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HomeMy WebLinkAbout15260 (20) I e -� j _ _�.� CITY OF DIAMOND BAIi � � DEPARTMENT OF COMMUNITY�DEVELOPMENT SERVICES 21660 E.Copley Drive Suite 190 (909)860-3195 Fa�c(909)861-3117 PRE$$ � '�' � BUII.DING PERMIT APPLICATION FIRMLY � JOBSITE / � /� APPUCATION .r RMIT fC' P/C/� o ADDRESS �qGr 3 �c�„S t ���F1�.° �•�� DATE �� NUMBER 1✓ � # V�� � ISSUE (s/� TYPE OCC APN LOT - TRA DATE t`"v CONST. GROUP � p OWNER �' "" ADD SS 20NWG SETBACKS Z CI ZIP T FRONT RW ❑ g APPLICANT r ,a REAR ❑ {s SIDE/SIQE STREET RW ❑ � CONTRACTOR Gt t � �Ba:C' SIDE ❑ ADDRESS � CIIY 21P TE� PROPOSED USE r t� v C�-C �� ' � ARG NG/ _ DESIGNEfl NO.DWEL. NO. NO. q. A�DRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. c�i� DESCRIPTION SQ.FT. FACTOR PSP ADJ.AREANALUATION p� OWNER-BWLDEH DECLARATION SFR/ADD/REM O Q 1 HER�Y AiFlRM UNOER PENALTY OF PEfiNRY THAT 1 AA1 EXEMPT FROM THE CONTRACTORS LI- GBtdgB/C3IPOft W CENSEIAWWRTHEFOLLOWINGREASON�5EC.7031.58iJSINESSANDPROFESSIONSCAOE:ANYCIttOP ((� . C.� WUNTYWFi1CHRE0UIRESAPERMiTTOCONS7RUCT.ALTER,IMPROVE,DEMOLISH,OHREPAIRANYSTRUG W Pflt10/DBCk - Z TURE,PRIOR TO ITS ISSUANCE.AL50 REQUIRES THE APPUCANT FOR SUCH PEfiMIT TO FILE A SIGNED - ' �- STATEMENT THAT HE OR SHE IS LICENSE�PURSUAN7 TO iHE PROVISIONS OF THE CONTRACTopS LI- � w �' CENSELAW(CHAP7Efl9(COMMENCINGWITNSECTbN7000]OFDIYISION30FTHE8USWE&SANDPFlO- V' PooUSpa - FESSIONSCODE)ORTNATHEORSNEISEXEMPT7HEREFFOMM707HEBASISFOHTMEALIEGEDEXEMP- -. TIDN.MlYVIIXATIONOFSECTION7Q91.5BYANYAPPLICANTFORAPEHMITSU&)EGTSTHEAPPLICANTTO Z Re-Root L_ A CIVIL PENALTV OF NOT MORE THAN FIVE HUNDRED OOLLARS{l600).j: �_ ❑I,ASON!NEROFTHEPROPERT',ORMYEMPLOYEESWITHWAGESASTHEIRSOLECOMPENSATION, � COmmBlCi31 WILL 00 THE WORK,AND hIE STRUCTl1RE IS NOT INTENDED OR OFFERED FOR SALE iSEQ 70N,BUS4 J - NESSAND PROFESSIONS CODE:THE CON7FiRCTORS LICENSE LAW OOES NOT pPPLY TO AN OWNEii OF �� PflOPEHTYWF10BUi1DSORIMPROYESTMEFiEON,ANDWHO00E55UCHWOflKHIMSELFORHEHSELFON = - �� THROUfiti HIS OR HER ONT!EMPLOYEES,PROVIDED THAT SUCH IMPROYEMENTS AiiE NOT INTENDED OR - � - . ,L�., ,OFFERWWRSN.EIF,HOWEYER7NEBUILDINGORIMPROVEMINiISSDLOWRHINONEYEAqOFCOMPLE- � TION,THE OWNER-BUILDER WILL HAVE iHE BUFDEN OP PROVINQ THAT HE OR SHE�ID NOT BUItA OR �; IMPROVEWP.THEPUPPOSEOFSAlE7. - � �J,J ❑I,AS OWNER OF THE PROPERTV.AAA IXCLUSIVELY CdMflACTING WITH L�CENSED COMRACTORS - ¢�; TO CONSTRUCT THE PRQIECT(SEC.70{4,OUSINE55 AND PROFESSIONS COD[:7HE CANTRACTOFlS LI- V8111d}�Ofl AOJ.AAEA ' -W� CENSEUWOOESNOTAPPLYTOANOWNEROFAPROPERIYWHOBUILDSOFIMPROYESTHEFEIXJ,AND �, Nh1000NTRACTSFORSUCHPRQIECTSWITHACONTRACTOR(S)LICENSEOPURSl1ANTTOiHECONTi7AG qUANTITY D S RIPTION FEE , �' TOflS LICENSE LAW.). J » . o O I AM P7 UN�ER SEC. B.&P.C.FOR THIS REASON � Q � � CJ tL � .z_. UI17E OWtJEF � __�� , y�s� LLI �6�; ICENSEDCO RSDEC ATION W �. --�K'�.- IHEREBYAFFIflMUNDEftPENALTYOFPERJURYTHATIAMUCENS[DUNb[flPflOVISION50FCHAPTER � -_=y�� �v,, .���-: 8(ODMMENCM!(i WI7H SECTKKi 7000�OF DIVI51�!3 Of THE BUSMESS AN�PflOFESSIONS CADE,AND � x'. AIY LICENSE 15 IN FULL ORCE AND EFFECT. Z -..W�` Gj/� a'"' .:,� . .�_ UCENSECLAS 'p LIQNO. �/L���� - ..� .V�.- DATE_� .pT_.V - CANTRACTORC� � W �- WOFiKERS'COMPENSATION DECLAHAl10N a . � d�.: ,�r-� U � � � ����- IHEREBYAFfIPMUN�ERPENPLTYOFPERlURVONEOFTHEFOLIOYJINGDECLAPATIONS: 4� � - �.. Q G)--, lINAVEANDWILLMAINTAINACFRTIFICATEDFCANSENT70SElf�INSUREFORWOflKERS' .T_ � - -.�` COMPEt1SATI0Y,A3 PRbVIDEO BYSECTION 370o OFTHE LA.DOR CODE,FOli 7HE PC(i�oRMANGE - W OFTHE WORK FOR WNICHTHIS PERMIT IS ISSUED. � 0. _I HAVEANO WILIMNINTAIN WOFKERS'COMPENSATIOfV INSURANCE,AS REOUIRED BY SECTION �) '-d�. 3700OFTHELABOACOOE,FORTHEPEflWRAIANCEOFTHEWORKWRWHICHTHISPERM1T15 � // '0��' �� ISSUEO.MY WORKEAS'COMPENSATIDN INSURPNCE CARFIER AIJD POLICY NUMBEfl APE: CONSTFjUCTION ���- ������:, cnantEA � PLANREVIEW 1 -��: ParoYNUMBER_ ELECTPoC -Z� - _`--_-"__"_ ¢, � _�_ . . (fWSSECIIONNE�MJTBEWNPLET�OFli$PEFiAYT6iOROM1'EFNt�DRmDqlh9�(5100)ORLESS} PLUMBING W' ICER'iIFY7HATINTHEPERFORMANCEOFTHEWOPo(FORWHICHTHISPERMITISISSUED,1 MECHANICAL ,{}LL ��SHAILNOTEMVLOYPNYPERSONINANYMANNEfl50A5T08ECOMESUBJECTTOTHE - y - - '- -�.�, WORKERS'COMPENSATIDNLAWsoFCALIf NIA, DAGREETHATIFIS ULDBECOAIE INSPECTIONFEE _ 'Sll&lE 70THEWdRKERS'COMPENSA PR NSOFSE(lYION- o00FTHELABOR ►=. _� � ISSUANCE �z �� ;��_ CWE, SMALL flTHWITH COMPLY W �TMO OVISIONS. 0" SMIP "p. pATE: � APPLiGAM: . . - �J�o� WARNING.FAILURETOSECUREWORKERS'COMPENSATIONCAVERAGEISUNLAWFUL,ANDSHALLBE ENERGYP/C �J' �SU&IECTANEMPLOYERTOCRIMINALPENAlTIESANDCIVILFMESUPTOONEHUNDREDTMOUSAND � ;u`.�- ENE{iGY PERMIT - � - OOLLAFS(f7oo,0oo),IN PDDITION TO THE COST OF COMPENSATION,DAMAGES AS PROYIDED FOR IN �q��J' ��: SECTION37080FTHELABOHWDE,INTEREST,ANDATTORNEY'SFEES. - RETENTIONFEE: _.�� '1 {���-�— '' � �_1—._—' ( �.��j� '�.�. 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