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HomeMy WebLinkAbout10245 - C[TY OF DIAMONfl BAR COMMUNITY DEVELOPMENT DEPARTMENT � �.,.{ 21660 E.Copley Drivt Sui[e 140 - PRES� (909)8603195 Faz(909)8b1-3117 �"" BUILDINGPERMITAPPLICATION FIRML� � p�����fl�� �l�� �� �� APPUGATION��� PERMIT �}� , RAC 7 OATE MUMB V M � ISSUE TYPE OCC APN l0T TRACT pATE CONST. GROUP p OWNER '� "" ADDR S "t E'_ - ZONING SETBACKS Z C17Y < _ ZI� TE FRONT RW ❑ g APPLICANT TEL. REAR ❑ � SIDE/SIOE STREET RW ❑ CONTRACT � � SIDE ❑ � ADDRESS � CITY � ZIP T . � PROPOSE�USE � o ARCH/ENG! � DESIGNER NO.DWEL. NO. NO. �y ADDRESS UNiTS STORIES BEDRO�MS � CITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOH P3F ADJ.AREANALU/4T10N � O OWNER-@l:1LDER OECLARATION SfR/AOD/AEM p I HEREBY AFRRM UNDER PENALTY OF PERJURY TNAT I AM E%FNPT FROM THE CONTNACTOS35 LI- GefeOB/Ce/p011 W CENSELAWFORiHEWILOWINGqEASONf5EF7Wt.6BU5ME5SINOPROFES510NSCODE:ANYCIiYOR (n � Z COUN7YWHIpIqEWiRESAPERWIT70WNSTRUCT./�iTFR,IMPROVE.DELIOLISM,ORREPNRANYSfRUG W P81i0f08Ck W NRE,PRldi TO�TS i55UANCE,AL50 REIXIIHES TNE�PPLICMIT FOP SUCH PEAMI7 TO FlLE A S16NE� W � 6TATEMENT�1NY HE�SNE IS LICENSED Pl1RSUiWT TO iME PFOV1510N5 OF THE CONTRAC70p3 U- CENSE lAW(piAPTEA G(COM4ENC�YS1 V11T47 SEC710H 7000)OF DM&ION 3 OF THE BUSIHESS AND PRb LL P��SVa FESSION5CWE�ORTHATHEORSHEISEXENP7THEREFROMANOTHEBASISFOHTNEALLEOEDE%EMP� ('J TION.MIYVIOUTIONOFSFCTION703f.5BYANVAPPLICAN7FOflAPERMIT5U8JECT5THEAPPLICJMTN Z Rp.ppp} � � ACMLPEN�LTYOflqTNCME71V�NiIYEHUNDAE�DOLURS(lSOD).�: � OI.ASOWNEflOFTHEPROPEHN,OqMYEMPIOYEESWITNWWESA5THEIRSOLECOMPENSAiqN, � COmII1BfC18I WIt1 DD THE YlORK ANO THE 9T9UCTURE iS NOT IHTEt�qED OR OFFERED FOR SAIE(SEC.7oN,BUSF J � NESS ANU PibFE55fON5 CODE:THE CONTRACTORS UCENSE LAW OOES NOT APPLV TO AN OWNER OF � PPOPERTY NM1W BVILDS OH IYPROYES THEREON,A*1D MMOOOES SUAi tMDRN H�MSftF Ofl H6R4ELF OR (L TNqIX1GHHISOHMEROWNENPLOYEES,PROV1�EDhIATSUCN�MPROVEMENTSARENOTNITEND�OR m WQ OFFENfOFORS�LE.IF.lIOMfEYFRTME&11LDWOOpIYPROVEMENTI55IXDWITMNIXiEYEMOFCOYPLE Z TqN,THE OwNER-81N10E0.WI1i HAYE TME BUA�fN OF FROViN(3 TH+1T f1E OR SME 010 NOT BUILD OR = WPf10VEFOqTHEVUHPOSEOfS�LE� ❑l!S OWNER OG THE PROPERTY,AN E%CLUSNELYfANTMCTiN6 WITH LILEK4ED CONTRACTORS Q TO CONSTHUCT THE PP�ECT(SEC 7Wt.B1/51NES5 AND PROFESSIONS COQE:TME CONTflALiDR8 LI� VSIU9110fl ADJ.AREA � � CEN3EUWDOE3NOT11PP�VTO�NOMMENOFAPPAP£RTYWHOHUIIASOPIYPROVESTNfREON,MID X6qpJNiMCT5FOq5UCNVR0.1ECT3WITH�CONTRACTOR(S�LICEN9EDPUNSIUNTTOtHECqJTA�G ou,wnTv DESCRIPTION FEE TOq$1,{CENSEUW.). � ❑I AM EXEMPT UNDER SEC. B.4 P.G fOR TYi1S REASQI � � � lL � DATE OVMEH z W �Q LICENSED CON?RACTORS DECLARATION W ` fL �M£R£9YAFFIRM UNDER PENK7Y OF PER.NqY THAT I AM LICENSED UNDER PROVISIONS�CHAPTEq � 9(COWIENCIN(3N7THSECTK1NTOm)OCSNYIS%N190FTNEBUSMESSANOPHOF'ESSIONSCOOE.AND Z -� - _ MV LICENSE IS M1 FlH.L FOPCE/NO EFFECL m lll .7 � � i10ENSE CLA � LIC.NO.�___�� j V DATE � CQNTMCTOR � a U.l � WOFKERS'COMPENSATION DECLARATI Q � IMEREBYAiFIRNUNDERPENALTVOFPERJURYONEOF7HEWLLOWINCDECLAMTKINS: Z d j d I NAYE MN 1M�LL MAINTAIN A CERTIFICATE OF COHSFNT TO SElF�WSURE FOR NGNICERS' _ C00.1PENSATION,ASPROVIDEDBVSECMk1370oOFTHEUBONCODE,F00.THEPERGOfW.�NCE W f Of THE YiORK FOR WHICH THIS PERM�T IS ISSUED. � I p I _�I NAVE M1D WILL M0.INTAM!WORKERS'O']MPENSAT10q iNSURJ�NCE,A5 REW IRED BV SECTION 4 � 3700 Of THE U60R CODE,FON THE CEPf-0RIAANCE OF THE W�RK FOR WHICFI i1flS 9ERMIT IS � ISSUED.MY WORKERS WMPENSATpN INSURANCE CARRIER AND POLiCV WMBER AqE: CONSTflUCTON � CARRIER PLAN REVIEW Zaaicw uuusEa ELECTRIC � � p (R�sEcnoNNE�tnraEmMH.ET�OFT#PEHURISPoaOt�FtAOP�0o11MSR7m10RLE5si Z I CEqTIFY 1F7AT W THE PEAFORMMICE OF THE N9Po(GOq WHICH THIS P RYI715 455UED,I MECHANICAL (�} SHALLNDTEMPLOYANYPER60NIEIANYMANNERSOqSTOBE ECTTOTHE � WORNERS'W�AVENSATION UWS OF CALIFORN AGR HAT IF FIOUID 6ECOAIE �1'SPECT101V FEE - � •��� $UBJECTTOTHEWORKERS'COMPENSATIpJ V1 S 37000FTNEUBOR � O i swiu� n�cvur�r vnni 5E � ISSUANCE iLL �p p DATE: — �Y APPLICaM: � . SMIP �� r wJ ENERGY P�C J WApNt41Q:FAILURET08ECUREWORKER5COl1PENSATK)NCOYERAGEI NU ,11NDSHAILBE �y SUBJECTANEMPIOVERTOC€iWIWLLPENALTIE3ANOCMLFIHESUP EH DTHOUSAN� ENERGYPERMIT OOLlAR5�f1ao,0¢0),INADDRIONTO7TIECOSTOF�yiPENSAiNXl,O ESASP EDiOR{N ¢ SECTId13]OE OF THE tABON COOE.INTEXEST,ANO ATTORNEY9 FEE9. RETENTION FEE: a CONSTRUCTtON LENOING AGENCY ppE•ALT FEE: O � iHERE9VAFFipMUNOERPENALTYOfPERJUNYTHATTHEREI5ACON5TRUCTIONLENDMlOA�ENCY iOfi THE PERF�PMANCE OK TFIE WOAK FOR NMICk1 TH�S PERMIT IS IS5UE0(SEC.9087.GV.C). W � IENDEiMBNAME �"- IE�ENSaWHE55 _ � iCEHTKYT1u1TiHAVEPE/S1THI3APPLICATIONMASTATETHAiTiEABOVEWfOHMAT10NI5WRRECL TQTAL FEES ��i � � � 1AGREE TO WYPIV W1TH ALICITY uW COUNiYORDINANCESAND STATE UWS REUTINO TO BUILDING r� CONSiWCT10N,�ND MEREBYAURIDHIIE NEPRESENTATNES OF TH15 CAUNT'!TO ENTEK UPON THE S�, A9pV6alE D VROPEflTY WR IN5PEC710N%1F�POSES. COMMENTS 9 �r a PFiW � s - � � sroN p DATE pECPT.N . 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