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HomeMy WebLinkAbout15614 i l .� � � / J ( � ; �'f CITY OF DIAMOND$AR �• ��"- -- -��'-- DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES � -.�w 21660 E.Copley Drive Suite 190 (909)860-3195 Fax(909)861-3117 PRESS � � 'y"" BUILDING PERMIT APPLICATION FIRMLY � � JOBSITE - ,� j`x� �y � � ,L,�;,,��_ ./ APPLICATIO PERMIT � P/C r o ADDRESS ��� t 4� � �/ �� ��`�- � DATE NUMBER #_ ; � APN LOT _ TRACT ISSUE TYPE OCC DATE CONST. GROUP ;� p OWNER,� . �� .J f)A'f/ S C'% o AODRESS ���q�• �!� �—L'r r�L's�/�fl�`�-• '�� ZONING SETBACKS � g CITY _ ZiP_ TEL._ FRpNT RW �7 � APPLICANT TEL. REAR ❑ �' SIDE/SIDE STREET RW (J " � CONTRACTOR F'%��- "`� �``,� cJ�" �'7N' SIDE p_^_ : ADDRE S ��� ' S t'_>c/ / � i/i �� U�. e i ..-. ¢ L- '�'---Z;4Y< :� w A C�G��'�, ZI �� TE ��"I� L.i:� - ��,. PROPOSED USE�I��`"� — -- � Z DESIGNER ` Y ���� ,� w — NO.DWEL. NO. NO. a ADDRESS a cn UNITS STORIES _ BEDROOMS _ � � CITY _ ZIP TEL._ '� � DESCRIPTION SG1.FT. FACTOR PSF ADJ.AREANALUATION OWNER-BUILDER DECLARATION SFR/ADD/REM � O � Q 1 MEREBY AFFIRM UNDER PENAUY OF PEFiIURY THA7 I NA EXFMPT FROM TFIE CONI'pACTOR4 LI• GdfOJB/CdfpOfl W CENSEUWFORTHEFOtLOWINQREA50N(SEC.7o37.5BU51NE55ANOPROFE5S10NSCODEANYCITYOA (n ;� U COUNiVWHIGiREWIRESAPERMITTOCONSTHUCT,AL7ER,IMPROVE,OEMOLISH,ORREPAIRANYSTRUC- W pptI0ID8Ck z� � NRE,Pfl10R TO ITS ISSUANCE,AL50 HE�i11flES THE APPUCANT(OR SUCH PERMIT TO FILE A SIGNED W � STATEMENT THAT HE Ofl SHE IS UCENSEU PURSl1ANT TO iHE PHOVISIONS Of THE CONTqACTOFS LI- � j CENSE lAW(CHAPTFR 9(COMMENCMG WITH SECTION 7000)Of DIVISION 3 OFTHE OUSINESS RNO PRO- POOUSP3 � '� FESSpNSCODE)URTMATHEORSHEISEKEMPTTHEflEFqOMhNDTMEBASISFORTNEALIEGCUFXFMG- (� . V TION.pNYV10LqTI0NOF5ECTICHJ7031.587ANYAPPLICANTFORAPEflMIiSU&IECTSiHF.APPLICMlTTO Z Re-Rool jI F ACIVILPENALT'OF NOT MORE 7HAN FIVE HUNDRED DOLLARS(55ao).): !� C71,ASOVMEROFTHF.PROPERTY,ORMYEM?lOYEESWITHWAGESASTVIEIRSOLECAMofNSRTION, n Commercial � �� WILLDO THE WOFiK,JWD TME STHIICTURE IS NO7 MTENDE�OP OFFERED FOR SALE(SEC.�oaa,eU56 � J ,i � NESS AND PROFESSIONS COOE�.TNE CONTRACTOqS LICENSE LAW L70E5 N07 AAPLY 70 AN OWNER OF � �,[ PflOPERTYYAIOBUILD50RIMPROVES7HeREOn,ANDWNa00c55UC1(iVORKHIMSELFORHER5ElFOq j Q THROUGHNISORHEflOWNEMVLOYEES,PROVIDEDiHATSUCHIMPROVEMENTSARENO7IMENDEDOR . m O OFFEREOFqqSALEIF,HOWEVEi�7HEBU1lDINGORIMPROVEMENTI5SOIDWITHINONEYEAROFCqMPL[• � Z TION,THE OWNER-6UILUER WILL HAVE THE BUROfN OF PROVWG TNAT HE OR SHE OID NOT BUIID OH � IMPROVEFOR7HEPl1RPO5EOFSALE). i7i � . UI,ASOwNEROFiHEPROPER'fV,AH1E%CLUSIVELYCONiRFCTI4GWIiHUCEN9EUCONTRAC70RS TO CONSTAUCT THE PPOJECT(gEC.77K 9USINESS AND PROFESSIONS COC[.THE CONTRAGiORS LI� V81U8ilOfl __ „__,,,_,_ ADJ.AREA ?{ W; CENSElAWD0E5NOTAPPLYTOANGWNENOFAPpOPERTIWHOBU1L0.50RIMPROVESTNEfiEON,AND -- '---- - 3 � NM1IOCONTRACTSFORSUCHPROJECiSWITNA00NTMCTOR(5)UCENSEDPUR9UANTTOTHECANTflAG a�ANrny DESCRIPTION PEE rau ucENSE uw.�. .� Ye - '� �' U�AM EXEMPT UNOER SEC. _.,B.8 P.C.FOR THIS RFlSON q �: ,— .__� �.. : � �_ lL, "_' _.__-- _" , � ' :. DATE�__ OWNER___"__ � � Oz _.�_ _�_--.-.._ W r,, LfCENSED CONTRACTOAS DECLARATION W �� ,��. t HEREBY AFFIRM UNDEq PENALN OF PEqJURY iV1q71AA/LICENSLD UNOER PqOVi510N5 OF CMA�TER �' � .° '�' B(COMMENCING WITH SECTION�OWj OF DIVISION a OF THE OUSINESSANU VROFESSIONS CO�F,AND � Z X MY LICENSE IS Ml FULL FORCE M�EFFECT. . m — � W tS �L y � ,�, LICENSE CLASS � LIC.N0. ""'_I � J � � �' � � # ,i' -- 7 „ .. ,� ~ OATE�__�. ,~ ��'�C•��GONTFu.CI'OR� � !�'__�� , 0.. U; � W .,., ���. �YOaKERS'COMP[NSATIOY DECLA ATION J ` p�.�.� P; �� Q e'.;_ti.t � �` ��.�'�p,., � �' 1 HEqEDY AFGIRiA UN�JER PE4AlTY OF PEfi1URY ONE OF THF.FOLLOWING D[CLARATION3: � �� " ;�;`4"T�<, r 2 � � � IHAVEANOWILLMpIN7qfNACERTiFICATEOF"CONSFkTT03Kf-INSURC.fORWORKERS' Z '' � � � COMPENSATION,A6PqOVIDEDRYSECT!ONa7CaOFhIEU��ORCODE.fORTHEPEfIFOqMANCF i U _�_ : ; ' ' ��� n OFTHE WORK FOfl'Mi1CH THIS PERMIT IS ISSUEU. W .. ��f.+.s�%�� �' O � W _IHAVEANDWIIIMAINTMNWOfiKERS'COMAENSATIONINSURANCE.ASFEOUiflEDBY5EC710N � Q 3)OOOf THE LABOR COOE,FOq 7HE PeRFOitMANCE OF7HE WORK fOH WHICHTMiS PERMl7'IS _-- - _-'-- -- 0.• ISSUED.MY WOflKERS'COMPENSATON INSURANCE CARRIER ANU PGI_ICY NLIMBER ARE: CONSTRUCTION � ¢ � �' CARRIER__"________'_ __..._""_'__ PLANREVIEW � ------- ---...------- -------`-- �-'-- � d ea.icruuMeeA__.__,.__,,..�_ _ ELECTRIC � -- - -----— � �Q (IHIS3ECIYJNNE�IATBECOFIP�FTFDOF11iEPER4tl75fCNi0tJEHUKAiEDD01.Wi5(510010R1E55). PLUMBING _..__..._ __.'___.._____ _ "' 'z I CEATIFY THAT IN THE PFFFORMANCE OF THE WOFlK FCJR WHICH THIS PLHMIT IS ISSUED,I MECHANICAL ('j SHAI.LNOf ElAPLOYAVY PEHSON iN ANV A5P/.N[R 50.45 T08[COMF.SUBJECi TDThIL i,,.. y WOPKEHS'CAMPENSATIONLAWSc7FCAL.IFORNIA,ANOA�flEFTNATIf'ISl10VLD6ECOMF. I FiCT E ____ _„_ ��.j__ � � SUAJECT TO THE WOFKEIiS'COMPENSATION Pf10VI510N5 OF SECTION 3700 OF TM[lAB � � _ -� / ���,� � 7 GUUE,I SHALI FOHTHV�ITH CoMPI.Y Wl7H hi0 PR ISIO . J,� ISSUANCE .. . _ r -_ -- O f�(�'— J-'�i 4 Cy �� �' ._✓/`� m ' • . p DATE:�" .� APPLICANT. � ._.. ______. y J WARNIHG:FAILUqETOSECUFlEWORI(F.RS'COMPENSA COVEFAGEISUNLAWfUL,ANbSHALI�E ENERGYP/C _.__. ____ __ _ � �y,,, SUBJEC7qNEMPLOYERTOCRRAINAIPENA�TIESAND IVILHNGSUP700NEHUNDREbTHCUSAND ENF_RGYPERMfT ____..__ ____..___ _ p O l 1ARS(ft W.00�).IN A�DITI O N TO THE COSTOF COMP[NSATION.DAMpCES AS PROV�OED FOR IN � � SECTIDN37080FTHELA00H�DE,IN7EREST,ANDATTORNEYSFFES. RETENTIONFEE: -_-__ -- __ __ _ -__ _ Ip CONSTRUCTION LFNOING AGENCY PREALT FEE: ' � INERE6VAFFIRMUN�ERPENALNOfPERJUFY71iAT7MEREISACONSTRUCTIONLENDiNGAGC:NCY j 4 FOH THE PERFONMANCE Of THE WORK FOR Vh11CH THIS PERMIT IS ISSUE�(SEC.3o91,CIV.G.�. —"'-'"'- ""- '-""'--" Z i ,°� � __..__.._ ._. "_'__ LENDEF1'SNAME..______.__ � _— _`__.. '� F- 'C�NUER'SADDfiE55_' '_'__ _... .'—,—__"—""_ "— "—___"_-"_ _"'____ _ � w 1 CF,RTIFY THAT I HAVE READ TIIIS APPLICAf�ON PND STATE h1AT TH[ABOVE INFORMATION IS CARRECT. TVTAL FE�S � d I ACREE TO COMVLV WITH ALl CITV PND COUNTY OR�INANCES AND STATE LAWS RELATIN(i TO�UILDING { � CANS'fRUCTION,ANDHEIIEBYAUTFiOR12EREPRESENiATIVFSOFTHISCOUN7YT0EN�ERUPONTHE � Z A90VE�MF.N710NE�PROPEHIYFORINSPEC7IONPURPOSES. _ --_-- - � COMMENTS___ _ i J � ,�,�.-�l,� �= �� x,...,l� �''�� � � -- — �- -- �---- --- ; m PER E N E�PRI � ^ � ' .�.�%°�- �� �.,,..=,�-.. � ._Z x�._�.V::�, -- - -- -- ; UJ ICNATURF F PERMITTEE - ---OATE "--"-"'-- '- -� '—'- " � RECPT.NO. ___. 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