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HomeMy WebLinkAbout16303 ^ _�� CITY OF DIAMOND BAl� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES 2t660 E.Copley Drive Suike 190 (909)860-3195 Fax(909)861-3117 PRE$S � ������ BUIGDING PERMIT APPLICATION ' FIRMLY Q� JOBSITE i�� fA/�.��(� � �'Z`� DATEICATION. � @��-���NUMBER� �`d°�� #/C ADDRESS -� �-T� ��d � ISSUE TYPE OCC APN—�-�—� LCDT TRACT �ATE CONST. GROUP °C OWNER L,. '`� SADDRE S ZONWG SETBACKS � CITY I� TEL.' FRONT RW ❑ APPLICANT TEL. REAR ❑ z SIDE/SIDE 8TREET RW ❑ a� CONTRACTQR � �3 �[,$ SIDE ❑ p� ADDRESS �- o CITY_ � ' ZIP TEL. PROPOSED USE oARCWENG/ � W ' DESIGNER NO.DWEL. NO. NO. n.: ADDRESS - UNITS STORIES BEDROOMS � CITY ZfP TEL cn — u� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION Q OWNER-BUILDER CIECIARATlON SFR/ADD/REM � I HEREBY AFFIRM UNDER PENALTY OF pERJUFiY THAT I AM EX@.1P7 FROM THE CONTRACTORS LI- GOfeJe(C8f�.10ff �:W�,. CENSELAWKORTHEFOLLOWINGpEFSON(SEC.7031�BUSINESSAN�PROFESSIONSCODE:ANYCITVOR (f� .'.'U,,� C011MryyIMICHREaU�pESAPERMI7TOCDN9TflUCT,AL?ER,IMPAOVE,DEMOLISH,ORFtEPAiRANYSTRUC- }.j,I pa4io/Deck �� z��, TURE.PRIOR TO 1T3 VSSUAl3CE,ALSO REQUIRES TkE APPUCHNT FOR SUCH PERMIT TO FILE A SIGNED W�', 'STATEMENT THAT HE OFl SHE IS.tICEN5E6 PUPSUANT YO THE PROVISIONS OF 7HE CONTFlACTORS LI- W ' ,��C�,'�CENSE LAW(CHAPTEH 6(COMMENCINO WITH SECTION 7q00j OF DIVI510N 3 0F THE 8U51NE55 AND PR0- u" POOUSPfl V I FESSIONS�E)ORTHATH'eOR5HE15'cXEMPTTHFREFqOMANDTHEBASISFOqTHEALIEGEDEXEMP• (� �:�V,'�,� 710Pl.ANYVIOU{iIONOFSECTION7031:5BYRNVAPPLICANTFORAPERMITSU&IECiSTHEAPPUCANTTO z g{e-Roof �.��. A CIYN.PENALTY OF NOT MORE THqN FIVE H'JNDHE�DOLLARS(5500).): �.i� pI,ASOWNEROFTHEPRpPER7V,ORMVEMPLOYEE5W17HWAGESASTHEIRSOLECOMPEN6AT10N, � Cpff11f1EPCIflI -' �',� M11LL DO iHE WORK,AN�THE STRUC7UflE IS NOT IN7ENDED OR OFF'ERED FOR SALE('oEc.7D41,0U51- J ,��,�� NESS AND PAOFESSIOfJS COi.'!E:THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF � ' � .PqOPERTY7NFIUBUBtDSORIMPP.ONESTVfEREON,ANDWHOPJCE55UCHWORKHIMSELFORHERSELFOR m ��,"����' THHOLIGHHISOSiHEHOWNEMPLOYEES,PFOV�OE�THATS[lCHIMPROVEMENTSAFENOTINTEN�EDOF ' p,.i',OfFERED WRS/LE IF,HQWEVEFI,THEBNLDINGORIMPROVENENYIS50lDWtYHiNON�VEAROfCCMPLE- .�,,Z..�',-710N,7HE OW'NER�BUILDEA WILI.HAYE THE BUfiDEN OF PflOVING THAT HE OR SNE D!�Nqi BUILD OR ,,�; , IMPROVEFORTHEPl1RPO5EOFSA:.E). ,��i,.; ' ❑I,ASOWNEROF4HEPROPEWiY,PAA.E%CLUSNELV.^AFJYPACTIP1GN/1THLICENSE�CANTRACTORS '�;�'''. �' TO qNSTRUCT iNE PF�.IECT(SEG 704d,BUSINESS AND PROFES510NS WDE;iHE CUNTFBACTORS LI- V31L'aYlOtt ADJ.AREA .'�i.L!','�: CENSEL9WDOE5N9TAPPLYTOANOWNEROFAFHOPERTY.WHOBUfLD50RiA4PROVE9?HSREON.AND '"��"�'.WF7000NTPAC7SFOR9UCHPRWECTSINITFiACOP1TRACTOR(S)LICENSEDPURSUANT"�OTHECONTRAG Q`JqNTIfY C.ESGRIPTION FEE � '�~'�' 'TORS UCENSE LAW.), �P� ❑B AM EXEMPT UNpEH SEC. B.&P.C.FOR THIS HEASON � � �•,�. .'.— . . � �'s', bATE oWNEp V ,'�-� ' .L6P �, LICEN5ED CONTRACTORS DECLARATiON � , � �.I HEREBYA�IRM UNDEN PENALiY OF PERJUFY THAT IAM LICENSED UhDER PROVISIONS OFCHpPTER o �� '.i(COMMENCING WITH SECTION 7UOo)OF D1VISfON 30�76iE BUSlNESS APdO DAOFESSIOHS COO�..APID �Z G. w ,MY UCENBE IS W FULI FCr�CE kND EFFECT. _ rr- �/ry ^''/� m ,,�..., '.LICENSE CLA S �-1� LiQ NO. ��� / / S_ � ~ ���ATE CONTRACTOR J U 111. � OR RS°COMPENSA710N DEC pTION � �� I HEREBY AFFIRM UNOER PENALTN OE AERJURY ONE OFTHE FOLLGWING DECLARATIONS: Z ',� iH �ANDWILLMAiNTMNi,CERTIRCATEOFWNSENTTO'oEiFINSUREFORWORKERS' _ PHdSRTION.AS pROVIDED BYSECTION 3709 OFTNE LP80R CD�E,FOR THE PEftFORMhNCE U �OF THE WORH FOR WHICH THiS PEPMIT I6 lSSUED. � I O � �IHAVEsWDWILLMA14TA1t1WORKERS'COMPENSATIaMINSUH/NCE,ASREQUIREDBYSECTION �BQ 37W OF THE IABOR CO�E,FOii THE PERFORh9ANCE OFTHE WOAK FOR WHICH THIS PERMIT IS ISSUE�.MY'NCtFRKEflS`COMPENSATION I I&UAP,FIC,,�yy'qqR/F A"N�'POLICV &AA[: CONSTRUCTION ? �� '�. f ���e PLAN REVIEW CARRIER � POLICYNUMBER ELECTRIC � (iHiSSECTR7cVNeL�NOiBE(�A�PLEtEDOFTnEPEFiFATISFOFl�:EHUI�DR� (57W)OPLESS). PLUMBING � __ Z I CEflTIF'!TliAT kIV hIE F�FiF6RMANC£OF FHE 4YilRK FOR WHICH THIS PERMI�i515SUc�,I MECHASJICAL �� SHALL kOT EMPLOY ANV PERSCN IN ANY MANN'cR SO AS TO BECO�.'.E SU9JECT 70 THE � WORKERS'GOMPEN TIONLRINSOFCAUF pNOAGREETMATIFISII�ULDBECQME iNSPECTiONFEE _ r SU&lE T07HE KE�SS'COt,4PEPJSATI PR NSOFSECTIQN37000FTHEiABOR �V" �'--_-� ,� CO�E, SHALLFOR HWITHCOMPLYWIPHT OS ROVI S. ISSUANCE _ - � /�g SMIP • DAT. . !./�AFPLICANT: —�y '}{��}�-- C? — — ;� - - EPJERGY P/C �V I f" .� � c.t�J d�i _ �W&ANING FA LU�7E TO SECURE WO(iKcRS'COMPENSATION CAVERnGE IS UYLAWFUL,AND SHALLBE � SU&)ECTANEMPLOYER?OCRIMINAL�ENALTIESANDqVILFINESUPTOONEHUNDREDTHWSANO ENERGYPERMIT DOLLARS(4/W.000),IN AODtTION 70 TFjE COSTOF COMPENSATIDN,DMAAGES AS PROVIOED FOR IN .,,� SECTION37080F7HELABORCODE,IN"fEHEST,ANDATTORNEY'SFEES. ' RETENTIONFEE: ,a COhSTP.UCTION LENDING AGENCY PRE•ALT FEE: � .IHEAEBYAFFIRMUNDEflPENALTYOFPERJURYTHATTHEREiSACqNSTAUCTIONLENDINGAGENCY _ ' _i � FOR THE PEflFORMANCE OFTHE WOR7C FOR WHIQiTHiS PERMITIS ISSUEO(SEG 3087.CIV.C.). � w �� LEN�ER'SNFIAE . � ' 7— �LENDERSAD�RE53 � TOTAL FEES I CERTIFYTHAT I HAYE READ THIS APPLICnTION AND STATETHAT T:IEABOVE INFORMATION IS CARFECT. �y IAGREE'f�CCIMPLYWITNALLCITVAN�JCOUNTVOR�INANCE5AN�5 TELAWSRELATINGTOBUILpING � 'CONSTRUCTION,ANDNEREBYRUtHORIZEREPRESENTATIVESOFTH COUNTYTOEN7ERUPONTHE , ' � �ABOVE-MEN710NE�PROPE TYFORINSPE TIONP4RPOSES. COPRMENTS � � �— , �� � � PF_RMi7T E IN7) ' � � ,Uj SiGNATUREO- RMIT1'EE ' D ' � - _ � HECPT.NO._ AID BY ,_VALIDATION ~ WHITE—CIe artmen:Co YELLOW—Financa Cc PINK—Assessor Co GOLDENRO�—Fila Co GREEN— licani's Co � P PY, PX PY. 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