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HomeMy WebLinkAbout15465 �;�^� � ��' �: 7�a CITY OF DIAMOND BAB `''" - ��'-- DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES ��; , 21660 E.Copley Drive Suite 190 � PRESS (909)860-3 t 95 Fax(909)86]-3117 � ��;9�'�� BUQ,DING PERMIT APPLICATION � FIRMLY � JOBSITE ,� / o ADDRESS=��� �--OL��`y/�al�I f�� � �'� DATEICATION �NUMeER F���/C � ISSUE 'TYPE � OCC � APN ` LOT TRACT'.. DATE__ CONST. GROUP p OWNER i"7I�S = �'C=/�C=�� ''��__ ___ ADDRESS ��}•C"7 � r ZONING SETBACKS � CITY _ ZIP TEL. l� FRONT RW ❑_ g APPUCANT TEL -�r REAR __ Ll � SIDFJSIDE STREET RW rl.______ CONTRACT'OR � y1�1� SiDE , ❑ � ADDRESS • � � r-'� PROPOSED USE � ��'�7��G"Z �����}i-�C_, � � CI1Y ZIP TEL.�IF1�/ �-�r� N •.: � � �. w ARCWENG/ �`T �^ � `WDESIGNER �_ '�'`i"�f��--�—+--�'-+—�' Fa ADDRESS NO.DWEL. NO. N0. �� � CITY ZIP TEL. UNITS__ _�_— STORIES _ __BEDROOMS c � v� ^ DESCRIPTION SQ.FT. FACTOR PSF ADJ.ARErWALUATION ,� p� OWNER-BUILDER DECLARATION SFR/AUD/REM O ';{ �, 1 HEREBV AFFlflM UNDER PEN/�ITY Oi'PERLLIRV 7HAT I AA1 F.XEMPT FROM THE CONiRACTORS LI� Gef.74e/C8fp011 ?� 'W CENSEUWFOflTHEFOLLOWINGHEASON(SEC.7P9t.58U51NE5SANDPROFESSIONSCOOF.:AYYCIT`/OFl (n COUNiYWHIqipEWIRESAPEF�IIYTOCANSTRLiCT,ALTER,IMPROVE,CEMOLISH,ORNEPAIHANYSTRUL`. . W P81i0/DOCk � 'W TURE,PHIOfi TO ITS 15SUANCE,AL50 REQUIFlES TiE AVYUCAtJT FOq SIJCH PERMIT TO FILE A SIONE� . w A . STATEMENT TNAT HE ON SHE IS LICENSFO PUflSUANT TO THE PNOVISIONS OF THE CUNTfiACTOflS LI� � '�S' GENSELA`N(CHNPTERe(COMMENCINGriITHSEC710N7aoo)OFDIVISION3OFTHEBUSINE55ANDPqO- u" POOUSPe ;� �Tj FESSpNSCQ�E)ORIHATHEORSHEIS[%EMPTTHEAEFROMANf7THE8A515FOPTHEALLEGEDEXEMP� , � .V� TIOld.ANYVKXATKKdOFSECTION7o3i,56YANYAPPLICANTFOftRPEqMITSUQ1ECi5TMfAPPLICANTTO � RB-ROOf �,r � ACIVIL PENAITY OF NOT MORE THAN FIVE HUNORFA bOLLARS(E61w).): - �� ~' ❑I,ASOWNEROFTHEPROPERN,ORMYEMPLOYEESWIT11WhGF5A5'RIFIRSOIECOMPENSATqY, [� 'g'� MIILL00 THE WORK,AND 1HE SYRUCTUflE�5 NOT INTENDE�OR OFFERED FOR SALE(SEC.7W4,BUSI- � COmmefCi�I '� N� NE55 AND GflOFES51(MS CODE:THE CONTRACTORS LICENSE LAW OOES NOT APPLY TO AN OWNER OF . � �d . PROPERTYWfiO8UIW50RIMPROVE6THEPEON,FNDWHODOE55UCHWOFKHIMSELFORHERSELfOR ',�{ 7Hi1q1GHHI50RMEROWNEMPLDYEES,VqOV1�E0THA7SLICMIMPFOVEMENTSARENOTINTEN�E�OH m �) W. OFFEqEDFORSALE.IF,ryOWEVF.RTHEBUIIDINOORIMPqOYEMENTISSOLDWfiHINONEYEAROFCOMPLE .'� '0� TION,THE OWNER�HUIIDEH WILL MAYE THE BUFDFN OF PROVIY6 TNFT H[OR Sk1E Il!�N07 BIIILU OR - --- �Z� IMPFqVEfOR7HEPURP09EOFSN.E). _� ❑I.PSOV7NEROG'THEPRbPEkIY,A/AEXCW51VElYCONTRACTINGWITHLICENB'cDCONTWtCTORS ��� W� TO CONSTRUCT THE PRQIECT SEC.�o�I,BU91NES5 AND PROFFSSIONu COf7E:THE CONTHACTOHS LI� :�, ( Valuation �.'t��2•" ADJ.ARkA.._...._.. • CENSEUW�OESNOTAPPLYTOMJOWNERQFAPROPERTVWH08UItASORIMPROYFS7HEFEON,0.N0 �-a- """�-�--'---'-"-""-"""-'-'"-"'"'-" iI ���, N}iOCpryTRRCT5FOR5UCHPRQIECTSWITHACONTAACTOF�S)UCENSEDPUHSUANTTOTHECONTRAP QUANTITY DESCRIPTION FEE ;j Y TORS UCENSE UW.). _ � a� I�I AM EXEMPT UNDEN SEC.�_� ,___B.8 P.C,FOR THIS R[ASON : Q � U 3 � ��, LL. D�TE_"_`__ OWNER___""_--.._.._... . . V 1 Z" � � �<F.;� LICENS[D CONTRACTOHS DECLARA710Y �; W � '.�:� I ISEftEBYAFflRM UNDER PENILN OF PERJURY7Hq7�µi��CENSF:�UNDEfl FROVISIONS OF CiiAPT�R � � � `;�'�.,; B(CAA/MENCINOWIlHSECTNNJ700�)OfOIVI5iON90FTHE13USME55ANDPfiOfE5510NSCADE,AYD ' Z'` _, � ___ � � MYUCENSE IS IN FULL FORCEAND EFFECf. — �.';�.p � Cfl �,�Or.; LICENSE C S� LIC.h0._.._..._�_� � �'� . � �1 �~r�� DATE� b�� _,_. CONTFlACTOR °"'� ; CL � ,.C�, �...i 4.. w.', � _.._._. � �--�`: WORK[RS'COMPFNSATION DECLARRTION � � � �.•.�i: � 4 Vy ' U �; 1 HEFEBY AFFIRM UNOER PENALTY OF PER1UflY ONEOFTH'c FOLIOWING DECIAHAT10Y5: Z � �(�;� __I HME ANO WILL 7AAINTAI4 A CERTIFICNTE 9F CONSENTTO SELFINSUHf:FOR WOHKEIiS' ` S, � :�� COMpEM5A710N,AS PFOVI��D BY SECTIOPI 3Too Oi TME LABOR COL7E,FOR Tf1E PFft�OPMANCE W___ _ OFTHEWORNFORWHICHTHISPERMITISISSUEO. � � W'' � ' _.,_�HAVE ANO Will MAINTAIN WORKERS'WMPEN3ATIDN INSUqANCE,AS RE�UIHED RY SF.CTION � // � ;G'� 37000F THE LAf30R CODE,FOR THE PERfUiiMANC�OF THE K'ORK FOR WH CH Tt115 PF.RMIT IS (1 /j .;A! ISSUED.MYWORKERS'CQMPEN"sAT10N NSURANCFCAPRIERANDPOLIGYNUME3CHARE: CONSTflUCTION _ ' / � _" ._ _ '_ '_""__.—_..'_""_'_ ___"_' J.; ' �— h �,. CANRIER�S t� s'"N'�__ CyG3 .. � PLAN REVIEW :�:�. 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R f.�R�,s 3� -/) �j,,�t . �c,...-� Y'�z.,<,�t::t'���'--s;:.e� DATE: . �" APPLICANT: �'�•i. ���� �� -�^.!_`�._ �" .d..— SMIP • � b '�_ ��, wt,�-:3��-��........ n...� ..------�'--�-'- �� WAFiNING: AILURE TO SECURE WORKERS'COMPENSATIOY COVLRA LE IS UNLAWFUL,ANU 511ALL BE � E N E P G Y P/C ���i,�,p.>_%�:�� •••{ �_�.�,Y . ---._...._........ ""�y'�' 5U0.1ECTMIEMPLOYEHTOCRIMINALPENALTIESAN�CIVILFINF.SUPTOONEHUNDREDTHOUSAN� ENERGYPEFiMIT .' UOLLARS(E100.000),INADDITIONTOTHECOSTOFCOMPENSATIOY.DAMAGESASPqOVIDEDFORIN ---�------------�----�--- ---- �J'. SECTbN 9708 OF THE IABOfi WOE,INTFfI[ST,AN�ATTORNEYS FEES. RETENTION FEE: __.,__. ,�' _ """' --- ��. CONSTRUCTION IENDING AGENCY PREALT FEE: __._ p� � -------- ������ INE.flEBYAFFIRMUNOERPENALTYOFPEFJURYTHATTMEf1FISACOYSTRUCTIONLEN�INGAGENCY �' FOkTHEPERWFMANCEOFTHEWORKFOFWHICNTHI5PERMITI5155UL�(SEC.]G9],CN.C.). �-- ------ --�-- Z .W- . _ ......____..._. .. _'.___ � LENDER'SNAME_". ..-"_"" _'-'_"'_ __...'___ ..�': __....-_'..." — "-_—_.. I-'' IENUER'SADDRESS___,,.,, .___.._. ___....__ �� ICERTIFYTHATIHAVEREADTHISAPPLICATIONANDSTA7ETHATTHEABOVEINFORMATIONISCURRECT. TOTAL FEES � �/ .� � W' IAGREE TO COMPLY WITH ALLCITYAND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING � �y ' V � CANSTRUCTION,ANDHERE6YAUTHORREftEPRESENiATIVESOFTHI&COUNTVI'OENTFfiUPONTHE ABOVE�MENTION[D PROPEFlTY FOF INSPLGTION PURPOSES. � Z� COMMENTS__.___._.. Q (� ' �'-__- � i[ - � Y�-^-�--� /'� -- '�----._--- _---'-.- ' m PERMITTEE N E RI 7.��.-_.,.� / A \/� �/ � Q / [ ///J � �!� � % .'\ � N `_ ' -.-�f � SIGNATUN O ITT E "' --_��--"�A7 _""_ _ ' = RECPT.N0.___ ___ � PAID BY __._, _.. _�' _ _VALIDATION ____ ~ WHITE-Deparlment Copy,YELLOW-Finance Copy,PINK-Assessor Copy,GOLD NRO�-File Copy,GREEN-ApplicanPs Copy __ �_ . . _ .j ��fr � -r � F � � � � , z � � � � � � } s r��� `� ��. � } � t I, r" i - i � ''^, f �W L ^�'� :s ,+� ; °! i I f ; - ` � � , , ^.". ,�u t � {. i I - i- ,� .� ;,� i� � s {� ��� . 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