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HomeMy WebLinkAbout13306 (17) � CITY OF DIAMOND BAA DEPARTMENT OF COMMUNITY dt DEVELOPMENT SERVICES � i � 21660 E.Capley Drive 5uite 190 (9Q9)860-3195 Faz(909)861-3117 PRESS ���^� BUQ.,DING PERMIT APPLICATION FIRMLY � DDR SS�a o33 a�eDs ��,� �� DATE�CATION - L- � NUMBER � #� � ISSUE TYPE OCC � APN LOT _ TRACT DATE CONST. GROUP � OWNER ADORE . � ZQNIMG SETBACKS � CITY �, r ZIP!'/�TEL. S -� FRONT RW ❑ APPLICANT TEL. REAR p � 31DE/SIdE STREET RW ❑ CONTRACTO SIDE ❑ � A�DRE CITY r L ZIP / U TEL. �� PROPOSED USE � ARCH/ENG/ DESIGNER NO.DWEL. NO. NO. ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL � DESCRJPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � � OWNER-BUILDEp DECIARATION SFRlADD/REM O � i�pEer�nn w+oEa a�r�an oF rEaxiar rH�T�ua ExEMor�nrE corrra�cro�u. Garage/Carport CEN5EUWFONTMEFOLLOlYCiOFFJI50N(SEG.7WI.SBUSIf�SSANOPROFES510NSCODE:MIYCIT'OR (� COUl1TYWHICMREWIitESAPEq1A1TTOCONSTRUCT.ALTER,NiGHOVE,DE110LISH,ORREW�FAN1'STi1UC- W pa110/DBCk TUNE.PaqR TO RS ISSUANCE.AL50 REW IRES 1HE MPLICAN7 FOR SUCM PERMIt TO FILE A StGNEO � STAiH,1ENT TUi HE OR SHE IS LICENSED WRSUANT TO iNE PROVISIONS OF THE CONTRACTOii3 LI- � POOI/S C@ISE LAW(CHAPTEP Y(COMMENCINO WIiH SECTION 7a00)OF OIVISION 3 OF T}1E BUSINE55 ANU PRO- Pe FE5910NSCODE)ORTH�THEORSHEISEXEMPTTHEPEFROp1ANO1HE8A515FOPTHEALLEGEDEXEYP- (� TpN.ANYVIIX.ATIONOiSECTION7W1.5BYAHYAPPLIGANTFORAPERMITSUBJECT57HE�PPLiCMlrTO z RB-R001 F ACNIL PENALTI OF NOT MOIiE TUN FNE FR)NORED DOlURS�t50o).): � ❑47SOWNEXOFTHEPR�VEHT',ORUYEMPLOVEESWI7HWAGESA57HEIRSOIECDMVENSATION, O Commercial NMl DO THE MIOR�(/lD iME STiM1CTUNE IS NOT 1NTENDED oR OFFERED FOR SALE(SEC.70M,BUSI- J /�SS A!ID VpDFE5S10NS OODE:171E CONiRAClORS LICENSE UW�OES NOT A7Pl V TO AN ONWER DF � PiqPERTYNMOBUIWSORM1PF10VESiHEREON,M1DMiMODOESSUCHWORKHiMSELFORHER3ELFOR � ('[ TNNOUOMH13011HENONMEMOIOYEES,VROVIOEOTHATSUCJ/1NPROVEIAENTSAREh1�TINTENOEDON m � OFFEAEDFaiSALEIF,FIOWEVEq,T7E8UIlDUAGORkAPROVEYENT153OL�N'�71�INONEYEIROFCqIRE• TqN,iF�ONMEq�BUILDEN IMLL HAVE THE BVRDEN OF PiiOVINO THAT HE Ofi SHE DID NOT BUILD OR = M1PRCIVEFOATHEPURPOSEOFSALE). ❑1,AS OWNER OF THE PFqPERTY,AA1[XIX.USNELV DOMMCTMG YNTM UCENSED CONTRACTORS � TO CWiS7RUC�TME PNOJECT(SEC,)041,BUSINE55 M10 PROFE:SIOPIS GODE:TNE CONTMCiOflS LI- VflIt18IIIX1 ADJ.AREA -- L{.! CEtLEIAWDOESNOTAPPLYiOANOWNEROFAPROPER7VWHO8UM.D50RWPppVESTXEREON,AND Z N4pCONTql1CTSFOq5Up1PRQIECTSWITMIICONTiUCTOR(S)LICENSEOPURSUIMNTIECQMTMG qunNnrr DESCRIPTION FEE �� TORS UCENSE LAW.). � ❑I AA1 EXEMPT UNDER SEC. B.8 P.G FOH THIS qEASON Q � U Q V' pItTE ON/NEfl � � � LICENSEDCONTRACTORSDECLARATION W J � 1 HEHEBY IIFFINM UIVqER PENh1TY OF PEFJUHY h1AT I NA L�CENSED UNDER PROVISIONS OF CNAPTER � � Y(COIYiENCRqIMIhISFCTpN)oa0�OF�IVISqN�OF THE BUSINESS M1D PROFESSIONS CODE,M'0 Z �� MYIICENSE IS M RAL FOflGEAND EFfECT. � 1 / � � LICENSE CUSS ���� LIC.NO. G����p ? 6{r� v �� �-/'Z I—f�_ corrrnncroa ly—=—�� a W � WORKERS'COMPENSATION DECLA,RATION E �� � i HEREBV AFFlRM IINDER PENALTV OF 7ERJURY ONE OF TME FOILOWING DE0.ARATIONS: U � 2 0 ___I MAVE NID WILLM�MTAIN ACERTIFICATE OF WNSEMTO SELF-MSURE FOR WDAKERS' _ � �pWENS�TpN,ASPHL+NOEOBVSECTION3700OF`MELABORCWE.PoNTHEPERFCRMANCE �U � �TNE M10RK FOR WMiGF1 TH�S PEPMIT IS ISSUEO. � � �1 H�VEAW1 NALL WUMM7 WORKER5 COFIPENSATION INSUflANCE.AS REW�PEO BY SECTION Q 370UOFNEIABORCOOE,wRTNEPERWRMµCEOfTHEWORKFORWHICI7THISPERMITIS � ISSUED.MVW6FKE Cj�t oEN5ATI0NIN5URANCECAP.P'ERAND?OLICVNUINBERAP�: CONSTRUCTION � � CMRIER �^ PLAN REVIEW � � va�cvm�A '-� P� ELECTR!C ;I w (iHeaECllot�tiE�NOT8E0oAPE7FDOF7FEPEPNrSibRaANU��[7RFn�ouARsB+o�)OFlLEss} BING � � 1 CERTIFYTHAT W THE FERFORMANCE�THE WORK FOR WF11CH 7HI5 PERMIT IS ISSUED,1 MECNANICAL � SMALI NOT EMPLOV ANY PEftSON IN ANY MANNER SO AS TO BECOME 5'JBJECT TO THE -' { � N WOFNERS'C011VENSATIDNIAWSOFCALIFORNiAl1N�AGREETNATIFISMOIADBECOME �NSPECTIONFEE i���i's� l�� � SUBJECTTOTMEINONKERS'COM7ENSATIONPROVISIONSOiSECTION3)OOOFTHEUBOR CODE,1 SHAlI FONTHWI7H CO�APLY MNTH THOSE PROVISIONS. ISSUANCE � p DA7E: �LI�� APR.ICANE � SMIP � ENERGY P/C _ WARNINO:FAILURETO SEWRE WORKERS'COMP�NSRTION COVEPAGE IS UNIAWFUL,AN�SHALLBE � , � SUBJECTANEHPIOVERTOCRMINALPEMALTIESANOCMLFlNESUPTOONEHUNDREDTHOt1SAND ENEpGYPERMIT ��TV'lli�L'<^R ith:� ' DOLUPS(f100.O11q),MIAD�ITIONTOTHECOSTOFCOMPENSAT0.lN,DMA11GE5�5PROV10EDFORIN •c. �-7--���'fg�-�--*-�-�-T---�g �I � SECTION3�M�T/ELABORCODE,INiEREST,ANDATTORNEY'SFFES RETENTIONFEE: ?,�f1T�f Tl��� T A - T ��..0� �. �-'�--s,,F fi�'!"`5 d CONSTRUCTION LENOING AGENCY pRE•AlT FEE: '� � IHEREBYAFFIRAIUNDERPENPLNOFPERIURVTHAiTNEREISACONSTRUCTIONLENDINCAGENCV FOR THE PERFORMMICE OF lY1E WOPK FOR WM�CM TiIS PEPMIT IS ISSUEO(SEC.3097,CIV.0.�. � W i � LEIAER'S NAME � F= IENDER'SADDRESS � �l� I � I CEpTIFV THAT I HAVE REAU THIS APPLICATION M!O ST�TE 7HhT TME A90VE�NFORMATION IS COHRECT. TOTAL FE ES C� d 1 AGREE TO CONPLY WITH PLL CITY ANO COUlTY ORUINANCES ANO SUTF UWS REL�TINQ TO BUILDING LONSTRUCTION.�ND HEREBV AUTNORIZE REPRESENTATIVES OF 7HIS COUNrY N ENTEH UPON TME � MENTIONED PflOPERTY FOR INSPECTION PURPOSES. COMMENTS � ��� � m c � PERNITfEEN�ME�PRRIn ��L f S/ � �- y SIGNATUREOFPEPNITTE� D�TE � � � RECPT.N0. � PAID BY VALIDATION j WHITE-Departmen[Copy.YELLOW-Finance Copy,PINK-Assessa Capy,GOWENROD-File Copy,GREEN-Applicenl's Copy ���`"�' ��' i�i���`�����:� ���;� �"��`����� ������� i .,;,� �,, . ;E ����y�. . _;� � x = s• � � � i �. �. � y . , ; _ ,. , ! 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