HomeMy WebLinkAbout10966 (5) �� --� CITY OF DIA�40ND BAR .
COMb1UNITY DEVELOPMENT DEPARTMENT
��....0 21660 E.Copley Dnve Suite I90 PRESS
(909)860-3195 Fax(909)861-3117
E3UILDING PERMITAPPLICATION � � FIRMLY
� JOBSITE r. ��- / �,f APPLICATION ,� I PERMIT 1
o ADDRESS�+{� S �'��'�''/`�� D�� ��+ DATE l NUMBER 1�
� ISSUE TYPE OCC
APN LOT TRACT DATE CONST. GROUP
p OWNER 1�f S
o ADDRESS �1' Gt� �t Gr '1 O ZONING SETBACKS
z CITY / � �u7,1� /7 TEL. /��J� FRONT RW ❑
o APPLICANT /1/��T_(�lL/►,S k�TEL. ` /� REAR ❑
Z SIDFJSIDE STREET FiW ❑
¢ CONTRACTOR U . / S SIDE ❑
o ADDRESS PROPOSED USE � �" � `�-' f^
o CITY ZIP TEL -- -.. _
ow ARCWENG/ ,
w DESIGNER NO.DWEL NO. NO.
n. ADDRESS
� CITY ZIP TEL. UNITS STORIES BEDROOMS
�
rn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION
p� OWNER-BCILDER DECLARATION SFR/ADD,'REM
O
p 1 HEFE6Y AFFIRA/UNDER PENAITY OF iERA1RY THAT 1 AA1 EXEMPT FROM THE CONTMCTORS U• Gar2g0/CdryOA
W CENSEUWfORTMEFOILOWWGREASON(SEC.)0.11.6BUSINESSMIDPROFFSSiONSC.O�E:MlVGTYOR (n
U COUNTYWHICNflEOUIRESAGERMITTOCONSTRUGT,ALTER�PROVE.DEMOUSM.ORREPAIHANYSTqUG W
W NRE.7RIOq TO RS ISSUANCE.I150 REWIRES THE APVLILANT FOF SUd1 PEHAIIT TO FILE A SIGNED w Pa:iO(DBGk -
STATE4ENT TMAi HE OR SHE IS IJCENSEO PURSUANT TO TME PqOVISIONS OF TME CONTHACTORS L4
� CENSE lAW(GUPTER a(COMAIENGNG VnTH SEC7qN 7000)OF DiY6�ON�OF TrtE BUS�NESSk:D PHO- LL" POOUSpe
� FESS�DNSCODEIOFTHATHEOR5HE15FJ(EMVTTHEREFROMAND7HE6ASISFOR7HEKlEGEOEXEMP•� C7
TION.ANYV�OLATqNOFSECTKKJ7a7f.5BVANVAPPLICANTFORAPERMRSU&IECTSTHEAPPL�CANTTO Z Fi8-ROO}
A GVIL VENALiY OF NOT MOHE THAN FIYE HUNDRED DOIURS(Isoo).):
� ❑4�SOWNEROFTMEPROPERTY,OflMYEMPLOVEESWITMWqGESASiMEIRSOLECOMPENSATqN, 0 COrtIrt10fCIdI
Z WILL DO TXE WORK ANO T11E SiRUCTUiiE IS NOT INTENDED OR OFFEReD FOq SALE(SEC.7M�,BU54 J
� HE55 AND 7ROFESSIONS COOE:THE CONTpACTORS IICENuE UW DOES NOTMPLY TO AN OWNER OF ?
FROiERTY YlFiO6UliD5OFi IM7ROYE5 TFiEFEON.AIvD 1VN0 DOES SUp1 WORK F6MSc"lF Oft HEFSELF OH '
[[ THROUGH HIS Dii XEROWN f1APLDYEES.PHOVIDED THAi SUGI YIPNOVEIAENiSALiE NOT W TEN�ED OR LO
_ 0OFFEREDFORSKEIF,MOWEVEF�iHEBU0.DWCORIM7ROVEMENTIS50lDWITNINONEYEAROFCOMPIE�
Z TION.TFIE OWNER-BUIIDER YnLL HAVE TME BURDEN OF PROYING TNAT ME OR SME DiD NOT&IILD OH
= W7(iOYEFORTME%IRVOSEOFSAIE�.
w 04ASOWNEROFTHEPROPERTV,AMEXCLUSIVELVCANIMCTINGWITHLICFNSEOCONTRACTORS
(L TO CONSTRUCT TME iRQIELT(SEG 7W�,BUSINE55 AND PROFESSKKiS CODE:TME ODNTMLTORS LL vdIU2l10f1 ADJ.AREA
W CENSELAWDOESNOTA7PLYTOANOwNENOfAGFOPERiYWHOBURD50RIMPpOVE5T1E0.EON.AND
� VAIOCONiMCTSFORSUp17ROJECTSM7THA00NTRACTOR(5)LICENSWPURSUANTTOTHECO4TRAC ounrmrr DESCRIPTION FEE
� TORSUCENSEUW.J.
� O I AM E%EAIP7 UNDER SEC. B.i P.C.FOq THIS RE/�SON ¢
� U
� ¢
DATE OWf:ER V
Z W
� LICENSED CONTflACTO 5 DECLARATION � _ ' W � �
�C INEREBYAFFIflNUNDEflVENALiYOFPERIURY7MATIANLICENSEDUNDEq�fiOVI510N50FGHAPTER �
� 9(C0IIMENCW6WITH5'eCTION7000�DFDM510ti�OFTHE8U5WE5SANOFROFE5510NSCODE,AND Z
X uY LICENSE IS W FULL FORCEANO EFFECT. m
LLI
� LIGENSE GUSS UC.NO. j
V �ATE CONTRACTOR d
W
� WORKERS'COMPENSATION DECLARATION �
d
� I MEREBYAFFIflM UNDEfl PENALTY OF PERNRY ONE OF iHE FOLLOYfING OECURATIONS: Z
� _IHAYEANDWiLLMtiNiAINACERTIFICATEOFCONSENiTOSELFaNSUREFORWORI(EfiS' _ �
� COA/PENSATION.ASPROVIDEDBYSECTION3TOOOFTMEU80HGODEFOHTNEPERFORMANCE W
OF THE WOR1C FOR WM�CH TNIS PEHA1iT IS tS5UE0. �
� _
w �iHAVEANDWILLEWNT/JNWORKERS'CONDENSATqNINSURINCE.ASREW�REDBYSECiION
O 37000FTMELABOHCODEFORTMEPERFORMMICEOFiHEWORKFORWHICHiF115PERM1T15
ISSUED.�YwORKERS'C0IAPENSATIONINSURANCEGARIERANDDOLICYNUMBERARE CONSTRUCTION
j cuaqieR PIAN REYIEW
0 POLICYNUMBER ELECTRIC [�
� (M1USSECtt[xINe�WrBEC�MRE7mOCT/EVEaAMr6lOFia:EHl�Oi7EO0ol1ARs(Stm�Oqtf551 PLUMBING . �m
Z I CEHTIFY THAT W TME PERFORMANGE OF TNE WORK FOfl WHIp1 TH15 PEiiMI7I5 155UED.l NICAL
(} SMALLNOi E�IPLOYANY FERSON W ANY AIMNEN SOAS TO BECOME SU&;ECi TOTNE
� WOW(ERS'COMPENSATqNUW50FCALIFOPNI^ANDAGREETHATIfI5FKK1LDBECAME INSPECTIONFEE
S SU&IEGT i0 THE WORKEFiS'COMPENSA7qN PqOVISIONS OF SEGiqN 3700OF THE UeOH
CODE,ISHMLFORTHWITHCOMCLYWITHTHOSEPROVISIONS. ISSUANCE '�R �'^+� 1
p OAiE: APPLICANL SM�P . .. I
J wARNiNG:FIUUIRE 705ECUHE WOfU(ERS'WIAPENSATION COYEMGE IS UNIAWfUL M10 SHALL BE ENERGY P/C
� SU&IECTANENPLOYERTOGRIMWALPENALTIESANOCMLFWESUPTOONEHUNDREDTIKKISAND ENERGYPERMIT
DOLURS(5100.0001.w�DDITION TO TME CASTOF COMPENSATION.OAMAGES AS PROYWEO FOR W —it�,I—r—T—r/t`
J SEGTqN]7080FTMEUBORCOOE.�NTEHES[M10AiiORNEY5FEE5. RETENTIONFEE: �� _ � � t� (�� �
�
a CONSTRUCTION LENDING AGENCY PRE-ALT FEE:
O
� I HEREBYAFFIqAI UNDER DENAITY OF VER/URY TNAT THERE I5 ACONSTRUCTION LEN�INC AGENGY
FOB TME DERFORAIINCE OF TME WORK FOR WNICH iHlS OEfiMIT IS ISSUED(SEG 7097,CIV.C.).
Z
W
� LENOER'SNAME
F"� LENOER'S/�DflE55
� TOTALFEES �
¢ IGEFTIF7THATINAYEAEAOTMISMVL�CATIONANOSTATETHATTMEABOVEWFORMATqNISCARFiECT.
W IAGREETOCOIA�lVW17�/ALLCITYANDCAUNTYOflOWANCE5M1�5TATELAWSREUiWGTO6UIL01NG
� CONSTRUCTiON,AND HEREBYAUTHORRE REPflESENTATlVES OF TMIS COUNTY TO ENiERUPON TME
ZABOVE�MENTpNEDPHOPERTYFORIN5GEG7 PURVOSES. � �
� /// / � , / /. COMMENTS
�
� �
m PEHMI E RINT) �
Q ' •
� � -�(�
� S�G R OF VERAIITTEE ATE /(/)
S
RECPT.N0. PAIO BY v"� VAUDATION '
~ WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy.GOIDENROD—File Copy,GREEN—Applicant's Copy
�: -
: „� - - - - - - - - -- - - - - - -
� �
�'�,I
� .
�� I" '
0
;
,
:�. ? o �
� � Q w J
,' Q ❑ :,O '� � Z � Q � � � J Z .
W � Q
� m O �,�' ¢ °� =po ownc� o ? ¢ � � ¢ z " � m
� z cn cri � �
U � c~_n � o Owwzm � Z � ¢ Uc� .� gz u7azLLa ad. �
z �l,J I. � � J J U V O O Z � C7 Q W Z Q O C7 a � Z 1= w (A i�; �
i -� � �- �- ¢ m z p ¢ Z �` c7 -i ui � W H z a - O °-_� W r C
;� O � W CL [L J � � � [D 2 = W It LL. F Q W U W N W = W � �
¢ ¢ W W d d = m J � [=j U' = J J J !A V J � F- J � � u- '
F Q p o = oa ¢ ¢ o �"iz ¢ woz000 � �wzzZz ¢ wwz ��
0 � u. LL � � � u. � co u. a m ¢ LL a a a O � u. � o � u. x o w �.�
u. U
O.W
� a -
U
v t
^ r . ,
� � £ " i e_ �
I , a a.
p I - _
�
. �
' � W � Z ¢ � � � � � N W
� .. �{ � O � ' U = F- Z N [� F- Z � S J f7 V Z (n - tn N ,
ln CC � W � j F-. Z CC F- U � m � d � Q ' Y F" F_ Z CL 00 F- - Y Cn
J W W W Q W � � -1 U7 .J V7 � I- Z� '� I
� C7 a p CL ¢ � Z � Z F U � Z
i�Y ¢ V ¢ � W W Z � w ..� J � � Z J W Z Q�
� U O o [cOcn2C� Ox W d ¢ �=. � - � t¢- H �" O W J J W 1-H
t � ¢ u ¢ z � a � v� zc� xxsw zc� ¢ o� UagUxwa � — Ua
� cmaw � ¢ � � OQo » > o � JJ � 3awuaia ¢ ¢ ¢ � i. aw
{.._ J Q J W Qy � Q � � � � S X ¢ W Q W W W d Z Z Z'Z � W W
. - ��(/l lL W (.7 ln F- } CC LL Q Q � � fn W � U ❑ (/J Cn (n f:3 lL lL lL lL U �(n