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HomeMy WebLinkAboutNo Permit Number (11) CITY OF DIAMOND BA� ��� �� -� DEPARTMENT OF COMMUNITY dc DEVELOPMENT SERVICES � . 21660 E.Copley Ihive Suite 190 (909)860-3193 Fax(909)861-3117 PRESS BUII.DING PERMIT APPLICATION FIRMLY oADDRIESS DATE CATION ,Q �`��C g NUMBER � +� �!C $ iSSUE TYPE QCC APN LOT ACT DATE CONST, GROUP g OWNER " ADD S ZONING SETBACKS � CI Z� �, FRONT RW ❑ APPLICANT REAR ❑ � SIDE/SIQE STREET RW ❑ CONTRACT SIDE ❑ � ADDR 5 . PROPOSED USE o CIIY ZI TEL. ' •- . � ARCFVENG/ L��-� DESIGNER � NO.DWEL. NO. NO. ADDRESS UNfTS STORIES BEDROOMS � CITY ZIP TEL. y DE5CRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER•BUILDER DECLAFATION SFRIA�DIREM � • � p I NEPWY AFFliMI UNDER PENILL7Y OF VERJURV TFiAT 114M E%EMPT FROA1 TNE CON7RACTORS LI• G9r8BB/C81yD1I �J C915EUNMfORTFiEFOLLO'MNOREA60N(SEC.7031bBU5INESSANDPROFF5510N5COGE:ANYqTY00. 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DATE CONTRACTO � � � WORKERS'COMPENSATION DECLARATION Q � T U � 1 HEREBV IIFFIRM UNDER PENAI.TV OF PERJURY ONEOFTHE FOLLAWINa DECLARA IDNS: Z O �IXAYEANOYYILLMAMTARIACEfifIFICATEOFCONSENTTOSELF•INSUflEFORriOPI(ERS' _ y� CONPENSATpN.A9PROVIDED9Y5ECTION97000F7NELABORCOOE,FONTNEPERFOAMANCE W OF 1NE WORK FOR WHIGI TIIIS PENMIT IS ISSUED. � � I HAVE MA rifLL MAIMAIN WORKER9'COMPENSATION INSURANGE.A9 REOUIPED BY 9EGTION Q97000FTHELABOHCODE,FOR711EPERWiMIWCEDFTFEWORKFORWHIG711115PEFU11T13 J ISSUED.MY WOAKERS' �tPEN5A710N INSURANC i1FIER AND POLICY NUMBER ARE: CONSTRUCTION 4 � � CARRIER PLAN REVIEW � Poucvrareen_ — LECTRIC � (ns;sEci��wreeoor�EnoFnf�r.+rsraaone�ooau�asR��loatFss} NG Z ICERTIFYTHATINTHEPERFORMMICEOF7HEYVORKFORWHICHTFASPEHMI71515SUED.1 MECHANICAI SXALL NO7 EMPIAYANY PERSON INANY MANNER SOAS TO BECOIAE SUBJECT TOTHE (n WORKEi15'COMPENSATpNLAWSOFCAIIFORNIA,ANDAOREETNATIi16HOULDBECOME INSPEC NFEE - � • � S SUBJECT TO TIE WORKER9'CONPEN9/�TpN PRONSIONS OF 9ECTION�Joo OF h1E IABOR ��T ISIiALLFO ITICONPLYW .i11�1bEPROW510N5. ISSUAN �'��`� ����_ � �?,9 �,�rr-' ��- � DATE: � APPLICAN7� C� SMIP . WMNINfi:FAILURETO SECURE WORKERS'COMPENSATION CAVERAGE IS UNLAWFUI,�ND SWILLBE ENERGY P/C �rT i C +9 9° �y SU&IECTAN EMPLOYER TO CRIMINAL PENALTIES ANO CIViI FINES UP TOONE NUNDRED THOU8AND ENERGY PERM�T OOLI.MS(i100.OW�.IN/N�ITION TO iF1E COST OF COMPENSATION,OAM�GES�5 GHOVIDED FOR W ¢ SECTIONliOBOFTHEUBOHCODE,NTEREST,ANUATTORNEY'SFEES RE7ENTIONFEE: /'�iTV a CONSTRUCTION LENDING AGENCY ,T�i *� PRE-ALTFEE: nTm r�rwrn � �.�T:m�� O aV�7i i7"f[7—;Z?'T.�J .. —r- � IMEREBYAFFlHMUNOERiENALTYOFPERJURYTHATTHEIiEISACONSTRUCTIONLENOWOAOENCY Z FOR iHE PERWRMNICE OF iHE WORK fOH WHICH TMIS PERMIT IS ISSUED�SEG 7oT/,CIV.CJ. W � LENDERS NAA1E �S LENDER'9A[f�RE53 W ICERTIFYTHATIXM/ERENJi}IISAPPLICATIDNMlDSUTETMIITTIIEABOVERVFOR1AATqNISCORRECi. TOTAL FGES � I AOREE TO COMPLY N7TM ALL CRY AND COIMTY OHDINANCES ANO S7A7E UWS NEUUING TO 6ULOINO � CONSTRUCTION.MqNEREBYAlJf1iDRRENEGRESENTATIVE50FTNISCOUNTYTOENCERUPONTHE � ABOVE�MENiIONED PROVEH7Y FOR INSPECTION PURPOSES. COMMENTS '4��A, � �..�- � PEIiMI (PRI . . BKiIiA ' ITTEE WTE � RECPT.NO. PAID BY ��S/ALIDATION ' YIMITE—Depertment Copg YELLOW—Ffnance Copy,PINK—Aasessor Copy,GOLDENROD—file Gapy.GFiEEN—ApplicanPs Copy E' � CITY OF DII�:I�ItONQ B/4►R � IRIS�ECTfOI�d RECQFiD . � i , . � . . e e • . � . �: ::v..:. ': ,. � ..: �- . _ .. . .. A SET BACK ' FLOOR JOIST �. •, , . ; . �, � -.� FfGS/FORMSJSTEEL . FHA R,EQMTS • . - ELECTRIC GROUND UNDER FLOOR,UU'CT' - - � , - � - _ .._ . . - - -• - -� GROUNDPLUMBING , . 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