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HomeMy WebLinkAbout17020 (38) �� CITY OF DIAM0�1D BAR � DEPARTMENf OF COtitMUNi'IY&DEVELOPMENT SERVICES �/=� ',\;� 21825 E.Copley Drive (909)860-3195 Fax(909)861-3117 PRESS BUILDING PERMIT APPLICATION FI MLY o ADDR'ESS �� � Ql` DATECATION '� � j U' NUMB R `�v� #/C � APN LOT TRACT ISSUE TYPE OCC DATE Z CONST. GROUP p OWNE�G'f'(��, J�AL�;¢�'-� o ADDRESS� 20NING SETBACKS z CITY � ZI �'j7tc-tEi.[9�s�4_�7�� FRONT RW O g APPLICANT TEL. REAR ❑ SIDE/SIDE STREET FiW ❑ � CONTRACTOR SIDE p � ADDRESS PROPOSED USE�i O 6() ' �i Q CITY ZIP TEL. o ARCFi/ENG/ �` �' �' w DESIGNER N0.DWEL. NO. NO. d ADDRESS UNITS STORIES BEDROOMS � CIN ZIP TEL N cn DESCRIPTION SO.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER DECLARATION SFFUADDlREM O I HEREBV AFFlRM UNDER DENALTY OF PERIURV THAi 1 AM E%EM7T FROA1 THE CONTRACTORS LI. GafBgB/CdlPOR W �CENSEUWFORTIIEFOLLOWINGREASON�SEC.7W7.SBUSINESSANDPRO�ESSIONSCOOE:ANYCITYOR (n C1 CWNTYWHICMRE�UIRESAGERMITTOCONSTRUCT,ILLTER��ROVE.OE��OLISM,ORREPAIRANYSTRUG W patio/Deck .z TURE,VRIOR TO ITS ISSUANCE./A50 REOUIRES THE A77LICANT FOR SUCN GE WA�T TO iI�E A S�GNED w STATEMENT THAT HE OR SHE 6 LICENSED PURSUNiT TO THE PRONSIONS OF THE GONTMCTORS LI• W � CENSEUW(CHAPTER9(W�.IMENCINoWITHSECTKK17000)OF�IVISION70FTHEBUSINESSAV7PP0• LL' PooVSpa FESSqNSCOO�ORTIUTHEOR5HE15EXEAIPTTMER'<FROMANOTHEBASISFORTNEALLEGEOE%EMP. (� V TION.ANYVIOLATKKiOFSECilON7031.SBYANYMPLI�MlTFORAPERMiTSU0.1ECT5TMEA7VUCANTTO Z Re-Roof ACMIPENALTYOFNOTMORETHANFNEHUNDREDDOLLARS(f5oo).1� � Z04ASOYMEFOFTHEPROPERTY.ORMVEMPLOYEESWITNWAG[SASThEIRSOLECOMPENSATqN, 0 Commercial � WILLDO iHE WOpKµD TME STRUC7URE IS NOT INTENDED OF OFFERED FOFl SALE ISEC.70��,BUSI• J � NESS AND OROFESSIONS COOE:TME CONTRACTORS�ICENSE UW DOES NOT/.PG�V TO AN OWNER OF � 7ROVERTYNMOBU0.050RIMGROVESTNEREON,A`1DNMODOESSUCMNARKHIMSRFOi7HER5ELFOq m CL THROUGMHISDRHEHOWNEMPLOYEES,VPOYIOEDTMATSUCNIMPROYEMENT511RENOTWTEKOEUOR lll OFFFRED FON SALE IF,/10W EyER TME BUIDING OR IIAPPOVEI.IENT IS SOID WITMN ONE YEAR OF COMPLE� � TION,TME OWNER�BUILDER WILL NAVE TME BURDEN OF PROVINO THAT HE Oq SHE DID NOT BUIID OR = IMPHOVEFORTMEPURPOSEOFSALE� W ❑I,ASONTIEROFiNEPROPERTV,IMEXCLUSNELVCOIRRACTIN6WfTNUCENSE'JCONTMCTORS (L TO LONSTRUCT THE VRQIECT(SEC.70N,BUS:NE55 ANO PROFESSIONS CO�E:TME LONTMCTORS U• V21U2l1Of1 ADJ.AREA W CENSEUWDOESNOTA7PLYTOANOVMEROFAVROPERTVVAIOBUItt7SORtl.IPROVESTNEREON,ANO � N7WCONTMCTSFORSUCHPRp1ECT5WITHACONTMCTOR(S)LICENS[� URSUANTTOTHECON7MG QUANTITY DESCRIPTION FEE � TORS LICENSE UW). � OIAMEXEMPTUNDERSEG B.6P.C. RTHISPEASON Q � U "—' L2�-27-o � Z w � LICENS RACTORS DEC TION w IHEREBVAFFlFlMUNDERPENALTYOFOERNRVTHATIIUAUCENSEDUHDCHPROViSpNSOFLMAP7ER � d Y(OOAIMENCINa WITH SECTqN 7000)OF DM510N 70F THE BVSMESS�ND PROFESSIONS CADE,IIND Z "� ��UCENSE IS N FULL FORCE AND EFFECT. m � UCENSE CUSS LIC.N0. j V DATE CONTRACTOR a W � WORKERS'COMPENSATION DECLARATION . ¢ N U N IHEREBYAFFIRMUNDERPENALTYOFFERNHYONEOF7MEFOLlOVlING�E0.11RAi10N5. Z Q G _IMAYEANDMAILMNNTAINACERTIFICATEOFWM1SENTTOSELF�INSUqEFORWORKERS' _ CqAPENSATION,ASVROV10EDBVSECTION3)ooOFTHEIMORCOCE,iORTHE7ERFOWAMICE U ¢ OF THE WORK FOR WMip17Mi5 PERMIT IS�SSUED. � 0 QW �_I/UVEMlDWRLMAIMAINWORKERS'CCMPFNSATiONINSUFUNCE,A5RE0UIREDBYSECTION /� /- 37000FTNEUBORLO�E,LORTHEPER�ORIAMICEOFTHEWORKFOqWHiCHTHISGERMITIS �G, �')/ ) � ISSUED.MVWORKERS'COMPENSATIONINSURANCELARRIERANOGOLICYNUM�[RME: CONSTRUCTION CJ •� /�/ J j c�aeiea PLAN REVIEW Z POLICYNUMBEH ELECTRIC C � (IMSSECIYYrt�EmNOTBEf1kAREiEDOFTVEGEF0,NT5fORONE/ilf�DRE�DD�l1/U15(St0070RLESS} PLUMBING Z ICERTIFYTHA7INTHEGERFORMANCEOFTl1EWORKFORWHICNTMISPERMITISISSUED.1 MECHANICAL (.�} 6MPLLNOT EMPIOY ANY PERSON W ANV MANNER SO�5 TO BECOAA[SU&1[CTTOTHE N WOPKERS'COMPENSATIONUWSOFC�LIFppNiAANDAGREETMATIF15MOULDBECOME INSPECT�ONFEE S SUaIECTTOTMEYpRKERS'COIAVENSATIONPROVISIONSOFS[CTION]7000FTHEUBOR COOE,I SHALL FORTIINATM COMP�V 1MTN TF�OSE VRONSqNS. �SSUANCE � SMIP • I� p DATE: APPLICAM: � ENERGY P/C WAiWINO:FNLVRETO SECURE`M�RKERS'COMPENSATION COVERAGE IS UNLAWNL,M:D SHALL BE �y SU6lECTANEMP�OYERTOCRIMINALPENALIIESMIDCNIlFWESUPTOONENUNDRCDTMOUSRND ENERGYPERMIT DOLURS(5100.Oo0�,IN ADOITION TO THE COST OF CpA1PEN5AT104,DAMACES AS GFONDED FOR IN ��(� � SECTION77oeqFTMElA90RCO�E,INiERE57,ANDATiORNEYSFEES. ' RETEMIONFEE: ✓V pw_. CONSTRUCTIONIENDINGAGENCY �� PRE-ALTFEE: O � IMEFEBYAFFIRMUNDERFENALTYOFPEfUURYTHATTHEflEISACONSTRVCT!ONLENDINGAGENCV a- fOqiHEVERWRMANCEDFTMEWORKFORWMIp77H15PERMITI5�55UED(SEC.3097,CIY.C.). Z W � LENDERS NM1E � LENDERS ADDRE55 /� � ICERTIFYTHATIMAVERE/�DTHISAPPI�CATION�NDSTATETIUTTMEA80VE71FORMATION15CONRECT. TOTAL FEES �{����G . w IAGREE TO COIAFIV WITH ALLCfTV ANO CIX)NTV OFL7:NANCES AND STATE UWS RELATINC i0 BUILDING � CONSTRUCTION,ANDH[REOVAUTNORIZEN[PRLSENTATNESOFTNISCWNTVTOEN7EqUVONTME ZABOYE�MENTIONED VROPERTY FOR INSPECTION VURPOSES. COMMENTS � i C"fi fL � � l-���C _ m oe �NnuE�o � ¢ M bgr��-� � - SIow�TUREOF MITTEE DAiE � ` � RECPT.NQ PAID f3Y VALIDATION ( WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy.GOLDENROO--File Copy.GREEN—Appliranfs Copy . � .. . .. .. . . , � . ... ., � .� i., �.. . .... � i. .. .�., . . _�� �... .. �. �.... _.."' 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