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HomeMy WebLinkAbout12984 (14) __�;.,,� CITY OF DIAIVIOND BAR �t�- DEPARTMENT OF COMMUNITY&DEVEE.OPMENT SERVICES t ' _ . W 21660 E.Copley Drive Suite 190 � PRESS %H�,., (909)860-3195 Fax(909)861-3117 ' BUILDING FERMIT APPLICATION --- FIRMLY ¢ ADDRESS � � ', } JOBSITE !�� � � �U,P" �E4 Q, DA7E CATION�.- t✓� L NUMBER � �����/C � ��. ISSUE r'� ,r_� ��� TYPE OCG ,- TRACT � DATE �l-- '"-k CONST. GROUP APN L 7, p. OWNEB __���i �C�.�C<i : G �- _ p ADDRESS , ZONING SETBACKS ,. F '�1 L9 CP' � � CITY ..��� ,'B�?�°:� ZIP .�,TEL. "� REART � , ❑� a APPLICANT I TEL._,__ SIDE/SIDE STREET ' RW G � CONTRACTOR I�E Y 9�'+VI � , ` 51DE C � CITI' ESS ; , ,' r. ZIP�:'P[7��L TE t� ,, PROPOSED USE Q ARCH/ENG! � �z DE5IGNER NO.DWEL. NO. � ApDRESS NO. UNITS STORIES BEPROOMS � C17Y TEL. DE$CRIPTION SQ.FT. FA�TOR PSF ADJ.AREA7VALUATI � ; QN. O `_ OWNER-BUILDER DECLARATION SFWADD/REM L� CENSELAW FOqTNE FOLLOWIN�RE.490N(SEG.�flY THAT I RM EXEMPT FPOM hIE CONTRqGiORS LI• - � , Gflf8J0/CBfpOf[ . . ' I HERE9Y AFFIRM UN�ER ENAL7V OF PE 7031�.5 BLISINESSAN�PRbFES910N3 CADE:ANY CITYOF C,7 COUNTyWHICHHEQUIRESAPER t7TOCONSTRUC7ALTEN IMPROVE,qEMOLISH,ORREPAIRANYSTRUP W Ratio/DBCk wiUpE,-PpIOR N ff'S I6SUANCE,�D�REWIqES 7NE APPWCaUT FOR�SLICH PEFMIT 70 FILE A SIGNE� � W � � �.STATEMENT THAT HE OR SHE IS LICENSED PUfiSUPM TO THE PHOVISIONS OF THE CONTFiACiORS LI- � , � ' �',I1CIVp.PENAL7YOFMOTMORE�GiNGWITHSECT10N7W�JOFO�VISION3�F4HEBUSMESSAN�pflO� ' ,�' POOYSp3 ��- ,CENSE UW(CHAP7EN 9(CQMM N ' - � FESSIDNSC�qOR7NATHEOqS,HE1SEXEMpTTMEflEFflOMANDTHEBq515FORTHEALLEGEOEXEMP� � TION.ANYVIDLATIONOFSECTI 7031:5BYANVAPPI:ICANYfORAPEflM7SU&IECTSTHEAPPUCANTTO � RB-ROOf ' � � AN FIVE HUNDRED DOLLARS(SSOD).): � '� ❑I,ASOWNEROFTHEPRO��CtiNORMtlEMPLOYEES,WITHWAGE5A5THEIRSOLEWMPENSA7ION, � C�mmBfcWl � � � � "�� . � ',Z ';hN1U,p0 THE WORK,AND TNE 5 RUCTl1FiE.S NOT INiENDE�OR OFFERED FOR SALE(SEC.7�b4,0U56 ,J , .NE55 ANO PqOFES510N5 CO�E:�fHE CONTRACTORS LICEIVSE LAW DOES NOT APPLY 70 AN OWNEq OF � � PiAPERiVNAiOBIIILOSORIMPROYESTHEREON,ANDW1i0DOE55UGHWORKHIMSELPORNFASELFOR = " ' O[ TFI�UGH'HISORHEflWJNEMPI�OYEE9,PfiOYlOEDTHpY5l1CHIMPROVEMEPRSARENOPINTENDEDOR '� ' ' " oOFFEREDFOR5AL.EIF,HOWEVEW7HEBUILDINGORIMPiiOVEMENTISSOtDWlTHINONEYEAROFCOMPLE � � 710N,THE OYiNER�BUlLDER WILta HAVE THE BUROEN 6F PROVING THAT HE OR SHE DID NOT BUILD OR . . . = IMPHOVEFORTHEPURPOSEOFSALE).: � . � �' � C I,A$ONTIER OF THE PRO�ERT1;AM EXCWSIYELY CONTRAGY�NG WITH LICENSED CONTRACTORS Q i0 CONSTIiIJCTTHE PHQlECT( C.YG49.BU$INE55 AR'D PROFESSIONS CODE:T11E COMTRACTORS ll� Va1113T1on ADJ.AREA_ � �� ����� � �'� LLI '�,CEry3ELAWWESNOTAPPLYTO�{1N6YvNEROFAPROPEflTYWHo9U1LDSOflIMPflOVESTHEqEON,AND , 7L '�,�i�{ppppRppCTSFORSUCHPRQJEC7&WIiY.ACONTRACTOR�E)LICENSEDPUFSUANiTOTNECONPRRC- QUANTITY I DESCRIPTION 'FEE�- � �TORSLICENSEL4W.). � �� � ❑I AM E%EAAPT UN�ER SEC.II� ��-� � � � �� B.8 P.G FOR THIS REASON 'Q � � � " �I, F` � — . :� ... . —LL'+ �ATE � tlWNER .0 . . � � � . .. . . . . , . .V,J � � �a�, LICE(V EDGOM1ITRACTORSpECIARATION �� ;'�w. - �C'. I HEREBYAFFIRIA UNDEH PENAL OF PER1l1RYTHAT I AM IICENSEp UNDEF PROVISIONS OF CHAP7ER � �.rt � p�I.8�(COMM6NCINOWITHSECTION�Oo�OFDIVISION30FTHE8U5WE55ANDPROFE5510N5CA0E,AN0 Z � / �I! P�/' •� ' �.�.�'�� AC' IUY LICENSE IS IN Ft1LL FORCE EFFECT. � LiCENSE CLASS LIC.NO ��,�.�$�_���.,/ �T°.,'g � p.''-,:,.� � . .. . . -� ' .. . ,. . . Cy '��h76 CONTRpCTOfl d C1S T �� WORKE�RS'COMPENSATlON DECLARATION Q . � ��� �iHEREBYAFFIRMUMDERPENRLT110FPERJURYONEOfTHEFOLIOWINGOECLARATIONS: - � ' " � fd] Q � �'�,';_IHAVEANGWIL6AfAINiAIt�ACERTIFlCATEOFCAN5EN7TO5ELFiNSUFEFORWORKEHS' Z CAMPENSATION,ASPflObI�ED6Y5ECTION37o0'dF"THEUBORCODE.FORTHEPEflFORMANCE U �� OF ikE WOF1K FOR WHiCH THIS PERMIT 131%SUED. � ' ��""�IHAVEAND'WILLMAIYTAI WORKER9'COMPENSATIONINSURANCE,ASREQUIREDBYSECTION " ' � Q 3TDOOFTHELA80RCOOEFOpTHEPERFORMPNCEOFTHEWORKFORWMICHTHI3PEFN1ITIS . ¢., ISSUED.MYWOR�RS' EN9ATIONIk3U N ECARflIERANUPOLICYNUMBEFARE: CDNSTRUCTION �, cpaql6R �� �'�� PLAN REVIEW , �., . POLICYNUM9ER � .. .. ,_. .. � ELECTRIC e �. ¢ I ���� � Q (tHB9EGTOPJNE�NOTBE Y'fEDOFTHEPER�WI'ISFOROfVEHUNXiEDD01.LM5(510o)ORLE55). PLUM8ING �' . Z�. ICEqTIFYPNA71N7HEPE�FORMANCEOFTHEWOPoCFORWNICHiHISPERMITI5ISSUED,I MECHANICAL � (� SHALLNOPEMPlOVANYP RSOIV�INANVMANNERSOASTOBECOMESUBJECTTOTHE �,. WORKERS'C]MPENSATIO�IAWS'CFCALIFORMA,ANDAGqEETHATIFISHQUIDBECOME INSPECTIONFEE �.—./}(�/..-.-�--�-�U,�'.(,-I-��-�- � �. � SLBJECTTOTHEWOFKER,�'�.W�IVENSATIONPROVISIQNSCFSEGTIDN37000FTHELABOfl �gSUANCE ������ G�+�B - CADE,I SHALL FORi WITHICOA9PLY WITH TF905E PflOV15lON5.gA� , � ��ATE: � °'� ' � APPLICANT:;�.-_�. (d 0"(�- �,��'''`'', SMIP „� ,� q�� '. � � � � � � ENERGY P1C �`» ' � i'.WAflNING FA�LURETO SECUfiE W RKF1iS'COMPENSATIQN COVERAGE IS UNLAWPUL,AND SHALLBE 'B��T�y����� �-- � eg �,SUBJECTANEMPLOYERTOCRIMIN LPEMALiIESANDCIViLFINESUP�TOONEHUNDRED'fFIOUSAN� S"p� �� '.OOILARS($100,a00),IN ADDITION Y�TNE COSTOF.COMPENSATION,DAMAGES AS PROVIDED FOR IN EN'�cRGY PERMIT ' J �SECTION370BOFTHEUBORCOO,IPlTE'REST,ANOATTORNEI"SFEES. � RETENTIONFEE: � . �.,'� CON�STAUCTIONLENDINGAGE�JCY PRE-ALTFEE: ' � ;IHEREBVAFFIRMUNOEflPENALTV�OFPEmJURYTHATTH2RE�ISACONSTRUCTIONLEN�INGAGENCY ' ' '' �.FORTHEPERFORMANCEOFTHEWbFKF(7RWHICH7HISPERMITISISSUED(SEC.3aW,CNCJ. . W ''� �����LEN�ER'S NAME ' � � � F-, LENDER'SADDRE93 '� ' �I .ICERiIFYTMATIHAVEREADiM15/1�PLIGATIONAN�STATETHATTMEABOVEINFORMATIONISCOqREGT. TO�AL FEES ' . � " �� ' ' �I ;��IAGREETOCOMPLYWITHALLCITY�N�COUNiYORDINANCESAN�STATELAWSHELATINGTOBUILDINO � '���,CDNSTRUCTION,ANDHEREBYAUT RIZEREPRESENTATIVESOFTHlSCOUNTYTDENTERUPONTHE � A90VE-MENTqNED PROPER'fV FOF INSPECTION FURPOSES'. COMMENTS �� �.:C�� �1 m I'.�..PE E(P NT) �I � � . . ��� �a �, � �/y .SIGN �PE MITTEE � OATE -' ' y�i � �,- , . . 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