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HomeMy WebLinkAbout17967 (25) CITY OF DIAMOND DAR � -�� � DEPARTMENT OF COAMdUN[TY&DEVELOPMENT SERVICES 21625 E.Copley Drive � �"` (909)860.3195 Fax(909)861-3117 PRESS ""%:� BUILDING PERMIT APPLICATION FIRMLY } JOBSITE �(� APPUCATION � PERMIT C��„ P!C o A�DRESS /ISr d bFhLosk ����c DATE `S °Z NUMBER ��s M � ISSUE TYPE OCC APN LOT TRACT DATE CONST. GROUP °C OWNER Si'�u� O "" ADDRESS S � ZONING SETBACKS gCITY ZIP TEL. ' �Y S REAR flw ❑ APPUCANT.I��NR�'r� TEL. �(����� SIDFJSIDESTREET RW ❑ a� CONTRACTOR 6� N�"� �l'�'t+`+ /�^�'• 't'�"� • SIDE ❑ ADDRESS sB 2 G o t-�t./ z� PROPO$E,D USE � ✓�'►��rl- S�wl�t� � I h S1�C �L`' !��- � CITY A�"IEnC- �- ZIP �� -TEL. `18t•L3"�i� �� .��.. �,{c w L � f �( o ., ZU o ARCH/ENG/ � DESIGNER ^�(� NO.DWEL. NO. � NO. ADDRESS UNITS STORIES BEDROOMS � CITY 21P TEL. y DESCRIPTION S0.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-BUILDER DECLARATION SFRlADD/REM O W CENSEUWFORTH OLLOVANGREASON(SEC.70J16BUSIN 5 M1D7ROFES�SqNSCW:EANYqTYOR GaregelCarpoA U COUHiYNMICHREOUIRESAPERMITTOCONSTRUCT.lLLTERIAIFROVE.DEMOUSH.ORPEPAIRANVSTRUP � W TUPE,VRiOR TO rt5 LSSl1ANCE,ALSO(1EOUIRES THE APPLICMT FOH SUCH PERMIT TO FILE A SIGNEO W P8Si0/DBCk � STATEMENT THAT HE OR SNE IS LICENSED PURSUANT TO THE GRONSIONS OF THE COMMCTORS LI• � CENSE UW(pIMTER 0(COMMENCWO WITH SECTION 70Do)OF DIVISiON]OF iNE BUSINESS AND VRG LL' PoaVSpa FESSIONSCOD�ORTHATHEOti5HE15EXEMPTTNEREFROMM10THE8A515FORTNEALLE6EDEXEMP• C7 TqN.ANYVIOUTIONOFSECTION7031.SBYANYAVFLICANTFOHAFERMITSU&lECTSTMEl1PPlICANTTO Z Re-Roo1 � A GVILPENALTI OF NOT MORE TWw FIVE MUNDAED OOLURS(f5o01.r Q 047150wNEflOF7HEPROPERTY,ORMVEMPLOYEESVnTHWAGE5A5THEIRSOIECOMPENSFTION. � COrt1111BfC18I ' Z WILL DO THE WORN,ANO 7HE STRUC7URE IS NOT INiENOE�OR OFFERED FOR SALE ISEG 7oN,BUSI� J � NESSANDPROFESSIONSCODE:THECONTMCTORSIICENSEUWDOESNOTAPPLYTONIOWNEROF � VROCEHTYMTIO BUILDS OR NAPROVES THEREON,AND WHO DOES SUCH WORK NIIASELF OR HERSELF OR [C THROUGNHISORNERONRIEtJPLOVEES,VHOYIDEOTHATSUCNM7ROYEMENTSARENOTINTEN0E00R m w OFFEREDfORSALEIF,HOWEVER111E8UIDINGORRADROVE6/ENTI550LDWITMNONEYEAROFCOMPIE• � TION,THE OWNER$UIL�ER WILL HAVE THE BURDEN OF VRONNQ 7HAT HE OR SHE DID NOT BUILD OR = MViIOVEFORTiEPURPOSEOF5ALE7. O I.AS OWNEH OF TME PROPEHTY,AM EXClU51VELY COMRACTINO WfTN LICENSEO CONTMCTORS � TD CONSTRUCT TNE PRQIEGT(SEC.7wa,BUS�NESS IWD PROiE5510N5 CODE:THE GONTHACTOFlS U• V31UefiOfl ADJ.AREA W CENSEUWDOESNOTAPPLYTOIWOWNEROFJIPROPERTYN7qBUItD50R9APROYESTMEREON.MID � WNOCONTMCTSiORSUWCRQIECiSWITHACON'RACTOR(5)LICENSEOPURSUnNTTOTHECON7MG pUANTITY DESCRIPTION FEE Y TORSLICENSEUW.). � J Q OIMIE%EYDTUNDERSEC. B.6P.GFOR7HISREASON U � � u" DATE OWNER V �Q UCENSEO CONTRACTORS DECLAFlATION w LZ IHEREBYAFFIRMUNDERPENALTVOFVE0.IURYTHATIAMLICENSEDUNDEFPROvi5i0N50FCHAPiER �yr d 9(COMMENCIN6WIiHSECTIONJOooI�DIVIS10N70FTHE8U51NE55ANOPROFE551ON5CODE.AND Z X W LICENSE IS W ML FOHCEAND EFFECL m LLl r � IICENSE CUSS ��C LIC.NO. ��S F�� '� j J v pnTE r �t- CONTRACTOR a w � WORKERS'COMPENSATION DECLARATION ¢ � U � IHEREBYAFFIRMUNOERPENALTVOFPE0.ri1RVONEOF7HEFOUAWiNGDECLARATIONS: � Z Q � _IHAVEANOWIILMAINTAMACERTIFlCATEOFLONSENTTOSEIf-WSUREFORNORNERS' _ -- � ��COMPENSIRION,ASPRONOEOBVSECTION7/o00F7HEUBORCODE,FORTHEiERFORMANCE 'U � l OF THE WORK FOR NMICH 1HIS PEfUAIT IS ISSUED. � w ��IHAVEANDWILI�UIMAINWORKERS'COMPENSATIONINSURANCE,ASREWIREDBYSECTqN A,, \ Q i7o00FTNE LABOR WDE FORTME PERFORMMICE OFTHE WORK PoF WHICHTHIS VERMITIS I ".M)J� ISSVED.AIYWORI(ERS'COMPENS�TqNINSURA. CARRIEFANOPOLICYNUMBERME: CONSTRUCTION ��- � GRRIER a'�°J�- � PLAN REVIEW Z vaicrNuueEa ��- '1�''L— V ' � ELECTRIC ¢ � (iHSSEC1101JNEmNOTB[COM15�E7FDOF'hEPFRMflSFORONEW�0i1EDDOlUPS(5�00)ORL65� PLUMBING W Z I CERTIFYTNAT W THE PERFORMANCE OF iHE WONK FOfl WHICM TMIS PERMITIS ISSUEO,1 MECHANICAL C7 SHA1.L NOi EMPLOY AN'!PERSON W ANY MANNER 50 AS 70 BECOME SUBJECT70?ME � WORNERS'COMPENSA710NUWSOFCALIFORNI/�ANDAGREETMATIFISNOULDBECOME INSPECTIONFEE S SUBJECT70MEWORNERS'COUGEN5A710NPROVISION50F5ECT10N�7000FTNEUBOR eooe oar�nn�couv�rvnn�rrasevaowsar+s. �SSUANCE �� � SMIP , �� p DATE: � APPLICANT: _ � ENERGY P/C � WARNIN6:FAil1RE TO SECURE WORKERS'LOMPENSAT ERAGE IS FUI.►ND SHALLBE �y SUBJEttANEN.PLOVERTOCRIAAINALOENALTIESANDCMLFWESUP7 NE NDFEDTMOUSAND ENERCaYPERMIT OOLURS(f1oo.Dao�MAD01T10NT0T11ECOSTOFtOIIPENSATKKJ, MA ASV(30VIOEDFOfi1N ¢ SECTION]MlOFTMELABORCOOE,INTEREST,/JJDATTORNEY'SFE RETENTIONFEE: a CONSTRUCTION LENDING AGENCY PRE•ALT FEE: � IHEREBYAFFiRMUNDEROENALiVOF7E0.NaVT1uT7MEREISACONSTRUCTIDNLENDINGAGENCY �- FOR iHE PERFOR6IANCE OF TNE WORK iOR WMltl/TMIS PENMIT IS ISSUED(SEC.7097.LIV.G). � � � LENOER'SNAAIE � LENDEH'S PDDRESS WICERTIFYTMATIHAVEREADTHISAPiUCATqNANOSTATETHATTHEABOVEINFORMA710NI5CORRECL T�TAL FEES � � IAGREETOCOMDIYWITNALLGTVANOCOl1NTYORDINMICESANOSTATEUNSREUTWaTOBU0.01N0 CONSTRUCTION,NID HEREBY AUTVIORRE REPRESENTATNES OF THIS CDUMY TO ENTER UPON THE ZABOVE�MENTIONED GROPERTV FOq INSPECTqN VURDOSES- COMMENTS � � W ����NG� m PERMITTEE NAME(PRINn ¢ 6 0 � � s�cruTua v � eE o�r � RECPT.�O. PAID BY VAUDATION WHITE-Department Copy,YELLOW-Finance Copy,PINK-Assessor Copy,GOLDENROD--File Copy,GREEN-Applicant's Copy ♦ � ... . . . . . . ... .. .-i...�.. . .. . � , ... . �4-i..� , .�Y.. .`.1.�� .n... .. . .l.r., . . :1'�� .� ... 1�� . ,". � i. .. � .. '- � . . ... .. �9 i�' �?F l71A'�FJ�Q�vC� ��"�.R i(�lS��C�IOr'�! f�ECC3R� ��►�E-'�.'a=i�:I�lc)i'@ _._ �,�,rr.= ._.I►,`��., -ie rc�w�_ _.�__--� f��!-'1:�'t�::�Cc'j►,�. �� �)•�F�=� :I►� .-1=,c'�1`a��.� . �......_...�.,_LL_.�.�_�_. _......._._... __.. . . . .._.___..........__._ .... '.__'_._. 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