LL' AODRESS ZONIMG SETBACKS 0 � CITY 21P TEL. — REAR RW ❑ APPUCANT TEL. SIDEJSIQE STREET RW ❑ � CONTRACTOR �+ � ' � SIDE p � ADDRE^�S ' J PROPOSED USE ciTv ff �q ZIP 9/�h/TEL �T, 'S � ARCFVENGI � � DESIGNER NO.DWEL. NO. NO. ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � rn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANAI.UATION ¢ OWNER-BUIIDER DECLARATION SFF1lAODJREM O � 1 HEREBY�FFlqA UNOER PENALTY OF PERRIRY T1UT I AM FXEIAPT FROb1 THE CONfMCTORS U- G2�898lCBIp�R CENSEUWFORiNEP011OY11NfREA50N(SE4103138USWESSWDiHOFE5510N5COpE:ANYCITYOR (n OOI,WTYNF11G1REWlNES�PERM(fiOCONSTqV6f./LLTERIMVpOVE�ENOl15H2ORREMIRANYSiRUP W P8IiD1DeCk NR�Pfl10q TO ITS ISSUANCE,/�L50 REqJIRES 7HE AiVLICANT FpR SUCH PERMIT TO FllE A SIGNED w 3TATEAIEM THAi HE Ofl SHE IS IICENSED PUPSUMIT TO THE PROYtSIONS OF THE CalITMCTORS LI- # � �F19E UW�CXMTER Y(OOMIAENCNq VIiTM SELf70N 7a0o)OF�IVISION 3 OF TNE BUSINESS AND PRO- u' POOUSn2 a FF8410NSGODE�OqiHATHEORSXEtBE%EM>TTNEREFROMANn7NEBq513FORT/1EALlEGEOEXFA�P� � 110N.ANVypL/i710NOFSECf10N7031.68VANYAPPLICANiGOR�PERMITSUBJECTSTHEAPPLIGNTTO a RB-ROOf � •pN�PENALTYOFNOTMOHETHANFlYEI4UNONEDDOLUNS�lsao).): � ❑A�SOMMENOFTHEPROPERN.Oi1MY£MPLOYEESW�THWAGESASTHEIRSOIECOMPENSATpN, � Commerc�al � YILLL DO TNE WOiY(ANO 7NE 57ltUCTURE IS NO'T RITENDFD OR OFfERED WR SALE(SEC.Tou,8US1- J HESS MD PROFES^elON9 CODB iNE CON�MCTOfl9 LICFN9E UW DOES NOT A7PLY TO AN 01VNER OF � PNOPER7YM11108UMSOqNIPROVE3TMEREON,ANDVMOVOESSUCNWORKMIMSELFORHERSELFOR � (� iHICUqN/HSOflHERO1MlENGLOVEES,PpOV1OFO7YUTSl1CHIYGNOVEMENT3ARENOTINTElAEOOR m � OLFENEOFORSALEIF,FIOWEVEitTHE&AIpNGOi{MPPOVEMFNTI5601DWITHINIXJEYEMOf�17MP1E- T10N.7HE OWNFR-0ULLDER YALL HAVE THE HUR�EN OF PPOViNO 7HAT NE Oq SHE OiD NOT BURlf OR � MPROVE FON iNE PLIRPOSE OF 9�V.E1. � ❑I,IISONMEROFTHEPROGEHfV,M1E%CLVSNELYCONTMLTIN6WI7HlKENSEDCONTRACT0R5 10 CONSiRUCT 7NE PROJECT l�C.70N.6USINESS AND PROFESStONS W�E:THE CONTMCTOPS U� V81Ue�ia11 ADJ.AREA CENS£UW DO£8 NOTAPPLV 7pAN OWNER OF�PROPER7Y WFp BVMDS Ofl MPROVES 1HEREON,ANO WAOCONTRACi3FD115UCHPPOJFCT9WITNACONTMCTOA(S)LICENSEDPURSUNifTOTHECONTRAG pUANTITY OESCftIPTION FEE � SORS 1lCENSE U1W.y ❑I AN E%EM7T UNDEH SEC. e,d P.C.FpR THIS RLASON � U LL � DATE OWNEH V � W LICENSED CONTRACTORS DECIARATION -� � � I IIEP£AY AKFlPM UI/�ER PENALTY OF PEflJURV THA71 AN LICEN5E0 UNDER PAOVISIONS OF CHAPTER � 1 � Y(COI/JENCWOV/11NSECTIDN70P9�OFDIVISICN�OFTME�ISWES6RNOPROFESSIONSCO�EPhO Z MY LICENSE tS W ML FORGE,WD EFFECT. m 1 � ti�N��,SS ��o ���.No. Z�923� � � v a�h �� c«+rancroa ' a � WORKERS'COMPENSATION OECLARATIQN f���f V � � G f 4 � �j� U 1 � INEREBY�ffNWt]NDER9ENAL7YOFPEH1UpYONEOFTHEFOlIOWtNQD£CUMT%%d5: �Ty,_ Z Q _I NAVE/J7D WILL MMPlTANJ A CER(�FlCA7E OG(7JNSENT TO SELFSNSURE FOR VARKERS z Z CplPEN5A7%]N,rS PROVIDEO BY SECTION 3lM OF TME U90R CME,FOA THE PERFOFMANCE C� � OFTNE WORK FOH WHICNTHIS PERMIT 18ISSUED. � A __I HAVE M!D N'ILL MAMAMI WOHKEAS'COMPENSA71oH INSUMNCE,AS RCqUiflED BY SECt10N � 3]OOpFTHEUBOFCWE.FQRTTIEPERFORMANCEOFTHEWORKPoRWNICMTHISVERM�T15 1 ISSUC-0.MYYA RS'CAU�ENS:\TqNiN URANCEC�q RANDPOLICYNUMB�R�,�y, ) CONSTRUCTION ✓ � c�,A�en�r�cr� , �� PLANREVIEW � 4ouCVNUueER G � � � , ELECTqiC � (iHSs[CIIONNFIDN�TBEOOMRETEnoFnEPEaMrswawEMRAI7�o0.1ai5tS�wlortt.E �} PLUMBING __�A,r Z1 CERTIFYhIRT M1HE PEAGOi47AANCf OF TME WDRK FOR WHICN THIS PERMI7IS ISSUEU,1 MECHAN�CAL (J SHAI,LNOTEMPLOYANYPERSONtt{MNMANNERSOASTOBEWMESU&IECTTOTHE (,A WORNEFSGOMPENSATpNUWSOFCA�IFOHNIqAN0A6REETHpTIF15M0ULDBECOME INSPECTIONFEE S SUBJEGTTOTHEwORKF.Ps'CONDEHSATKN/PROV151WVSOFSECT10H37a00FTHEUeQH ��� (� � ���� r"} s / iSsunNCE Fy cooe i swvt wrmrnim con+riv wirH� �w/'/� G � �� SM4P y'i ,i� � �s A D p DATE:,._(� APfL1CANT:� ^/�._ JF�]-�� , . . w � WARNiNO:FA0.URE TO SECURE WOi1KER5 COMPENSATION COVEtiAGE IS UNLAWFVI,AND SHILLL BE ENERGY P/C ��TiLi�i�����1 v�j a _ �� zz..IJ'Tl' .�s'n 1�� �y 6UBJECrAMEMPIOI'ERTOCqiMIW�LP£NI1L17ESANOCMLFINESUPTOONENUNOREDTHCNISAND ENERGYPERMIT DOLURS(f loo,uoo).IN A�rtION TOTHE COST OF COAIPENSATION.ONMGES AS PROYIDEO WR IN ¢ SECTqN97aeOFTHEIAEORCl1DE,MlTERE57,M1�A7TOflNEYSfEES. qE{EPjTIONFEE: a CONSTRUCTION LENDING AGENCY PRE-AtT FEE: O L�L INEREBYAFFIRMi)NDERPENAL7YOFPERIURYTHATTHEREIS�WNSTRVCTIONLENDING�GENCY �L FOR TN£PERFORMPNCE OF TNE WOPI(iOR WNIGM TMIS PERMIT IS ISSUEO(SEG.]OHI,CIV.C.). � �L LENDERS NA4E �i�' IENDER'SADOHESS 1 CSRTIFI TNAT I HAYE READ 7H6 APPLIGTIdI ANO STATE THAT THE/90VE iNFORA1A7pN IS CORRECT. � IAGFiEETOCOMI'LVWITHN.LCITYM'OCOUNTYORDINANCESANOSTATEIAWSqELATMGTOBU4AIN0 TOTAL FEES L � � CONSTRVCTION,MID HEREBY AUTHORRE REVilESEMATIVE9 QF TH7S COUNM TO EIirER UPON THE S�. 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