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HomeMy WebLinkAbout13408 (29) CITY OF DIAMOND BAE — DEPARTMENT OF COMMUNITY�,DEVELOPMENT SERVICES � 21660 E.Coplcy Drive Suito 190 �`� PRESS � (909)860-3193 Fax(909)861-3117 ��M�'��� BUILDING PERMIT APPLICATION FIRMLY y JOBSITE APPLICATION PERMIT C.�� P!C � ADDRESS���,��N'/flll�l� �I J�.• pq� � NUMBER t � ISSUE TYPE OCC APN LOT TRACT DATE CaNST. GROUP � OWNER 57-� LCJ� L ktr ADDRESS ZONING SETBACKS � CI7Y ZIP TEL. R�R RW � � APPLICANT '��Y TEL. SIDFJSIDE STREET RW ❑ CONTFIACTOR � u� / 4 . SIDE ❑ ADDRESS PROPOSED USE �F • SII" � � CITY ZIP 917I� TEL.�I g��.-hT r L ARCHIENG! 7663 DESIGNER NO.DWEL. •NO. NO. ADORESS UNITS STORIES �_9EDROOMS CtTY ZIP TEL � DESCRIPTION SQ.Ff. FACTOR PSF ADJ.AREANALUATION ¢ OWNER-BUILDER DECLARATION SFFVADDIREM O I IIEREBY AFRfAI UNDEH►El41T/OF PERIURY TXAi I MI EXBAPT FROM TNE CONiMCTOfl9 U• Q��9�B�rt CBISEUWF9RTHEFOLLOMIINGREMqV(SEC.70.l1.6BUS�NESSANOPIpFE3510NSCODE:ANYpTVOP (n WIMYYYFAO/XEOUWESAPEF9AfflOODN5TRIICT.ILTER�PROVE,OflAOWMORREPAIR�IN�SiAUG• W PfitlO/DBCk IURF,PRIOR TO RB 18SUANCE.AL90 REGUIRES 7HE APPLICAHT FOR SUCH PERMIT TO FILE A 81ONEG W 6T�TEYENT TIAT ME OR BHE IS LICEN50D PIlRSUANT 70 TME PNW7510N9 OF 7ME CONIMGTORS LI• CENSE lAW(C1IAPTER i(OOMYENCNO WITN BECTION 7a0D)Oi DINSION 80F ME BUeINEeS AND Pq0- LL' PooUSpa FE6910N5 COOE�OR 7WlT ME ON 6NE IS D(EMVT iMEREFFiOM ANO 7ME BASIS FOR 1FIEALLEOEO fXEMP- '7qN.ANVVIdA71DNOF8ECi10N7os7.6BYANYAPPLIC�NTFORAPERMRSU&IECTBtHEMPI�CANTSO Z Re•qoof A CINL VENAI.TY OF NOT IAO(IE TIMN FIVE NUNOREO OOLI/WS R500�.): �� � OI.A9OWNEROFTHEPIiOPERT',ORMYEMPIAYEESWRHWAOE3A5TNEIR50LE00MPENSATION, (� �mmerdal - YALL DO 7HE WON�(.A!ID 7NE BTRUCTURE B NDT INTEND60 OR OFFERED fOR 6ALE(BEC.7M�,B1151. �.J NEeSAlID PROFESSIONS OOOE:7NE OONTMCTORS L10EN6E I,AW DOES!qT APiLV TO AN OWNER OF a � PqOPEHfYNM1IOBURDSdiNAP110VElTIIERE4Y,ANONIIAOODESSUCMWOqKICMSELFORXERSELFOq � 1NHOUGH MIS OR NER OVM EMPLOVEES,iFiOVIDEO THAT SUd1 IMPROVEMEN7'S ARE NOT WTENDED OR m � OFFFAEDPDREALEIF.IqWEVEit71EBULdNOORWPROVEMB.TI850LDWRMNdJEYEAiIOiCOYPIE �110N.11E OWNER�UILDEN WILL HAVE TME BURDEH OF PHOV WO iHAT HE OR WE DID NOT BUIID OH YViqVE Pai iNE PURPOSE OF SAI.E�. � OI.ASOMMEROF7HE►ROPEiRY,AMOfCIUSiVELYCOMMCTINOYYRNLICENSEOCONTMGTOqS 10 OONSTiIUCT TNE PiiOUECT�SEC.Mu.BUSINE89 AND Pi10FE8310NS COOE:TFiE CONTHAC70pS IJ- V91U0f1IX1 A�J.AREA CENSE UW OOES NOTMPLY MAN OWNER OF APROPEitTY W1108UL�8 OA MPROVES 711EREON,ANO WFqCONTpACTBFOReUCHPROJECT8WIT11ACOWTNAC70R�9�UCENSEDPURSUMRTOTMECONTRAC QU14NTITY DESC IPTION FEE � TORS IJCEIYSE LAW.} , . ❑IIWI E7fElAPf UNDER BER B.i P.G FOR THIS REA90N � (..� W DATE OYYNEN r Z w � LICENSED CONTRACTOR5 DECLARATION W � IMEpEBYAFiINMl1NOENPENKTYOFFER1URViMATIMIIICENSEDUNOEHVflOVIS�ON50FCHAPTEH � •�0044ENGNO NRiN SECTpN 70W)OF DMSqN 30FTHE BU8INESSAND PROFESSIONS CODE,/ND Z W IICENSE 16 N Fl1LL FORCE M1D EFFECf. � uc�se aass C uc.No. � �' � � wtE_ - carrw,croR � _ a WOFKER5'COMPENSATION DEC T10N yIMERWYAFFlPMI�IDEHPENALTYOFiE1W11YONEOFTHEWLLOWINOOECLAMTIIXJS: Z � __I14lVEAN�WILLMAMTNNACERTIFlCA7EOFO0NSfiNTTOSELF-INSUREFORWORKERS' _ OOIIPENSATION.�S PROVIDEU BY BECiION 9700 OF TME L/BOR CA�E.FOR 1T1E PER WRMNNCE w OF TNE WORK POfi NM1iIGIT113 PERMIT 6165U�. � ��I WNE A!m 1NLL IMMAIN YYONKERS'OOMVENSA710N INSUNANCE.115 HEIXIIRED BY 9ECTION n /\ � a7000FTHELMONO00E.FORIMEPERFORNANCEOFTiEWORKWRWHICH7HI5PEHMIT�3 �1 ISSUED.NYVNDRKERS'COMPENSATION NSUpANCfi CARkIER AND POLICV NIIMBER ARE: `. CONSTRUCTION JU � � CMRIER �r7���NfD /;,.T� 1 PLAN REVIEW � POLICYNUMBER //�O � 7 ' ELEC7RIC ''� �11i6B[L'TqNNE�NOTgEOD�,qETEppF7HEPE(Mfi6FORaNEWlOAEoOCU.VtS{Strol��? PLUMBING r �� � I CERTIFY 7HAT N THE PERFORMANCE OF iHE WORK FOR WN�1/iHIS PERMIT I515SUED.1 MECHANICAL �� 6HALL NOT EMCLOV ANY iERSON NJ ANY 4ANNER 90 AS TO 9ECOME SU9IECT 7D TNE WORKERS'CGMPENSATIONUWSOFGLIFORHIRAN�AOREEhMTIF161KK/LOBECOME INSPECTIONFEE S 6UBJECTTOTHEINORKERS'COAIOENSATqNPROV151diSOFBECTION770o0FTHEUHOR � .. cooe.i�N1 FORnmimcoMr�rwminaaeanrnisio ISSUANCE !�7�+V�^c � � DATE:_��Z� 6 APPL�ANT W�� SMIP `-J.J� L �J��',I�Ita�i.lJk�M .,. . WMNING:FAILURETO ECUNEWORKERS'COM SATIONCOVEMOEISUMAWNI,ANO5141LLBE ENERGYPlC�3UII.���1r�� �� � � BU6IECTM1EMPlOYER70CRMINALVB41LLT1E5ANDCIVILFlNESUPTOONENUNDREOTNOUSIWD ENERGYPERMIT � DOLWi6��f00,000),NADDITIONTOTHECOSTOFCOMPQI6�TION,DMUdESASPRONOEDFpRIN � BEC110N970lOFliELABOROWE,MTERESi,ANOATTORNEY8FEE3. 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