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HomeMy WebLinkAbout16997 CITY OF DIAMOND IIAR �� DEPARTMENT OF COMMUNITY R DEVELOPMENT SERVICES �' �xy � 2(825 E.Copley Drive (909)860-3195 Fax(909)861-3117 PRESS BUILDING PERMIT APPLICATION FIRMLY } JOEiSITE ^� ' t APPLICATION � PERMIT P/C o ADDRESS����� �o'E-'rd�G�Oc7� Ln./ DATE NUMBE ��1 � APN LOT�— TRACT ISSUE TYPE OCC p OWNE��. �,�t "�-ti ,���O r� DATE CONST. GROUP o ADDRESS ZOPJING SETBACKS gCITY ZIP��� 7� S ^ ,2 FRONT RW ❑ APPLIC T _T A-�n TEL. REAR p � SIDE/SIDE STREET RW ❑ � CONTRACTOR� � �t�f' SIDE ❑ Q ADDRES PROPOSED USE o CITY ' ZIP�j�f TEL,7L,�1•,�n��4 o ARCH/ENG/ cA�l �r�:Gt �< <"' DESIGNER fia N0.DWEL. NO. NO. n. ADDRESS �CQnCf� 2 � � � CIN ZIP TEL. �'� UNITS STORIES BEDROOMS � cn DESCRIPTION SO.FT. FACTOR PSF ADJ.AREANALUATION p� OYJNER-BUILDER DECLARATION SFR/ADD/REM O � 1 NEREBY AFFIRM UNDEN VENALTY OF VERAIRY TYUT I AM EXEMPi FRpA THE CONTMCTORS L4 GaragelCarport W CENSEUwFORTMEFOILOWINGREA:ON(SEC.7071.SBUSIfrE551W�7ROFE5510N5CODE:ANYCIiYOR (n U COUNryNMICHRE0U1RE5APERMITTOCONSTRUCT,ALTERIMPROVE,DEMOLISH.ORREPNRANYSTRUG W Pd1iO/Deck � NRE.PHiOR TO RS ISSUANCE.I1L50 REWIqES TNE APPLICANT FOR SUCH PEN4IT 70 FILE A SIGN[D W STATEAI[NT THAi HE OR SME IS LICENSED DURSUANT TO TN[PROV!SIONS OF tH[CONTiUCTORS Lb � CENSE UW�CYU7TER Y(COAOAENCING WITH SECTION 7000)OF D�VISION 1 OF TNE BUSMCSS AND PFla � PooUSpa FESSIONSCODE�OFTHATHEORSHEISEKE�PTTHEREFROMANDTN[BASISFORTHEILLEOEDEXEMP• C3 g TION.ANYYqLATqNOFSECTION70]I.68YI1NYAPVLICANTFORAVERMiTSU&1EC75TMEAGPLICANTTO Z Re•Roof � A CML VENIWTY pF NpT MORE TW W FNE HUN�RED DOLUAS(f500).�' ZOI.ASOWNEROFTHEPROPERTY,ORMVEA�PLOYEESWITHWAGESASTMEIRSOLECOMFENSATqN, ❑ COmm0rCi31 1NLL DO THE WORK�ND THE STNUCTURL IS NOT INTENDED OR OFFERED FOR SAIE(S[G 7W1.BUSb _1 � NE55 AfJD VROFESSIONS COOE:7ME CONTMCTORS L�CENSE UW DOES NOT AGPIV TO A4 OwN[R OF j VROPERTV V11q BUttDS OR II.APROVES 1MGREON,I W�Vnq DOES SVCH WORK Hi1.15ELF OR HERSELF OR WTHROUCHNISOi1HFRONMEIAPIOVEES,PROVIDEDTHATSUCHIMPRDVEAlENTSARENOTINTENDEDOR m � OFFEREDiORS�LEIF,FIDYYEVERTMEBUILDINOORMPflOVEM[NTISSOLDWITFIINONEYEAROfWNVLE� Z TqN,TME OWNER�BUILDER WILL MAVE TME BUADEN OF GROV W6 TMAT ME OR SHE OiD NOT BUILD Ofi � MVROVEfORTHEPURaOSEOFSALEI. LLl ❑lN^�N'NEROFTMEPROPEH7Y.AME7(CLUSIVEIYCON7MCTINGWITMIICENSEDCONTMCTORS Ct TO CDNSTRUCTTHE GROJECT(SEC.7oN.BUSINCSSAND VROfE5510NS CODE:THE COMMCTOf15 LI� Valu3t�On ADJ.AREA W CENSEUWDOESNOTA7PLYTOMIONMEROFAPROPEflTYWHOBURO50RBAPROVESTXER[ON.AN� � W11000MRACTSFORSUd1PRQ1ECTSWITHACONTMCTOR�S�UCENSEDVURSVANTTOTNECONTMG QUANTITY DESCRIPTION FEE tORS LICENSE Uw.�. � O IAM EXEMP7 UNDER SEC. B.a V.C.fOR TNiS RLASON Q I LL � � DATE _ OWNER / � , Z F LICENSED CONTRACTORS DECLARATION W � IMERCBYAFFIRMUNDEHPENALTYOFPEM1RYiHATIAMLICEN4EDUNDERiROV15�ON50FCMAPTER � p„ s�CpaMENCwON7THSEC710NtoaolOFDrvi5iON70FTHE8uS:NESSANDPflOFE5510N5CODE,IwO Z X MY LICENSE IS M iLll FORCEAND EFFECT. � LLI � IICENSE CUSS IIC.NO. � � J oare corrrrucron a w � WORKERS'COMPENSATION DECLAHATION Q � IMERCBYAFFIRMUNDER7EN4LTYOFOE0.NMONEOFiHEFOLLOWINGD[CUiUTIdJS: Z � _IMAVEANDWILLMAINTNNACERTIflCATEOFLONSENTTDSEIF�INSUREFORWORKERS' _ COh�PENSATION.AS VROViDED BY SECTION 77oa 0F TME LABOH CODE.FOR TNE VERiONAANCE W OF iHE wORK FOiI WHIp17H15 PERMIT IS ISSUED. � 1 � �IMAVEMlDWILLMAIMAINWON(CFS'COMPENSATIONINSUR�NCE,ASflEOUIRE�BYSECTION O77000FTHEU90HCADE,fOFiMEPERFOPM�IJCEOFTNEWORKFORYMIC7iTHI5YEqMIT15 = ISSUEO.MYWORKERS'COMPENSATIONINSURANCEURRIERANDPOIIC'INUM9ERARE: CONSTRUCTION � GRR:fR PLAN REVIEW Z POLICYNU/ABEii ELECTRIC Q � (fH155ECT70NNEmNOTBEWMLFTmOFT1EPER.7T6fi7R0�LMULN�CDWUAit51f:(CI�LESS} PLUMDING Z 1 CERTiFV THAT INTH[OERFORu.WCE OF iHE WOaK FOH WHiCNTNiS PERuiT IS ISSUED,1 MECHANICAL � � (} SMALLNOTFIAPLOVANYVERSONWANVMANNERSOASTOBLCAMGSU0.IECTTOTME � WOqKERS'COMPENSATqN�AWSOFCALIFORN:AAN'JAGREETHATIFISFIOVLDBECOME INSPECTIONFEE ��'- -- SUOJECT TO THE MIOR%Efl5'COMPENSATION PROV1510NS OF SELTION l70o OF THE UBOR J�-^-��;.;�� �� 'I �, �j CO�E,I SHALL FORTMMTM COMPLY WITH THOSE VROVISIONS. �SSUANCE y L pDA7E: AVPLICANT: SMIP i � WARNINO:FA0.URETOSECUREWORKERS'COMPENSATpNCAVERAGEISUNUWF�A,AND4NALlB[ ENERGYPIC I 1 � SlR1ECiANEMP�OYERTOCHIM9JALVENALTIE5IWOLMLFWESUPTOONEMUNORED7MOU5AN0 ENERGYPERMIT � DOlURS(f I00,000),W ADDITON TO TME fAST OF COMPENSATqN,DM�AGES AS PROVIDED fOH IN � SECTION]70eOFTHEU00RCODE,WlERESLANDATiORN[Y5FEE5. RETENTIONFEE: �},�\`r' � L._._-.-—-----�-.. a CONSTRUCTION LENDING AGENCY PRE•ALT FEE: --'" � O � IMEREBYAFFIHMUNOER7ENAl7YOFPEFWRVTHATTMERE15ACON5TRUCTIONIENDINaACENCY FOR iHE PERiORMANCE OF iHE WORK FON WNICM THIS PEfiMiT IS ISSUCO(SEC.]oY7,CIV.41. Z W � LEKDER'SNMI[ F-- LENDER'SADDiiE55 w I CERTIFY TMAT I HAYE RE�D iH15 APPLICATION Ml�STATE TMAT T/E�BOVE INFORMATION IS CORqECi TOTAL FE ES /n�� �O � I AGREE TO C0IAPLY WITM ALl CITY iVl�fAtMTY ORDINANCES ANO STATE UWS HELATWG TO 91lCDING t� CONSTRIICTION,AN�MER[BY AUT110W 2E P[VRESENTATIVES OF THIS LOUNTV TO ENTER UPON THE Z �BOYE-M NTIONEDPROPEflTVFOi1IN5PECT10NPVRPOS[S. COM�,ALNTS O � �-C� I TL-f �_�<,' e�1 m p¢wa NM1[�vwNTJ /' Q � /�� � / tn G�t e-�.:.Cw-� � � � � s�cr+- �v�we t�[ DaiE RECPT.NO. " PAID '� VALIDATION � WHITE—Deparlment Capy.YELLOW—Finance Copy,PINN—Assessor Copy,GOLDENROD—File Copy.GREEN—Appl�canl's Copy . . �. . . �_.. ,� . .�. _�.:.--�•. . . , .. . . .. ,' " '.. . . 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