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HomeMy WebLinkAbout13173 CITY OF DIAMOND BAB � --�--- DEPARTMENT OF COMMUNITY dt DEVELOPMENT SERVICES � > 21660 E.Copley brive State 190 (909)860-3195 Fax(909)861-3117 PRESS ��'�'� BUILDING PERMIT AP'PLICATION FIRMLY � JOBSITE ,�y n � /J ��(�, APPLICATION PERMR �3i�3 �/C � ADDRESS �`I���� J_1�.X�..d1�.ir.� DAT� NUMBER � APN LOT TRACT DATE ��Z� _1� CONST. GROUP � OWNER ADDRE ZONING SET6ACK5 CITY�� IP TEL. ��j,_^G��j FRONT RW ❑ APPLICANT TEL. REAR ❑ SIDElSIUE STREEf RW ❑ CONTRACTOR 51DE ❑ � ADORESS CITY ZIP TEL PROPOSED USE ••< � ARCWE DESIGNER NO.DWEL. NO. NO. ADDflESS UNiTS STORIES BEDROOMS � CITY ZIP TEL. w t�r DESCRIPTION SQ.FT. FACTOR PSF AQJ.AREANA�UATION Q OWYER-BUILDER DECLARATION SFR/ADD/REM O 1 MER�Y AFFlRY UND[R PEN/1TY OF GEMIRY THAT I AY EXEYVT fROM THE CONTRACTORS�I- Gflfege/CeIpOA CENSE1AWWi1T1EPoLLOWNORE�50N�8E0.7o3t.68USINESSANDPROFE551d15CODE:M1vGTYOR (f) OOUNfYYNtlC11RE0UIRESAPERMRTO00N5TfWCT,1ICTERIMPHpVE,OEMOUSM,ORHEPAIRANY$TRUC• W PBtIOIDBdc 7URE,ORIOR TO ITS IBSWUICE,ALSO REOUIRES 7NE APPIICANT fOR BUCN PERMIT Tp cILE A SIONEO � �TATEMENT TFIAS ME OR 9HE 19�,ICQ19E0 PURSUANT TO 7NE PHDVISIONS OF TlIE CONTMCTOqs tl� CENSE LAW(QUPTER�(COMMENCWO N7TH SECTION 700D)OF DIYISION 9 OF 1HE BUSINESS�ND PRO- V' POOI/Spfl FEBSIDNS OODk�OR TNAT HE OR SHE 16 EXEMPT TIEREiROM AND THE BASIS FOR TVE ALLEGED EXENP- 710N.ANYVIOIATIONOFBECTION7W1.bBYANY1lPPLICMfTfORAPERMITSUBJECTSTNEMPLIGNTTO Z Re-Roo1 � � A CIVIL rENNAL7V OF NOT AIORE 111AN iNE HUNOREO DOLLAR9�t5aD}.�: 04�01NIEROFTHEPROPERTY,ORMYEMPLOYEESVATHWAOESASTHEIRSOLECOMOENSRTION, 0 CommefCl81 WILL DO THE WORK AND 7T1E BTRUCTURE 16 NOT INTE�ED Oq OFFEREU fOR SALE 15EG 7M4 BU51- J NE55 M1D VROFE8SqN5 OODE:TME CONTRACfORSIICENSE UW DOES NOT AVPLY TO AN OWNER OF � PIiDPFAIYWNOBV0.D30RMPqDVE9THEREON,ANDWHODOE59UCHW'ORK171MSELFORHERSELFOR � (T TNROl70NW5OFNERO'WNOAPLOYEE9,PROVIOEDTHATSUCMWPpOVEMENTSMENOTIN7EN0EOOR m ��•� OFFkREUFORiALE1FM�WEVERTMEBIALDIN00RWPpp1rEMENT1660LDWITHINWEYEAROFCpMPLE- � 410N,iXE OWNER-0UILLER YYILL/4�VE TME BUN�EN OF PROYWo TMT NE OR 8ME DIU NOT BUILD OR LL1Vi10VE FORiNE PUHPOSE OF SAI.E�. � O4�SONMEROFfHEPROPER7KAMEXCLUSIVELYCONTMCTN�WITHLGEN8EDCONTFUCTOR9 TO CANSTRUCT TFIE PqpJECT(SEC�?M{.BUSME55 M1D PROFESSIONS COJE:1'HE CONTMCTORS LI• SI9IUe2Iq1 AOJ.AREA CEA19E UW DOES NDTAVPLY TOMI ONMEq OFA PROPERTY WIiO BUILDS OR IAAPpOVE4 TIEREON,ANO YRIOCONTRACT6PoRSUWPROJECTSYNTIACd11MCTOR�9�LICENSEDPURSUANTTOTHE00N7MG QUANTITY DESCRIPTION FEE � TOFiS LICENSE UW.). + ❑I AM EXEMYT UNOEi18EC. B.l P.G FOR THIS RFASON � U �' o�rE ownEa V �...000��� LICENSED CONTRACTORS DECLARATION W � 1HEREB�AFFIRMUNOERPENAITYOFPEWUHVTlNTIMILICENSEDUN�ERPFiOV151DN5OFCHAP7ER V. 0(Od�4ENCYHi MA7N SECTION 7000)OF DMSION J OF iNE BUSINE59 AND PROFESSIONS CA�E,AND Z W LICENSE IB N M.L�FO+RCE AND EFFECL m � LICENS�E CLA55 `'� ( LIC.NO. � � � DA7E '7��'�'�� CONTMCTOR a WORKERS'COMPENSATION�ECLAFlATION a � I FIEREBY AFFlRM UNDFR PENAL7V OF PERIURY ONE OF THE iOILONnN6�ECUMTpNS: Z (� _1MAVEANDWILLIMNTAINACFRTIFICATEOFCONSEMTOSEIF-INSUREFORWORKERS 4 � COMPENSATpN,I1S PiqV10ED BY SECl10N 3700 OF THE IABOR CWE,FOR iME PERFOqMANCE U OF WONK FOR MM1IICM TMIS PERMIT IS 159UED. � � IWIVEANDWILLMAIMMNYNDRKERS'COMP�NSA7pNIN5UiUNCE,ASHEIXJIRED6YSECTION Q 97000F1MElABORC00E,FORTNEPERFOfl4ANCEOFTMEWOMFORWHICHiH15PERMITIS Q�.�/1 SSUm.MY WORKERS'COM SATION 1 URANCE RIER�ND POLICY NUMBEii ME: CONSTRUCTION c� � � GIRRIER_�,��j�l / PIAN REVIEW � POLICV MMA9ER ��,_�� ELECTpIC p (i►ass[cinr�r�eoNoreew�iIDaFnfrew.�r�siaaa��uronEuoauasRiao�oAtFss1 PLUMBING q-'�^,�� 1ZtJ 1 CERTFY THAT W THE PERFORAUNCE OF TME WURN FOR WMICHTMIS PERMIT IS ISSUEp,l MECHANICAL ��r O� (�' SWLLI NOT EMPLAYANY VEIiSdJ IN JWY AIANNER SO AS Ttl BECOME SUBJEC7 TO TNE � -�'� (n WOHNER6'COMGENSATqNUW80FCALIFOqMA,ANOAOREETHATIFISFKK1lOBECOME INSPECTIONFEE � SUB.IECTTO THE Y/ORKERS'CO�APEN5�TION PFtOVISIONS OF 5 ION 1700 0F THE VHOR ( OCODE,I S.�H�AI'1'�FOpRryTMw1TH COMPIY WIIH .E PROVISIONS ' ISSUANCE �_ p DA7E�F�_/,=( AaaL�CAM7: ,�� SMIP �� � WAANINO:FAILURETOBECUPEWORKER3'COMPENSATIONCOV qAGE15UNLAWFUL,ANDSH,tILBE ENERGYPlC ) �_ �y SUBJECTANEAIPLOYEflTOCRIMINA�PENALTIESANDCMLFINESUPTOONEHUNDNEDTHOUS/WD ENERGVPERMIT � � DOLLAHS(i100,oaa),R7l1DDIT10NTOTl1ECOSTOFCOMPENSATION,DMIAOESASPROVIDEOFORIN � SECTIDN 7708 OF 7HE U�BOR CODE,N17EpEST,ANO ATTORNEV'S FEES. RETENTION FEE: '�:� � CONSTRUCTION IENDING AGENCY PRE-ALT FEE: � � � INEREBYAFFMMUN�ERPENNLTYOFPEp,1URVTHATTHEREISACDN5TR4CTIdJLENDN6A6ENCY FON THE PERFORMANCE OFl}�E WORN PoR WHldi THIS PERMIT IS ISSUED(SEC.]CVI,GIV.C.). � LENDER'S NAME � �] n � � C LENDER'SADDRE55 � ICERTIFYTMATIHAVEREADTiI3AFPLICpTqNMIDSTATETHAThIE►BOVEINFOIiMATqNISCORRECL TOTAL FEES � IACiREE TO OOMPLY WRH ALL CITV ANO COUNTY ORDINANCES ANU STATE UMIS REtATINO 70 BU0.DINa � CONSTHUCTIDN.ANDMEREBYAUi}qRIZEREPRESENTATNESOFTFI15COUNTYTOENTFRUPONTHE ABOVE•MENTqNED FI�FERTY FOR INSPECTION PUqPO5E3. COMMENTS � � m PERMI7fEE NMI ) �. Q N � 510NA7lNi F P pp � RECPT.NO. PAID BY VALIOATION WHITE—Department Copy,YELLOW--Flnenoe Capy,PINK--Asseasor Copy,Q06DENR00--File Copy,OREEN—App icanl's Copy _ _ � � . , , . , , . . . . � . K,... _ . 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