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HomeMy WebLinkAbout16074 (20) _�� � � ` � CITY OF DIAMOND BAI� �—-��` DEPARTMENT OF COMMUNITY&DEVBLOPMENT SERVICES � W 21660 E.Copley Arive Sttite 190 ' (909)860-3195 Fazc(909)861-3117 PRESS r�'�J� BUIL;DING PER1dIIT APPLICATION F�RMLY �N JOBSITE � — ,A ADDRESS �/ ���..� ����.� DATEICATION � NUMBER��O� #/C � ISSUE TYPE OCC APN LOT TRACT DATE CONST. GROUP p OWNER �� �' � �1" ADDRES � /�L4 ZONING SET8ACK5 � ' LL' CITY � ZIP /1 'j TEL. �rd�'7 � REART RW ❑p � APPUCANT TEL. SIDE/SIDE STREET RW ❑ � CONTRACTOR �✓--� � ly/ SIDE -- ❑----_-- � CIIY ES� n +ZIP I"7 S TEL. �` �� PROPOSED USE � � i4ss/ -� ��✓ C � d�� w ARCH/ENG/ r=� �� W ADDRESS NQ DWEL. NO. � � NO. � � ��F c u°S' UNITS STORIES BE�ROOMS f � CITY ZIP TEL. � v� - DESCRIPTION S�.FT. FACTOR PSF ADJ.AREANALUATION ;.� OWNER-BUILDER pECLAFiATION SFR/ADD/REM O ..,�_ '- 1 HEREBY AfFlRM UNDER PENALTY OF PERJURY THAT�A.M EXEMPT FROM THE CONTRACTOFtS LI- G8/fl98JC9tp01'I ''W CENSELAWFOR7NEFOLLOWMGflEA50N(SEC.)031.SBUSINESSANDPROFESSIONSCAOE:ANYCI7YOR (n - - ._U. �COUpIT/WN�(�iRE-0UIRESAPERMITTOCqNSTRUCT,AI.TER,IA�PRPVF,DEAA041SH,ORREPAIRANVSTRUC- � patiolDsck - -,'�- 7URE,PRIOR TO ITS ISSUANCE,M.SO REQUIRES THE APPLICANT FOR 3UCH PERMIT TO FILE A SIGNED W - � �� � STATEMENT TNAT HE OR SHE IS LICENSED PUHSUANT TO 7HE PROVISIONS OP TME CONFRACTORS Lb � CENSE LAW(CHAPTEF 9{CAMMENCING WITH SEC710N 7000)OF DIVISION 3 0F THE BUSINESS ANO PR0- POOUSPB -_:� FESSqNSCODE�OR7HA7HEOH5HEiSEXEMPTTHEflEFflOMANOTHEBASISFORiNEALIEGEDEXEMP- _ (�� - ,.V TION.ANYVIOLATIONOFSECTION7o37.58YANYAPPUCHNTFORAVEHM1iSUBJECISTHEAPPUCANTTO Z Re-Roof � p„_,' ACIVILVENAI.TVOFNOTMOAETHANFNEHUNOPEDDOLLARS(ESOD).)� ' ' ' , ❑I,ASOWNEROFTHEPROPERTY,ORMY[MPLOV[ESWITHWAG[SAST}1EIRSOLECOMPENSATION, CORIII7BfClal � � _.��_ ��WILL DO THE WORK�D THE STflUGTURE IS NOT IPIrEN�EO OR OFFERED FOR SALE(SEC.7044,BUSI- - �'� - � ',-�; NE55 AN�PROfESSIONS WDE:THE CONTRACTORS LICENSE LAW OOES NOTAPPLY TO AN OWNER OF � � PROPERTYWHOBUILOSORIMPROVESTHEqEON,ANOWrIODOESSUCHWOFlKS{IMSELFORHERSELFOR - - '.��:-TNROUGHNISORMERONMEMPLOYEES.PROVIqE0TMA75UCHIMPROVEMENTSARENOTINTENDE00R -m � � - � -W�_ PFFEREUWRSAI.EIFHOWEVERTHEBUILOMGORIMPROVEMENTISSOLDWITHINONEYEAROFCAAADLE- � � . :'�'�-z�� ���TN#d,7NE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE�ID NOT BUILA OR � . . .:_:.. IMPROVE fOR THE PURPOSE OP 3ALE). � �W, -. ❑I,ASOWNEROFTHEPROPERf1;AMEXCLUSIVELYCONTRACTWGWITHLIGENSEOhQNTRACTORS y :� TOCONSTRUCT THE PR0.IECT(SEC.7oaa,BUSWESS AN�PROPESSIONS CADE:TNE CONTRACTORS U- V81Udtion �I/ - � ADJ.AREA ��Q �.-'Lll- CENSELAWDOESNOTAPPIYTOANOWNEROFAPROPERTYWHO8U14DSOflIMPROVE3THEREON,AND - ' +!-`�r `VhIOCONTRACT5FOR5UqiPR0.1ECT3W17HACONTRACTOR(S)LICENSEDPUFiSUANiTO7HECONTRAG QUANTI7Y DESCRIPTION FEE � .:..;Y. .TORS LICENSE LAW.J. . . . : . --,�-0y�_.- ❑1 AM EXEMPT UNDER 3EC. � B.8 P.C.FOR TNIS REASON. Q � ? (j � u'. �ATE OYINER � . . .. U .� . . . . . �_:�o . . . W .. .. . �, LICENSED CQNTRACTORS DECLARATION W � OG� IHEREBYAFLiFMUNDERPENALTYOFPERJURYTHATIAMLICENSEDUNDERPRCVISIONSOFCHAPTEfl- ' � --.d; 9(GOMMENCINCiWITH3ECTION70oo)OFD�YIStON30FTHE8U31NES3ANOPROFES910N3��✓Ayp � " - �X`. MY UGENSE IS IN FULL WRCE AND EiFECT. .J� m � LICENSE CLASS ���LIC.NO. .��( / �� ;� a � , '�.'.V, DATE CON7'fiAG70R�. . ..� � J . a- � �e t.i �I.S. . w � �� � „'�' WORKERS'COMPENSATiONDECLARATiON, , ¢ ' � J. ' `e�` IHBflEBYAFFlRMUNDERPEMM1LNOFPEflJURYONEOFTHEKO�LOWiNGOECLARATIDNS: � . Z � � - - . ' ' .- 0': _IHAVEANUWILLMAINTAINAGERTIFlCp7EOFCONJENTTOSELF-INSIIflEFORWQNKEHS' � - � x COMPENSATION,AS PROVIDEO BY SEC570F1370o OFTHE LA90R CQbE,FOR TFiE?EAPoRMANCE W OfTHEYdORKFORWHICHTHISPERMITI5i55UE0. - � ��� �IHAVEANUN'ILLMAINTAINWORKERS'COMPENSATIONINSURANCE,ASREQUIREDBVSECTION' - ' -Q� 37000FTHELABORCODE,FOR�fNEPERFORMANCEOFTHEWORKFORWHICHIHISPEFMITIS -�� ISSUED.MY WORKERS' SATIO SU NCE CARRIEft AND POIICY NUMBER AFE: CONSTRUCTION '$� ' �¢- CARRIEfl �' ' �6�� . y..�� .9. �PLAN REVIEW c ...,.�,_ POLICYNUMBEF ' � ^ .f—=-J ELECTRIC �HE�7� �—_—"-- .. �, (fHISSEi."TIONNE�NOTBE�0.4'LEfEDOFiIfPEM9TISFORQVEFiUDpREDooi.uas�po� PLUMBING I . .,W: � �p t �Z� ICEHTIFYiHATINTHEPERFORMANCEOFTHEWORKFORWHICHTHISPERMiTISIS UEDJ �MECHAIV�� f. _.('f; SHALLND7EMPLOYANYPERSONINANYMANNERSOAETOH[CAMESUBJ[CTTOTHL _ � _�� WORKERS'COMPENSATIONUWSOFCAUFOPNIA,ANDFGREETHATIFISHOUIO�eECAA9E - (NSPECTIONfEE � SU&IECTT07HEWOqKERSCOMPENSATIONPFO S E ION WOFTHELABOP �. cooe,isr+nuFoaniwin�coMP�vwin�r�o w .� ISSUANCE i ( :.O "''p.. OATE: APPLICANT: SMIP __ .:;;J:: WARNING:FAILUPETOSECUREWORKERS'COMPENSATIONCAVFRAGFISUNIAWFUL �SHALLBE ENERG�`��APp� _ --��y- SUBJECTANEMPLOYER70CRIMMA4.PENAI.TIESANOCIYILFINESUPTOONEHUNDREDTHOUSAND '"ENERty�E n � �� `-�� � I S GR+�� _ �- DOLLAflS(5100,000),IN A�OITION TO THE COSTOF COMPENSATION,�AMAGES AS PROVI�FD FOR IN ��.���(((['�� wT, , SECTION37080FTHElABORCOOE,INTEREST,ANOATfOFNEVSFEES. RETE�ICNV�Pttl. J F QA1 tl p�RM�T FOR - : a, CONSTflUCTION LENDING AGENCY pqE_p���� . �� -������ �NA� - �:--.-Q�_- IHENEBYAFFIRMUNDEHPENALTYOFPERJURY7HATTHEflEISACDNSTRUCTIONLENDINGAGENCY ES�P�-ANSSMA � � ,Z.; FOHTHEPERWRMANCEOGTHEWORKWRWHICHTHISPFflMITISISSUED(SF.C.3o9],CN.C.1. RE�UE�����' W . ' � LENPER'SNAME - - � � -F--. LENpERSADOflESS , �: /� , ����.': I CEFTIFY THAT i HAVE READ THISAPPLICATIONAN�STATE 7HAT THEABOVE INFORMATION iS CORRECT. - � � d' IAGREETOCOMPLVWI7HALLCITYrWDCOUNTYORDINANCESANDSTATELAWSREIATINGTOBUILDING TOTAL FEES � �(� - : � CONSTRUC710N,ANDHEREBYAUTHORIZEHEPRESENT�TIVESOFTF{ISCOUNTVTOENTERUPONTHE . ' . 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