HomeMy WebLinkAbout15088 (29) � , �
CITY OFDIAMOND BAR
-� �� - DEPARTMFNT OF COMMUNITY&DEVELOPMENT SERVICES �
�,c . 21660 E.Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117 PRES$
�`�^'� BUII.DINGPERMITAPPLICATION � FIRMLY
o ADDRESS �,i� 7J Gl' D�J�JW'u./D �Fi'�TL �� DATEICATIO L NUMBERI�OSU ����� �
� APN LOT TRACT ISSUE � TYpE pCC
DATE � f�-�7v CONST. GROUP
p OWNER n
p ADDRESS '� ZONING SE7'BACKS
� CITY ' � ZIP � TEL ,.�.. � FRONT RW ❑
APPLICANT TEL REAR ❑
� 51DFJSIDE STREE7 RW ❑
CONTRACTOR SIDE p
ADDRESS
� CITY � ZIP TEL � � AOPOSED USE '
� ARCHlENG! � �
DESIGNER NO.DWEL NO. NO.
= CDn,DrRESS ZIP TEL. UNITS STORIES BEDROOMS
�
v� DESCAIPTION S0.Ff. FACTOR PSF ADJ.AREANALUATION
d ONRVER•BUIIDER DECLAFlATION SFR/ADD/FlEM
O
p I MEREBY AFFIRM UHDER iENALTY OF PERA/NY iMA71 AM EXEMPT FflOM THE CONTMCTORS LF Garage/CarpoR �
llJ CENSEUWFORiHEiOl10WNOfiL.l50N(SEG7W1.68US4lESSANDCROFESSKKJSLOOE:ANYCRVOR (n
� pOIMTYNR11C11REdJIi1E5A7ERYRTOCONSTAUCT.A1iERNPROVE.DE110LISH.OqREPAIfiANYSiAUC. W PBSINDBd( -
NRE PAqH TO RS ISSUANCE,h150 REWIRES TNE APPl1GWi FOR SUCH VERMIT TO FILE A SIGNED'
��� lTA7EMENT iHAT HE OR 6HE IS UCENSED PURSU/fR TO iHE PNOVISiCHS OF THC CON7MCTOFiS ll� �
� CENSE UW(OIAPTEN i(WN4ENCNO WIiH 5EC11�N 7000)OF pVI510N!OF TNE BUSINESSM'D PRO• LL FooVSpa �
fE3SqN5 COOE)OH THAT HE OR SME IS EXEMPT MEREFRqA M'D TME BASIS FOR TME 11LLEGED E%ENP•
710N.AHYV�OLAiIDNOFSECT10N7o7t.6BVAHYAPPIICAHiFORAGEP/AIT6lAJ[CfSiHEMPLICAPfiTO Z RrRoo1
� /G7V4,VFNALTYOFNOTYdiETHANiIYEHUNDFEDDOLUN5I75o0)J:
� Ol�a'�NEROFTHEiROPERTI;ORMYEMPLOYEE5W1T11WAGE5A3TME�ASOLECOMPENSATqN, O COTme(dal -
Wl1 DO THE WOPo(ANO THE 6TRUCNRE IS NOT IMENO[D OR OFFERED FOR SALE(SEG 7a�,BUSi� ,...I
� �SSA1aVq�cE55qNSO00ETMECOH�MCTON5l1CFN5EUWDOESNOTAPP�VTOANOWNEROF ? .
iROiER7Y WHO BU4D9 OR IMPROVES TIEREON,/ND Wlq DOES SUGI WORK MiMSCLF pq MEPSEIF OR
� 7MHOUONMSORHFRONRIE4PLOYEES.FROVIDEOTHATSUpIN17ROVE�IENTSAq[NOTMENDEOOR m .
�7 OFFHiFS7iORSALEIF,110N�VERiMEBURDWOORIYPROVE4ENTL4SOlpN7TYNONEYFAROFCOA1q.E•
Z �710N,TNE OWNERbU0.DER WiLL Yt�VE TME BUPDEN OF VROVINO T1AT/IE Ofi 6HE DID tqT BUItD Oit
= W PRDVE FOR TF1E PURPOSE OF BALF�
�y,� ❑IJISOMMEROFiHEViiOPEHfY,IWE%0.USNElPCONTRACfwCNiTNUCENSE�CDNTMCTOfiS
� ,�70 0DNS7RUCT THE iROIECT(SEG 7W,BU51N[59/JIO PROFESSIONg C0t1E T11E CONTMC70RS t1• ValUBtion ADJ.AREA
,CFHSE UW OOES NOiAPVLYTOMI OWNER OF APRO�EHiY WMO BUILDS OR 0.�PROVE9 THEREON./ND
Z� WIqCDMfUCf5fOR5U01PR41ECT5YATHACONTMCfWyS)LICENSEDFURSUMfTTOTNECONiRAG pUANTITY D[SCRIPTION FEE .
- � ^rauucenseuw.}
O I AL E7fEYPT UNDEfl SEG 8.�V.G FOR THLS pU50N Q
t V�C
� Q4TE OWN[R r
� U � .
LICENSED CONTRACTORS DECLARATION W
� IHEREBYALFIitlAI.NDENPENALTYOFOERIUR�'TIATIIUALICFNSEDl1�1�EAPRON5qN50FCMAPTER Ur
� ��COLWENCWOYlIT75ECTION700oI�FDIViSqN]OFTMEBUSINESSANDVROFESSIONSOOD�ANO Z -
�� MYLICENSEISNFIALfORCGANDEFFEC7. m
� 110EN5Ea}SS���r LIC.NO. � 2
�"j wte {�—?— [�'9 cor+rAncroR (� J c.o.
w
� WORKERS'COMPENSATION DECLARATION 1 o�31� a
� INEREBYAFFlN.IUNDEHiE1ULTYOFPEKIUR'/ONEOF7/1EFOUAWINGOECUMTIONS: Z
� �IHAVEMA1NlLMNNTAINACERTiFIGTEOFCONSEMT06ELFaN.^,UREFORW01LCER5' y
� COI,IPENSATpN,ASPFlOVDEDBYSECTIONl7000FiNEL/�BOFCOD[,FORTFIE7EPCORMMICE �
OF Tl1E Wq1K FORYMICH TMIS DER4ITIS ISSUED. �
G
� �IHAVEANOWILLMAMA:NWORKERS'COAIPENSAiIDNINSUMNCE,ASHEWIREDBVSECTION
Q ]7000F1f1EUBORCOO�FORTHEPEHFON.�AFlGEOF7NEWORNFORWHIpihIISGERMITIS ��'G�
ISSUfD.I.(YWO{IKERS'CpAPENSATIONWSUHANCECAAHIERA4DPOLICYNUlABERARE: CONS�FiUCTION 1
r
j CAqPoER�� <- "1 � U PUW REVIEV! � � - � ,
� PoLICV�7UMeER t � ELECTRIC fl"�� e S',f`� :
' p (M65ECiCNrSEDWYBE00AFlEiEDOFMPEfixf6i0a01StL�fxiFDDOLLIIL"ptm)OqIESSy PLUR7[31NG
Z ICERY�iYT1uTIN7HEPERfORMANCEOFTIEYKMiNfORWMIdiT1n5PE�lit5155UCD.l MECHANICAL
(7 S�ULLNOTEMCWYIWYVEa50NNAM�YANNERSOA570BEO�lA"SU&IECiTOTHE �
� WOM(EFS'CdAPENSAT10NUW50FGWFOfWIq/WDIGREETNATiIS�KK1lOBEWYE INSPECTIONFEE . j
SU&IECT Tb TME WORKERS C01.IPENSATqN VFONSpNS OF SECTpN 77000F THE IABOIi ,�y
s E,19wLLFORTNnTHCOMMYW17Hri105EPROV1510NS ISSUANCE 'J: '.79� D. �D �
O •,�y I
DA7E: � � "� AaPL�c�wL SMIP II � �
W ENERGYP/C JT�, �� �I n
� WAiWIt1�:FALURETOSEWREVNHNERS'COMPENSAT COVE GEISUNUWFU4ANDSHALLBE —� r/�
� SIAJECTANEUPLOVERTOCRIM:NALPENALilESANDpVILFWESUPTOONf:HUNDRE0TH0U5MA ENERGYPERMIT � U � �/��1
DOLLAHS(f 100.D00�.W A;1DIT10N TO TME COST OF CDYVENSATpN,DAAIAGES�5 PROVIOED FOR IN �
� SECT�DN�7DEOFiN[IABORCOOE.NTEREST,ANDATNRNEY5FEF4. RETENTIONFEE: � I����a�^v �
oCONSTRUCTIONLENDINGAGENCY Pq ALTFE� �.A1t>.��i�1 i
� IMEREBYAFFIRYUI�DERPENALTYOFPEiWRYlHATTHEREISACON5TRIIGTIONLENDINOAGENCY l)�. L .
FdiTNEiERFORMMICEOFiHEriORNFOflMMIp17H15DENAITI5I55UED(SEG.]OD7,GV.C.�. .��,
Zti LENOERSNM+E ���� I I
g �r
C LENDER'SPDORESS �
W� TOTAL FEES � '
ICERTIFYMATIFIAVERE�LTWSAPPlICA7pNANDSTATETFIATTMEABOVENFON.iAT10NI5CORAECT. '
� IAGREEiOCOMPIYYVITHAl1CfTYlV+UCOINTYONDPUWLESANOSTATEUwSRELATNOTOBInLDINO /� A .
� CONSTRUCTqN,ANONENEBYAUT/qi11ZEPEPflESENTA71VE50FiH15COlMttTOENTERUPONTHE � 7 �Mjl� � I /`� �' M_� - � • • �
ABOVE�uENTqHEDOROPERTYFORINSDECT10NplIRfOSES. ✓ �"
o . COMMENT�, '�'�U J !�-tJ v.,�y� -
-� �' �n �l Y
� q����
m v¢auirrFE � lvfLr+r ' �
¢
� �
y SICNATUHE OF RMI RTE ��
� RECPT.N . PAID BY VALIDATION i
WH17E-0e0anmant CopY.YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENHOD-file Copy,GREEN—Appticant's Copy �