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HomeMy WebLinkAbout16428 (32) � �` �,� _� CITY OF DIAMOND BAB � DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES 21660 E.Copley Ihive Suice 190 " (909)660-3193 Faa{909)861-3117 PRESS. `"^�"� BUII.DING PERMTI'APM.ICATION FI MLY Q ADDRIESS ��S/ SE j��� �� • APPLICATION �1 PERMR P/C o �ATE � NUMBER 7� � APN LOT—�i�- TRACT �SSUE h TYPE pCC g OWHE�/L K�"^� DATE " CONST. GROUP p ADDRE ZONING SETBACKS C�TY �/A'�EEt ZIP_�-TEL. - FRONT RW ❑ APPLICANT TEL. REAR ❑ SIDEJSIDE STREET RW p CONTRACTOR SIDE ❑ r u g CDDRESS � �P 4 o a TEL. • f • �'ROPOSED USE e ARCHlENG/ � DESI(3NER NO.DWEL. NO. Np, ADDRESS UNITS STORIES BEDROOMS CITY ZIP TEL. v� DESCRIPTION SQ.FT. FACTOR PSF ADJ_AREANALUATION Q OWNER•BUILDER DECIARATION SFR/ADDIREM O 1 XEREBY 11FFIIp/tMUER PENALTY OF PERAl11Y THA7 I AM E%EMP7 Fi�M THE WN7RACTORS ll• .��e�.��N CETREIAWFORTNEPoLLOWNOIIFA.AN(SEC.76i1.68U51NE55MlOPROFESSpNS00DE:ANYCITYOR (n OOUNfYMMK.HRE0UIRESAPEiWRi000NSTRUCT,ALTER�MPPoDYE.DEMOUSH,011REPAIHMYY9TRUC. W PBfIOIDBdC IURE,VPIOR TD RS IBSUANCE,ALSO qEM11RE5 THE APPIICANT FOR SUC}I PERAl1T TO FILE A SN7NED � lTATiMQJT TiAT HE OR BHE IS 110EN3ED PURSUANT TO THE PRONSION6 OF THE CONTRACTOii3 ll- CENSE UW(QUPTER�(COMMENCINO WIIH 9ECTION 7000)OF DINSION 7 OF THE BUSINE55 AN�PHO• LL PDCUSpB FESSIONSCOOqORTHATHEORSHEISIXEMP7IHEXEFROAIANDTFEBASISFORiMEALIEOEDEXEMP- (�] 710N.ANYVqLA7qNOF9ECTION7m1.68YNYYAPYLICANTFORIIVERMITBU&IECTSTIIEMPLICqNTTO Z Re-Hoof � A QVIL PENALTY OF NOT MORE 7NAN FIVE F#1NDRED DOLURS(i5oa�.1: _ ❑4�dM7NEROFTHE►ROPERT',ORMVEMPLOYEESWITFiWAOE5AST1E1RSOlECOMPENSATION, ❑ (',pmmBfCiel WILL OD THE WORK,Ml�iHE STRUCTLRE IS NDT MTENDED OP OFFEREO fOR 9ALE(SEC.7a��,BUSI- J NESS AND OpOFES91ON5 COOE:7NE OO�RRACTOiiS LICENBE LAYV ODE3 NOT ADPLY TO AN OWNER OF = � PQOPERfVWWOBU4LSORMAPRDVE57HEREON,ANGMM1p00ES6UCMYpqNHIMSEIFIXiMEH6ELFOR � 7HROUCYIWSORNFRONNEMPL4YEES,VROVDEOlF1�T8UCHNAPR�VEMENTSMENOTWTEND£OOR LO OFFERED IORS/LE IF,FIDWEYER iME BUILGNG GR MdPROVEMEMl IS bOLD WITHNONE YEAR OFCOMPIE- TION,THE ONfNER�BUIILER NALL MAVE TME BVRDEN OF PROVIN(i THAT ME OR SHE DIU►qi BUILD OR tAPROYE FOR iXE PURPOSE OF SIILEI� . ❑L A9 OYMER OF TiE iROPEHTI;AM EXCLUSNELY GONTq�CTNO WITN LIf7ENSE0 CONTRACTORS � TO CONSTRtICT�HE PRO.IECT(9EC.70N.BllSINESS AND VAOFE3510N9 CODE:THE CaNTRACTORS LL Vl11u8tion ADJ.AREA CENSE LAW OOES NDT MPLY TO AN OWNEH OFA PpOPERTY WIIO BUILDS OH I►IVROYES THEqEON,AND YA�OOOMRACBFORSUdIPR6.lECTSWITHACONrMCTOR�SJUCENSEDPUR5UAN7TOTNEC�ONTRAG pUANTITY DESCRIPTION FEE � NRS 110ENSE IAW.). � O I MI EXEAIPTUNDERBEC. B.�V.G FOfl THIS REA50N � U � DATE OWNER � �` LICENSED CONTRACTORS DECLARATION � � I NEREBY AFFYW UNDER►ENALTV OF PE0.IUR`/THAT I AM LICENSED UNDEH PROYISIONS OF CNAPTER Z r-'r� � //Yi� � D •(COMMENCWO WIM SECTION 700U�OF D�YISION 9 OF THE 6USINE55 AND PROFESSIONS CODE,Ml� Y1'LICENSE IS MJ FU^LL FO C D EFFECT. � LICENSE CLAS �" '�� LIC.NO.��I�`�' � �j DATE � � CONTRACTOR � a � WOFKERS'COMPENSATION DECIARATON Q � 1 MEpEBY AFFlRA111N�ER GENALTV OF PERJURY dJE OF THE FOLLONANO DECLARATqNS: Z C _IMIWEANDWILLMANTNNACERTiFIC�TEOFCONSENTTOBELFIN&UREFORYYORKEHS' _ t OOYPENSATION,113 VROVIDEO BY SECTION 77000F?HE LABOR CADE,FOR THE PERFORMANCE �U Q FK FOR WHld/THIB PERFAIT 19153UE0. � IH4YEANOWILL WORKERS'COMGEN IONI J ,ASpEWIREDBV6ECTDN q 97u00F TI1E COD FOR THE PERFO . T O H FOC FOq WHICHiH15 PERMIT IS _ � I65UED.MY WO iCEA PEN TWN IN E AN�POLICY NUMBEH CONSTRUCTION �j. CAitNIER PLAN REVIEW � POLICY NUMBER ELECTRIC � (n9ss[croNr�NareeaoRsi�naF'nfe�wartaroi+ar� oauas � a�tFssG PLUMBING \ Z ICEPTIFVTHATINiNEVERFORMANCEOF751EWORKFOqWHI HTMS ERMI7IS SUED.I MECHANICAL � '� � (y,�S, SNIILLNOTEMPIAYANYPERSONNIANYIMNNERSOA3 &JECTi THE (n WOPoCER6'COMPEN6ATIONlAYV50FCALIFO � et w� �s�wu� Eoorae INSPECTIONFEE SUBJECTTOTHE WORKERS'COMPENSAT 7T00 fHE IABOR Oi swu.�w rn coMP�rwm� sE a s. ISSUANCE p OATE��APPLICANT: , SMIP � ENERGY P/C WARNINO:FA0.t1RETOSEWREWORKER9'CpAPEN9ATION - AOEISVNLAWFVL,ANDbMALLBE � SUBJECTANEMPLOYERTOCIIIMINIILPENALTIESANDCIVILFWE9UPTOONEHl1NDREDTNOUSANO ENEHGYPERMIT OOLLARS(�10D,000),IN ADDITION TO TFIE COST Of GOMPENSATION,OMIAGES AS VflOVIDEO FpR IN � BECTpN 97a!Of 7HE LABOR ODOE,IN7ERE57.M'OATTONNEV'S FEES. RETENTION FEE: OCONSTRUCTION LENDING AGENCY PRE-ALT FEE: � IHEAEBYAFFIRMUNDERPENALTYOFPERIURYTHATTMEREIS�CONSTRUCf10NLEN01N6AGENCY Z FOR iME PEfl W RMPNCE OF TME WOFK FOR NT11CH THPS PERIAR IS ISSUED(SEC.]OY7,CIV.C.�. i Li � LEl0ER5 NAME F-� IENDER'6AODRE55 _ IAfiREE o�,;�R;;°�'�,�o0o Y �o��,��DSTA�EIAWS RPELATMO'TOBUIIDIMG TOTAL FEES , ���y� � CONSTRl1CT10N,ANDHEREBVAVfHORRE �DR EMATNESOFTWSCIXINTVTOEMERIIPONTIE � S� ABOVE•YENTIONED PROPER SPE 10 PURPOSES. � 0 �/ •'c COMAAENTS � l.�r' e J � PERMIITEE ^ � � � ��"�/ � SIONATUREOF RM�TfE DA E � RECPT.NO. PAID BY �: VALIDATION WHITE—DepeAmenl Capy,YELLOW--Flnanee Copy,PINK—Aasesaw Capy,GOLDENROD—Fle Copy,GREEN—AppicanPa Copy crrv Q� o�ar,�or�� s�R . �t���ECTior� c�Eco�� � �:.„� ..�, �, y , � 1� "�: -���'����� � . ,� � �.' '�'' � " ��� � �°����._ ���.�: � -�� M����� , ., • .� ,�. ... .... . . �, . . � ,�_......�'.,� _ � � SET B�1CK , . 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