HomeMy WebLinkAbout13818 (14) � CITY OF DIAMOND BAx � DEPARTMENT OF COMMUMTY&DEVBLOPMENT SERVICES 21660 E.Copley Drive Suite 190 (909)86Q3195 Fax(909)861-3117 PRESS "°�' BIJII.DIIVG PERMIT APPLICATION FIRML.Y � JOBSITE APPLICATION � ,�j � � ADDRESS /�����((t'� �/^ DATE ���NUMBEFl `'� #� � � ISSUE TYPE OCC APN LOT TRACT DATE CONST. GROUP p OWNER o ADDRESS 20NING SETBACKS Z CITY ZIP� TEL. ' REART Rw p g APPLICANT TEL. SI�EJSIDE STREET RW ❑ � CONTRACTaR SIDE ❑ g ADDRESS PROPOSED USE CITY ZIP��TEL.�� Pu ARCH/ENG/ DESI6NER NO.DWEL. NO. NO. � ADDRESS UNITS STORIES BEDAOOMS � CITY ZIP TEL. � rn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION ¢ OWMER-BUILDER DECtARAT10N SFFUADD/HEM p ��kwr�aa urmEr+vewLLrv oc rEa�my r inr i nra E.x.EMrT Facw n+E coutq�cToqs u. Garage/Carpon CEMSEUWFOR7M�FOLL01NpVORE115p1(SEG7031.5BUSINESSAN�PROFESSIONSCIXIE'ANYCIIYON (n CdR71YWMICMREOUWESAVERMRTOCON5TqUCT,A,LTERMPROVE,DEMOUSH,ORREPAIRANYSTRUC W PeNo/DeCk lUf1E,VRIOR 70 IT5 45SUMJCE.�150 REa11qE5 THE MPLICINT FOR S�CN 7ER41T TO FILE A SIGNFD w � 97ATENENi TF7/.T HE OR 311E 13 LICEHSED PUii5UM7T TO TME PFpY1510NS OF TME CONTMCTOFlS U� C�1lSE UW(ClUP7ER Y(COAIMENCINO WITH&ECTION 700D)OF DIVISION 3 OF THE BUSW E55 PND PRO- � PooUSpa FESSqKS CODE�OR THAT HE Ofl SME IS EXEMPi TFIEREFRON M1D THE BA515 FOR THE ALLEGE�E%EMP- (�J TION.ANVVIOLATqNOFSECTION)W1.58YANVAPPLICANTfOflAPERMITSUBJECTSTHE�PPLICANTTO � Re-Roof � 11 GVIL VENALIY OF NOT AIdiE 7/W.I FNE NUN�PED�OLLAHS(f6W).): � ❑AASONMEROFhIEPROPER7Y.ORMYENPLOYEESwiTHWAGESASh1EIR50LECOMPENSATION, 0 COmmetCial - NMl DD 7HE M70RK,AND THE S1AlICTUfiE IS HOT IMENOEO OR OfFEREO fON SALE(SEC.70U,BUSI� J NESS NiD PAOFESSqNB CODE:TNE CONTFUCTORS LICENSE UW DOES NOT APPLY To AN OWNEP Of � � PqpPERTVNRfO&JNDSd1NAPROVESTHEREON,ANDNA/000ES6UqiWOAKHIMSELFORHERSELFOH (t TNNOVOHHISORMEROWNEYPLOYEE$VflOVIDEUTHATSUCNIMPHOVENENTSARENOTWTENDE00p m QOFfEAEDPoRSN.E1F,110NEYERTiE8U1LDtNGORIMAROVEIIBl7155IXDWITHMlONEYEAAOFCOMPLE• Z iION,THE ONMER-BUI�pER VJILL 1UVE THE BURDEN OF PROVLVA 7HAT HE Oq SHE DID NOT BUR.p OR = IYPR011EFORhIEPURPOSE�SALF1. W ❑4 u Q�EA OF TtiE PipPEqfY,µt E%CLUSNEIY CONfRrCTM�WITH LICENSE�CON7MCTORS [[ iOCONSTAUCT 7ME�FCLECJlSEC.74M,BUS1NE55�ND VNOfE5510N5 CO�E:THE WNTRACTORS LI� Vtiu2�iq1 ADJ.AREA W CENSEUWDOESl1OTAPPI.YTOANOWNEHOFAPROPEHiYYhWBULLOSOflI4PiiOVESTHEREON,AND FNMqCONfH1CT5PoRFUCHVfqJECT5W17HACONTR�CTOR(S)LICENSEDWRSUANTTOTHEOONTRAG pUPNTIN DESCRIPTION FEE � 70R3110EN5EUw.). ❑I AM IXEM�T UnWEN SEC. B.a 7C.FOR THIS REq50N Q 3 � � � } DATE OWNER U ; � W � � LICENSED CONTRACTORS DECIARATION w � � INEF�YAFFlfMIIMDERPEN�tTYOFPEAIURYTHATIMIUCENSEDUMDEAPROVISION30FCHMTER � (� i(CO►WENCMK3 WITH SECTION 7000)OF DMSqN 30F THE 8U£INESSAND PFqFF551OtJS CWE,AN0 Z � X W LIGENSE IS W FULL WfiCEAND EFFECI m � LL! �<L�� � IICEfSE CCASS G�� LIC.NO. 1-�- � V DATE�� CONTRACTOR _ � WORKERS'COMPENSATION DECLARATtON `���, Q � ` _ � U N 1HEREBVAFFlRMUNDERPENALTYOFPEfiIURVONEOFTHEWLLOWINGDECURATIONS: v Z � Q r � C IMAVEMbWILLMAMTniNACEflTIFICATEOiCONSENTTOSELF-MSUPEFORWORKERS' = y � � �COVVEN$ATION,ASpROVNEDBYSECTION37000FTNELA80{iCODE,FORTHEPERFORMANCE �U OF iHE WORK FOF VM�CM TNIS PERMIT IS ISSUED. � � 6 �1 NAVEAND WILL MARlTAW WOPKER9'COMPENSATiON iNSURANCE,AS REW�RE�BY SECTKKJ 9700�TMEUBOROODE,FORTHEPEft(OPMNJCEOFTHEWOFlKFDRWHICHTNISPERMITIS � � ISSUEO.MY COMOENSATION INSUPANCE CARNIER D POLICY NUMBER AflE� CONSTRUCTION jcr�fuEq � i /L PLAN REVIEW � PIX.ICYMIMBEN .__ � '� ELECTRIC inwssEclvanE�No7ae0or.stt�moFner�rsrdtavEt�,rar�000tt,�ts�siaa)oatEss} PLUMIBING ���/..'�",�� p' _ . Z �CEp'Tlf`(THAT pJ 7HE PERFORMANCE OF THE WORK FOR NMICHTHIS PEPMIT IS ISSIJED,l MECHANICAL � (J SWdL NOT F.MP�OY M!Y PERSON IN ANY MMINER SO RS TO BECOME SUBJECT TO THE �/ � WORKEpS'COMPENSATIONUN90FCAGFqFfWA,aNDAGREETMATIFI5FM17ULDBECOME INSP IONFEE S S1161EGTTOTHE NOflKERS'COMPENSATION PROVISIONS OF SEG7pN 3700 0F THE U60R 'i� ��� � CODE,ISHALLFORTHWIiHCOMP�VWRNTiOSEPROVi510NS. �SSUANCE � � � o oah: �..v��nar �,� � SMIP '�IT�'�T'3:,,�rF��#��3�$ J WMNI :F�OSECUREN'ORKERS'COMPENSATIONCOVENAGE�SUNUWfUL,ANDSHALLBE ENERGYi�CU��dI !'+ y� �_�_p��-�Y J Lrt�l.TcC,'�1J.}!Ti'L'+�- � SUNECTINEMiPLOYERTOCRIGI!WLPENALTIESANOCNIIFINESUPTOONEHlN1DREDTMOUSAND ENERGYPERMIT � DOLLARS(S70D.Oao�,iN ADDITiON 70 TiiE COST OF COMPENSATlON,DAMAOES AS PRD4IDED FOR IN � SECf10N3�a80F1HEUBORCWE,INTEREST,ANDATTDRNEI"SFEES. RETENTIONFEE: � CONSTRUCTION LENDING AGENCY pRE-ALT FEE: O � IHEREBYAFfIRMUNUERPENPITYOFPERIURYTHATiHEREISACIXJSTRUC7/ONLENDINGAGENCV FORTHE PEHfORMANCE Oi TME WORK FOR WHICM MIS PERMIT IS ISSUED(SEC.3o97,CIV.C.). Z W � LENDER'S NAME F— LENDERSADDFE33 � ICEFTIFYTHATIHAVEREPDTF�ISAPPLICATIONANDSTATETHATTHEABOVEINFORMATKKJISCORRECL I OTAL FEES ) d IAGREE�OCOMGLVWITNALLCI7YANOCAUNTYORO�W�NCESANOSTIITEUWSRELATINGTOBUILpING � CONSTRUCTION.ANOHEREBVAUT/IOPIZEHEPRESEHTATNESOFTHISCOUNTYTOENTEFUPONTME PHOVE-wENiIONED PROPERTY FOR INSPECTION PURPOSES. COMMEN7S O �////� {� ��{� � ��ra�ca�ra4_!�`��'v�I� m PERAAITTEE NMIE(� a �/fA uJ St6HA UR FMRTEE � ATE � � RECPT.NO. � PAID BY VALIDATION WHITE-0epaRment Copy,YELLOW--Finanaf Copy,PINK—Assassor Copy.GOLDENROD--File Copy,GREEN—ApWicant's Capy ' � E � � E' � 0 , ( � � E I `i �� �� . � ! � � __ "3 }'' I � ,: . : � , .� F � � . ; � E �� i., ' r � i`� � ���C I � �;� � I u� � . . � � •� � ` ; � , I � I � � I � � � ' � ' � ; ' I , , I I -- ; � ,, z , `' � . i , ` ;_ � � � 1_; � � , � � j ; , I � 1 -. , ' I � � , � , s t a , � I 4 � , i � ; � � � i � ' � " � � � : � � : ! ' ! P: , I ! I � : I � � , � ' � ' � ' -: , ' � � � ; , ' I ' r j � ' � � ' � sa E . ; , I �. , � � ; 1 I � � � ; � i I , > � � �I , � i � : i � � � l � --�— ' I ' ` I ' ! i I I i � ; i � i i-- ( ( t — � � � j � ! ' � � i � � � i 1 �' i � i i ( i � i � ' � i i I � j ' � j ( t I i � � i j i ! � i [ , � i I rr: i 'i R ',� � i ��, � �_ i � i , �( , i .., i i ii i i } i . � � � i ' � i � i � � r i � I � . ! � i � � I � � I � ' " �` .s, I � � � � � .�. � � � � � � � � � � � � � I f � � � � � I p I `.' �p `^ I j i 1 � ! y i i ') i � z I � ' � �� ( + i I � � I i � '� i i i E E � i ; � I ( �! � ( � � i I � # � I � ; ' s i ! � ; � { � � { � I l � � I � } � � � j � ;_ ' � � , � � ' � � i � , � E � '�- � � � �: - � ° , ; � � � � , _ � . - -rt k ; , � � - + a- _ E I � --� � � � I , ( � (rn�• � I � ,•i E Ia C3 -o �) �-n � w -� c i-n�-r ����-��-n � � { 3 �� -- s .�[r� � C�� )� � C ir� � -'i --�It� T� �� � � � i , i i � � � � i I � � ; 1 �� {rn! � Ie�� �' ' G� � Ca � e � � ,�; r� � � I� � .�`� � � i s € , � ;,� i �� �r I (� � � �ir-- P n m ry� ;� i I � � � 1 � t l i "'-i ' '� �i 1���� C:l ) I� � 1 I � L'� I i � � i � t � f:� I ' � .FT7 r I >� r "� .r -t -{�`i �— � 4 I I � ; � � � ' � ' I'-' 1 � ' ( ��r%�C` 7�!��rz � �i��� ��c`,I.� �i �r O�G� t v � �` i� I � ' � j i i I I � -� (C I r�� i 7' �� t'' ;L� �I�?��.� �-"v7i� �?�J [�S.�i�v �•� G�.'-, � � ( i ( i � ..' r , c, � � b �'�4 � CJ Ci � � I ��a I i , � ; � I � I � ; ( 'c:i � � j I (u'� � �� �� ��r? c � � � � � � 4 ' ' ! ' � � , � �', ' ! � � .' I I ( I ! � �r � �� �f��� I � � i I . � � i i � I � � � i i � . ��4��( � {� �,. � � ( : '; I ` I _ ' i ( � ! � ,. � .. 1 � � � �� I { ; �,. i ' , I � I i • � - - - � ' - , , i.. .._ _ .._ x ' � � .' , ( , ' . - � ; _� � , � � �_... ` � i. , i � , � i � ' j i ' i� ( I - � ` � � .' r a .. _ I � i i � � , l � � � j 1 i, � t • � i � � � : � � i � , ; i ' � i �' ! .� , , li � i � ' ; � ' � � I I '. , 7 � � � ' � '- - , � - . � � _-� � . i i � ! i . � _ i , � . � � = . - � � I . � ' .�,. 4 �' � , � � ' I � � � I 1 I � �' ` I i � .Jt�' � i {��. _ i . .,� . I � � � I { � i � f � � � ,� � �� � t. } ' - ( i � ', i i � � j � , � i i I i � ! i i � � � �� ` `� � �� � i+ � i I � 1 � � � �� ' � � i i ' � ' I i ( . � � � � � i :r � ; � I � _.. '._. i.. _l__ � ; � ' � � � ____,_..___o- _`_� �_..�_..��`._�_____ � �__---_��___� � ' ! __ . _._ _. __rt _. . __. _ �._ _ _ _. _ ._�...... , � �