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HomeMy WebLinkAbout16973 (37) �� CITY OF DIAMOND IIAR � � DEPAR'IMENT OF CO;v(MiJNITY&.DEVELOPMENT SERVICES E. �Y� 21825 E.Copley Drive (909)860-3195 Fax(909)861-3117 PRESS `-•� BUILDING PER�iIT APPLICATION FIRMLY � JOBSITE u _ D�G� APPLICAT�QN PERMIT 1 P/C o ADDRESS DATE X'� ��J '�d� NUMBEfl 1 M 1 '� c� ISSUE NPE OCC APN LOT TRACT OATE CONST. GROUP p OWNER ��rtl1 - ��,�, ADDRESS ZONING SETBACKS gCITY L�r��tjJC•� R/IlL ZIP TEL_ REART RW O APPLICANT TEL. SIDE/SIDE STREEf RW O � CONTRACTOR � � N , /►'y SIDE O � ADDRESS r1i'1 � � o CITY #y�{�� ZIP� TEL. PROPOSED USE w ARCH/ENG/ W DESIGNER NO.DWEL. NO. N0. n. ADDRESS UNITS STORIES BEDROOMS = CITY ZIP TEL. � DESCRIPTION SO.FT. FACTOR PSF ADJ.AREANALUATION � ¢ ONMER-BUILDER DECLARATION SFR/ADD�AEM O p I HEREOY AFFIRAI UNJER PENALTY OF CE0.AIRY THAT I AIA E%EMC7 FROM THE CONTMCTORS L4 Garaga�Carport � W CENSEUWFORTMEFOILOWINGREA50N(SEC.7071.68USMESSAHOOROFESSIONSCODE:ANYCIT/OR (n U �pVNTYWHICHR[OUIRESAPERMITTOCONSTRUCT.�LTER.II.iPROVE.DF40LISN.ORREPAIRANYSRFJG W P2IIOIDOGI( w 7URE.PRIOR TO RS ISSUiV10E.K50 REWIRES THE MPIICANT FOR SUCH PERM17 TO FILE A S�GNED W � STATEMLM THAT ME OR SHE IS UCENSED YURSUANT TO THE PROVISIOhS OF THE CONTiUCTORS U� � GENSE UW(07APTER Y(CO�AMENCINO WITH SECTION 7000)Of DIV:SqN]OF THE BUSINE55/�ND GRO� LL PooUSpa fES5pN5CODE)ORTHATHEORSHEISEXEMPTTHEHEFROMANOTHEBASiSFORTME�4LEGE0ExEMP- � TqN.ANYVIOLATIONOFSECTION709�.S8YANYAPPLIC�4TFOHAGERMITSUBJEGiSTH[APV�IC/WTTO Z qe-Roof 2 � A CML pENALT'OF NOT YORE THAN FIVE MUNDHED DOLURS(f500))� � OI�OWt�EROf7HEVROVEaTv.ORMVEurLOVEEStviTNWAGE5A5THEiRSOLECOIADENSAT�ON. O COTrtiofCiel Z MALL 00 TME WOqI(,/WD THE STRVCTURE IS NOT IMENDCO OR OFFEREO FOR SALE�SEC.70�1 BU56 J N NESS IWD VROFESSIONS CODE:iHE CDNTRACTORS LICENSE LAW DOES NOTAPPLYTO AN OWHEROF ? PROiERfY WHO BUlD50R IM PROVES THER[ON,MiD WHO DOES SUCH V/ORN NIMS[LF OR HERSEIF OR � THROUCMMISORMEROWNEMGLOYEES,VHOVIDED7MA75UCHMVROYEMENTSARENOTMTENDE00R m LL OGFEREDiORSALE1F,IqWEYERTMEBUIL0INGORIMPROVEMENTLS50lDYY�TM:NONFYEAROFCOMPLE• 0 TION.THE OWNER�BUILDER WILL HAVE TH[BUROEN OF PROYINO TNAT HE OR SH[DID ND7 BUIID OR Z �.1PROV[FORTHE PURVOSE OF SALE). = Olti`ONT![ROFTHEVROPfRTY.NAEXCIUSIVELYCONTRACTINGWITHLICENS[OCONTMCTORS w �,F O c� [L TO CONSTRUCTTHE PROJECT(SfC.7o��.BUSiNC55AND PPOFESSiONS CODE:7ME C0N7RAC70R5 U• V31u3tiOn �' ADJ.AREA W �ENSEUWDOESHOTAPPLYTOANOWNLROFAPROPERTVMMOBJiD50RIMPROVESTMEREON.A4D � Y11qCOHTMGT5FOR5UCHiRQIECTSWITMACONTMCTOR(S�UCENSEDPURSUANT70TNECAN7MC- QUANTITY DESCRIPTION FEE Y TOFiSUCENSEUW.�. � OIAAIEXEMPTUNDERSEC. B,aRC.FORTHISREASON U � � � LL' DATE OYn:ER � W � LICENSED CONTRACTORS DECLARATION w � IMERE9YAFFIRMUNOERPENAlTYOFiENJURYTHA7�A/ALICCHSEDUKDERCROVISION50FCHAVIER Vr � 9�COMAIENCINOWITMSECT10N7oao)OF�IVISION]OFTHEBUSINESSAN�PROFESS�ONSCODE.AND Z X M'/LICENSE IS M FULL iONCE AND EFFECT. Lll m � LICENS[ClASS LIC.NO.���0� Z� � H `�, VDATE��L[��f CONTRACTOR L/•�/1,�Til� a u, —v - � �.. � WORKERS'COMPENSATION DECLARATION a = U � I HEREBV IIGFIRM UNDER PENALTY OF VERRIM ONE OF TME iOLIOW:NG DECLARAT10N5: C/� Z Q � _INAVEMIDW:LLUAiNTAINACEfifIFICATEOFCONSENTTOSEIF�INSUREFORWOHNERS' S � Cp1APEN5ATION,l15 PRONDED B�SECTION 7'/000F T11E LADOH COOE,FOR TNE OERFOHMANCE �U OF THE WORIC FOR WHICFI THIS FERMIT IS ISSUED. � � W iNAVEANDWILLMAINTA:NWORKERS'COMPENSATIONINSUflANCE.ASREWIFEDBY5EC710N ^ L Q 7700 OF T11E UBOR CODE.FOR iME GERFORAIMICE OF THE WORK FDA WNICH iH15 PERMITIS I 1 1'1 S� ISSl1ED.MY WORI(ERS'WMPENSATqN INSURANCE CARHI/�a AhD POLICV NU4BERARE: CONSTRUCTION �y����� � CMFIER � �N�C/� PLANREVIEW �. � - - Z POLICVNUUBCR - �� ELECTRIC ¢ � (naSSECfqNMEmwTOEtd.ltE7m0inE�EPMTBPo(10�[NtltNi[DOOW�fY'iR'OCIORlE551 PLUMBING W MECHANICAL -- --�--- � z 1 CERTIFr iHAT W THE PERFOHMANCE OF THE WORK fOR wNICM THIS FERM17 IS ISSUED.I ('} SMAILNOTEMPLOYANYGEA50Nrv/WYMAYtiER50A5TOBECOMESUBJECT70THE L �J',:�� j I � � �l � WOFU(EFS'fl�MFENSATIONIA'NSOFLAUFORN�tiAN�AGREETMATIFI5��0UlD8ECOME INSPECTIONF � L� ('`(\ S St161ECiTOTMEWORNERS'COMPENSATqNVROV1510NSOFSELTqN770DOF HEUBOR ISSUANCE vv CODE,I SIwLL FORTIIMATM C04�PLY WITN T1105E Dii7 51ON5. p OATE:��APPIICANT. _� SMIP I � � � ENERGY P/C � WMNiNG:FuIURETOSECUREwDPxERS'COMPENSATqNLOVEMCLISUNLAWiUL.ANDSHALLBE LL SV0.IECTANEMPLOYERTOCRiMINALPENALTIESAN�CNILLINESUPTOONEHUNDR[OT/ql,SAND ENERGYPER T.�f�- - DOIURS�f1ao.000),INAODITIONTOTXECOSTOFCOIAPENS�TION.OAIdAGE5A5PROV10EOFORIN y� � �___ � SECTiON]7C0 OF TN[LABOR COOE,INTEREST,ANO�TTORNEYS FEES. RETENTION F - a CONSTRUCTION LENDING AGENCY PRE-ALT FEE: O � IHEREBYAFFIRMUNDERPENALTYOFPE0.NRVTHATTHEREISACQNST0.LICTIONLENO;NG�GENCY FOR TME CERFOfiMIWCE OF THE WOFK FOR YAIiCM THiS PERMIT IS ISSUED(SEC.]oVl,CIV.C.�. W /h,/1 1!� . � LENDEfY3 NAME F- IENDER5A0DRC55�� — — �(��y` �J /� I• /l�' WICERTIFYTMATIM�VEREADTMIS�PPLICATIONA�DSTATETHATT11EA80VEWFO�MATKKJISCARRECL TOTALFEEJ / /�v � {l(��v � IAGREETOCOMPL�WIiHALLGiTYANDCOVNTI'O(iDiN1WCE5AN�5TATEUw5PCU7iNGTOBUI�DiNC CONSTRUCTION,AND HEREBYAUTMOf71ZE REPRESENTATNES OF TNIS COVN7YTO ENTER UPON THE � �� [�I' Z ABOVE�IAENTIONEDiROPERTYFORINSFECTIONV�S� � COti�MENTS.��C,u.���e(,'.r2 � YK�� o �o"a / , � ¢ VEFMI IPRINTI / �.h.L' 1/�t/V ��� N y SiGN�TUREOFPE �cE DATE � RECPT.�'0. 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