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HomeMy WebLinkAbout15485 (23) � � CITY OF DIAMOND BAbt � ; -- DEPARTMENT OF COMMUNITY 8t DEVELOPMENT SERVICES j • ,� 21660 E.Copley Dtive Suite 190 � I (9Q9)86Q3143 Fax(909)861-3117 PRESS I ��p''' Bt�a.onvc rE�rr Ar�.[cAT[oN FIRMLY ¢ RDDRIESS �Z4��i L7�Y� C (�v`, APPLICATION '�� (� PERMIT �/C a S `/'C OAT6 1/" NUMBER N $ ISSUE il) TYPE OCC APN lOT TRACT DATE ��� CONST. GROUP p OWNER��' V�+� �A�rCr�ct �` ADDRESS v��< .G.pi., ZONING SEIBACKS � CITY �j�+nco�d �a✓ ZIP �II � TEL.��" �Ct/�� FRONT qW ❑ APPLICANT 21 St �cn�t��r i2�:.id�i� re�.'Lrt�-645=39�1 SID SIUESTREET RW ❑ a� CONTRACTOR Z.1 S�f. Cev�-�J+'� Raa���i� SIDE ❑ � ADDRESS(Y3SW�.��[.- A-v�.K-I.a pROPOSEDUSE�LAV^at�"CxtS�/'���.SNyf•Ii Nb iorZaF:1i CITY Go4t4 /'�1esg� ZIP 2'1 TEL.9�-`YS-3�3/� al� S•� � p�✓ ,�' L1?a � ARCWENG/ • DESIGNER NO.DWEI. NO. NO. ADDRESS UNITS STORIES BEDAOOMS � CtTY ZIP 7EL. � cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION Q OWNER-BUIIDEfl DECLARATION SFWADDIREM 0 I HEqEBV AFFlIMI UAER PEN�LTY OF VEIWRV THAT I/W E%EMPT FROM iHE CONfRACTORS U- GBfAQB/CBfpOft CENSELAWFOR7lIEWlLOYi1NOHEA�ON(SEC.7O31.6BUStltESSAN�PROFE55lON3CODE:ANYCITVOR (� ODIMTYWHICMRE0UWE5APERY?TOCON3TRUCf,�LTERIIAPROVE,pEMOLI5i1.ORREDNRANVSTAUG W P8t10/OBCk TUNE,ifilOti TO ITS 155�1ANGE,i1L50 REW IRES 7ME APPLICANT FOq SUCH PEHNIT TO FILE A SIGNED � .� STATFl1ENT THAT HE OR SHE IS UCENSE�PUqSUANf TO 7HE DRONSIONS OF THE WNTMCTORS LI- LL � CEMSE UW�CIWTEfl Y(COYYENCMO WITN SECTIOq 7090)OF DIVISqN 3 OF THE BUSINE55 AND PR0. 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O I lll IXEAIPT U/AER SEC. B.d P.G FORTHIS PEA50N Q }� U LL � DATE OWMER U � J � LICENSED CONTRACTORS DECLARATION W ° 1 HEREBYAFFIRAI UNDER PENALTY OF VERJURY 11i+V I AM LICENSED UNOER PROVISIONS OF CNAPTEH � (L 9(W6NENCWOWfTFiSECTqN7000)OFDMSpN90FTHE8U51NESSRNDPFOFES510NSCODE.AND z ?C 4Y LN:ENSE 16 M FUIL FORCE MID EFFECT. `0 UCENSE C1A99 ^l�+� 1 LIC.NO. ���+'� � � UATE ��Z.L+OO CONTMCTOR��C2� ,� 4 �� a = WORKERS'COMPENSATION DECLARATION (//�� /f'►( � IHEREBVAFFR�IUNOERPENALTYOFPERJUPYddEOFTHEFOLIOWINGD 5: I�I� "� y Z O __IHAVENAWILLII�MlTAINACERfIFlCATEOFCONSENTTOSEL ..SUREFOR KERS' � � COMPENSATKKJ,ASPROVIDE�BYSECTION97a00FTHEUBO COOE,FORTHE7ERF0 OFTHE NpRK FOp WHICN THIS 7EAMR IS ISSUEO. W 0 � W V I MAVE AND YNLL MARlfA91 WOPofERS'COMPENSATpN INSU CE,AS D BV.!TION /�� Q 3700 0F THE UBOR CODE,FOR THE PER WRMANCE OF THE W ICH TML�P MR I 1 3 � V ISSUE0.MV WOPo(ERS'COMPENS�tION INSUflANCE CAHR�ER I ICY NUMBER -C STRUCTION � CAFPoER �,�/�� U+'ld LANREVIEW Z ���B�n�.77-J_ 1 � � ELECTRIC Q � �r+s�cm�r�wrt�aa,aFre�oFn�vEparsw r�ENu ooll�wsR+ )on PLUMBING Z 1 CERTIFVTNAT W THE PERfOR41ANCE OF TNE WORK FOH W THIS P E�, MECHANICAL - �J SFNII NOT EM%.OY ANY PERSON IN ANV MPNNER 50 AS TO PE ECT TO vj WORNERSCOMPENSATIONUWSOFCAL�FORNIAANOAGREETHATIFISHIXILOBE INSPECTIONFEE S b71BJEGl TO THE NR�RKERS'COMPENS�TION PROVISIONS OF SECTION J7000F 1HE LA H _ pppE�SF1ML FOqTIWITH COMPLY WITN TMOSE PROVISK]N5. �SSUANCE o � /' p OATE: ~�"��U APPLICANT. ����i � SMIP � � ENERGY P/C � �y }� f�h�+SnND WARNIN9�F��LUNETOSEWREWOPKERS'COMPEf�SATpNCOVEMGEISUNUWFUL.MiDSHALLBE ����y��✓�F-�+- ` �j � SU&IECT/�NEMPLOYERTOCRIMINALPENALTIESMlDGMLFlNE6UPTOONEHUNDREDT}�WSAN� ENERGYPERM�T rt'y���j�T�rf���Stt�1 d. .r OOLUNS 11CO,aaO),M/�DOITION TO THE COST OF WMPENSATION.OMIAGESAS PROVIDEO Wfl IN ._���d�+ J SEC(ION37ulOF7HEU90RCODE,IN7EREST,IJiDATfORNEYSFEES. pE7ENTIONFEE: 2 a CONSTRUCTION LENDING AGENCY pRE-AlT FEE: O � IHEREBVAFFlqMU1�ERPENA�TVOFPERIURYTilAT7HEREiSACONSTRUC710NlENDINGA6ENCY � WRh1EPERFORMMIGEOFiHEWOPKfORWHIdiT115DERMITI8135UED�5EC.3oD7,CIV.C.). . 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