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HomeMy WebLinkAbout15228 I . ,. _; � CITY OF DIAMOND BA& DEPARTMENT OF COMM[JNITY dt DEVELOPMENT SERVICES � 3� 21b60 E.Copley Drive Suite 190 (909)$fiQ3195 Fax(4Q9)861-3117 PRESS � � -�'� sun.nnvG r�R�'�r�.ICA�oN FIRMLY N JOBSITE a ADDRESS ��L 1 �a.°�—�l'�'Ar?�'1 '�eC����'��' APPUCATION��, J '�—�J PERMIT J �� P/C p �� � a DATE NUMBER / � {F ISSUE /J TYPE OCC � APN LOT TRACT DATE /" � I�.r�D CONST. GROUP � QWNER r^5 � � ���t''� �t �4 � ADpRESS_1�1� �:_�{ Af�!"�1 S7�L� •/�L. ZONING SETBACKS � ,.t� ,, �, c FRONT RW ❑ C�TY T.�j. ,e.�,. ''S ZIP�n4� TEL. REAfl ❑ APPLICANT L.�y_t.Qir-+.j SIDElSIDESTREET RW ❑ � CONTRACTOR � ' � - SIOE ❑ ADDRESS � � cirr�,���ziP_p��3,� r�.. �' .- - �sE"�'1 c t r t�fl �itr�iC� y���� C D X � ARCWENG/ y �c,i3�7./ ~Z �+�+.��s -�r,,_�i,} � � � DESIGNER `�'(�4 ' _L"h.�,tat iEYI �t, ta]�F=L.YiT S I�Yj'�� ADDRESS NO:DWEL. NO. NO. � CITY Z�p �� -tiiP1�TS STORiES �s BEDROOMS� y u� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANAtUATi�ON Q OWNER-BUILDER DECLARATION �p/pDD/REM O � 1 HEREBY AFFlPM UNDER PENALTY OF PERNRY THAT 1 NA IXEMPT FROM TiE COMMCTORS LI- GflfHgB/C81POR CET/$EUWFORTHEFOILOWM�aREA30N(SEC.7W1.5BUSINE55/WDPFiOFESSIONSODDE:ANVCITYOR (,/� CqMTVYY1qCi1qEQU1RESAP�qA1/fTOCON5TRl1CT,ALTERR�Vti�VE.OEMOLISN,�NRFPAIRANYSTAUG W PetblDeck 7UNE,PRpN TO IT6 I68UANCE,ALSO REWIRES TME APPLICMIT FOR SUCH PERYIT TO FILE A SI(NIED W � STATFNENT TUT HE Oq SNE IS UCENSED iURSUM(T TO TNE PROVISIONS Of THE CONTMCTORS LI• � CENSE LAW(CHAPTEH C(CONMENCRlCi WITH SECTION 7000)OF�NISION�Oi T1E BUSINESS ANO PRO� � Pool/$pa fE331LWSCODE�OATFI�THEOR5HE15EXEMPTTiIEFEFRO�IANDTMEBA3ISFORTHEALLEGEDE%EMP- � TION.MIYVKIUITIONOf5EGT10N7v31.58YANYAFPIIGANTFaiAPEfq11T5U61ECT57MEAPPLICANTTO Z qe.Roof ACML PENALT'OF NDT MOfiE THAN FNE HUNDRED DOLLARS(3600).): � D4��MAdEROfTHEPI�PERTV,OqMYEIIPLOVEESWI'MWACESASiHEiRSOLECOMPENSATIaJ, ❑ COtfIfllBfCldl ' WILL DO THE WOFY(,AND THE STRUCTURE IS NOT IMENDED OR OFFERED FOR SALE(SEC.70N,BU51� J y FrcSS M1D PADFES6WN6 COOE TI�CONTfUCTOHS LICENSE LAW DOES NOT APPLY TO AN OY/NEN OF � �'? .t,},��� �+ +-- ,��,�q ORDPER'fl'MM1IO BUlDS OR MIPROVES THEREON.ANU�NIO bOES SUCH WORK HINSEti OR XERSELF Oq �� 'V�++ � T}1ROVOHHIBOqHEROWNEMOLOYEES,PFbV1DED1NAT5UCHIYPPOYEMEMSARENOTIMTENDEOWt m OFF£REO FORSALE IF,MOYiEVER��LDINa OR WPflOVEYER7T IS SOLD WITHW ONEYFIROFCOMPLE � Z TqN,TME ONMER$ULOER WILL IUVE THE BUHDEN OF 7ROVINO THA7 HE OR SHE DIO NOT AUILp Oq . � WPIiOVEt�fii}iEPURPOSEOFS�LEy. ❑4���NFROF THE PROPER7Y,AM EXCtU9NELl'COHTR5C71NCi WfTH LlCENSEO CIXl�RRCTORS TO COMSTRIJCT THE VR�IECT(SEC.7as1,9USINE55 AND GIiOFESSIONS COOE:tME CONTHACTORS LI- 91U0f1011 ���L�� ��' ADJ.AREA R 1 W f�EUWDOESNOTAPPLYTOANOMMEHOFAPROPERTYN'hpBUNASOFIMPROVESiHEREON,AND � NRIDOONTRACTSFORSUCHPROJECTSWI7HACONTRACTOR(5)LIGENSEDPURSUAMiTOTHECOHTRAP QUANTITY OESCRIPTION FEE � lOAS LICENSE IAW.). O I AN EXENPT UNDER SEC. 8.8 P.C.FOP THIS REASON � � � DAtE OVMER V � LICENSED CONTRACTORS DECIARATiON W I HERERV AFFpYI tRlDF(1 PENALN OF oERIURY iH�i 1 AM LICENSED UNDER PROVISIONS Of GUPTER Vr � 0(COMAENCMXI WRH SECTiON 7000)�DN151oN s Of THE PUSINESSAMD Pi�FESSIONS CODE.AND Z NY�ICENSE IS W FUl FORCE NiD EFFECT. 0 '� � � LICEKSE CLASS__!��� LIC.NO. . I �� � � U p�7E �I��L"'C�7 CONTMCTOR d LLJ � WORKERS'COMPENSATION DECLAHATION � ¢ j � 1 E Y�FFlfUI UNOER PENALTY OF PERJURY ONE Of THE iOLLOWING DECLAMT�OlIS: � � VJ Z Q � � I HAVE MID W1LL MMNTNN A GENTIFICATE OF CONSEM TO 9ELF-INSURE FOR WORNERS' _ � � CONVENSATpN.AS FHOVroED 6v SECitON a7oo OF TNE UBOR t�DE FON THE PER�OftMANCE W � Q OF THE VYORK FOR WHICH TMIS PEFMIT IS 155UED. ,� � W _I HAVE AND WILLMAIMNN WOR%ERS'COMPENS�TION INSURANCE,AS REOUIPED BV SECTKKJ Q 37000FTHEIAHOii00DE,FORTMEPERWRMRNCEOFiNEWORKFORWHICHTM�SPEfiMIT15! I ISStIE'�.HY WORKERS'C0IAPENSATION INSUFANCE CARRIEW ANO GOLICY NUMBERARE CONSTRUCTION IA " � I�D � � �pq�Eq L PLAN REVIEW '• � ��7'�. � POL�CYNUA6EFi � ELECTRIC �"�'-� � (fF9ssECIpNNL�NoieEool.�iEfEnaFnlFVEw.fisR7aaJEHf�I7�D0a1?1tsR+ro)e PLUM8ING �fl i W MECHANICAL �)�� Z ICERTIFYTHATIN7HEPERFOP)AANCEOFiHEWORKFORVMICHTHISPEFlMITI5155UED, ����G.J.j/.J+y (J 6HALL NOT EMPLOY ANY PERSON IN�NV MANNER SO AS TO BECOFIE SU&IECT TD 7NE "V(� � V/OflKERS'COMPENSATIONUWSOFCN.IFORN�A,ANOFGREETNATIfI5Fi0ULDBECOME INSPECTIONFEE SU&)ECTTO TME WOii%ERS'C0IAPEN5ATION PROVISKKdSOF SECTION J7000F TME R � /+ WDE,ISH.LLLFOFl7MWIh7COA1PLYWITITHOSEP s -' ISSUANCE �j O�� � �i U� \ �y/�r]� �7���--- p DATE: ��I�..�-Z'� APPLICAM: . � � SMIP 4 Y'�+k��- �� ��1� OO J ENERGY P/C T� WAFMlINO:FAa�aETO SECURE WORKEFS'COMVENSATIO!!COVEMGE IS UNUwFuI,AND SM,LLLBE � SVBJECTANEMPLOYERTOCRMR�ALPENFLTIESANDCNILFINESUP700NEMUNOFEDTHOUSANO ENERGYPERMIT OOlLM1RS(i1o0,oW).IN MDITION TO THE COST OF COYPENSATION,DAMA�ES AS PROVIDEO fOR IN I � SECTION 3'!oe oF7HE UBOR CoOE.MTEREST,AND ATfORNEI"S FEES. RETENTION FEE: pW„ CONSTRUC710N LEN�ING AGENCY PRE-ALT FEE: O '' � 1 HEREBVAFFIPM UN�ER PENALTYOF PEk1URY THAT THERE IS A CONSTPUCTION LENDM�AGENCY WR 7ME 7EFFORMANCE Of THE WORK W H WHiCH THI3 FERM�T IS ISSUED(SEC.30B7,CIV.¢�. � � IENDEWSNAME l—��� F- LENpER'SADDRESS W 1 CEflTiFY 71iAT I MAVE READ THIS APFLICATION M1D STA7E TFiAT TME ABOVE�NFORMATqN IS CORRECT, TOTA L FE ES �� � I AGREE TO COMPLV WiTH ALL CITY MiD COUNTY ORDINANCES AND STATE UW5 REUTING TO BUHD WG / ` CONSTRUCTION,AND HEREBY AUTFIORIZE REPRESENTATNES OF THIS COUN7V TO ENTEfl UPON THE �/'7 ZPBOVEMEHTIONED iPOPERTY FOR INSPECTpN PURPOSES. COMMENTS d � � _ m PE TTE r E(PRl � ` �1 1(_' �� C L.��L.. ) 1 , y SIOfL�IU EOFPERMITfEE DATE J�� T ��" —J� � RECPT.NO�• • ` � PAID BY 7 VAIIDAT70N , WHiTE—Departmant Copy.YELLQW—Finance Copy,PINK—Asseuor Copy,GOLDENRO�—File Copy,GREEN—ApplicanPs Copy � _-_._���_.._ �,�c�s���� i� -� : �, , i�I�� r� i��ci rr'. .� T7-� � � P :� C t"`� ,i � � �� � � �� I { �I-.���.7 � ,I � `r ,, � - � E, � � � � ! g, �t r '�' �� � � 1 � �i` i j ! � � `t Y- t ',,, ��. :.�. _.(�,. � ` ..rt`7 �l ���, � � � � � ` I�: t � z i � � > � I 3� �, � - r �"� i y � r j ��.�,��C-�1 i-; � ! ' �r+l�"1�1�.. r � `"_. � �{�� {��- � � �. ! r rar I � I � ��r `-�rr�l �'' i �� c: ��. � + i t i � ��� '�i <;^ C:)���� � � Ir, ' i 4 . . � � � t ' ( � i - i i i k ` t ! � -� 1 � � I G I E � ! 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