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HomeMy WebLinkAbout14607 CITY OF DIAMOND BAA /� -- DEPARTMENT OF COMMUNTfY&DEVELOPMENT SERVICES � _ : � 21660 E.Copley Drive Suitc 190 (909)860-3195 Fax(909)861-3117 PRES$ ` ���' BVII�DING PER1VtIT APPLICATION —__ FIRMIY } JOBSITE r,,,,,, t ,ti�� � ,y APPLICATION,•, j : PERMIT +- P/C 4 ADDRESS s•�,�s � o i°��.. i t. L«.; �'i i°1�; �,� � �# I �.Q D ��� ;M p DATE �' NUMBER � ISSUE TYPE OCC APN LOT TRACT pATE CONST. GROUP p OWNER �' ,d,`- � �-F�r e..#�% p ADDRESS ' ''�'� ZONING SETBACKS Z CITY �;ia��e,..,.s.�; t��,�o�. ZIP s� " s�gy FRONT RW ❑ �(TEL. �*" g APPUCANT •*.i,=�— TELW�� x��x #�.�+�} SID SIQESTREET RW��._. - � CONTRACTOR SIDE ❑ g ADDRESS PROPOSED USE " o CITY ZIP TEL. ARCH/ENG! DESIGNER NO.DWEL NO. NO. = CDDRESS Z'P _�L UNITS STORIES BEDROOMS � cr� DESCRIPTION S�.FC FACTOR PSF ADJ.AREANALUATION � OWNER-BUILDER DECUIRATION ���� O p I MEREBY AFFFNI UNDER PENALTY OF PERJURY THAT 1 MI EXEMPT fFi0A1 THE CONTMCTORS LL G�� .� rt C�ISEUWfOR7YlEFOLLOWINOilEA.90N(SEC.M31.68USWESSANDPROFESSIONSDOOE11NVdTYOR (� � � OOUNTVWHN�IREOUIHESAPEpMITTOCONSTRUCI;ALTE0.lA1PROVE.DBdOLJS1i.ORREPNk�N/S7RUG W Patio/Dedc TLIRE,PRpp M ITS ISSUANCE.ALSO HEGUIqES i}iE MPLICANT FOR 9UCH PERMIT TO FILE A SIpNED W STATEMENf THAT HE WI SHE IS UCENSED PURSUMlT TO THE PROVISIONS OF hIE COMIUCTOR9 U• � CENSELAW(ClIAPTERa(COMMENGNOWITHSECTIDN700o)OFDM8KKi30FTHE8U31NES5ANpPRO- �' PpOVSpe iE58Kz`:SCG"JOiORFHKPHEORST:SiSE7(EMFTTr1EREFRG�IANDTtiEBP515F-0RTPIEALLE6EDE%EMP � TION.ANYVIOlAT10NOFSECTIDN7W1.68YANYMPUCANTFORAPERMRSUBJ6C757HEAPpLICANTTO Z Rg-Rppf � ACMLPENAL7YOFNOTMDREIHANFNEHUN�RE000L1ARS(t6001J:. U �l7.11SOYYNEROFTHEPROPERTY.OFlMVEMPLOYEESWITHWAOESASTNEIRSOLECOMPENSATION, � (;pmmaroia) - � WILL DO iHE WOqK,AND fliE SiRUCiIJRE IS NOT INTEND6O OR OFFEp�FOp SALE'(SEC.70Y.8U54 J � NE&4 AND 7ROFESSION3 COOE THE OONTRACTORS 110EN8E UW DOES NOT APPLV TO AN OWNEp OF � PHOiEp'fYNFIp BULp3OR MAPqOVES7NEREOH,ANDN7q DOES SUCH WORK HIMSEGFOR HER5ELF OFl � THROUGHHISOPH910NMEAIPIAYEES,PRONOEDTHATSUCHIMPqOVEMENTSMENCTMTENpEDON m GFFERW FWiSN.E.�F.HONIEVER111E BUIIOWOON YdPiIOVEAI@R IS SOI.DYRfMNONEYEAHOFOGNiPLE Z �TIDH,TIEOWNEFi�UUN,DER 1NILL MAVE TiE BUMEN OF PROVIN(i THA7�NE OR SHE OID NOT BUIID OR = IMPAOVEWRTIIEPUHPO6EOFSALE} , . W ❑I.ASOYMEROFTHEPROPERfY,AMEXCLUSNELYCONTMCTIN�YATHLICENSEACONTMCTOFS � TOOONSTAUCTTHE PRO.IEC7(SEC.7W4,BU81NES5 N!D PROiESSI0N3 CADE TF�CONTRACTORS u�� V81U91iW1 ADJ.AREA CEN9E UW DOES NOTMGlYTO AN OWNER dFA PROPEH7Y Wi10 BUtlDS OR IYPROVEB TFYEREON.AN� NM1�OOOHTR�CTSFORSUCHPROJECTSNATHAWNTMCTOR�S)LICENSEDWRBUAHTTOTFIECONTM6 OUANTITY DESCRIPTION �E rans uc�s�uw.>. � ❑I AA1 EXEMPT UNOER SEC. B.6 P.C.FOR THIS REASON Q � �k:4 L¢� �, ��L�� ` � � 1 ��i L—`' wi� ; �" a ��'t� 6Y:.�ER ;� �`+�t_�e., U � ` LICENSED CONTRACTpRS DECIARATION W � IHEHEBYAfFIpMUNDERPENALTYOFPERlUMiHATiM1LICENSEDUf�ERPROVI310NSOFCHAPTER � � •(OOMMENCiNOWR1i5ECTiDH7000)OFDMSION30FTHEBUSINES6ANOiR�E55qN300�E,AND Z � MYIICENSE IS M FULL FONCE AND EFFECT. m � LICENSE CLASS LIC.N0. � �j DATE CONrHAC70R � OJ. W � WORKERS'COMPENSATION DECLARA110N � � i HEREBY AFflRM UNDEH PENALTY OF PEitR1RY ONE OFTHE FOLIOWINO DECLAMTIONS: Z � _INAVEANGWILLMAINTAiNACER�FM.tTEOFC9N3EM'TOSFLFdNSUREFORIM]RKERS' $ . COMPENBATION.ASPi10VIDW8YSECTON37WOFTHELABORCODE,FOR7HEPEHPORMANCE W O OF7HE WORK FORNM1IKYITHIS PERMR IS ISSUEO. � � _IHAVEANDVALLMIAINTAINWORICERB'COMPENSATIONINSURlWOE,IlSREOUIREOBV8ECTqN � 97o00F TiE LAHOR COOE,FOR THE PERFOqMANCE OF THE N'ORK FOR WHICH 7HI8 PERMIT IS . � ISSUED.MY WORKERS'COMPENSATION IN31/MNCE CARRIERAND POUGY MIMBERME:� CONSTRUCTION ?. CARRIER PLAN REVIEW � POLICYNUMBER EIECTRiC � ? , �-�.`:� � �nss[cn�r+r:emrar�oo�oF��scaam+�e��oolnrs�i+a�oq� PLUMBiNG � . Z ICER71FY7HATINTHEPEHWRMMICEOF7HEWORKFORWHIpihIISPERMRISISSUE0.1 MECHANIGAL C_'3 SWLLINOTEMPIOVANYPER90NINANYMANNERSOqSTOBECOMESUBJECTTOIHE d. . y WOPoCERS'COMP9JSATION LAWS OF CALIFORNIA�ND AOREE THAT IF 19FWt1lD BEDOME INSPECTION FEE ' SUBIECT TO THE WORKE0.S'COMPENSATION PROVISIONS OF SECTION J700 OF 7NE LNBOR 7p� � � coos,i s�wt coannvm�ca.�ai.v wm�nase nAowsaNs. ISSUANCE ?��.C,�'f 1 ,g� ' - p OA7E: APPUcntti: - . SMIP �— . � ENERGY P/C WARNINO:FAIIUqE TO SEWRE NfORKERS COMPENSA710N COVERAOE IS UNUWFUL,AND SHALL BE y_ SU&IECTANEIAPIAVERTOCR141NALPENILLTIESMIDCMLFINESUPTOONEHUNpqEpTHOUSANp ENERGYPERMIT �OLLMS(f100.o0a�,IN�DOITION TOTHE COSTOF CO►tPENSATION,DAMAQES AS PROVIDW FOR IN 91 � 9ECTION97olOF1HELA90RCODE.INTEPEST,MDATfORNEY'SFEES. RETENTION FEE: 'i � �'7'��h Ri(f"1T"'1 TS n r� ��Y 37SY EST.T+.'_Rs7'j�T� O CONSTRUCTION LENDING AGENCY PRE-ALT FEE: R'���� R��c-�y,�.-._,�_ � -IHEHEBVAFFIRMUI�ERPENALTYOFPERJURYTHAT7HEREISRCONSTAUCTIONIENDINOAGENCY � � � � � - , FORiHE PEFlFORMANCE OFTHE WORK FOR VhiICHT113 PERMIiI51S5UED�5EC.3007,CIV.C.�. Z , W � LENDER'S NAME � .. ... � � - . h—� LENDER'SAWRESS � ICERTFVTHATIFUVEREAD7HISMPIJCATIONANDSTATETHATTiEABOVEMFORMATIONISCORRECT. TOTAL FEES �� 4"' � �� ' � � � �' W -f7cOREE TO C9MPlY WTi ALL qTY AND COUNTY ORDINlWCES AN�9TATE UW3 RELATA1Ci TO BU0.DINO � CONSTRUCTION.ANDHEREBYAURfORIZEREPRESENlATIVESOFTMSCOUNTYTOENTERUPONTHE� �. �- .. .. � ABOYE•MENTIONED PiqPERTY F9R INSPECTION PUFP4SE5. COMMENTS . . .. � . � y / . . . - .. . . . �, _ �4" hs.�#Lr��,i Cr'�1 � PERMIITEF,{YNA��PRINn " - / � � ,d !1 ^L� d�! � [„�`4 , � N 9qNJ1TURE OF PEtiMfTTE �� RECP7:NO. � > � PAID 8Y 'VAIIDATION��. -..•.-�^�'"�� . � WHITE—Depertrnent Copy,YELLOW--Finanee Copy,PINK—Meeaeor Copy,GOLDENROD�—Flb Copy,4REEN—ApplieanPs('.opy . . .. _ . _ . .... .... .. . ... ... �Z -� � �-.--.- � ��� 0�- � - � � �.��