HomeMy WebLinkAbout12290 (6) CITY OF DIAMOND BAA
• �- DEPARTMENT OF COMMUNITY&DEVELOPM NT SEItVICES
_ _ � 21660 E.Copley Drive Suite 190
(909)860-3195 Faa(909)861-3117 ��� PR ESS
'��f BUQ,DING PERMTP APPLICATION FIRMLY
� JOBSITE �J Oi1 n�yr�. I ��1L�) APPLICATION /�Li PERMR �Z � P/C
� ADDRESS �'7 V ��1l��w/\'i �«<'�"'� DATE `'`� NUMBER N
� ISSUE TYPE OCC
APN LOT TRACT DATE CONST. GROUP
S OWNER �
p ADDRESS �-� ZONING SEfBACKS
W C� � � -�� FRONT RW ❑
� APPLICANT TEL. REAR p
� SIDE/SIQE STREET RW ❑
CONTRACTOR / SIDE ❑
AODRESS
� CIT( ,� �,6 � GA• ZIP TEL PROPOSED USE
� ARCHIENGI
� DESIGNER NO.DWEL NO. NO.
ADDRESS UNITS S'T'�RIES BEDROOMS
� CITY ZIP TEL.
�
u� DESCRIPTION SQ.FT. FACTOR PSF ADJ_AREANALUAT70N
¢ OWNER-BUILDER�ECLARATION SFR/ADD/REM
O
� i HEREBYl1fFlRM UNDEA GEtU1T/OF PER0.7RV THAT�MI EXEMPT FiWM THE CONTAAC7Dp5 tJ• Gefe�B/Cefp011
CENSELMYF�11'flIEFULI.OWRK3FiE/�4U'7f�C.7�1.59USWE5SANOPf�FE5510NSCWEPNYC1iYOq (n
Cd1RVW1#CN�SAPERI./RTOOONSTAUCT.ALTE0.IAAVROVE.DEMOLI3N.ORREPAIHANYSiHUG w P9t10/DBCk
IUHE,PItlOR 10 RS ISSUANCE,ALSO HEOUIPES 1NE APPL1CM17 FOR SUCFI PEINAIT TO FllE A SN3NED
� STAiEMB(!TMAT ME OR 9HE iS t10EN5ED PURSUIW�TO TNE PROVISIONS OF TF1E CONiRRCTOR3 U- �
� CEp3E LAMI(dUMEA Y ICOAIMENCNO WIiH SECTION 7om)OF UMSION 90F TNE�1SINE55 AND PRO- PODI/S(Ie
FESSqN3 COD�IXi 71MT ME OR SHE IS IXEMPT T7EREFROMAND 1HE BASIS FOR 1HE ALLEGED E7fEMV-
TpN.ANT VIOLA710NOF SECTION 70J1.68Y ANV IIPPLK:AHT FOR A PEPodiT SUBJECTS THE AVPLICu�NT TO Z Re-Rad
`,,, ACrvL aENlltiv oc Noi MONE Twu1 FlVE Ma+oREo oauFs K�I�1�
� �I,ABOWIiEROFTHEPROPEHTY,ORMYEMPLOYEE6WITHWAGE6A67H�RSOLECONPENSA710N, O Commercial -
WLL DO THE WOi1K,M1D iNE STRUGTURE IS NOT INfEMED OR OFFEHEO FOR SALE(SEC.7ou.BU51• J
� lIES4 AND PFOFESSqN,4 OODE TNE OONlMCTORS IICENSE LAW DOES NOT APPLY TO AN ONMER OF �
PROPEHfYYN10 BUIlD80R IMPRWEB THEREqy ANDYNiO DOES BUdi YAOAK HI/ASELF ORHERBELFOiI
6 TFWOUOfIWSORIffROWNEYPLOYEES,PROVIDEDTHATSUCMMIPROVEMEMSAREt1OTMTENUEDOR m
� ,OFfE�1PDR3ALE6F10VlEVER71�BV0.0R�H30RIMPROVEMBlTISSOLDVA'MNONEYFANOFOOIAPLE-
� T10N.TF�OVMER�M/p.DEN NALI HAVE 7NE BURDBI Oi DNONNO TNAT HE OR SHE DD NDT BUILD OR
IUif10NE FQR THE PUNCOSE OF 9KF}
(y� OLASON7iER�THEPPOPEfif1;AME%CLUSNELYOOMMCfRNlWITHIA�lISEDCON/WICfORB
(= TO CONSTMICT TF�PHQIECT(SEC.7Du,BUSMES8 AND PROFES310NS CODE THE CONTFWCTORS LL Velualian ADJ.AREA
W CEqSELAN'DOESNOTAPPLYTOMlOYIyEROFAPROPEfITVYAIOBUNA50HIMOROYESTHEREON.MA
� 1MMOCqPfHAClSiORSUQIMI�JECTSrifINJ�00N�MCTOR(S1LiCENSEDPURSUM(T70iMECOHiMP QVANTITY DESCRIPTION FEE -
� mnsuca�uw.l. . . .
o i,w�unuER sec. B.d P.C.FDR THIS REASON ¢
� U
� �
WTE OY/NEN U
� UCENSED CONTRACTDRS DECLARATION W
� W
1 t1ERE8YAFfRiM UOER PENALiV OF PERRIRY TNAT I MA LICENSED UrDER PROVISION50F CHAPTER �
� •(OOLMIENCINO YYIiH SECTION Moo)OF DMSqN S OF TNE BUSUiESS AND P(i0FES510NS CODE,AND �
� MY IICENSE IS N FULL FOHCE M70 EFFECT. �') �"' z .
� I.ICENSE CU55 LJC.N0. G� Y� / �J j �
� J
pATE CONfMCTOR a
� WORKERS'COMPENSATION DECLARATION 4
� I HEf1EBY AFFlPM UNDER PEN�LTYOF PEiiRIRY ONE OFTHE FOILOWING DECUMTIONS: - Z
O _t MAVE NA MMLMIIMTARIACERi1F�CATE OF CONSEHT TO SEIfdNSURE FOR NOHKERS' _
Z COMP@ISATION.A4PilOVIDED8Y45CT10N370oOFTF1EU00ROODE,FOi1TNEVERFOiA1ANCE U
Q /OFTlIE Y/OFCC WR tl'MiG71TN15 PEMiCT IS�SSUEO. �
F
1-HAVE AIA WILL M�RRAN WORIfERS COMPENSATpN INSUMNCE.AS REOUIRED BV SECTION
Q 71a0 QF THE LABON COOE,WR THE PERf-0IWANCE OF 1HE WOPoC FOR VMtt�f THIS PEPo11rt IS
� 1g9UEp,MY NqRKERS'CONPE�NSA�T/IO�N INSUaV!+CE CARRIEH ANO POLICV N A�fR ARE: CONSTRUCTION
� GIRRIER �C.��f%E��'+Ut! �� PLANREVIEW
� POLICY MMBEH__�L�, �� ��� EI.EGTRIC
� �s�cnor�r�wreEmr,at�aFtrfa�rsr�a�Mwn�oatnasmao�ar�t� PLUMBING 1
Z 1 CERTIFY THIR M TfiE CENFOR4MICE OF iHE WOPoC FOR WHNSf THIS PERMIT IS ISSUE0.1 MECHANICAL
� 9/MLL NOT EMROY NIV PEIi50N M7 ANY MqNNER SOAS TO BECOME SU&lECT70 THE
� WONKEHS'COAtP@lSATION U1WS OF CtLIPoqNII�pND AGREE TMNT If I SYqULO BECOME INSPECTtON FEE
S SI�JECTTOTHEWORKERS'CdAFENSAiIONPROVI51adSOFSECTION37000FTHEUBOR
cooE,i swst,ronnMnni caar�v rnni nrose rrrows ISSUANCE ��_
O
p OATE_��APPLICANT. .. . .
� WAiM11NO:FAILUPE TO5Eq1PE M/OHKEA5 COMPElSATION COVERAQE IS I1MIMTUL,M�O SHAI.L 8E ENEflGY P/C
� Sl1BJECTANElAPLOYERTOCRMW�LLPEWLLTIESMIDCMLFWESUPTOONElk11AflEDiFiOUSMID ENERGYPERMIT - - - -
DOLURS�i100,000),IN AWfIION TO7ME C0.5T OF COMPENSATpN.DAMAGES AS PROVIOED FOR IN
J SECTION a7o!Of 1HE UBOR CODE,M'fEREST,ANDATTORNEYS fEE3. RETENTION FEE:
� CONSTRUCTION LENDINCi AGENCY PHE-ALT FEE `''I
�
1 HEREBY AFFlIW UtmEN PENALiY OF PEf WRYTHAT iNERE IS ACONSTAUCTION IENDINO AOENCY �
Z ipR TlIE PERFORMANCE OFTHE WORK FOR WHIp/T/IS PENd1T IS ISSUE�(SEC.3DW,CIV.CJ. .
W
� LENDER'SlUME
� LENOERSADDRESS
� ICEHTIFY7HIITIHNEFFJIOTHISIIPPLIChT10NANDSTATETWRIHE�BOVEMFOflMATIONISCORRECT. TOTAL FEES ���
d I MREE TO COMPIV N77H ALL CrtY AND COIR/TY ORDINMlCES AND STATE UN5 REUTMICi TO BUILDINO
CONSTiA1CT10N.AIN HEPEBV AURiOPoZE REPRES ATIVES OFTHIS COUNiY TO ENTER UPON TNE � �
� �BDVEdAENTqNEOPPOPEHT'(fORINSPEGTIDN RPOSES.
COMMENTS
o r'� (`: -e��D �
�
m PERIA HM�(P .
Q
CA !'
y SNiNA7URE OF PERM E U E
� RECPT.NO. PAID BY VALIDATION
WHITE—Oeperlment Copy,YELLOW—finance Copy,PINK—Aasesea Copy,QOLDENROD—File Copy,GREEN—ApplicenNs C�opy
� c,LS M�
� �� CJ, � m � � � � � � o � � m � � � � � T � � � � � m � m
I ��I ,�� tntii - �;zzz7bmmtn � myY� zOOOO � ODm � � r m
R7'O � o A D�A D � fn "[7 � � r . O C C c a A o -+ � 0 m ,�, W
� ro-i � r r r r s, -o _i rn � � G� G� G� �n � �n m ro W C) cn
�c, rnac'> � vt� � ]+ � � i mxxxnzm � -o � z y � A
-1-I � �. � m� O ..i 'a p rr- � cn = -rn � x O � ix m O A � c� � �
z c �- m C
r � `C"
m . ''c o
-� C) --I 2 St �
Z CA
T> � C m D r G�
C Z - U' cnr �' - c =^ mm mm
-i D -a � v>
z m z --i � c � c� -t � c �
0
w � - �
-4 -i • z
- � -{ - _
U7 r-
-i -
T� m � CS � O cn
- L? � - -i
Z --� _ 2
IV cn � G7 � z � d � m z � L7 r- z m rn c m . �
RI�y .. G7'� Z � � � � � � 0 � .
� z O
;,�' Z
� -
i -
f "-
x .
�J
O (n 3
m o
n �
� mox -n � o -noo � v -o � � mv � m � � � cc -n -n ={ Q
! z m rn j7 � � � � m -n O O O z O m � z � - 70 � z Z = � o
r ► m < D �p y � Z D O T� O O O - C Z m A . � m m p � A p � n �
i � �n � O � 1 C�is r n m r r r = G� = L� r Tp � 'rv 'r9;A � m � � +��-,
m 2 m N Crl C') m D � T �-n RI 2 �7 W O,
. � Y ' '< m p � O e y z -� m Z m r L� � 2 A O Z OJ �" D�-n,-n D � � �
� - tn -1 Z G7 O D Z m 77 D � p � p p (��.c�.r r � Q (11 z
'o ro -n Z 'o � Z � � n � d D z � tri � m -n O O t�i� .-�I. � �
o � zy � � A � o' � � � � � m D m a O � 9 �
' � r � � � � q.Q � � � �'� e � �
. A , g, oJ � C7 �j
- r � � p�-I
� p -i
Z
..I ..
� ,
i � I;
� ` r �,
� `
•