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HomeMy WebLinkAbout13513 � �� _ CITY OF DIAMOND BA8 j� DEPARTMENT OF COMMiTNITY d`c DEVELOPMENT SERVICES ( �') � . 21660 E.Copley Lhive Suitc 190 � PRESS (909)860-3195 Fax(909)861-3117 ��`'�"�±� BUQ.DING PERMIT APPLICATION FIRMLY � JOBSITE p APPLICATION PERMR f� P/C o ADDRESS I� I Sa���!re �n� DATE NUMBER ��"-' 1t � APN L T TRACT Z Ov ISSUE ��li I._ �j� TYPE OCC DATE-- `��t� � CONST. GROUP p OWNER � ` " ADDRESS N ZONING SETBACKS � CITY ZIP� TEL S�•— / � �ONT RW ❑ APPUCANT TEL. REAR ❑ SIOE/SIDE STREET RW O CONTRACTOR K i • t[� SIOE ❑ � ADDRESS , PpOPOSED USE CITY f�. V. ZIP 9z� TE d Pu ARCWENG/ DESIGNER NO.DWEL. NO. NO. y ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. cn s� DESCRIPTION SQ.FL FACTOR PSF ADJ.AREANALUATION p� ONrtJER�BUILDER DECLARATION SFWADDlREM O 1 MEREBV AFFIRIA IAiDER PENALTY OF PERIUNY 7MAT 1 AM EXEMPT FROM 7HE CONTRACMH6 ll- GBf906/Ce1�MR CENSEUWFOqTMEFOLLO1VTiOqEJ1SON�5EC.7091.60UBWES3MVDGROFES510NSCO0EANYCRYDR (n COUMYMh1M71RE0UIRE5APEHMRTOC�ISTRUG7,ALTEA.WIPROVE,DEMOLISH,ORREPAIRN1Y87AU6 w Pptlo/Dack� IURE,PRqR 70 RS 189UANCE,AL50 REW IqES THE APPLICAt(T FOR BUCN PERMIT TO PILE A SI�NE� BTATEMENT TNAT HE OR S/IE IS LICENSED PURSUMIT 70 7HE PROVISIONS OF hiE COHTMCTOR6 LI- CENSE U1W(CHAPTER Y(OOiAMENCINO WITH BECTIDN 7000)OF DMSION�OF THE BU9INESS AN�PNO- � POOIISpB '^" CO�QOphiATMEOHSME1501EYPT7MENEFROIAAN�TFIEBA51SFOq7HEAlLEOEDEIfEMP• iqN.ANYVI0LAT10NOF8ECT10N7031.68VANVAPGLIC.WTFORAPERMITSUBJECTSTXEAPPLICANTTO z Re-RooT r A CML PENAL7Y OF NOT MORE 7WiN F1VE HUNDRED DOLLARS(t600).�: -. � 04�OMMEROFTHEPROPERTY,ORMYEMPLOYEESWITNWAGESASiHEIRbOLECOMPENSATION, CDIflRIBfC18I � YALL DO 7NE YiORK,AND T/E STRUCTURE IS NOT INTENDED OR OFFEREO FOR SALE(SEC.7041,BU31- � NELS AND IROFESSIONS GOOE:7NE CONiMCTOR3 LICENSE LAri DOES NOT APPLV TO Ml OWNER OF � Pi1DPEi[fYYYIOBUM5DR61PNOVE37HEFEON,MJ0VR1000E39UCHWOqKNINSELFIX11/EHSELFOR = � 7MI10UGHMI5�IMEROWNEMPLOYEES,PpOVI�EOTHAT9UCNMAPRDVEMENTSMENDTMYTENDWOR m OFFERW WR S/LE�HDIVEYERTHE BUIDINCi OR MIPROVEMEN71350LD WITHNONE YEAR OF ODMPLE- '710N,TYIE DWNERSUILDER MALL MAVE THE BUROEN OF PROVINQ THA7 NE OR BHE DID H�T Bl1RD Oii �APRDVE WRIMEPUNPOSf Of Si1LE). � O4��M/NEROFMEPIIOPEffTY,MtEXCLUBNELVCONTMCiNOWiTNUJENSEDOONTAACTOR3 TO CONSTAUCT iHE PHOJECT(BEC.70M,BUSINESS AND PROiES910N5 CDDE:THE CONTRACTOR9 U• VA�U81IOf1 ADJ.AREA CENSE L11W DOES NOT MPLY TOIN OWNEH OFA PHOPERTY YYIIO B111L08 OH M1PR]VEB iNEREOfi,AND WipWNTMCTbFOR8UG1PRQ1ECf9WITHACONTMCTOR�byLICENSE�YURSUANTTO7HECONTMC• pUANTITY DESCAIPTION FEE � lORSl10ENSEUW.). ^ ❑I IW EXEAIPT UNDER SEC. B.a PG.FOR 7HIS REASON Q S V(� � WITE OKNER r � � LICENSED CONTRACTORS DECLARATIDN W � 1HEREBVAFFINAIUNDERPENALTYOFVERJUilYTF4tTIAMLICENSEDUN�ERPROYISqNSOFCHAPTER � � �(COAIMENpNON7TMSECT10N7000)OFOMSIONSOF'RIEBU6INESSMUPROFESSIONSOOOE,AND z W UCENSE IS Ci FULL FORCE AND EFFECT. m L�✓t� � u��«�ss u�.No. l, �'"�7Z / � 3 /. 3 0 _ � at� — conrr�ucroA�i��»"Ty/, a 'r � WORKERS'COMPENSATION DECUIflATION a yIHEREBYAFflMEUNDEHPENALTYOFPERAIRYONEOFTHEFOLLOWINf30EClMA7qN5: Z � _IXIIVEAN�WILLMAINTAINACERi1FIG4TEOFCONSENTTOSELF-INSUREWRWORKERS' a OONPENSATIDN.A9 VpOYIOED 8Y BECTIOH 970a OFTHE LABOR COOE.FOR TME VEP.FORMANCE 'U OF TME WORK FOR WHICH THIB PERMIT 18 ISSUEO. � � LIMIWEANDYYILLM/UMNNWORKERS'CDMPENSATIONINSURIWCE,ASREIXJIqEDBY9ECTION � 970DOFiXEI,A80RCOUE.�ONTiEPERFORMANCEOFTHEWa1NWRYh11CH7NISPERMITI3 � I63UED.W WOPKER9�P���INSUR�E CMRI£R AND POLICY NUYBER ME CANSTRUCTION � CARNIER � r�10 IL _ PLAN REVIEW � aa�nrwuMeeq_�IA(�/' /�Q /Q'>��� ELECTRIC 7'� To7'— (MSSEcfnNNE�IVo7eEaohYLElIDOc1)EPER.9isFaRohElalN7FtmoalAfisplo�oRIESS�. P UMBING � ICERTIFY7XATNTHEPERFORMANCEOFTHEWORKFORWXIG7hIISPERM1T13155UE0,1 tu1ECHANICAL a � -`'� 6FNLl.NOT EMPLOYANV VERSON IN ANv MANNER SOAS To BECAME Sl/BJECTTO7HE (q WORKERS'OdAPENSATIONU1W50FCALIFORNIAMN�GREETIATIFIBFIWLDBECAME INSPECTtONFEE � SUBJECT TO TFIE VlOR%ER5 CqAPEN9ATION PROVI310N3 OF 9ECTqN J70D OP THE 1A80R '/ cooE.i swut.FORnrmrn cornP�r wmi rHosE rnov�s�s. /� /� /j SSUANCE l 6n7E: r-��P���. iG�iqrd /'t. //IQ(/�i1 SMIP _��"a.°,�'� ' •n� c� � i::�� � WAM11N0:FARURE TO BECURE M/ORKERS'COMPEN9ATpN COVERAOE IS UNUWFUL,AND BHALL 9E ENERGV P/C � �y, SU&IECTANEMPLOYERTOCFUMIN/iLPENALTESMlOCMLFINESUPTOONEMUNDREDTHDUSANO •• �• _�:�' ! ��t.��•� � •� ���,�'- DOLlARS�itau.00o),NIII�DITIONTOTMECOSTOFCOMPENSATION,DMUGESASPROVIDEDFORIN ENERGVPERMIT � • ' � � SECTqN 970lOF TIE WBOR OO�E,WTEREST,MIDATTORNEY'S FEE3. RETENTION FEE: � s��'"'"�" �' "'`�`� '"��F J� OCONSTRUCTION LENDINGAGENCY PRE•ALT FEE: � IHEREBYAFFIRMUNUERPENKTYOFPERIURYTFIATTMEREIS�CONSTRUCTIONLENDINQA(iENCY FOR iHE PERFORMAMCE OF 7HE WORK FOR WHIC317HIS PERMIT IS ISSUE�(SEC.30Y7,qY.C.�. Z W � IENDERSNAME C t � LENDER'S1{DORESS � ICEIiTIFYiXATIHIIVEFEAO7HI5APPLICATIONM105TATE7}7ATTFEl1BOVEINFaRM�TIONISCONRECT. TOTAL FEES d IAOREETOCOMVLVWIfHALLCRYANDCOUHTYOI�INANCE5AND8TATEUYV5REU7WOTO8UILDINp � OONSTRUCTION,AND NEREBY AUTHORQE HEPpESEMATIVES OF THIS COUNTY TD EARER UPON 7NE ABOVEdAENTqN�PHOPENTY FOR WSPECTION PURP06E5. COMMENTS � �,�kurd- A � �n�ile� � PERMITTF�d EIORI � �'II_w 9 � � %' (/� 810NAN OF PERMITfEE DA7E � � RECPT.NO. PAID BY YALIDATION YYHITE—OeDartment Copy,YELLOW--Flnance Copy,PINK—Assesaor Copy,(iOL�ENROD--File Copy,GREEN—Applicant's Copy G!T'Y taF DIAlV9C3f�D BQ,R IhlSP�C�Tit'Jtv F�E�C)E�l� ,, . .�. p �, w� _ , € , r�(. _.�,.. 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