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HomeMy WebLinkAbout15631 CITY OF DIAMOND BAfi } , ---�'� --- DEPARTMENT OF COMMUNFI'Y dc DEVELOPMENT SERVICES � . � 216W E.Copley Drive Suite 190 (909)86Q3195 Fax(909)861-3117 PRESS � �'^�'�� SUQ.DING PERMIT APPLICATION FIRMLY o ODRESS ���� E�E� APPI.ICATIQf`� PERMIT � P!C - DATE "!�'L�o^ bG• NUMBE� � � �� �� � ISSUE TYPE OCC APN LOT S4" TRACT DATE CONST. GRQUP g OWNER � � o ADORESS C�� LbCC: _ ZONING SETBACKS �'' CITY�1x�t+..oyC� be ZIP TEL. � FRONT RW ❑ � APPLICANT 7EL. REAR ❑ SIDFJSIQE STREET RW ❑ CONTRACTOR � taba-.. SIDE ❑ � ADOflESS 4-'� Q- � CITY 4 t"`- t , Z!P 7EL'� � 6 PROPOSED USE Pu ARCFUENG/ � DESIGNER l � NO.DWEL. NO. NO. ADDR S � �� UN1TS STORIES BEDROOMS CITY �D � ' ZIP r TEL'Z� � y DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-BUtL�ER DECI.ARATION . ' SFR/ADO/REM O 1 MEREBY JIFFlRM UHDER PEWLLTY OF PEIWHY TWR 1 AM E%EMPT FROM THE COMRAC70R5 LI- GB�AQ�CfifpOrt COJSELAWFORi11EfOLLDWWOREA80N(SEG70.91.6BUSINESSAN�PROFESSIONSCOOE:ANYCIIYOR (n COUNfYNh4CMREOUli1E9APERAAITTOCONS7i1UCT.ALTERIMPRDVE.DEMOLISH,ORREPAIRANYSTRUC- . W PHtIqJD6Ck �� � T1RE,OAIOq TO IT9 189UANCE.ALSO REOU�RES 7HE APPLICANT FOR SUCH PENMIT TO RLE A SIGNED fTATEAIB�lT TINT NE OR SHE IS 110EN3ED PURSUANT 70 THE PROVISIONS OF THE COMAACTORS LL CENSE UW(CHADTER G(CdAMENCINO WITX S[CTION 7000J OF�IVISION]OF TME BUSINE53 ANO 7fi0- � PoWSpa PESSIONSCOO�ORTNRTNEORSHEISIXENPTTHEREFRONANDTIEBA919FOA1HEALLEOEDE7t[1�7P- ' (� 1pN,I1NYV10LAT10NOFBGCT10N7037.6BVMIYAP7lICANTGd1AiENM�TSUBJECTBTXEAVPLICJ�MTTO � Z �g-Rpp} �„_ ACMLPENALTYOFNOTMOHETHMIFIVENUNOREDDOLLARS�i60u�.): � O�,I�BOYN�EROFTHEPF47GERTl,ORMYEMPIAVEESWITHWA6ESASIHEIRSOIECOMPENSATIDN, COTRIBfC18I " YALL DO T1E YYORK AND TME SiRUCTUHE IS NO7INTENDED OH CFFERED fOR SALE�SEC.70u,6U51- �J NFSSAND iROfE5510NS QOOE:7HE CONTMCTORS LICEN6E 4AW DOES NOT MVLV TO AN OWNER OF ? � PROPEAiYWFq8U4,DSORRAP110VE37NEREMI.M1DriNO00ES9Ud/WORKFNMSELFORHER9ElF011 ¢ 1NROUGHiYSON/1ENOVMEMPLOVEE3.GRDVDWT1�TeUCHWDpOVEMENTSARENOTINTENDEDOR m � OFFEAEDPORSALEIF,lpYYEYERTMEBUL.WNOORIMPROVEM@RIS80LDWRWNONEYFAROFCDNPLB- � TION,7NE OWNER�BUIIDER WILL HAVE TNE BURDEN OF PROV WQ hU7 HE Ott 8HE DID NOT BUllp Op YPRDVE fOq 7ME YUfiPOSEOF 9ALE�. 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B.dP.C.WHTWSREASON Q LL' DATE OWNER � Z W � UCENSEDCONTRACTORSDECLAAATION � W ' y;� „ ���. � 1 HEREBYAFFqiN UNDER PENKTV OF PE0.IURY h1AT IAM�ICENSED UNDEP PROVISIONS OF CHAPTER � � �(LONMENCNO WITN SECTION TOOU�OF DIVISION 9 OFTME BUSINESS AND PROFESSIONS CADE,ANO Z �� MY LICENSE 16 p!FULL FOFiCE AND EFFECT. —7�81�� m 0 UCENSE C S �_LIC.NO. � � ,� � "' � � v"' O� �`J�'�.�.P '�'� r►y.. a . ...._ .. � pATE NTRACTOR e�' . �r : x:f 1�i�f 1�a � WORKERS'COMP ATION DECLAflATION G � �''� = •J:��i ' yIHEREB'�AFFIRFfUNDERPENALTVOFPEfWRV 4EOFiHEfOLLAWINODEC1A0.4TIONS: $ � , • � C ��IHAVEANDWILLMAINTAINACEIifKIC11T OFCON�ENT70SELFINSUREFORNfONKERS' • " �' � ' • � � �� � ' • � ., � ' � COMPENSATpN,ASPROVIDEDBY4ECT ?t000FTHELABORCODE.FORTIEPERFORMMICE CJ � OFTlIE YYOWC FOR WFIIp1 iH15 PERMR 18ISSUEO. � , �INAVEANDWILLMAIMNNWORI�RS'COMPENSATqNINSUqANCE,ASPEWIREDBY9ECT10N O � � 9700 OF TME LA90R COOE,FOR T11E PERFDRMANCE OF THE WORK FOR WHICIi iH15 PERMIT IS � , . ._.. ISSUE�.W WORKER9'C041PEN5�INSUNAN�E CARRIER ANO POIJCV NUMBER ARE: CONSTRUCTION � CAAqIER `x�� �`�f`d� PLAN REVIEW � POLICYMIM9ER y�- ELECTRIC �p (MssfetqNNE�rarBEooA�LErEnaFn#PEanncrOFia+EFL1�dlE000unRs�s+m�oH � PLUMBING Z I CERTIFY7WIT W 7T7E VEFlFORMMICE DF THE WOFiK FORriHICN TN15 PERMiT I5 155UE0,1 MECHANICAL 8lN��NOT EMROY ANY PERSON N ANY M/WNER SO AS TO BECOME SUBJECT 70 THE y WORKERS'COMPENSATIOHUWSOFCALIFOflpIA,/WDAOREEh1ATiFISNWlDBECOME INSPECTIONFEE S BUBJECTTOTHEN'ORNERS'COMPplSATIONPROVISIONSOFSECTbN77000FTHElABOR �, caoe.i sruu�oRrHnnn�ca�nv�r wi�n� se vqowsioQns{.� �SSUANCE pDA7E: �b���APPL�cANT: • IS�7v"`^ SMIP � � N(ARNlNO:FMURETO BECURE WONKERS'COMPENSATION COVENAOE IS UNLAWFU4�ND BHALLBE ENERGY P!C �y Sl1BIECT1WElAPLOYERTOCRIMINALPENALTIESANOCMLFMESWTOONEXUNOREOTNOU5AN0 ENERGYPEHMIT ' OOLlARS(I1m,0oo�,Ml MDITqN TO TiE COSi OF COMPENSATION,DAMAUES AS PROVIDED FOfl IN � SECilON97080FT1�UBORCOUE,WTEREST,ANDAITORNEY'SFEE3. 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