HomeMy WebLinkAbout17456 (26) CITY OF DIATvIOND BAR
�''�j , DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES EXPIRED
��` 21825 E.Copley Drivc
(909)860-3195 Fax(909)861-3117 PRESS
�`%:� BUILDINGPERMITAPPLICATION JUN 191002 FIRMLY
yy, JOBS�TE�3(OO MOIIll[11E17t CSIIyOII APPLICATION �f PERMIT P/C
o ADDRES DATE ��l NUMBER I 7 y.SG p
m ISSUE TYPE OCC
APN LOT TRACT DATE CONST. GROUP
0 owNea Cimarron Oaks I HOA
" ADDRESS fi75 W FnQ�i 1 1 R1,Y�j, #1Q1� ZONING SETBACKS
gCITY('.larPmnnt� 21P91711 TEL�99-�1(]� REART RW ❑
APPLICANT TEL. �
� , SIOFJSIOESTREET RW O
� CONTRACTOR �n�al Rnnf Cn_ SIDE ❑
� ADDRESS q,C�( �� ���g ��� PROPOSEDUSE '�`E,�� �€€ Weg� SI38{E89� ��8�8��
oCITY ZIP n� TEL.���1nn—
w ARCW��— �+w� �wv-
w DESIGNER 7692 NO.DWEL.
a ADDRESS UNITS STORIES Y_WO BEDROOMS
� CITY ZIP TEL.
c�i� DESCRIPTION S�.FT. FACTOR PSF ADJ.AREANALUATION
� OWNER-BUILpEii DECLARATION SFR/ADD/REM
O
p I HEREBY AFFlRIA UNDEA GENALTY OF PEiL1URV THAT I MA f%EMPi FROM iHE CONTMCTOHS U� GHf29e/C01pOrt
W CENSELAWFORTHEFOILOVlINGREASON�SEC.7W7.58USINESSANOVROFESSqNSCODE:�NYQTYOP (J)
U COUNTYWHICHREOUIRESAPEFMITTOCONSTRUCT.ALTEfl.IRIPROVE,�EMOUSH.ORi1E�AIRANVSTRUC- W patiapeck
�L TURE,PRIOR TO ITS ISSUANCE,/L50 REOl11RE5 THE APPIICAM FOR SUCH VEPMIT TO FILE A SIGNEO W
� STATEMENT T1AT ME OA SHE IS ULENSEO PURSUANT 10 TME PRONStONS OF TNE CON7MCTORS L6
�, CENSEUW(d�.��TER1(C01A4ENCWQYATHSECTION7000)OFOIVISION]OFiMEBU51NE5SIW'JPRO� LL POOVSD3
iES3lON5 COOE�OR THA7HE Ofl SHE IS E%EMPTTHEREFROM ANO TNE BASiS FOR iHEALLECEO EXEMR (�
� TqN.ANYVIOLATI0NOF5ECTION70�1.S8YANYA7PlICMlTFOHAPERMITSUBIECTS7HEAiPLICANT70 Z qB•ROOI
A GML YENALTYOF NOT MONE T/UN iIVE NUNORE�DOIUAS(fSoo).j:
0 04�SOWNEROF7HEFROPERTY,OA��EAAPLOYEESWITHWA6ESASTHEtR50LECOAIPEN5AT10N, � CORITBfC�I
Z VALI DO THE WORIf.AND TME 9TRUCiUFE IS NOT INTENOEO OH OFFEREO�OR SALE(SEQ 70u,BU54 J
NE55 AND OPOFESSIOHS CODE:7HE CONTRACTORS LICENSE Uw DOES N0T�7PLY 10 AN OWNEA Of
� FROPERTYWFqBUIIDSORiMPiqVE3THEREON,ANONMODOESSUCHWORKHIMSELFDRFIEASE:fON =
� THpOUGHM50RHEROWNEIdPLOYEES,PRONOEOTHAT5Ud1iMPROVEIAENTSARENOTWTEN�EDOF m
Q OFFEREDFORSALEIF,NOwEVEFIMEBUILD:NOORIMPROVEMEM1550lDWRHINONEYEAROiCOMPLE
, Z TbN,THE OWNER-BVILDEN WILL IUVE TME BURO[N OF Oi70VWG THAT NE OR SNE OID NOT BNLD ON
= IMPRWE FOfl TNE PURPOSE OF SALE}
W OL�SOWNEROFTXEOROFEpTY,AMEX0.U5NElYCONTRACTNGWITMLICENSEOCONT�U.CTORS
(L TO CONS7RUCT THE vROJECT(SEC.70��.BUSiNE55 An0�FOFESSIqvS CODE:TNE CON7MCTOR4 Lt� V0luoti�� SOOO AOJ.AREA
W CENSEUWOOESNOTAPPLYTOANONMEROFAPAOPERTYW1106UILDSOHMvqOVESTMEREON,AND
� WIqGONTMGT5LOR5UpiPRQ7ECT5WITNACONTRACTpR(5)LICENSEDPURSUA4TTOTNEGONTMG QUANTITY DESCRIPTION FEE
Y TOFS UCENSE Uw.�. .
� ❑1 AM E%EMPT UNDER SEG B.t PQ FOR THIS REASON U '
4. ¢
DATE OWNER V
Z w
� UCENSED COPlTRACTORS DECUIRATION w
� IHEFiEBYAFFIRNUNDERiENAITYOFPERIURY7HATIAML�CEN5E0UN�ERFflOV1510N50FCHAGTEfl �
d i(COIAMfNCING N'ITH SECTION 7Doa)OF OMSIQ4]OG THE BUSINESSAND PROFESSIONS CO�E,ANO z
X MY LIGENSE IS N FULL PoRCEMID EFFEGT. . m
lll
� UCENSECtASS�,:���I i�� _,[�,�g€j� �
� IIC.NO.
� UATE�=�i�_ , CONTRACTOR�Q�����_ a
w
� WORKERS'COMPENSATION OECLAFATION �
� U
N INENEBYAFFIRMUNDERVENALTVOFPENURYONEOFTHEGOlLON9NCDECUMTIONS; 2
4
� __I/UVEANDWILLMAWTAINALERI�FICA7E�CONSENTTOSEIf-INSUREFORV✓ORKERS' S
CAu0EN5ATtON.ASPqOV�OEDBVSECTION]7ooOFTHELABORCODEFOi1THEVERFORMANCE W
OF THE 1N0{LC FOR WMICH TNIS PERIAIT IS ISSUEO. �
�
� ���IHAVEANOWILIN�MTAWWORNERS'COMFENSATIONINSUfUNCE,A5RE0U1RE�8Y5ECT10N . /�� qqq
4Q 77000F THE UBOR COOE,iOR TNE PERFORUMICE OF THE WOqK FOR WHICH THIS iERMTIS �(��J
ISSLlEO.MVWOHNEflS'COMPENSATIONWSURANCECMNiENANDPOIICYNUMBERAflE: CONSTRUCTION v
� �pqiEq A.M.S. PLANREVIEW
� POIICYNUMDER �+rr� ��Q�Q 06T,7 ELECTRIC
0 (fHSSECT�ONAEmwTeE�.aLEtEpotnEpEaAreFOqoNEHLr�OrlE000tuRSlitm)oHLFss} PLUMBING
Z ICEHTIFVIHATIN7NEPERFORMANCEOFTNEWOPNiOFWNiCN7M15VEPA1R15155UE0,1 MECNANICAL
� (,'J SMALL NOT EMVLOYAY117ERSON N ANY MANNER SOAS TO B[CAME SU0.IECT TO TNE
� WORNEASCOMPENSATqNUWSOFCYIFORNIA�N�AGREETIUTIFISIqULDBEOD4IE INSPECTIONFEE _
SUO.IECTTO TXE WORKERS'COYYENSAI�ON iqOV1510N5 OF SECTpN NOOOF TnE UBOR � I- �.'.-� - -� �!.: �-'�
�j LOOE,ISHALLiORTM'ITHCOMV�YVATHTh105EPFWN510N5. ISSUANCE ( � ' ' � � �
� SMIP f n : 5J
p DATE: APPLICANT.
W ENEHGY P!C � z��J 1
� WARNING:FAILURETOSECUREWORNENSCOM►ENSATIONfAVEHAGEISUNlAWF11LAND5MALLBE
J SUBJECTAfJEMPLOYERTOCHiNINA�PENALTIESANDGMLFINE5U7TOONEMUNDflE07HOU5AND
LL' DOLLARS(f100,000),INADOITIONTO7NECOSTOLLOMPENSAilON,OAA�ACE5�15PROV�0E0FORIN ENERGYPERMIT �
� SECTIDNJ70lOFiNEU�ACODE.WfEREST,ANOAtTORNEYSFEEs. �^
RETENTION FEE: �^^ - ��
pW.. CONSTRUCTIONLENDINGAGENCY PRE-ALTFEE: ��-��—'-'- --- -----
O
Q IHERfB�AFFIRA/UNDEAOENALTVOCGEiWR�THATTNERE�S�CONSTRUCT�ONLENDiNG�GFNCV
n- iOH TNE oENFpRA1ANCE OF TME�Nd1K FOR WHICH THIS 7EpMiT IS 4SSUE0(SEC.7ovT,pV.C.�.
Z
W
� IENDER'SNAME
F— lENOER'SA'JORESS
� I CERTIfY TMAT I HAYE READ THl$MiLICAT10fi AN7 STATE THAT TNE ABOVE WfaRMATION I5 COARECL TOTAL FEES /�� ��
W IAGREETOCOMPLVWITNALLCT'JWOCOUNTYONDWMICESANDSUTEUWSHEUTINGT06VROING �
d' CONSTRUCTION.ANDHEREBYAUTHOPIZEAEPRESENTATNESOFIWSCWNTVTOfNTERUPONTME
Z /190NE.MENTIONE�iPOPERTYFORINSPECTIONPURP0.5E5. COMMENTS
� T Imbru ��a
�
m GERuI E N � P{UNT)
� < <2_t{—� �
� SiGNGNREOiPEHM177EE D�TE Q Z pqIDBY � �' VAUDATION
� RECPT.NO.
WHITE—DepaRment Copy,YELLOW—Finance Copy,PINK—Aasessor Copy.GOI�ENFO�File Copy,GREEN—Applicant's Copy
!__ _---- _
�_
f2 7 ` � �
�