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HomeMy WebLinkAbout16490 (22) CITY OF DIAMOND BA8 -- — DEPARTMENT OF COMMUNITY dc DEVELOPMENT SERVICES 21660 E.Copley Drive Suiu 190 (909)860-3195 Fax(909)861-3117 PRESS ' ��` svII.nnvG��rr�rri.[cATTox FIRMLY � DDR'SS l 8 2 3 S i I JQ-✓ha�k D Y. APPUCATION �'��(11 PERMR P/C p DATE `� NUMBER�0 � � APN_�,� LOT T� CT ISSUE TYPE OCC �j OWNER ��JMe dGF'1 DATE CONST. GROUP ADDRESS �a 3 8�' f� r• ZONING SETBACKS CITY D• ZIP ql'11�5 TEL. - O I FRONT RW ❑ APPiICANT TEL. REAR ❑ SIDFJSIDE STREET RW ❑ CONTFIACTOR R)CN F1�q s�.o E�ctr�c,�! LnC, SIDE ❑ g ADDR SS�.� �� PROPOSEO U5E CITY )1_� k � ziP GI 1�lT TEL.�/.��7tq q 3 � ARCWENGJ DESIGNER NO,DWEL. NO. NO. ADDRESS UNRS STORIES BEDAOOMS � CI7Y ZIP TEL. � v� DESCRIPTION Sa.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-8UILDER OECIARATION SFFVADDIREM O I NEPEHY 11FFlRM IAJ�ER PEN�LT7 OF PERJURY THAT I AM EXEMP7 FROM THE CONTqACTOH3 LI- GefegB/C9fpOR CENSEUWFORTlIEFOLLdWWGREASON(SEC.703f.68USINESSANDPPOFESSION9COOE:ANVCIT'OR (n OOUHTYYNi1CHqEOUIFiEBAPEFWRTOCONBTifUCi,ALTERMPROVE,OEMOLISH,ORREPAIRANY97AVC- W PgtiO/D6Ck TURE PRIOH TO RB ISSWNCE.ALSO REOUIRES TiE MPIICMlf FOH 9UCH PERMR 70 FILE A SIONED W STATFIAEM TIiRT ME OR BFIE IS LICENSEO VURSUNIT TO THE Pi10VISIONS OF TIiE CONTRACTORS l4 GENSE LAW(CFUPiER i(GOLB�IFNpNG WiTX EECTIDN 7Wu)OF pIVI510N i OF 7HE BUSINESS I1N0 PRO• V' �00�$P8 FFSSqN50DD[)diTF1ATHEORSHEISFXEIAMTHEREFROMAN0THE8tiSISFOHMEALLEOEUIXEMP- (� TION.ANVVIW.A7fONOFBECTI0N70a1.6lYANYMPIICANTFOR�PERMITSU&IECiSTHEAPPLICANTTO Z �Re-Raof � A C1VR YENAL7Y OF NOT MORE iMAN FNE HUNDRED DOLWiS(i5oo1.1: � �I,ASOWNEROFTXEPqOPER'1Y,Oi1MYEMPLOYEESWITHWAOESAS7HEIRSOLECOMPENSATlpp1, � CORIIIIBfCIaI - WLL 00 THE WORIC,AND THE 9TRUCTURE 19 NOT INTENDED 011 OFFERED FOR B/�LE(SEC.70��,BU51- J NESS AND PRDFESSIONS COD@ THE CONTFNCTOfi51JCEN5E UW OOES NOT AVPLY TO AN OWNER OF = � MiOVERiYW110BUq,D50RMPROVES7NEREON.ANDWHO00ESSUp/WORK/NNSEIFORHERSEIFOR Q tHilOU6HIN50RHEFOWNEMPIOYEEB,PROYIDEDT11AT6UCHMAPROYEMEMSANENOTMITENOEDOq m � OFFEREDWN8ALE6.MOWEV[R7MEBUL.DINOORWPROVEMENTISSO�DWRFNNONEYEAROFWMPLE- � TION,THE ONTIEILBULDER N7LL MAVE 1NE BURDEN OF PROVING iNQ N8 OR SHE DID NOT BU�LD OR MPROVE FOR 1NE PUHPOBE OF 6ALE7. � ❑I,ASDVNJEROFTHEPROPEHiY.AA1IXCLU9IVELYCON7RACTllqYNTHUCENSE�COMMCTORS 10 CONS7RUCT TME PiIO.IECT(9EC.7ot1.BUSINESS NA PROFESSIONS CODE:7HE CONTi1ACTORS LI- 1/6h19tlon ADJ.AHEA CENSE UW OOES NOTAFPLYTO MI OWNER OF 11 PROPERTV WFIO BUMDS oq W PROVEg TIiEREON,AND MfFpOONTRACTeiORSUf]IPH6IECTSWITHAODATRACTdqB)LICENSmPUfiSUMltMT1ECONfMG pUANTITY DESCRIPTION �E � tORS LICB�SE LAV1.1. _. ❑I AA1 EXEM7T UNDEA 8EG B.i O.C.FOR iMIS REASON � � U � DATE OWNER U ., � LICENSED CONTRACTORS DECLARATION W • � � 1lIEREBYAFFIPoJUNDERPENAITYOFPERri1HVTHATIAMLICEN5E0l1NDEHDROVISIONSOFCHAPTER � •�CONYENCWC!WRM SECTION 7000)OF DNISION 3 OF TME BUSINE6S AND PROFESSIONS CODE.AND Z X MY UGENSE IS W FIAI FORCE NO EFFECT. � IICENSE��SS �� LIC.NO. �I ��'� � � onrE 5—��l—O 1 caurRacron a WORKERS'COMPENSATION DE RA I ��� ` 1 � 1HEHEBYAFFIqMUNDERPEWLLTVOFPERNRVONEOFTMEPoLLOWINGDECLARATIONS: V � �_IMAVEANDM/ILLMAIMAMACEifTIFICATEOFOONSENTTOSELF-INeUFEFORNpRKERS' � Cp�7ENS11T70N,�S PROVIDED BV SECTION J�a00FT11E LABOR GOOE,FOR TNE PERFORMANCE W ` OF THE WONK FOq WHICH THIS PEqYrt IS IS5UFD. � � /' I Y1AVE MID MIILLAIAINTAIN WORKEflS'COMPENSATqN INSUfUNCE,AS REW�NED BY SECTION Q J7000F TNE IABOH GODE,FOqTHE PERFORMANCE OF THE WOPN iOR WHICH THIS PERMIT 45 133UED.MYMqRKEPLS,'��OOIAP SATqNINSUMNCECARRIERANDCOLICYNLIYBER�RE CONSTRUCTION jawA�Ea�I • ` �rneX� Cr4 � PUINREVIEYV � POLICY NUYBEn N L �U 1�D�f)Z.�' ELECTRIC �I � (MssEcipuNE�lNorBEaoRaEfEDOFn+EVEwAisroHa+EH1�DiiEDooLLARSR�mlORLEss? PLUMBING - - � I CEqTIFY THAT p17NE PERFOqM1.NCE OF THE WORK FOR WHICH TNIS PERYIT Ig ISSUED,1 MECHANICA� � SHALL NOT EMPLOYANY iEflSON W ANY M�NNER SO AS TO BECOME SUBJECT TO T1iE y WORKEH9'COMPFNSATION UWS OF CALIFORNIAAN�AGHEE TIiAT IF ISHOULO BECOME �NSPECTION FEE � S SUB.IECTTOTHEMIORNERS'COMPENSA710NPROVIS�ONSOF6ECTpNeIaoOFTtEUBOH E.I �LL��LY WIIHTFqSE PROVI510N5. ISSUANCE O � SMIP p D11TE: IAPPL ANT: � ENERGY P1C WqRNING:FNLU �TO SECURE WORKERS'GOMPENSATION COVERAGE IS UNUWFUL,AND 9FULLlE � BUBJECTANEMPLOVERTOCRILIINALVENALTIESMIDCIVILFlNESl1PTOONEHUN�REOiKriISAN� ENERGYPEHMIT DOLLM6(tt W,OW),Ml ADDITION TO THE COST OF CpMPEN511T10N,DAMIIGE6 AS PROVIDED FOH IN J SECTqN 7T0!OF THE 1A80R CODE,INTEFlEST.AND I1TfORNEYS FEES. RETENTION�E: �� CONSTRUCTION LENDING AGENCY PRE-ALT FEE: � IMEREBv11FFIpMUNDERPENALTYOFpERIURYTNAT7HEPEISACONSTpUCT10NLENbINCiACiENCY Z FOR THE PERFORMANCE OF iHE WORN FOR WMIp1 THIS VEHMIT IS ISSUED ISEC.�oY7.CIV.C.). W � LENDER'S NAME � LENDER'SADDRE59 1 O � 10ER'TIFYTNATIWWEREADTHISAPPLIC/�TKJN�WDST�TETM�TiME�VEWFORNATqNISCORqECT. TOTAL FEES �1 A �� � 1 A(iHEE TO OOAIPLY WfTH ALL CRY AND COUNTY �IN�NCES MO STATE lANS RELATINO TO BUILOING �2' � CONSTRUCTION,ANOHEREBYAUlYqR12EREPRES NTATIVE60FTH15COUNTYTOENTSpUPONTHE �BOVEMEMqNED VROPERiY FOR INSPECTIDN P RPOSE3. , w GOMM@NTS � SW � P M� �- - � � VJ & UREOFPENMI7TEE DAE � RECPT,NO. PAIO 8Y VAUDATION WHITE—Depertment Copy.YELLOW--Finence Copy,PINK—Anaessor Copy,C30LDENROD--File Copy,GREEN—Appicant's Copy ,� . CITY OF DlAtq1P1�JRD B�R . ' � It,4SP�C'i fU4'� F��COE�C� ��`Y .����g4�����u���h ry $�li v '^.4 ,� �� �$ �.�� ip,?8�!^ � �'vxeY�.`^q�iS` . ,..,. .. . . ' sFT�r�cr i ; , � , � �ioc��J(JIS�f . . .... --------------...._- -------.;.- — -• -----..,--------- --- � .- - - -- __ -- � --- _._ ._. ,_ � __...-- ----_� __--..r_:_, .-- �-- _ ._. 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