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HomeMy WebLinkAbout16453 (20) �`� ��� CITY OF DIAMOND BAx -- � DEPARTMENT OF COMMLJNTITY ds DEVELOPMENT SERYICES .,,• 21660 E.Copley Drive Suite 190 - (909)660-3195 Fax(909)861-3117 PRESS ����'�+ BUII.DING PERMIT APPLICATION FlRMLY y JOBSITE `I ,p � y� APPLICA110N � PERMIT � !C o ADDRESS ��I Z� 1 L V�G i� Qi41� (17 DATE NUMBE � APN LOT TRACT ISSUE TYPE OCC DATE CONST. (3ROUP g OWNER M4ZS = C-L� F-�Qt12T LL ADDRESS S T�NING SETBACKS � CITY V ZIP TEL. � O FRONT RW ❑ � APPLlCANT C.l TEL. � REAR t] SIDE/SIDE STREET RW ❑ CONTRACT Qf V SIDE ❑ ADDRESS '- PROPOSED USE � � '� CITY u ZIP TEL. ARCWENG/ pESIGNEH NO.DWEL NO. NO. AODRESS UNITS STORIES BEDROOMS CITY ZIP TEL. y pESCRIPTION SO.FT. FACTOR PSF AW.AREANALUATION Q OWNER-BUILDER DECLARATION SFRlADDlREM O 1 HER�Y AFFliW UNDEH PENALTV OF PERNIRY TNAT I MI E%EMPT FROM THE CONTMCTORS ll- G8f8Q9/(�.BIp011 CENSELAWFONT11fcFULLOWNaNEA80NISEC.7W1.68U51NES5M�PROFES5qN9CO0E:1YWCrtYOR (n OOUlRYNM1pCMRECIANESAPFRMR70CqVSTRUCT,ALTEKIMPqOVE.OEMOU&i.ORREPAIRANYeRiIIC- W PHIIWDBG( TURE,PRIDR TO ITE�SUANCE,AL80 REOUIRE9 THE APPLIQWf FOR 8UG7 PERMIT TO FILE�&ONEp W lTATEYENf tHAT ME OR!HE IB LICENSED PURSUANf TO 7HE PHOVISIONS OF TFIE CONTMCTOFS l4 CFNSE MW(CHAPTEq i(COMMENCMIG WITH HLMION 7000)OF DIVI610N f OF THE BUSINESS MID Dp0- LL' POOUSps FESSqNSCODEj qi 7}IAT ME ORSME IS E%EMPT TMEHEFROM AND TME B/SIS POFl TMF ILLLEOEO EXEMP- TqN.ANVVIOlA7fONOFBECTIONIDJI.6BYANYAPP�ICANTFORAPEitlJ1T81161ECT87NEAVPLICANTTO Z R�Raot 2 � ACIVILPENALTYOFNO7MOHEh1l1NFNENUNDREODOIL�Re�i6a01.1: � ❑I.A501M1EROFTMEPROPER7Y,ORMYEMPLOYEESWIT/IWAOESASTMEIR801.ECOhIPENSATIDN, 0 �qnmercial WILL DO TNE WORI(AND 7VIE BTRUCTURE IS N071NTEl0ED OR OFFERED FOR 6ALE(BEC.70u,8�36 J NE35 A18 MqFE5510NS COOE:THE CONTMCTORS LICENSE U1W DOE9 NOT APPLY TO AN OYIMGR OF ? � OROPEATYNhiOSIII�SORIYPAOVEBiHEREON,ANDriqO00E99UCHWORNwMSELFORNERSELFOR � THROUGHHI80flMENONME�.�PLOYEEB.PROVIOEDTM�TYUCMMdVHCVEMENTSARENOTMTENUEDOp m OFFERFD POR 6ALE IF,FIOWEVER TME EtNLDINO OH IMPFIOVEMENTIS 50LD WITHINONEYEMOFC04PlE TION,TNE OVMER�UILDER YALL NAVE 1NE BUR�EN OF PqOVNO hIA7 HE OR!HE DIO NOT BL11Lp ON MPFiOYE iOR T1E iUPP06E OF ML4 w OLASOYMEROF7NEPROPEHf1;AL1E%CLUSIVElY00NTMCTWOWRHUCENSEDCOMMCTOR7 �-7 C'C 70 CONSTRUCf THE PROJECT(SEC.7ou,BUSINE89 AND ViqFE55iON8 OOOE:TNE CONTMCTOH9 iJ- {�IU81i011 ! d"'� ADJ.AREA µJ CENBEIANfDOEBNOTAiPLYTOANOVMEROFAVROPERTYM1/qBULD50AWPFlOM1fE57HEREON,AND Z MMDOONTRACiBWNBUCXiXWECfBWITMA00N7MCfOR�S�LICENSEDPUPSWNTTOTXECONTMG QUAhfTITY DESCRIPTION FEE � TOfi5llCfMSELAW.). J ❑IAIA IXEYPT UNDER SEG B.f P.C.FOR THI9 HEASON q � H pA7E OWNER V � IICENSED CONTRACTOR5 DECURATION � � W I MEpEBY AFFIRAI UFDER iENALTY OF OERIURY THAT I AM lICENSEO UNOER PROVISIONS OF CF44PTER � � �(OOMMENCNOWfRISECTqN7000�OF01VIS1ONlOFTHEBUSINESSANDPPOFESSIONSCODE,AND Z �� MY LJCENSE IS IN FUIl WFiCE AND EFFECT. m o u��sE�S �,�.�o. �4�9 z � � _ � oa� 1 cormwcron� 1C.l� a WORKERS'COMPENSATION OECLARATION Q � I NEHEBY 11FFIRM UNCER PENALTY OF PERIURY ONE OF THE PoLlAM9NG DECURATIONS U y Z 4 � �IHAVEANDWILLYAMITMJACERTIFCATEOFCONSENTTOBELF-INSUREFORNARKERS' _ OOYPENSATIDN,A9PRONOEDBYBECilON77000F7FIELABORC�OE.FOHTlIEPERFOHMANCE `U OF�11E WORN FOA WHICH 7NIS PEPMIT 1618SUED. ,� � �I HAVE AND N7LL�NIAN M/ONKERS'COMPENSATIDN INSURANCE,AS REWIRED 6V lECTION ��� � f7aDOFTMELABOROO�EFOR7MEPERFOHMANCEOFTHEWOfiKWRYN7ICMTNISPENMITIS t 183UE0.W V/ORKFAS'COAIPENSA7qN INSUfiANCE CARRIER MJD POL�CY NUMBEH AqE� CONSTRUCTION � CARqtER PIAN REVIEW � po�pr Nuue¢n ELECTRIC (naseEcnonnE�noreeaoha�eoa7�rew.RswAa��unnqEooaw�s(s,00la+u-ss1 PLUMBING B �CEpTIFYTMTMTHEPERFORMANCEOFhIEWORKFORNM1I�CMTMISiERM1719�S5UED,1 MECHANtCAL � SIWLNOTEMPLDYANYPERSONWANYMANNER90ASTOBECOM'eSUBJECT70THE � YYORKER$'COMPENSATIONLAINSOFCMIFORNIA,ANDAGNEETIUTIFISWOULOBEOOLIE INSPECTIONFEE �� S BUBJECTTOTNEM/ORKERS'LVAIPENSATqNPFlON510N50FSECTqN]7ooOFTHELABON CODE,I6NALL FORTF�NITN COAAPLY WIT11 THOSE PN04151oNS. L' ISSUANGE � poATE: APaLICANT ���_``� SMIP , -- —�•,. � ENERGV P/C �"+ � WARNINO:FA�WRE TO 9ECURE WORNE115'COMPENSATION COVERAGE IS I1NhWFU./JJD 9WLLL BE � $UBJECTANFMPLOVERTOCRIMI/LLLPENALTIESANOCMLFINESl1PTDONENUNDREOTMOUBlWD ENERGVPEAMIT .f, OOLLhRS(S7a0.0001.�'1 ADOITIOH TO TNE CO57 OF COMPFNSA7qN.DMIAOES AS PFlOVI�ED FOH IN � BECTIDN970BOF1{/EUBORC006.IHTEREST,AN�ATTOi1NEY'SFEES. RETENTIONFEE: d CONSTRUCTION LENDING AGENCY PRE-ALT FEE: � 1 HEREBV AFFIqAI UlqER OENALTV OF PERJUR�'THAT TMERE IS A CONSTqUCT10N LEND WC AOENCY _ Z FOR TNE PENFOfiMANCE OF THE 1MORK FOR N'N�CH THIS PEPMIT IS ISSUED(SEC.�OV),CIV.C.). ---_.,_ W � LENOEiYS NAME � t,EN�ER'8 ADORESS �� , � ICERTIFYTIUTIHAVEREADTiISMPLICATpNANDSTATETIMtTTHEABOVENFORMATIONISCORNECT. TOTAL FEES d I MiflEE TO COMPLY N7fM ALL CRY MID COUNT/OflDINANCES MlD STATE UWS RELI�TINCi TO lUID�NG CONSTRUCTION,AND NEREBY Al1TNORIZE REPRESENTATIVES OF 1HI5 COUNTY TO EMER UPON TFIE � ABDVE•MEPIr10NED PROPEHTY FOfi INSPECTION VURPOSES. 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