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HomeMy WebLinkAbout17036 (39) CITY OF DIAI�40NDIBAR 1- �� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES I 2(825 E.Capley Drive (909)860-3195 Fax(909)861-3117 PRESS "'-� BUILDING PERMIT APPLICATION FIR LY � JOBSITE .\ APPLICATION U PERMIT P/C o ADDRESS ��• C�'A�-C-�C�. K «��I�N DATE � �� NUMBER ' �� �N � ISSUE � TYPE OCC APN LOT TRACT DATE CONST. GROUP 0 owNe��1AL2 D "" ADDRESS 20NING SETBACKS Q CITY ZIP TEL� ' � REART RW OO o APPLICANT TEL. SI�FJSIOE STREET RW O � CONTRACTOR -i � lY'-,�_ Cl`n��Z'�IQ,L l. C_-�Tt;x� '' SIDE O Q ADDRESS � ' - PROPOSED USE � y - � CITY 6� fnli?U� ZIP ql�F�i TEL - 4 L ' - p -r—�--^ � b�G (3 LA'kil L.�\� ►��A!!r w w ARCN/ENG/ �C'3���jLT-1°^� ''��5�� � z DESIGNER NO.DWEL. NO. NO. = CDDRESS ZIP TEL UNITS STORIES ( BEDROOMS N DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � � OWNER-BUILDER DECLARATION SFWADD/REM O p 1 HEREBV AFFlRM UNOER VENAITV OF CER1L'RV TNAT I AM EXEMPT FR061 THE CONTMCTORS LI• G31899/CB�pOA W CENSEUWFORTHEFOLLOWINGREASON�SEC.7a'f1.66U51NE55AN�FROFE551DN5CODE.ANVLITYOR (/) C� COUNTVYIH�CMPEWIHESAPERMITTOCONSTRUCT.ALTER,IMPROVE,OEIIOLISN.ORRE7A:FIINVSTRUG W Pa(IO/DBCK � TUHE.iR10R TOITSISSUMlCE,AL50 REWIRES TH[APPLiCANT fOR SUCH PERMIT TO FREASIGUFD W � SiATEIAEM T4�T HE OR SME IS LILENSED PURSU�NT TO 7ME PROVISIONS OF THE OONTMLTORS LI- � CENSE UW(CMAPTER Y�COMMENCING WITM SECTqN 7000)OF DIVISqN 70f THE BVSME43M1D GRO� � PooUSpa FESSIONSCADE)ORTHATHEOHSNEISE%EMPTTHER[fROM11NDTMEBASiSiORTHEALLEGEDExEMP- (� TION.ANVVIOU710NOFSECTION]071.SBYANYAPFUCANTFORAVERIAITSU&ECTSTHEAPPUCAN7T0 Z Re-Roof � ACML VENALTV OF NOT MORE TNAN FNE HUNDRED DOlURS(5500)): � � OI.ASOWNEROFTHEPROPfRTV.OR1AVE4vLOVEESWiTHwAGE5A5THEIRSOLECOMPENSATION, � pammercial Z WILL DO TME WORI(ANO iHE STRUCTURE�S NOT INiENDED OR OFFERED fOR SI1LE(S[C.70U,BUSI� J NE55 AND PROFESSIONS COOE:TNE CONTRACTOfis IICENSE UW�OES NOT APPLY TO AN OwNER OF � PROPERTYVrtqBUILD50RIMPROVESTHEREON.MlDWHODOESSVp1WORKHiMSGLFORHERSELFOR m Q TMfiOUGMN150RHEROWNEMP�OYEES,iROYIDEO71�AT5UWIMPROVEA/ENTSAft'c�OTMENDEDOR W OFFEREDFORSPLE.F,HOWEYE0.TMEBUIIDWGOHv.1VROYEMENTI550lDmTMMONCYE/JiOFCOMPLE• � TION.THE OWNER�BUiLOER WILL HAVE THE BURDEN OF FROVINO TW�T ME OF SNE Dip NOT BUILD OR z IMPROVEFORTMEPURPQSEOFSALEx � = pI,ASOVnJEROFTHEPi70PER7Y.AUEx:AUSNELYCONTMCTINGWITNLICEN5E000NTMCTORS W (Z TO CONSTRUCT THE PR0.IECT(SEC.70U,BVSINESS AND VROFESSIONS CODG iHE CONTMCTORS LI� V2IU3110f1 ' AD.I.AREA W CENSEUWDOESHOTAPPLYTO/WOWNEROFAFROPERTVWNOBUILDSORIIIP0.0VFSTHEflEON.AN� � NTIOCAMMCTSFORSUCHFR0.IECTSWIT/IACONTMCTOR(5)UCENSEDPURSUMRTOTI/ECONTMG QUANTITY DESCRIPTION FEE Y TORSLICENSEUW). � � OIAMEXEIAPTUNDERSEC. 8.6VGFORTMISREASON � O � � � OATE OWNER � �' W � UCENSED CONTRACTORS DECLARATION W � IHEREBVAFFIRMUNDERPENALTYOFPEfWRYTNATIAMLICEN5E0UNDERPROVI5lON50FCHAV7ER Ur d Y(COMMENCINO N'17H SECTION 70aa)OF OMSiON 00P TME BUS,NESS ANO PFOFE55iON5 CO�E,AND Z W UCENSE LS Pl FULL FORLEAND EFFECL m � UCENSE CU15�.�9 UC.NO. ���-�a�' J 1-- V DATE���-�� n I CONTRACTOR ��/IJ �,. K.l M _ d W � WOFKERS'COMPENSATION DECLARATION , 4 N IHEREBVAFFIRMUNDERPEN�LTYOFVERIUNYONEOFTHEFOLLOWINGDCCLARATICNS. � � Z Q O �IHAVEANDWIILMNNTAINACERTIFICATEOFCONSENTTOSELFdNSUREfCRWORNERS' S � COMPENS�TION.ASGROVIOEDBYSECTION77o00FTMElABORCOCE,FOR7HEPERFORMANCE W OF iHE WORK FOR WHICN TMIS 7Ei71AlT IS ISSUE�. � � : w �IMAVEANDWILLMAINTAINWORICERS'CA�PENSATIONINSUfUNCE,A5RE0UIqEDBVSECTION (Y�- � Q �7000FTHE UBORCODE iORiHE PERFONMANCE OFTME WOFI(FOR WMCMTMIS�ERMITIS /`�� Z ISSUE�.MVWORKERS'COMPENSATIONINSURANCfCARRIERANDVOIICYNUMBERARE: CONSTRUCTION � j c,�pq,Eq PUIN REVIEW � POIICVNNABER �'1E�LL.�C�C)at1 ' ELECTRIC 0 (IHISSECfXNNEmNOTBEWFsiETEi70FTMEPERM1�T6F0�1Ch£H�.tafi[DDtt1A25Rt00)OqLE5S1 PLUMBING Z I CERTIFVTNAT N1THE DERCORAAANCE OF1HE V+UFK FOR WHI[N7HI5 PERMIT IS ISSUED.1 MECHANICAL ('} SNAIL NOT EMPLOY ANV PERSON IN M!V MMNER SO AS TO BECO,A[SUBJECT TO TNE Vj WORNER5CdAPENSATIONIAWSOFCALIFOiWIA,AYDAGRCETHATIFI5NIXILDBECOME INSPECTIONFEE S SVBJECTTOTNEWORKERS'COMPENSATIONPROVIS�ONSOFSECTIOh]70oOFTHEVBOR �SSUANCE COOE,1 SM/LL FORTM^ATM GOMPLY WITH TMOSE PROVISIONS. j� � 1 SMIP � v p DATE:��T�1. APPLICANt � ENERGY P/C J WARNIN�:FMLURE TO SECURE W�tKERS'COMFENSAiqN COVEMGE 15 UNLAwFUL M+D SHALL BE � SUBJECTANEAIPLOYERTOCFIMMALFENALTIESANDCMLFMESUPTOONEHUNDRED1FqV5AND ENERGYPERMIT DOlURS(f1a0.000�,IN ADDITIIXJ TO THE COST OF COMPENSATION,OAMAGES AS FROYIOEO FOR IN � SECTioN�7oeOFTHEUBORCODE.INTEREST,ANDATTORNEY5FEE5. � RETENTIONFEE: pw_, CONSTRUCTION LENDING AGENCY ', PRE-ALT FEE:. O ' Q IHEilEBVAFFIRMUNDERPENALTVOFGERNRYiHA7THEREISACDNSTFlVCTiONlENOINGAGENCY a- FOR TME 7ERFORMANCE OF THE WORK FOR WHICH THIS VER�AIT IS ISSUED�SEC.7097,qV.CJ. Z W � LENDER'S NAME F— LENDER'SADDRE55 wI CERTIFV TMAT 1 HAVE NE/�D THIS APPLICATION Ml�STAiE TNAT TME ABOVE INFOR�IATION IS CARRECL TOTAL FEES l I � •�� d IAGREETOCOA��LYWITNALICT'ANDCIXINTYOR7�NANCESANDSTATEUwSRELAT�NGTOBUILOING CANSTRUCTION,AN�HEREBV AUTHORIZE REPR[SENTATNES OF iMIS COUNTV TO ENTER UPON THE ZABOVE�MENT10NE0 PROPERTV FOH INSVECTION PURPOSES. COMMENTS � �,u� � �1� , J � QVERMITTEE NAME(PRiD7T) �,Y (n 6 ��-� `a� N SIGNATUREOFPERMITTEE OAiE � � FECPT.h0. PAID BY VALIDATION WHITE—Department Copy.YELLOW—Finance CoOY,PINK—Assessor Copy.GOLDENROD--F�Ie Copy.GREEN—ApplicanYs C py " . . ' .. . . ' , i , , . . , .. � ,. • � , . . , , . . , ., ., . . ... . 1 .. �_...,, . . ., � , , ... � .. �•,.e , �-i } �r /C'.,s e r .�i , , _ . ,..��ll�.r'..�.. 1 � �_. f .� . !: ".,, ..='k. . i:..i�S i".'i�...`.'i�..._ ,_._,..�...�..'__"'_"'."'_ _,_' . . _ . . ___. . , . .. . .. ._ __. ...... . .. . ... . .. . .__._ .._.__.._ .._..... _ .. �1�t^i��=�".�i G�.l:" �... . i:`F:,C�: ��.� . ;r„`,: .. . 'i l'-�p'i. i,.`L� _ . _.-li�Iti�:��:.0 SeIC{�..__. SET F�;C�: I '', '�LC;:)�J�IS? _ I - . .. 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