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HomeMy WebLinkAbout14291 (19) � � �� C1TY OF DIAMI�AID BAR � DEPARTIVIENT OF COMMUNITY&DEVELOPMENT SBRVICES 21660 E.Copley Drive Suite 190 (909)860-3195 Fax(909)861-3117 PRESS ��'�M° BUII.DING PERMIT APPLICATION FIRMLY } JOBSITE � a / / ��/ APPLICATION �j- ']� PERMIT �, ���-� ' P/C a ADDRESS��C�'� /�!CT //�{�/�,S �O.�i( DATE � ` � NlJMBER I __ #_ � ISSUE TYPE OCC APN _ LOT_� TRACT __ DATE CONST. GROUP p OWNER .i " ADCi�ESS r'�'y ` ZONING SETBACKS Z CITY � t �/ Z�P��TE `LY� ��� FRONT RW - !�--- g APPUCA ' _ __, TEL. ___ REAR __ _ LI_____ � . SIDE/SIQE STREET______ RW___ f]____ q � CONTRACTOR f � �„� SIDE ________ ❑ ADDRE �C � CITY. '.7 � �.; z�p��"' � �•t�.;�,3� PROPOSEU USE _ 0 1 �d!'r l-E , wn ARCH/ENG! --"-- — Z DESIGNER ---- � ADDRESS ' NO.DWEL. NO. NO. '� y ------ ----- UNITS___ STORIES ________BEDROOMS '! � CITY ZIP TEL. — � u� -- DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREA/VALUATIpN d OWNER-BUILD OFCLARATION SFR/ADp/REM � � � I HEflEBV�iFIRM UNOER PENIILTY OF PERIURY T I�N FXEMPT fROM iHE CONTRACTORS LI- G9fflQ0/C8f(7Cf[ W CENSELAWFOiiTHEFqlOWINCrFEA50N(SEC.7031.5BU ESSANDPROFESSIOtifiCODE:ANYCINOR (f� U CWHT`/NR{ICHflEQUIRESAPFAMITTOCONSTRUCT,ALTEfl,.. 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ISSUANC[ _ �' SMIP p DATE:_---- APPLlGANT: ___.__"'."..".'-_-_'__" �.�°� •• r _.__.___ '____._'____.__'_....._-_'_.._ ;i J WARNING:FAIIURETOSECUREWORKERS'COMPENSATIONCOV[RAGEISUNLAWFUI,ANDSHALLBE ENERGYP/C ... .. ._.,�p_._�._._ ,_...:`. �_._ °1Or LL'� $DUOL�LARBA¢OOOW)INADUITOINTOTHECO`STOFNCOM EINSATION,DAMAG SASPROVI�OFOSNN ENERGYPERMIT ._ _. _S1_.1���¢%_,,��rt_�����.lY'�';?'� J SECTION 3708 OF T}1E LABOH CODE,INTEREST,ANDATTORNEI"5 FEE6. )' g�1t,�; M1 RETENTION FEE: �, Y���� t�f^� ��,,,,_.•�tttY.-�t_.�.'�-��F1"�#c`.41���—'-'----._..._.._._ a� CONSTRUCTIONLENDINGAGENCY PRE-ALTFEE: _„ ,____._,__ _, O. �' 1 H[REBV AFFIRM UNDER PENALTY OF PERJURV THAT THEfiE IS ACONSTPUCTION LENDING AGENCV � FORTHE PERFORIAANCE OF THE WOI1K FOR WHICH THIS PERMIT IS ISSUED(SEC,3047,CIV.C.). �� Z' W. _ -'__ ' LENDER'S NA1A['_"_'__'......._ _-_ __ '_"-'_ ......._..""" H� LENUERSADDRESS . - �' 1 CEHTIFV THAT I HAVE tiEA�THIS APPLICATION ANC7 STATE THAT�HEABOVE INFQRMATION IS CORR[CT. 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