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HomeMy WebLinkAbout16542 _ � CITY OF DIAMOND BAA , DEPARTMENT OF GOMMUNITY&DEVELOPMENT SERVICES �' � W � 21660 E.Copley Drive Suite 190 (909)860-3195 Fax(909)861-3117 PREss 9�'� � BUILDING PERMIT APPLICATION FIRMLY � JOBSITE /� J,� APPGCATION L�.,� 1 PERMIT -�I)��P/C o ADDRESS ���� ��'�✓���C�R h.�� � DATE �...J lf���� NUMBER j� # � ISSUE TYPE OCC APN LOT', TRACT DATE CONST, GROUP � OWNER p ADD ESS ,��C"'l_ �'� �1�tY1Y�i23ir1 �/'T -� � ZDNING SETBACKS gCITY�I �' f� a<" ZIP.�i`7�'fE �� �"�� REART Rw ❑ APPiICANT ��-j,g'� �Cr�i'ItC;��2�TEL.��6�3�"R�",�I�i4¢ SIDEJSiDESTREET RW C I � CONTRACTqR e C � Y �7 f'.� SIDE ❑ � ADDR S5 I�_ , �.t7 g� CITY Y ZIP�I��TEL.c i0����-f�I� PR�POSEDUSE o ARCH/ENG/ Z DESIGNER NO.DWEL. NO. NO. pW., ADDRESS ' UNITS STORIES BEDROOMS �' CITY � ZIP TEL. � DESCRIPTiON SQ.FT. FACTOR PSF ADJ.AREANAIWPATION ' - �Q - � � O,WNSR-BUILDER�DECLkRATION SPR/ADD/ftEM � � a L] I NEREBYAFFlRAI UNDER�NALTY OF PERIURY YHAT I AIA EXEMP7 FROM THE CANTAACTORS LI- Gd!d90/CZfpOfl � W CENSEI.AWiOfiTHEFOLLOWIN REASON(SEC.7037.58USINESSANDPflOFE9310NSCODE:0.NYCIttOR (/] 6�7 .CpURryyWHiCHqEWIRESRPE I7TqCOM1STRUCT,Ah7ER,IMPROVE.DEHIOLISF�,ORREPAIRANYSTFUC- W patio/�eck W. TURE PppR TO 1T5�SSUANCE�lSO RE�UIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED W n��. STATEMENT THAT HE OR SkE ISIElCENSE�PURSUANT TO THE PAOVI510N5 OF THE CONTRAC70RS I:1- � GENSE LAW(CHAPTER 9(COMlAeNCINd WITH SECTION JOQOJ OF DNISlON 30FTHE BUS!NESS AND PRO �� PaoUSpa � PESSIONS�OE�ORTHATHEORISNEISEXEMP77HEREFROMANDTHEBASI6FoqYHEALIEGEDIXEMP- . �, � , , �� �� TKKJ_ANYVKILRTII�NNOFSECYIOt�17031.5BYANYAPPLICANTFORAPERMITSUBJECT57HEAPPLIGANTTO z RE-RODf . r,� ACMLPENALTYOFNOTMORE7HANfIVEHUN�REDDOIIARS(i5oo).): . ❑I,ASOWNEROFTHEPROLIERTl;Oq0.AYEMIPLOYEESWITHWAGESASTHEIRSOLECAMPEN3ATION, L� ' CORIR18fC18I ����� WILL�O iHE WORK,.M1D THE STRUC7URE IS NOY INTENpEO OR OFFEflE�FOR SALE(SEC.7ua4,BUSI- J � '�, NESS AND PFOFESSIONS CODE:tHE CONiRACT6RS LICENSE LAW�OES NOTAPPLY TO AN OWNER OF � � ' PqOP61TYlMHO BUIlDS OR IMPROVES h1ERE-0N,AN6 WHO OOES SUCH WORKHIMSELF OR FiEflSELFOR � �,pC THROI�°�GHHiSORHEHONMEMPLOVEES,�R�6VIDE�iHATSUCHIMPP.OVEMENTSARENOTIN7ENDEDOF m � L8i': OFFERED FOH SALE IF.HOWEVER TFiE 9UILDING OFi IMPROYEP.9ENT IS SOLO YdITHINONE YEAR OF COMPLE ',Z', �TIUH,THE OWNER-SUILDER WILI NAVE THE BUROEN OF PROVING THAT HE OR SHE P��NOT BUILD Oq �..�� �IMPROVE FOH TME NURPOSE 4F$IU.EL � �,ty ' ❑I;ASbWNEROFTHEPRbPEflil;'AiAE%CLU61VE4VCANTRACTINGW?TNUCEPIEED:qNTRACTORS '.(L �.TO COP15YqL1C!THE PIiO.IECT(S�EC.7044,HUSIXESS AND PflOFES510N5 CODE:THE CUNTRAG70R5 LI� ValU2IlOPi kDJ.AREA � .,.W, .CENSELAWDOESNOTAPPLY70�1N0'MdEHQFAFROPERTYWFl08UlLDSORIMPROVESTHEREON,AN� . ' � p��,- �wHocordrwec'rsFOAsucHaaascrswinaacaura�4craa�s�uc��vs�onuasuaurrorHeconTan� Q�qNTITY DESCRIPTION FEE � �. rons ucewse tnw.t. , ❑IAAA EXEMF7UNDEfl SEC.', 8.&P.C.FOR THIS REp50N a I O � (3 � � � . OAlE O'JVNER '_ ; . . . . Z � d LICENSECICONTFtACTORS DECLF+RATION ,a ' � , ��'. 'IHEREBYAFFIAMiiNDERPENALTNOFPER:URYTHATIAMLICENSEDUN�EHPROVI510NSOFCH�IPTER � __ � �- , � ��q � ,e(COMMENqNf3 WITH 3ECTION 7b00)OF DIVISIOIr'3 OF7HE 9USINESSAIdD 7RQFESSIONS CODE,AND 4-d� �' X .,MYtICENSE IS iN N FORCEANp 6FFECT � � E � � � � LICENSE C;ASS C��l�"!LIC.NO. �, �-��.�� _ U ,oare �t/��J � cowrRacToa '�"1��°!, _ a�'. w ' �'.� WGF.��RS'COMPENSATION pECLARATION � Q _ � � - _ � 1 ', � ���� I HEREBYAFFIRM UN�ER PeNAI_7}'OF PERJURV OPdE OFTHE FOLLOWI4G OECLARATIOSJS�. � � ' t�� �IHAVEAhI?WILLMAINTAIMACERTIFICATEtlFCCNSENTTOSELF-INSUREFORWORKERS' � I � � COMPENSATION,ASFRO�IDED9YSEC710N37�OOFTHELABORCOOE,FORTHEPERFORM1AtJCE U a OF7HEW9WCFQFYdl91a.}i1THISPERMITI5155UF0. � L6! ,�1 �_IHAVEANDW7LLWAItdTA6'ry WORKERS'GOF9FENSk110NIN6URdNCE,ASREQU�RE6BYSECTION @ 3i00CF7H6U880RCODE,FORTWEPER�OflA3&PJCEOFTHEWORKFORWHICNiHISPERMlTIS � ISSUED.MYCI4Q KEqS�'�,Lh9PE�5�AilONiNSU NCECARflIERANDPOLICYNUM9ERARE: CONSTRUCTION "� ce�aR��Ry,� `�TC ����� PLf:NREVIEW � d.., pd�. � � P061CYNU°ABER U���Y"'E]I '!c� �J`� ELECTRIC ---,_.--- - —��� �—���-- � (iF&SSECMMINEEl1a�JTB�'�PI_Ef�OFT1iL-PEfkrCTISFOHHCXUEHtJtd)RED�LIRS(510�}ORLESSa PWMBiNG `�f 1„yl V' � I O � ICERTlFYYtiATIF4THEPE�eOq�9ANCE0FTHEWORKFOfl`NHICHTMSPEftM,ITISISSUED,I MECf1ANICAL '�, � SN,qLtNOTEMPLOYANY RSONINAP3YMANNERSOFS7�08ECOMESU9JEC7TOTHE ""- jfr YIOPKERS'COF!PENSATI NLAWSOFCALIFORNIA,AND.4GREETHAYIFI6FKKILDBECOME ONSPECTIONFEE � ''�, � OATE'SL_—_�IT'"�H' ��PLI�CAdT:W'�THUA�iSI�OSSOF5ECT10�7ooOFTHELABOR .SMIPANCE � a" ^` �^.'_ ._`.. •L..... -• , ',I, ��i.��' r�� J'�, WARNING:FAILURE TO SECURE l"IiORKEPS'COMPENSATION COVERAGE IS UNL4WFUL,AND SHALL OE ENERGY P/C f �j„ SUBJECTHNEMPLOYERTOCRIMINALPENALTIESAN�ClVILFlNESUPPOONEHUNOR'cDTt10U5AND ENEP,GYPERMIT OOLLARS(Z100,aoa),iN ADDITION TD T}iE CQST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN ��, SECTIDN37beOFTFiELA90RCOqE,IN7EFEST.ANDATTDRNEY'SFEES. ' RETENTIONFEE: e��• a� CO�IUSTRUCTION LENDING AGENCY PREALT FEE: __ _ ___ _ � IHEREBYAFFIflMUNDERPENALT`{oFPERJU0.YTHAT7HEflE15ACON5TRUCTIONLENDINGAGENCY � FORTHEPERFORMANCEOFTHE`NORKFOPWHICHTHISPERMITISISSl1E�(SEC.309],CIV.C.). , . � W ��� LENDER'S NAME � � . �' LEN�ER'SADDRESS ' � ICERTIFYTHATIHAVEREA�7HIS�PPLICAiIONAN'JSTATFTH4TTHEABOVEWFORMATIONISCARRECT. 1 O IAL�EE� �, � yJ � d„ IAGREETOGOMPLYWITHALLC:TyANDCOUNTYOft01NANCESANDSTATELAWSRELATINOTOBUILOINO . �,� CANSTRUCTION,AND HEREBY AUtHORIZE REPRESENTATNES OF THIS CAUNTV TO ENTER IIPON THE - , ABOYEN�EM E�AflO?EflNFiqINSPECTIONPURPOSES. GOMMENTS " �' �" PE � ,NAME(PRINT) I - � ' Q. � ��� BYaN O RMI'IT � DAT ' � - � RECPT NO. PAIDBY VALIDATION S ~ LNHITE—De ment Copy,YELLOW--Fin�nce Co PI,'�K—Assessor Co GOLDENROD—File Co GREEN— IicanYs C � . Part PY. 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