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HomeMy WebLinkAbout16163 (35) � - -� ---- - -- -- �-- �-� 1�_ CITY OF DYAMOND BAB `��, ' � DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES p n� 21660 E.Copley Drive Suite 190 " , � (909)860-3195 Paac(909)861-3117 ~ �� RESS "=':"�'�•,, BUILDING PERMIT APPLICATION _.` i�. ' � ? � FIRMLY ' y JOBSITE c� �'�} APPLICATION C�, _ PERMIT ( � P/C ' Q ADDRESS tG—.� ��-� G�T,"�3iiT V���7�� DATE s��`�� NUMBER � �� vT�� � ISSUE TYPE OCC APN LOT . �°3d TRACT ��� �� DATE CONST. GROUP p OWNER � � � �� p ADDRESS ��`W�f P �f'�P►`1Cs.f�1� ZONING SETBACKS w CITY ��`vQ,�� ZIP�` 7 TEL.�3 Z►'�'-`2�7-•t!� FRONT RW C � APPLICANT ,��P-' TEL. �arf"1� REAR ❑ � SIDE/SIQE STREET RW ❑ � CONTRACTOR �ea Y SIDE ❑ I � ADDRESS � f PROPOSED USE r:i.;`� o GITY �fy'�t1�?' ZI�'��TEL.��jj"�^��c9�w zl'°l � w ARCWENG/ iz pESIGNER �:1 � ��� NO.DWEL. NO. NO. � ADDRESS � UNITS STORIES BEDROOMS � GITY ZIP�'TEL.�fi�p.� �n, DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALU TION � � � OWNER-BUILDER DECLARATION� SFR/ADD/REM � � O � � I HEREBY AFFIRM UN�ER PENALTY OF PERIURY TkAT I AM EXEMPT FROM THE CQNTRACTOflS LI- G21dge/C2!(70R '� ' W GENSEUIWFORTHEFOLLtlWINGPEA50N(SEC.7037.5BUSINESSANDPROFcSSION5CA0E:ANYCITYOR (J) � 9 � � COIXJfYNh11CHREWIRESAPERMfTTOCONSTRUCT,ALiER,IMPROVE,DEMOLISH,ORREPAIRANYS7RUC- W Pg[i0/DeCk TURE,PRpR 70 ITS ISSUANCE,AJ.50 REQUIRES THE APPLICANT fOR SUCH PERMIT TO FILE A SIGNED S7ATBAENT PHAT tiE OF SHE IS',LICENSE�PLiRSl1ANT TO THE PROVISIONS OF THE CANiRAC70PS ll. W �, CENSE LAW�CHAPTEP-.e(COMMENCIPIG WlTH SECYION 7000�OF DIYISION 30FTHE BUSINESSAND PR0- � POOUSPO '' �' I � ' . . � FESSpNSOODE)ORTHATHEORSHEISEREMPTYHEREfRWAANDTHEBA515FORTHEALLEGEDEXEMP• (�J �V�� TION..4NYVIOI.ATIONOFSECTION7IXi1.5BVANV6.PPLICANTFORAPERMIT5U8JECTSTHEAPPLICANTTO Z R8-ROOf � '' � A CML PENAL'TY OF NOT MORE THAN FIVE HUNDRED DOlUR3(55m).j: , , �:, � ❑I,ASOWNEROFTHEPROPEPTY,'ORMYEMPLOYEESWITHWAGESlSTHEIRSOLECOMPENSA710N, � Comme�Ci91 . -� WILL DO THE WOAK,AND THE STRUCTURE IS N071MTEND�OR OFFEREO FOR SALE(SEC.7od4,BUSI- J . �. NE55 AND PpOFESSIONS G6DE:THE CONTRACTORS LICENSE LA1R'DOES NOTAPPLV TO AN OWNEfl OF j .. .. . PRORERTVWHQBUILb50RIMPAOVESTHEFiEON,ANDWHO�0ES5UpiWORKHIMSELFORHERSELFOR ' "' S" TtFiOUGH H190R HER OWPi FJNPLOYEES,PROVIDED THAT SUCN IMPFOVE�NTS AqE NOT INTEN�EDOR m � ' Q�,"�, ,OFFEREDWAS�I,EIF,HOWEVER7MEBUILDINGORIMPROVEMBJTISSOLDWITHINONEYEAqOFCAMPLE ' ,z., 'TION,THE OWNER-BUILDEP WILL HAVE 7HE BUHDEN OF FRWING THAT HE OF SHE 61D Ntl7 9UILD OR � W, IMPROYE FORTHE PURPGI5E OP SALE), o ,� ❑I.AS 6WNEA OF 7HE PROPEFRV,AM IXCLU5IVELY CQNTRAL`TING WITH LICENSED CON7RAC'ORS p['i 70 CONSTHUCT 7HE PROJECT{6EC.7a44,E3USINE55 AND PROFESSIONS CODE:THE CONTHACTORS U- VHIUBSian s ADJ.pREA � 611�I. GENSELAWOOESNOTAPPLYTqiANOWFBEROFAPROPERTYWHOBU1LU50R4APROVESTNEREON,AND ���.,, NRIOCdN7AACTSFORSUCHPRQIECTSWI7HACONTMC70R�S�LICENSEDPURSUANT70THECONTRAC QUANTITY � DESCRIPTION FEE � TORS UCEN3E LAW.). . �; J Q',':�'., ❑i AM EXEMPT UNDER S�C. B.8 P.C.FOR 7HIS REASON Q ' U 3 � . ,/ ,� f, � � } � UATE � CWNER �' � T�� � � LlCENSED CCNTRAC70RS QECLARATION -� `.�` fQ- w � .:v ' ,IL�', 1 HEREBYAFFIRIA UNDER YENALTV OF PERIURYTHAT I A0.1 LICENSED UNDCP PROVISIONS OF CHA?TER � .0 . � IYI FTH U ES AND FESS 00 ' 9 COMMENCINO WRH SEC710N 7000 OF D SION 3 O E 8 SIN 5 PRO IOMS C E,RND �� 6_I 1 ) Z I X�,, MY UCENSE IS IN FULL FOaCE �EFFECT. � �_ � " �� �,. � UJ �-[� o'�. UCENSE CLASS_y�,�LlC.tJO. � P�J--1 � j 1�+ 'P/y"1 ' .V��. DATE ` ""��I�+"�'j CONTFACTOR �[� �� ! ��_> Y �l�' . W�. 6 - • I�. . �' WpRKERS'COMPENSATIQN DECLAFIATION � `,` . ��.� Q� ,t �" t/l.. � H RM Pl U OF�H OWIN C RATIO � � . N I ERE5YAFF1 UNDEfl PE ALTY OF PERJ flYONE E WLL G OE LA N5. Z �� �' a.6HqVERNDWILLMAIN'fAIMACERTIFICATEOFCANSENTTO5ELf-INSUREFOR`NORKERS' S e'�� � COMPEHSftTfON,ASPROVIDED0Y5ECl➢ON370a�FTHELABORCO�E,FORTHEPERFORMANCE �U � � e�/�+ U OF THE WORK FOR IMHICH hllS YERMIT IS ISSUED. y�j �', C � V i �I�I�:�II�� LSJ . , a �i HAVE ANO WiLLMAli4TAIN WOHKERS CAhAPENSAPON fNSURANCE,AS AE�UIRE�BY SECTION i - / - p�, �'� 37WO�THELA90qCGDE,FOP.?@iEPERFOiiP.SANCEOfTHEWORKFORWHICHiFiISPERMI?IS ' Iy„�"� ,�y � 4./ I�� �� l55UED.M1' NERS'� PENSAT;ON INSURANCE CAflRIEFi/4Y0 POLICY NUM6ERAflE: CONSTRUCTION 6.�� D ti� k y cnnniea ' '.. ._sh- �a� �.�. . �� PtAN REVIEW i ,Z � `� �, � Z�, aa.icrnufneEa__�iy�� :°°"f.-- � - ELECTRIC 1 V � j'� a T� / ' . �. � . � (fHM�5EC?NJNFlEIDNoi�OJ!l�PIF1FbOF5HEPEFlIkiISFDROMEFiuhDaE60a1nRs(51oo)oRIES} I PLUMBING � V � ,�-�) , I Q /� W , �" ICERTif'Y THAT IRI THE PERFORMANCE OF THE VJORK F00.NIHICHTHIS PEpMIT IS ISSUEO,I I MECHANiCAL 1„ � �/ _ �` �� �� � „ �(',�' SHALLNOTEMPLOYANYPERSONINANYMRNNERSOAS709ECAMESUBJECFTOTNE , ' — WORKERS'WMPENSRTION UWS OF CAI.IFORN10.AND AGPEE"lHAT IF I SHOULD BECAME INSPECTION FEE �.',�~^'��— . tl9"' CTT RK PENSAT7 PROVISION OFSECTI 37000F7 60R I . � SUBJE OTHEINb ERS'COM ON S ON HEL?. yy� F�' > � CADE,I Sh1ALL FOFiitiWlTN COMPIV WITH T SE PflOVI5iON5. �SSUANC� . V�3'p �. 3 5 M1 � � . � �.� w � � p� �ATE: "r��'^ - APPLJGANT. SMIP _ ' �� . WRflNING FAfLUAE TO SECUflE WORKEflS'COMP£NSATION COVEflAGE IS UNLAWFUL,ANO SHALL BE ENEFlGY P/C � � J �� SUBJECT AN EMPLOVER TO CRIMINAL PENALTIES AN�CML FWES UP TO ONE HUNDRED 7HOl1SAND . !�-� ENE ERMI DOLLARS(y7 o0,a00j,IN AODITION 70 THE COST OF COMPENSA710N.DAMAGES AS PROVIDED f-0R IN RGY P T s� �J�'. SEC710N3708OFTHELpBORWOE,INTEREST,AN�ATfORNEY'SFEES. ' RETENTIONFEE: � ' I�I d� CONSTRUCTIDN LENDING AGENCY PRE-AL7 FEE: �� O ��' I HEREBVAFFIflM UNDEfl PENAITY Of PERJURYTHATTHEAE IS A CONSiRUCTION LENDING AGENCY � - d FOH THE PERFORk1ANCE OF 7HE 6YORK FOR WHICH THIS PERMIT IS ISS�ED(SEC.3oW,GY.CJ. - . w rN E I„'adW'�� id C'3� L.�OER'S NAM � F— LENOER'SADDRE55 /?��y �II' � c �( �% _l � W ICERTIFYTHATIi1AVEREADTHISAPPLJCATIDNAN�STATETHATTHEABOYEINFORMATIONISCARR..CL TOTAL FEEa7 p (7�� tQ I . .�, I AGAEE TO COMPLV WITH ALLCITV ANO�COUNTY OROINANCESAND STATE LAWS REIATMG TO BUILDING ] �� �, CONSTRUCTlON,ANDHEREBYAUTHORIZEREPRESENTATIVESOFTHISCOUNTYTOENTERUPONTHE ' Z ABOYE-MENTIONED PROPERTY FOR INS?ECT�ON PURPOSES. COMMENTS -- I�';�III,�',�III,�' . p�, . ' . � .,��� �' PERMITI'EE NAIAE(PRIN'n ' ',��.:.. � Q� �. '�" SIGNATUREOFPERMITfEE DATE ' � � _, � RECPT.NO. 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