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HomeMy WebLinkAbout16689 (40) .� - ------- - --- - _ °� w �`�0� ^�,� CITY OF DIAMOND BAIt `� ��� DEPARTMENT OF COMMUNITY&DEVELOFMENT SERVICES ) w 21660 E.Copley Cicive Suite 190 `��. - (909)860-3195 Fax(909)861-3117 PRESS �¢, �', BUII.D G PERMIT APPLICATION FIRMLY � '._ _ __ -- � JOBSITE "r? 5' � � � APPLICATION;� � �� PERMIT ��p P/C o ADDRESS DATE NUMBER� # c� � ISSUE TYPE OCC APN LOTI TRACT�p'Z DATE CONST. GROUP p OWNER �LI�k�'�,'�'V1��'j ADDRESS ZONING SETBACKS Z CITY � I ZIP TEL. FRONT RW ❑ g APPLICANT ` �, °'� A ': 5' TEL.�'r�';l^��pI ')��Pe� S DEJSID�E STREET RW ❑ � CONTRACTOR SIDE ❑ ADDRESS ' ' ° o CITY;,,,�;$'a`,�?=�� I ZI� TEL.���e'��3")��� PROPOSED USE w ARCHIENG/ �i W DESIGNER i NO.DWEL. NO. NO. n, ADDRESS UNITS STORIES BEDROOMS � CITY � ZIP TEL. c�ii I DESCRIP710N SQ.FT. 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PHOPERTYWHOBUILDSORIIAFqOYES'THEFEON,ANflNMOO�ES5l1CHWORKHiMSELFORHERSELFOp . �� '"TliROUGH HIS OP H�F OWN EMPLOYEES,PROVI�ED iHATSUCN IMPROVEMENTS AHENOT INTENDED OR m - ' .'�,OFFEREDFDRSALEIFHOWEVE 7HEBUILDINGORIMPAOVEMENTISSOIDWITHINONEYEAROFCAMPLE- �. ��;TION,THE OWN@R$UILDER W�HAVE TPiE BURDEN OF PROVBN3 THAT HE OR SHE DID NOT BUItD OR W :IMPPAVEWRTHEPURPOSEOFSAI.E). � ❑I,AS OWNER OF THE PFW PEfliY,AM E%CL1151VELV CONYRACTING WRH UCENSEG CX7iJTRACTORS �_ ��TO CONSTRUCF THE PR0.)EC7 q$EC.7044,BUSWESS ANO PHOFESSIONS COQE:7HE CDNTRACTORS Lb VeIUHPiOii - ADJ.AREA W �.'�,OENSEUWDOESl;OTAPPLYT0�.4NONMEflOFAPROPERT'WHOBUILDSOflIMPROVF.STHEREQN.AND . � ':WHOCONTpACTSFORSUCHPRQIECTSWITHAO�NTRACTOR(S)LICENSE�pllqSllANTTOTHEEONTRAG QUANTITY DESCR{PTION FEE � � 70RSUCENSEIAW;). }y� /� �` 3 ❑1 M!ES(EMPT UNDER SEC� B.&PC.FOR THIS REASON Q (j7 _ V r'i/�� S U � � �DATE ONRIER U � . Z W o�. � � U�EN��9ED CONTRACTORS DECLARATION � - . �� I HERE6Y P.FFIRM UNDER PENPLFY OF PEflJURY TMpT�NM IIGENSED UN�ER PROYISlDNS OF CHAPTER � � 9(COMMENCINOWITHSECTION OW�OFOIVISION3CFTFlEHUSINESSAN�PROFCSSIONSCADE,AND Z �X MY UCENSE IS IN FULL FORCE�D EFFECT. m LL o. LICENSE CLASS_`�___ LIC.NO. j- �. F-- '� �y� DA7E GONTNAGTOR a � W � WORK flS'GOMPENS1iTION DECLARATION ¢ . ���. I!lEREBY AFFIAM UNDEA PENAf:�V OF PERJURtl ONEOF THE FOLLOWING OECLARATIONS: Z ��, "�IHAVEANDW:LLMAINTAIAlACERTIFICATEOFfANSENTTOSELF-INSUREFORWOfiKERS' _ � COAIPENSATION,ASpR�11DE�9V5ECTiOP13?o00FTHELAHDRCADE.FORTHEPEPr'ORMANCE `U OFTNE WORK FOR WFIICHTHIS PERM7T IS ISSUEb. �� � �.' � � � � I NAVEpVdO WILLMAtNTAIN W�,FNcR5'CO�IAPENSATiON IIVSURANCE,AS R'cQUIRED BY SECTION Q� 37000F THELASCH CO[S�E,FQR THE PEAF-0AMANCE OFTHE WORK FOfl WNICHTHIS PEFiMIT IS P ISSUED.MY WORKERS'f}4MPE 5ATIOfd WSURANi�'CARRIER AND POJCV N MBER ARE: CONSTRUCTION � CAFRIER � VLAN REVIEW k'� z PctoCv NUMBER ° � ` . 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(iHLSECI7CNNE�A�ieE00�I.EPmOF'MEPEF�ISFQRONEfi11t�0REUD�LWaS(57C0)ORLESSG PLUMBING � -I CEflTIFY THAT INTHE PI RFOHMANCE OF 1'HE WORK FOR WHICH TNIS PERMR{S ISSUEU,I MECHANICAL _ (,� SNALLiJOTEMPIOYRN�PERSpP11NANYMANNERSOASYOBECOME5U6JECTTOTFiE �,g WORKE645'COARPEHSATI NLAWSOFCAi.VFORNlA,APiCAGREETHA71FI5HDUL�BECAME INSPECTIONFEE SU&IECTTOTHEWORK RS'COMPENSATIONPAOVISION56PSECilON37000FTHELABOR D � fA��,ISHALLFOPTHWI�fHCOMPLVWITH7HOSEPFiO`JI NS. � �SSUANCE ���� p DATE:'����'_ APPLICANT: .e�.�,�, .SMIP � WAfiNING:FAIIUqE TO SECUR�OFIKERS'COMPENSATION COVERAGE IS UNLAWFUL.AND SHALLBE ENEAGY P/C � SU&IECTANEMP�OYER70CRI INALPENALTlESAN6CIVILFINESUPTODNEHUNDPEDTHOUSAND ENERGYPERMIT DOLLARS�f�00,000),INADDITI TOTHECOSTOFCOMPENSAT�ON,DAMAGESASPHOVIDEDFORM � ' SECTION37o80FTHELABOACOD'c,INTEFEST,ANDATTOqNEY'SFEES � I�ETENTIONFEE: �� CONSTRUCTION LENDiNG AGENCY PRE-ALT PEE• O �IL� � I HEREflV AFFIftM UNDEfl PENAI¢V OF PEFiJURY iHAT iHERE IS A CONSTRUCTION LENDING AGENCV FOftTHE AERFOftMANCE OFTH&WORK FOfl WHICH PHIS PERMIT IS ISSUE�(SEC.309�,CIV.C.). . 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