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HomeMy WebLinkAbout16461 (75) �� _ CITY OF DIAMOI�TD BAR • � DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES ti �,� 21660E.CopleyDriveSuite190 � PRESS (909)860-3195 Fax(909)861-3117 , ����TM' BUILDING PERMIT APPLICATION FIRMLY N JOBSITE APPLICATION PERMR P/C o ADDRESS K1 DATE I l0 �_NUMBERI(s�L lo� N 8 ISSUE TYPE OCC g OWNER �OT TRACT�4� DATE ��I O 1 D� CONST. GROUP LL' ADDRESS1��01 VOA/ A/11191},AI SLI/ ZpI� ZONING SETBACKS w cmr�,�lwf� Ga ��P�.c� rE�aHq-7'}'1-� FRONT Rw ❑ � APPLICANT'��-p�,,�,�?j" TEL. �b..r.E REAR p � H""""' � SIDEJSIDESTREET RW O CONTRACTOR��AM6 A� �QL� SIDE ❑ � ADDRESS PROPOSED USE CITY ZIP TEL � ARCH/ENG/ • DESIGNER NO.DWEL. NO. NO. ADDRESS UNRS STORIES BEDROOMS � CiTY ZIP TEL. y OESCRIPTION SO.FT. 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UCENSED CONTRACTORS DECLAAA710N W � IFIENEBYAFFlRIJUNDERPEN�LLNOFPfiWM'TIA7IAAILKENSEDUNDERGROVISqNSOfCHADTER V. - s �(COwAENGwOYnTNSECT10N7ooa)OFOMSiON70FTMEW5:NE55�NDFNOFE55iON5COCE.�wO Z X W LICENSE R N FUIFORCEAND EFFECL m � UCENSE UJ15S 11C.NO. 7 � p,trE corirFucroa a WORKERS'COMPENSATION DECLAHATION 4 = U N 1lIER[BYAFfIRMUNOERFENALTYOiFERIURYONEOFTHEFOLLOWWGDECUMT10N5. � q � _�IHAYENA1MiLLWMTA:HAGEHTIFIUTEOF00N5EN7iOSELF-INSUFIEFORWONCERS' _ COYOENSAiION.ASFRONDEDBY5ECT10NJ7000FTNELA80pCOD[.FORTHEPEAFOMUNCE w OF TIE VJORK FOR VM1CF1 THIS VEq611T 15154JED. � � _I MAVE AND Wttl NA►fTNN WOi1KERS'OOMPENSA710N INSUHANCE,AS REOVIRED BV SECTqN 40 ]700 OF THE IABOR CODE,FON iHE OERWFIIANCE OF THE K'Oi1K fOR M'HICH THIS PEPAl1T IS ___ _ lSSUED.MYWONCERS'GOMPENSATpNiNSUiW/LEGMRiERANDPOLICYNUMBERME: CONSTRUCTION � CAMIER PLANREVIEW o POLiCYM1Y8ER �3r ELECTRIC � �mss�cmarrmrvoreEm�s+FrEoocnEv�aro�rsfano+ew�oo�u�u+sRim�a�tFssl PLUMBING Z ICEFTFYTU7N7H[PERFOfUUNCEOF7HEM/ORKFORWMCHTMISPER1At715155UED.1 MECHANICAL U 51ULLNOTEMPLOYANI'VE �MINM7YYANNERSOASTOBECOAIESUBJECTT07HE •-�— � WORKE1i5'Cd.�PENSATqNUWSOFGLLIFORNItiAND�CREE1MA71F151qULOBE0DAIE INSPECTIONFEE ��� S SU61ECii0T17EV/OfINERS'GOMVENSATIONCAOVISIONSOFSELTION]7ooOFiNEUBOR - ' - ' * p� E,ISNALLFOqT1lw1THCOMPLYYniHTHOSEP SiON ISSUANCE � �/�b� �� SMIP p DATE:�r.t�i— APPLICAM: . W ENERGY P/C � WMNINO:F�4l1RET0 SECURE WORKERS'CdIPENSATION COVEMGE IS UNUY/FUL,ANO SHAl1BE � SUBJECTMIEMP�OYERTOCJ1nAiNALPENALTIESMlOCmLiINE5UP700NEM1NDRCDTFqU5AN0 ENERGYPERMIT DOlL�RS�1100,000�,IN ADD(T10N TO 1ME fASY OF CdAPENSATION,DAIAAOES AS VRONOEO FOR IN � SECTION]7oe0FTMEUBOflCODE,IMEREST,ANDA7TORNEYSFEE3. RETENTIONFEE: - a CONSTRUCTION LENDING AGENCY PRE-ALT FEE: � O � IHEREBVAFFIRIAUNOfRPENKTVOFPERIURMTMATiNEAEISACON5TiU1CT10NLENDWOAGENCY Z fOH ME PENW MIANCE OF'IME WORK FOp Wr�ICM 7H15 PERAIi71S ISSUED(SEC.1oa1,CIY.C.} W � LEr.IDERS NAME . � lFNOER'SADORf55 � i�caEEio�i i�r�vmxui„cmumc�rou�rnv�Tu±u+cT sTu+osT�uwsa��n aroeUinE� TOTAL FEES � CONSTRLKTION,ANOMEREBVAUiHORIZENE�AESENTAT1YE50FT715COUN1YtOENTERUVONTHE /^ , S� ABOVE-IAEMIONEDPROPEHTNFOqINSPECTIONVVRP03E5. CO�AMENTS W��� � �►r1�' /2DDilE�}Fi?J21TI� � m I � PER EE NAM �PPIi f/) � y 6 OF E ITTEE 1 ' � HECPT.NO. PAID BY VALIDATION WHITE—DeDertment Copy,YELLOW—Financa Copy,PINK—Aseessor Copy,GOLDENROd-File Copy,GREEN—Applicanfs Copy " , . . � ' . J; � . , .4.. . . .. . '. _ . � .. .. -'Y. , , ' . . � .. .. � , �. . - „ _ . • CITY OF DIANiOND,BAR , : . , � � . , .. . �:�. it�SPECTiOtJ;RECORD �,;..::�• :. .���.. , � . . . �� •_i�_i�s:��;'"�lWl�i� �ol:.�ih�+�(►`_�-.�..��.�a'.�.�',1 S ,.._. .�►'�.�:��a'9[�;��I _,.,y_ .' ;�����r= ij��(y�:i�1 i.rd r y .r' ��^�.. ..,.«� �- .. . _. L�. �1J`;a9�..,�`r F ;SET BACt: �,� � -i, 1 ; 1 . ��FLOOR dQIS�=�--- .,�= �I.y:,.�:,...�a..��;y`:,tl�:'..'. i _ ` iFTGS/FOR��1S'ST—EEL l.:. �..: ... . ..� _ ;-r:i..•�. . FHF,REQ4�fsti''��'=-!':, "�=',='�•'`��``"'��a j-:�-�-t�,.�<� -- _ .. _ ,_ - 1__._— 1 '.!! .'"` UNDER FLOOR Dl1CT;�-;.;:Y �. ; �-LFCTRIC CROUNQ___ . . U j ' "'}—i`� �C;G�OU�JD PLU�v161i�G I • - UtJDER FL . �v'�Of�Dt1{�' � � �?!,-',��' , ' ' -..-�Glir'��s�hd-\a . �.-...iF-�. 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