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HomeMy WebLinkAbout16854 (23) �,� CITY OF DIAMOND BAA DEPART1vYENT OF C011RMUNITY&DEVELOPM NT SERVICES _ 21660 E.Copley Drive Suite 190 , ����5� �� �.�� pRESS �e� �w BUILDING PE tRMTT APPLICATION FIRMLY � p � � `� APPLICATION PERMIT �k� Q DDR�ESS � ' �`� DATE �� � �NUMBER ����" #1��� ISSUE �,��,,,('�y TYPE OCC � APN l T � ACT DATE "LCONST. GROUP g OWNER ZONING SETBACKS Z CI7Y E� , '� I � � TEL. - " FRONT : RW C � APPLICANT TEL. - REAR d S�DE/SI�E STREET RW ❑ � CONTRACTOR SIDE D � ADDRESS PROPOSED USE O CITY P T w ARCWENG/ -� a—y " � DESlGNER � .� ,, ' . NO.DNlEL NO. , NO. --d ADDRESS_ T i UNITS STORIES BEDRO�MS ' � CITY� ZIP TEl�. � � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREAN^�AIUI{TIQN Q OWNER-BUIL�ER OECL4RATION SFR/AOD/REM � � �y,,, .�� . O (�� '� � I HEREBY AFFIRM UNDEfl PEP10oLN OF PERJURV THAT l AM EXEMPT FAOM THE CCNTAACTORS LI- GHfdge/CBfpOlf . .�„��lj'f� 6 � �SLJ CENSELAWFORTH6fOLlOWINGf1eASON(SEC.7031.58USENESSANOPROFESSIDNSCA�E:ANYCfIVOR (n C.7 CWNTYWHICXREqU1RE5APERMRTOCOMSTFUCT,AITER,IMPFOVE,OEMOLISH.ORREPAIRAN757RUC- � pdtiO/DBCk W ,NRE,PRpR TO RS ISSUANCE,AL50 REOUIRES THE APP�JCANT FOR SUCH PEPMITTO FILE A SIGNED � .� STATEMENT hIAP HE OR SHE IS IiCEId3ED PURSUAIdT TO THE PROVISIONS OF 7HE CANTRACTORS LI� � CftdSE UW(CHAPTEH e{COMAYENCMG WITH SECTION 7000)OF DIVISION 3 OFTHE BUSINESSAND?RO- LL' P0o1/Spfl FE6SIONSCOD�ORTHRTHEOFSF4EISE#EMPThIEREFR6MAN07HE8A515FC1RTHEALLEGEDE%EERP• �f V '.TION,ANYVIOLATIONOFSECTION7031.59YkNYAPPIICqNTFORAPERMI7SU&lECTSTHEAPPL!CANTTO z Re-Roof � ' � NCMLP£NALiVOFNOTMOReTHANfNEHUNDREDDOUARS(SSW).): . . - �; ❑i,A50NTJEROFTHEPROPERTY.ORMYEMPLOVEESWITHWAOESASTHEIRSOLECOMPENSATION, C.� Commerclal I � � WILL p0 THE W6RK,AND THE SYRUCTURE IS N01 INYEN�£D OR OFFERED FOF SALE(SEC.7ol4,BUSI- �.l HES$AND PROFESSIONS CODE:THE CONTRfaC'fORS LICENSE tA,W DOES NOT APPLY TO AN OWNER OF � Y' , , ' '�y� "�`' � �� PROPEANYJI�OBUILDSORIMPROVESTHEREON,AN�Vhi000ES5UCHWORKHiMSELFORHERSELFOR � / �✓ �� THfeOUGH HIS ORHER OWN EMPLOYEES,PROVIDE�THATSUCH IMPROY'e'MENTS RHENOT INTENDEDOft �✓" �� cs�,� - � W��� OFFERE6FOR6KEIF,HUWEVERTt�BUILDINGORIMPSiOVEMENTISSOLDWI7HINONEYEAROFCOt1PLE �b�' . '� ��� ��TIOPI,THE OWNER�BUILDER WLL.L HAVE THE 6URDEN OF PROVING THRT HE OR SHE DID NOT BUILD OR .., . , . . � IMPROVE FOR THE pURP6SE OF SALE). yJ ❑I,ASOWNEROFTNEPROPEHTY,AMEXCIUSIVELYCANTRACTINGWITHLlCENSE�WPJTRACTORS . � p[ TO CANSTRl1Ci'THE PROJECT(SEC.7u4e.,�L751PJESS AND PflOFES51�hd5 C4DE:THE CONTRACTORS LF Vai��ation j ADJ.AREA ..�; CENSEUW60ESNOTAPPLYTOANOWNEROFAPROPEflTYWHOSU1LD50RIMPF?O:'E9TNEREON,AN� .. . . � Wf1000NTMCTSfORSUCH7ROJECT9WITHACONTRACTOR(S�LiCENSEDPUfl6UPATTOTHECDNTqAG QUAhITITY DESCRIPTION FEE.�'� � TOFS LICENSE LdYJ.i. . u " - 7 o� ❑1 AM EX6aAPT UNDER SEC. _ &&P.C.FOR THiS REASON v Il �.�1 � . �. - � t!i . ;..,��� Z DATE OWNER — � �,�� �' � W o�[` LICENSED CONTRACTORS DECIARAl70N uj �¢ Ll-, 1 HEFEBYAfFfHAS UNDER PENALT!OF PERJURY THAT 1 AM LICENSED UN�En PAOVI�I6N5 OF CHAPTER �r S! a"�- ,� ,, � �, � �'� 9(COMMENqpY3 Wf7H SECTI6W 7000)OF DNISIGN 30:�THE BUSINE55 ANq PROFESSIONS CO�E,pN0 Z f/ MY UCENSE IS iN FULL FOflCE AN�EFFECT. � , o iic�s�uss�LIC.NO. � � � ('� ♦ +� a U �ATE � �`�g CO!dTRACTOR a �� r� � u � �,��� WORKERS'COMPENSATlON DECLARATION � ,_ �� � � . � � v � 1 HERE AFFIRFA UNDER PENALYY OF PERJURY ONE OFT}iF FOLLOWMG DECLARA710NS�. Z ' !Y♦ I �� � \6 > G ����IHAVEANDW�LLMAINTAfNACERTIFlCATEOFCON5ENT705E!F-INSUqEFORWOPo(ERS' x � -'t.A , ;;C1 COMP�N60.TION,pfiPflOV19EDBY^oECilON37000FTHELA60RCODE,FORTNEPERFOFll6ANCE U ��f v @ f THE WORK FOR WHICH THIS PERMIT IS ISSUEO. g i Ll � i HAVE PNU WILLMAINTWN WORKERS'COMPENSATION INSIfAANCE,AS REQUIP.ED BY SECTION � 37WOF?HELRBORWDE,FQRTHEFEFWRMANCEOFTH6WORKFORW41CH7HISPEi7MITIS 165UEQ.MYY+°ORKER ' PENSATIORIIMSUFiAN E�CyA�ARIERANOP�,LIC,gY� MBE/q�FE� CONSTRUCTION _ ♦ ¢ cnnnien y�'� ��104'➢�� `�"'f f�'E�'�r PLAN REVIEW � P�G YNl1MBER�s) .��3 ��.� �` ELGCTRIC f�� � d {n�5"�N�r5drs�Fr,naFrr��r�anr�swaau=_�u.nmr�E�muaas�sim�oa�ess�. PLUMBING �v � � (�`� i/� � � I CEp11FYTHAT IN7WE PERFORMANCE OF THE WORK FOfl WHICH THiS PEAMIT IS BSSUED.I MECHANICAL J ly� • U •�" f!S SHpLL NOT ESNPL�Y ANY PER�N IN ANY MANNER SOAS?O BECOME 3UBJECi TOiHE . � WOftstERS'WMPENSATIQNIAWS�OFOALIFORNa,MlOAGREETHATIFISHOULbBECOME !NSPECTIONFEE � SUBJECT T`J 7HE WORNERS'COhiPENSATION PROVISbNS OF SECTION 3�Oo OF THE LAeOR � E,f SH FORTkI ITH G'MPLY WI 'THOSE ROV7510 5. ISSUANCE ______�_ C�,�1 y �,�� I,�I,�Y°Y ��g� SMIP "1 _L�__ � � [� DA75: ����! If�APPLICANT: � � s9�'!� �W,y ENERGY PIC � � WRRNING:FAIWRETOSECUREWORKERS'C�MPENSATIONCOVERAGEISUNLAYJFUL.ANOSHALLBE _ ff �y, Su3JECSANEMPLOYERTOCR)MIMAL?ENALI�ESANDCIVlLF1JESUP"fOONENUNDREDTHOU3AND cNERGYPERMIT ' �� � 00l.1.Aft3(51C0,0001.IN A�DITION 50 THE COST OF COfAPENSATION,DAMAGES AS PflOVI�ED FOF IN `� � SECTION 37080F THE LABOfl CODE,INTEREST,ANDATTORNEI"S FEES. RETENTION FEE: pW_, C0�37RUCTION LENDfNG AGENCY PRE-A:T FEE: ._ � � O � 1 HEFEOYAFFIRM UNDER PENAL7V OF P�RAIRY THAT?HERE IS A WNSTRIJCTION LENDING AGENCV FOR'HE PERFORMANgCE OFTHE WORN F.O�'ft}WHICH THIS PEAMlT IS ISSIJEG� G,309],CN.C.). � � � LENDER'3 NNAE {��R P' �4'V���fi A�� �' .1�— LEI�ER'S AD�RES& �� � � ICEflTIFYTHATIHAVEFiEA�]THlSAPPLICATIOYANDSTATETHATTMEA90VEINFORMATIONISCORRECT. TO�AL FGC� � IA�FEE10CpMPLYWITHALLqiYANDCOUNTYOR�iNANCESRNDSTAYELAWSRELAT!NGTOBUILDING � w� � CONSTRUCTION,AND HEREOY RUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ,��; � A@OVE-MFNTIOP1EOPflOPERIYFORINSPECT1pNPURPOSES. COMMENTS � � _ � � PER�II7T ENAt1E(P I ' �� '� ����� . . . � SI U EOFPER�, E DATE �l' y '' � RECPT.NO. 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