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HomeMy WebLinkAbout16540 � �� CITY OF DIAMOND BAK � DEPPeRTMENT OF COM1AiiiUNTfY&DEVELOPMENT SERVICES 21660 E.Copley Drive Suite 190 (909)860-3145 Eax(909),$61-3117 PR'ESS �°� � BUII;DING PERMIT APPLICATION ' FIRMLY � �Gl�fs��•Ji� � SUE � � � ° NUMBER ' #�`d" a A�D RESS ���'� � ^ APPLICATION ,,. PERMIT /C �`� � � TYPE OCC APN LOT_� TRACT DATE CONST. GROUP p OWNER ��e�C-�'-�1 &��4,+��� ZONING SETBACKS Q ADDflESS c���l ��._cas2:os�— :�s'�" � CIIY �S' �°"�"t� 'ZIP ��G�TEL:. FRONT RW p APPLICANT I "� TEL:°1 i.��"���. REAR ❑ � 81DE/SlDE STREET_ RW ❑ � CONTRACTOR �' ="�f a�C."' SIDE � � ADDRESS ,— PROPOSED USE �� � G O gITY ZIP TEL.e�I �. _ _ w ARCWENG/ 4 ' " :. . ' �i � d DESIGNER �a'2�'`§�'� J�� �� eG-� � ADDRESS - 9�.� ;,� � �,���— ° NO.DWEL. NO. NO. '-���'' �-�i6�� �` --�'� UNITS STORIES BEDROOMS � CIT( i rC.^d"1nJ'A` ZIP � TEL. ' t�i DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATfC1N p� dVYNER-BUILOER DECi.ARA7iON SFR/ADD/REM ' O I HEREBY RFFlRM UNDER PENALTY OF PERJUR�'THAT'I AA1 EXEMPT FpOM THE CONTPACTORS EI- G81'dg8lC3fp011 W CENSEIJIN'fOR'HEFOLLOWIN REASON(SEC.7031SBUSINESSRNDPROFESSIONSCODE:ANYqTYOR [f� L7'.� .COUMYWkiICHREQUIRESAPER�[TTO,CONSTRUCT,ALiER.IMPROVE,DElAOLISH,ORREPAIRANYSTRUF �[,f �tIOlDOCk' ' � ' ' ' �'� TIRE,PRIOR 70 ITS ISSUMICE, 5o FiE�U1RE5 THE APp�ICANT FOR SUCH PEFC.,117 70 FLLE A SIGNE'J � '' �STATEMENT THAY HE 6R SHE IS LICENSED PUFI9UAN7 TO THE PROVISIONS OF THE CON7RACTOR5 LI- � � , � ".CER/5E LAW(CHi1PTER 9(COMM�CING WITH SECTION 7o0a}O DIVIS!ON 3 OF THE 9USINESSAN�Pp0- �"L' POOJSQB � � � FESSIONSWDE)Oft�'i9ATHEORSHEISE%EMPTTMEREFROMANDTI9EBASISFOflTHEALLEGEDEXEMP- (� �TpNANYYI6LATlbNOFSECTION703�bBYANYAPPLICANTFORAPERMITSU&IECTb'THEAPPLICANTTO Z Re-Roof � ACMIPENALTYOFNo7MOHET ANFIVEHUN�REp'DOLLARS{5500).): . . �I ❑I,MSOWNEROFTHEPROF�EATY,ORMYEAAPLOVEESWITHWAGESASTHEIR50LECOMPENSATION, ' G GomrnefCi81 . � � � ��N7LL DO THE WORIC,AND THE S FlUC7URE IS NOT INTENDEO OR OFFERED FOR SALE(SEC.7044,BU51� � � NESSAND PflOFESSIONS CWE E CONTRPCTOPoS LiCENS�lAW OOES NOT APPCV TO AN OWNEfl�F = . ' ' ' � . �PA�pEFTYV/F108UILD80RIMP�VESYHEREON.M'dN'HOOOESSUCHWOflKHIP.iSELFORNERSELfOR ' � "�THRIXIGHHISORHEHOWNEMPOYESS,PROVIDEDiHAT�.SUCHIMPHOVEMENTSAREN071MENDEAOR m W '..OFFEwECFORSN',.EIF.HOWEVER,TNEBUILDtNGORINPROVEMENTI55oLD'NITHINONEVEAROFCOMPI.E- VE ' Z, �.TWM,THE OWNER-BUILDER WILL NAYE''��?NE BUqOEN OF PROVING TNA7 HE OR SHE DID NOT BUlL�;JR . _ 'IMPROYE FC1R FHE PURPOSE OF$ALE).�� W ❑I;A$'OMMEROFTFdE'PRO$ERTY,AMEXCI.USIVELYCON8F9ACTiN6WI71;L7CENSEDCONTRAC70fl3 � � (r TO COtSSTqUC7PNE PR0.1EC7(SEC.9o'M.BUSINESSAND PqQFESSIONS CODS:7HE CONTRACTORS L6 � V9IU2t10f1 S P,Dd,AREA � W ,CENSE'LAM'DOESPqYAPPLYTO{�.�'•1 OWPoER�APRtlFERNWHOBUILD50fifMPflOYE5Ti1EfiF:9N,AND � ''�WFFDCANTRACiSFORSUC}iPflOIIECTSNATI+AC'SNTpACYOR(S}LICEN3EDPURSURNPTOTHECONiP,AG (�UAfJTITY QESCP.IPTION FEE � , �.. YORS LICENSE LAW.!' . I.. . . . ' o ' , B.6 P.C.FOR THIS REASGNI Q � � ' ❑IAN E%EMPT UNDER S�C.!� ' '� , r. � �, U .. .. . . . . . LL � DATE '�. .. obVNEP V . ��' . Z I . . W �..... � . . � . . � Qy[�. . � LIGENSED CPNTRAC70RS DECLARATiON � � -' �� � , f�Y' IHEREBYAFFIPMUNUFAPENALT�'OFP�ER!URVTHA71AML10ENSEDUN�EPPAOVISIOWSOFCHAPTER � , '' (i 9�COMMENCSNGWITHS'cC710td70W)OFtlIVI510P�30FaHEBU51NES5pNDPROFE9SIONSCODE.AND � MY LI�NSE IS IN FU4.6 FOftCE hIV�EFFECT. � � g �'� Q, LICENS�6LASS � �,, . LIC.N0. '� w �. ��_�„ . �� V�. ,DATE - ,j��,�_,__ CON7RRCYOR a �L� �i'9s� �I lil. � d��� WORK�FIS'CO�APENSATlON DECLARATION Q �, ��� i HEAEBVAFFIqI.i UNDER PENALN OF PERJURV ONE OF7Hc FOLLOWMG DECLqRATI�NS: � '. �'� ^IIiAVEANDWILLMA1NTpIp�ACLRTIfi�A7EOFCONSENiTOSELF-INSUREFORWORI4ER5' _ � 1XJMPBdSATlDN.ASPROVOECBVSECT10N37000FTNEUBOpCODE,fOpTHEPERFORMANCE UW OFTHE WORK FOfS WHI�THIS PERMIT IS I�SUEO. " �',:� �� ' , I � � �� �IHAYEANDWILLMARINTA%WtlRKER3'CAMPENSATIONINSURANCE,A3flE�l11REDBYSECTlGN �� �„ �^ 9Yoo 0�'THE�OSUR WDEI FOft7HE PE9r'ORMANCE OF hIE WORK FOR WHICH iHIS P'cpM1T 15 '9r19 ISSLIED.AAYWGWK�S'CX7�MPEN§ATIONIHSUR&h10ECARRIERMAPOLICYNUMBERARE: CONSTRUCTION (f`a �� caqaiEa � � �^ PLAN REVIEW - � , �� rot�icrNUMeER - ELECTRIC �_ d . �, (5HI5SEGT:cA'NEEUW7TBE�I�CC.AriP[�.EIEDOFT}�PEr'N7�ISPJRUNEHUI�PiE�CAlARS{Sta@ORlESS). PLUMBiNG _ ' Z' � d CERl'lFYTNA7 W TNE PF,RFOflMANCE OF iHE WOpK FOR WHICH THIS PERMIT IB ISSUEO,I MECHANICAI. �. - SHALL?J07E0.1PLOYA^iYR�RSqVINA��IYAAAMNEASOA570BECOPAESUBJECTTOTHE , �. WORKERS'COMPENSATIOh1.LAW50FCALIF061NIA,ANDAGREE7HATIFI3HOULD9ECOME iPJSPECTIONFEE �,r '� SUBJECT YO PNE WORNE'p8'COpAPENSATION PROVISIONS OF SECTION 370o OFTHE LABOR �� GOOE.tSHALLFORiHWITY�COMRtlMtliTHTHOS^ ROYISIONS. ISSUANCE --�,�_.._� _I� p, DATE• - AqPLICqNT.• '^d�, ,� �SMIP �' T� � `'y� �i�4 � ��, �� 1 �' ENEFGYPIC �� 4 ���— WARNING:.fqILURENSECUflEWy�9KER5'GOM. SATICNCOVERAGEb'UNLA I,ANDSHALLBE rp $ ', �, SUBJECTAN EMPIOVER TO CFIMIHAL P�NALTI �AND CIVI�FlN�S UP TOONE NDRE�THOUSAND �NERGY PERMIT �� r� q ' WLLARS(3'tOqObD),IN AOnITION T THE'CDSTOF COMPEkSqTK]N,�pNAGES AS PROVI6E0 FOR IN '. J SEC?ION 37ae Of THE 1A80R CAD�INT�flES7,ANDATTOHNEY'S FEES. RETENTION FEE: �' '�. aw.. COi�SPRUGTiON LENDINGAGENCY PRE-AL EE� � O � �' lHEREBYAFFIRMUNDERPENALTyOFP�'RJURYTHATTHEflEISACON57AUCilONLENDINGAGENCY _ - - ' ' � FORTHEPERFORMANCEOF7HEV�,ORKFORWHICHTHISPERMITISISSUED�SEC.309],CIV.C.). . . W. . t �� LENDER'SNAME � � ' � � ' - �. F—�� LENDEH'SAD�RESS � �� � � ICERTIFYTHATINAVEREAATHISAPPLICATIONANDSTAPETHATTHEABOVEINFORMATIONISCOpRECT. �OTAL F�ES . ,� �,�i IAGREE TO COMPLV WITH ALL CITYIANO COUNTV ORDINANCES AND STATE LP.WS RELAi1NG TO BVILDING � � � ' CONSTftUCTION,lWDHEREBYAUTMORIZEPEPRESEN7ATIVESOFTHISCOUNTYTOFM'ERUPONTHE � � � - � � . , � '�, ABOVE-MENTIONED PROPER7V FOR INSPECiqN PURPOSES. COMMiENTS ' � 3��� �✓�L.'���+" e _ . ' . � .. ' . ,. . � ;.,YER EE�NAME(PRINTI � . . . � � , � . c�s r� .2-2 :�'' � " .s [` � (/,�,��;�'., NATURE F PE lTTtE � I "" TE ' � ' ' � �,,�,; . 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