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HomeMy WebLinkAbout12913 (13) /�14 _ � CITY OF DIAMOND BAI� ' DEPARTMENT OF COMMUivITY&DEVELOPMENT SERVICES � _�_ ,; 21660 E.Copley Drive Suite 190 (909)860-3195 Fax(909)861-3117 PRESS ���A�°`� BUILDING PERMIT APPLICATION : FIRMLY a ADDR'ESS `�W�S����L-A��rY �i\� APP��CATION j�� Y PERMIT � ( P/C DATE_ NUMBER � !k c� ISSUE TYPE OCC APN LOT-,, �TRACT _� DATE CONST. GROUP p �WNER ���IS i=.�S�"Ff•F ti1�/N C'�'�"�' ADDRESS �-`�.' ZONING SETBACKS Z CITY ZIP TEL. FRONT RW ❑ -$ APPLICANT TEL. REAR n SIDE/SIDE 5TREET RW ❑ � CONTRACTOR SIDE ❑._ � ADDRESS CITY ZIP TEL. PROPOSED USE i ''� Q- � w ARCH/ENG/ .i� Q �ia.l GVl��'kAA S f• Q''s1 (l�.C; .9 W DESIGNER NO.DWEL. NO. NO. � ADDRESS UN�TS " STORIES BEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.Fi. FACTOR PSF ADJ.AREANALUATION � _ � OWNER-BUILDER OECLARATION SPR/ADD/REM O 1 HEHEBY AFFlRM UNDER PENALTV OF PERtt1RV THAT I AM E%ElAPT FROM THE CONTRACTOHS L6 G8f8Q0/C2(p01t W CENSEIAYtFOH'fHEFOLLOWINGREASON�5EC.7037.50U51NE53ANDPROFE3310N3CODE:ANYCITYOP � (n , - C� COUNiVWNICHHEQU1pE5APERMITTOCONSTRUCT.ALTER,IMPFOVE,UEMOLISH,ORREPAIRPNVSTRUC� W PffiIO/DBCk - W -TURE.PRiDR TO ITS ISSUANCE,ALSO FtEWIFES TME APPUCANT FOR SUCM PERMRTO FILE A SIGNE� w � 6TATEMENT TF�AT HE OR SHE IS LICENSE�PURSUANT TO THE PROVISIONS OF THE CONTRACTOHS L4 �- ,4 CENSELAW(CHAPTERB(COMMENCINGWITHSECTION7W0)OFOIYISION30FTHEBUSINESS/WDPRO� U- PooUSpa � FES9pN9CODE)OflTHATHEORSHE�SEXEMPTTHEREfROMANDTHEBASISFORTIEALLEGEOEX[MP- C7 V TIDN.ANVVbLATIONOF5ECT10N70313BYANYAPPLICANTF-0RAPERMITSU&IECTSYHEAPPLICANTTO � � Re-Roof � ACIVIIFENAl7YOFNOTMORETHANFIVEHUNDRED�OLIAflS(55oD).): o ❑I,ASOWN6iOFTHEPROPERTV.ORMYEAIPLOYEESWITHWRGE5A5THEINSOLECAMPENSATI�A1, � � CORIrtIBfC18I -' - - . Z WILL 00 THE WORIC,AND TME STRUGTURE IS NOT IYTENDED OR OFFERED FOR SALE(SEC.70a4,BUSI� .J MESS ANO PROFES&IONS CODE:THE CANTRACTOFIS LICEMSE I.AW DOES NOT APPLY TO AN OWNEP OF � PfiOPERIYWF7O8UIL�SORIMPROVESTNEFiEON,PNDWHODOESSUCHWORKHIMSEIFORHERSELFOR = . � THRWl3HHI50HHEflOWNEMPLOYEES,PROVIDEDTHATSUlX11MPROVEMENTSARENOTINTENDEDOR � - _ -L�J �FEFiE0FOR5AL.EiF,HONEVERNE�If.�INGOflIMPRaVEMENTIS50LDWfTHINONEYFAROFCOMPLE� � - �-•� TKKd,THE OWNER�UILOER WILL HAYE iHE BUfiOEN OF PROVING THAT HE OR 54E Di�k0T BUILD OR - -� IMPROVE:ORTNEPURPOSEOFSAL�. - ❑i,AS OWNER OF THE PROPEFiT:AM EXCLUS!VELY WNTRACTIN6 WIiH LICENSED WNTRACTORS - � TO CDNSTAUCT THE PR0.IECT(SEC.7al4.BUSINESS AND PROFESSIONS WDE:THE C�NTRACTORS LI� VeluellOfl ��"�� ADJ.AREA . -W GENSEUWDOESNOTAPPLYTOANOWNEFiOFAPFiOPEflNWHOBUILD50RIMPROVESTHEREON,AND -. F NM1pCONTflACTSFORSUCHPROJECTSWITHACqNTRACTOR(5)IiCEN5E0PURSUANTTOhiECONTRAG QUANT{TY DESCRIPTION - FEE � TORSLICENSEUWJ. - -0 ❑1 AM EXEMPT UNDER S�C. B. P.C.FOF2 TMIS qEASON U � 7 � LL ~ F OA7E oWP1ER U W - O LICENSED CONTRACTORS DECLARATION ;W � �HEREBYAFFIRM UNDER PENALTV OF PEf3lUHV THAT I AM LICENSED UNDER PROVISIONS OF CNpP7EF � - d 9(WAIAIENCINGW17H5EC710N70�0)aFOIVIS10N3oF7HEBU5INESSANOPROFE55lON5CC�E,.tv� z _ ]^C MY IIC�dSE�S IN Fl/Ll FOiiCE M1ND EFFECT. -� tl.l O � - � LICENSECLASS LIC.NO. .�. - V DATE COMRACTOR - - � n- - W � WORKFAS'COMPENSATION DECLAAATION_ Q . - -� IHEREBYAFfIRMUNDERPENALTYOFPEtUI1RYQYEOFTHEiOLLOWING�ECLARAT10N5: U [n__ Z Q 0 _IHAYEAt1DWIlLMAINTAINACERTIFiCATEOFqNSEMTOSEIF-!NSUflEFORWOHKERS' _ -� COMPENSATKKd,ASPROVIDEDBVSECTIQY3lWOFTHElA90RCODE.FORTHEPEHFORMANCE � _ OF THE WORK FOR WHICH iHIS PERMIT IS ISSUED. � _ lLl _I HAVE AND WILL MAIMAIN WOliKERS'COAfPENSATION INSURAPlCE,AS REOIIIRFD BV SEC7ION � - Q 37000FiHEtAeORCOOE,FORiHEPERFORMANCEOFiHEWORKFORWHICHTHISPERMITiS ��� �� � ISSUED.MY WOPKEAS'ODAIPENSATION INSURANCE CARPIEF AND POLICY NUM��RAflE: CONSTRUCTION }� jcARqiER PLAN REVIEW - � POLICYNUMBER ELECTRIC - "- - �ss[criavnE�naisEmnw.ErFnoFn�rEwxr�sraaoNErnx�xtE000un�s(Stroloa�Essl - PLUM6ING . C] - �� -Z �CERTIFYTHATINTHEPERFORMANCEOFTHEWORKFORWHICHTHISPERM.ITISISSUE0,1 MECHANICAL _____ � _ :�. - .� SHALLNOTEMPLOYANYPERSONINANYMANNERSOASTOBECOMESU6JECTTOTHE _ . . -� - - �- - -WOflKERS'COMP`cNSATIONLAWSOFCAL�FOflk�A,ANDAGREETHATiFISHOUIDBECOME INSPECTIONFEE ^ -� SU&IECTTOTHE�'�ORKERS'COMPENSATIDNPROVISIDNSOFSECTION3IUOOFTHElA00F ISSUANCE '� I��A.�A�._T_��� � �T� � -� COOE,ISHALLFOqTMWITMCAMPLVWITHTHOSEPROVISIONS. `�,���/ _o . . SMIP •"1 `� "' - p- DATE: APPLICANT. 7��p+�s�� p�y WWAflNINGFAIIUftETOSEWREWORKEflS'CAMPENSATIONCOVERAGEISUhLAWFUL,AND5HALI.BE ENEAGYP/C�=l.TBgyC.�lye�,�I�IA.��`i�T�-�'C11! �� � SU9JECTANEMPLOYEP70CRIMINALPENALTIESAN�CNILFMESUPTOONEHUNOREDTHOUSAND - �ENERGY-PE��JJ:q �e�"�C ,G���i��k��� DOLLARS(5100.Oo0),IN AD�ITION TO THE C09TOF CAMPENSATION,DAMAGESAS PROVI�ED FOR IN !-� -� SECTION97080FTHELABORCODE,INTEREST.ANDAT70RNEY'SFEES. - RETENTIONFEE: ';; � CONSTRUCTION LENDING AGENCY PRE-ALT FEE: "- ------__ ._.—..___ .�. IHEHEBVAfFlRlAilYOERPENAL7YOFPERJUFVTHATTHEREISACONSTHUCTIONLENOWGAGENCY - __.___—_ d -FOflTHE PERFORMMCE OFTHE WORK f-0R WHICH THIS PEflMIT IS ISSUED ISEC.3o97,CIV.C.), Z W --�- LENDER'SNMAE F– LENOERSADDfl[SS �� ICEFTIFYiHATIHpVEREAD7HI5APCUCATIONANOSTFTETMATTMEA80VEINf-0RMATIONISCORFECT. 7aTAL FEES i _� IAGPEETOWMPIYWITHALLCITYANDCOUNTYOflDINANCESANOSTATELAV�'SRELATINGTOBUILUING - - CONSTRUCTION,AND HEREBV AUTHORIZE NEPqESF.NTATNFS OF TNIS COUNTY TO ENTER UPON THE . ZABOVE�MENTIONEDPFOPEFTYFORINSPECTIONPURPOSES. COMMENTS - � ��K�tF � � N�-ff J m — a PERMITTEENAME(VPINn cn � 4 � '� ^ - .N SIGNATUREOFPERAI(TTEE � OATE ' -� Z- RECPT.NO. 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