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HomeMy WebLinkAbout10748 7��-�2s=�o88 - �uv� ,� ' � ... ' " CITY OF DIAMO[VD BAR �." COMMUNITY DEVELOPMENT DEPARTMENT �,. 21660 E.Copley Drive Suite 190 f (909)860-3195 Fax(909)861-3117 PRESS """', BUILDINGPERMITAPPLICATION FIRMLY A';�z JOBSITE �/ ,/ -/� APPLICATION �,rr��NUMBER�_ #/C � •�•��o� ADDRESS L T�b I .V�Y(�I V1 �V I V�'v DATE � v ��� '�: A � � T S I TRACT Z S� �SSUE TYPE OCC DATE CONST. GROUP °�` V�-' .S ne, p- OWNER r,� o ADDRESS���fJ ( A.V Y!VL �ir j . ZONING SETBACKS oCITY ZIP��TEL.�nA �(�0__TZ.�L� REART RW ❑ p ARPLICANT 7EL. ❑ z f - - SIDE/SIDE'STREET RW ❑ a CONTRACTOR SoQB SIDE U � ADDRESS � CITY ZIP TEL. ROPOSEDUSE #�-�A_�G. �� �M-dWfr �oiLe✓ �-- w ARCH/ENG/ 1� ",� �r r�'-r-Hr� wiGcL,at�4 ra,.. ��p S��e z DESIGNER CaY►� L�va�iH�7u�S w NO.DWEL. NO. NO. a ADDRESS 'o � � TIA�fi'�i �— cn � UNITS STORIES BEDROOMS _ � CITY SoLtln.'fa�. h a ZIP�TEL 7/ _ D• � l DESCRIPTION SQ.Ff: FACTOR PSF ADJ.AREANALUATION p� OWNER-BI:ILDER DECLARATION SFR/ADDIREM O p I NEREBV AFFIRM UNOER PENqLTY OF PERJURV 7HAT I AM E%EMPT FROM THE CONTRACTOq5 L�� � G8f8QB/C31p0lf , W CENSELAWFORTHEFOLLOWINGREASON(SEC.]031.SBUSINESSAN�PROFESSIONSCODEANYC17YOq �: (n U CWNTYWHICHREQUIflESAPERMITTOCON57RUCT,ALTER,IMPfiOVE,�EA/OL15H2ORREOAIRANYSTRUF �,:;;w NHE,PRWp TO ITS ISSUANCE,ALSO RE�UIRES THE APPLICANT FOFt SUCH PERMIT TO FILE A SIGNED � W Patio/Deck ;�� SiATEMENT THA7 NE OR SHE IS LICENSEO PURSl1ANT TO THE PRONSIONS OF TNE CONTRACTORS ll- � ,� CENSEUW(CHAPTER9(WMMENCINGWITH3ECTIONIWo)OF�IYIS�ON30FTHEBUSINESSAND7R0� POOVSpH 0 FESSIDNSCO�EJOPTHATHEORSHEISE%EMPTTHEREFqOMAryDTHEfl4SISFORTHEALLE6EDEXEMP- �� (� .V TKKi.ANVVIOLATIDNOFSECTION7031.5BYANYAPPLICANTFORAPERMITSU&IECTSTNEAPPLICANTTO � Z Re•Root � pqVILDENALTVOFNOTMORETHANFIVEHUNDRED�OLUIRS(f500).j: � ❑I,ASONMEROFTHEPflOPERTY,ORMYEMPLOVEE5WITHWAGE5A5THEIR50LECAMPENSATION, ,'.0 CORI�IIBfGiel :Z. N7LL DO THE WOqK,AND THE STRUCTURE IS NOT INTENDEO Ofl OfFERED FOR SALE(SEC.7044,BU51� �� � '��. NE55 AN�PflOFESSIONS C�E:THE CONTRACTOPS IICENSE LAW�OES NO7 APPLV TO AN OWNER OF �'. � � PROPERTYNMOBUILDSOR�MPROVESTHEREON,MIDWHODOESSUCHWORKHIMSELFORHERSEIFOq �� .�.Q^ THflOUGMHI50RHERONMEMPIOYEES,VqOVIDE�THATSUCHIMPqOVEMENTSARENOTINTENDEDOq �. m ;Q� OFFEREDFORBALE.IF,HOWE�ER7MEBUILDINGORIMPROVEMENTISSOLDWITMINONEYEAROFCOMPLE- Z TION,THE OWNER-BUILOER WILL HAVE TNE BUi1DEN OF PROVING THAT HE OR SHE DID NOT BUII�OR � IMPROVE FOq THE PURPOSE OF SALE). t .W; ❑I,ASOWNfFOF7HEVROPERTY,AME%CLUSIVELVCONTRpC71NGW1THUCENSEDWNTRACTOqS '� TO CANSTRUCY TFIE PROJEGi(SEC.7oq<,BUSINESS AN�PROFESSIONS fqDE:THE fANTRACTORS LL yl�a��p� � ADJ.AREA__ '�'� CENSEUIWppESNOTAPPLVTOANOWNEROFAPROPERTVWFi09UILD50RIMPROVESTHEREON.AND - —' '�` WHOCONTRAGTSFORSUGHPRQIECTSWIiHACqNTRACTOR(5)LICENSEDPURSUANiTOTHECONTRAp qUANTITY �ESCRIPTION FEE Y� TORS LICENSE IAW.j. �' C7 IAM EXEMPi UNDER SEC, B.8 P.C.FOR THIS HFASON 1 Q � �� U ���� --_..- -- - �. ¢ LL DATE OWNER ~ � I- .�� :Z., "' —_ _ - W � LICENSED CONTRACTORS DECLARATION � �.; W �; IHEREBVAfFIRMUNOERPENALTYOFP[RJURYTHATIAMLICENSEOUNOERPROVIS�ONSOFCHAPTER '� � 'p.,,1 9�COIAMENCINGWITHSECTION70o0�OFDN�510N30FTHE8USINE55ANDPROFE9SIONSCADE.AND Z X�� MY LICENSE IS IN Fl1LL FOflCEAND EFFECT m �W� ^�- '-7 Q �:, UCENSE CLASS Q""I LIC.NO.�/���/ ' , j H� J W; DATE _ CONTRACTOR �S_ ' d .�; WORKERS'COMPENSATION DECLAfiATIONL��•C� a '��, i HEREBV AFFlRM UNOER PENALTY OF PERJURY ONE OF THE FOLLOWING DECURqTIONS: Z 0�� _IHAVEANDWILLMAINTAINACERTIF�CATEOFCONSENTTOSELF-INSUflEFOPWORKEflS' _ � '¢t CAMPENSATION,ASPflOVIDEDBYSECTION37o00FTHElA80RCODE,FORTHEPERFORMANCE W OF THE WORK FOR WNICH THIS PFRIAIT IS ISSUED. 0' � QW" ,I HAVE AND WILL MAINTA�N WORKEHS'COMPENSATION INSURANCE,AS RC-0UIRED BY SEC710N �' 37000FTHELABORCODE,FORTNEPERWRMANCEOFTHEWOHKWRWHICHTHISPERMITIS ��,,,�� IS5UE�.MY WDRKEFS'COMPENSATION INSURANCE CARRIER AND POLICV NUlABERARE: TION J' �. CAqqIER d 1 S� LAN REVIEW �� POLICVNUMBEN__Q�.. d �. (IHIS6ECTIONNE�NOTBEOOMPlf:7E00FTHEPEFAttISfORONEMRNJDRFA00 (S1U)ORLESSJ. PLUMBING _ . Z �CERTIFYTHAiINTIiEPERFORMPNCEOFTHEWOflKFOflWMIGXTHISPEflMITI5155UE�.1 MECHANICAL CJ SHA�L NOT FMPLOY ANY PERSON IN ANY MPNNER SOAS TO BECOME SUBIECT TO THE � (n WORNERS'COMPENSATIONLAWSOFCALIFORNIA.ANDA6HEETHATIF SNOULDBECOME INSPECTIONFEE � SU&IECiTOTHEWORKEflS'COMPEN6ATIONPROVISIONSO ECT FTHEUBOR �: �iy 7 j COD,ISHAII.FOqTHWITHCOMPLYWITNTHOSEPAOVISI ISSUANCE __ �•J t%�.Y 'SYY'#� ��, �.+� ` �p� DATE:�O __ APPLIC SMIP � •"`'y'�'�� J WARNINO:FAILURE TO SECURE WORKERS'COMPENSATION CAVERNGE IS UNIAWFUL,AND SHALL 9E ENERGY P/C �y SUBIECTANEMPLOYERTOCRIMINALPENALTIESANDCIVILFINESUPTOONEHUNDREDTHOUSAND Ppq e /� /��gq � OOLURS(5100,a00�.INAO�ITIONTOTHECOSTOFCOMPENSATION,�AMAGESASPROVI��FORIN ENERGYPERMI7 isCi S Ns �U69/ �� J SECTION97080PTHELABORCOOE,INTEREST,ANDATTORNEV'SFEES, °' �� �— p� RETENTION FEE: I a a , CONSTRUCTIONLENDINGAGENCY PRE-ALTFEE: O — �� I HEREBV AFFIRM UNDEfl PENALTY OF PERJURY THATTHEflE IS ACONSTRUCTION LENOING AGENCY __ FORTHE PENFORMANCE OF THE WOflK FOR WHICN TNIS PEflMIT IS ISSUED(SEC.3097,CIV.C.�. Z W --- � LENOEk'3 NAME___,_._ __, � LENDER'SAD�RE9S „_ , _ . W 1 CEflTIFY THAi I HAVE READ THIS/PPUCATIDNAND STATE THATTHEABOVE INFORMA710N IS CORREC7 TOTAL FEES � � •�� , d 1 AGREE 70 CAMPLY WITr7 ALL G�TY AND CAUNTY ORDINMlCES AND STATE LAWS RELATING TO BUILDING � CON6TflUC7lON,ANDHEREBYRU7HOR12EREPRESENTATIVESOFTHISCOUN7Y70ENTERUPONTHE ' Z, ABOVE-MENTKKJEO PROPERTV FOR INSPEC710N PURPOSES, . � � COMMENTS__, _ �- r ca�- � m PERMITfEENAME( ' Q � � �.. Uj SIGNATUREOF ITfEE ATE 7✓ � � RECPi NO. PAID BY VALI�ATIO ' WHITE—Departmen[Copy,YEL�OW—Finance Copy,PINK—Assessor Capy,GOLDENROD—File Copy,GREEN—Applicant's Copy . . � , _ i . �_.._�. I _�_ _�....--I �.... ,,, � !_...I i .r,...�_ i _.�_. 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