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HomeMy WebLinkAbout12534 (6) : ; ,�.� � I CITY OF DIAMOND BAA �` - -��— DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES �r�-st ' ��; 21660 8.Copley Drive Suite 190 ��% (909)860-3195 Fax(909)861-3117 PRESS� �"9�°. BUII,DING PERMIT APPLICATTON FIRMLY � JOBSITE v�f�C�1 �� ,/ APPLICATION (� PERMIT� /C A ADDRES&.�Cc.�y _�(..,1 7� � ".C- C! � DATE �" Z� � NUMBER ��� # � ISSUE TYPE OCC APN LOT TRACT DATE CONST. GROUP � OWNER ,�at �.�.�t._f.ILr.'�/'LG_,�� LL ADDRESS .�--� .t�� � `~��-C��--�c.-�� C.L�t . ZONING SETBACKS w �'�`L�2�� - ��� FRONT RW_ ❑__ � CITY . � Z� 'II �L1�� TEL. �„SZI"".�S �1 '� REAR ❑�--- APPUCANT '� ck--.r'1-�t•� TEL. SIDEJSIDE STREET RW_ ❑ � � ` 7 � CONTRACT���';����r�_��_t:aF>�C�4^_ SIDE �7_____ I ADDRESS� Ci ' 1.'�C°��c t Cl?c o + � CITY��r� ( ��v�c< ZIP �� • TEL. 'I! ,� PROPOSED USE iS � ARCWENG/ � DESIGNER NO.DWEL. NO. NO. � ADDRESS_ UNITS STORIES BEDROOMS CITY ZIP TEL. — � — cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-BUILDER D�CL4RAT10N SFWADD/REM O p I HEFEBY AFFlRM UNOER PENALT7 OF PERJURY THA7 I AM E%EMP7 FflOM TME COMRACToflS LI� ' Gdr8g9/CBfpoll W CENSEUWFORTHEFOLLUWINOHEASON(9EC.7037.SBUSINESSANDPROFESS�ON5CODE:ANYqTYOR (J) U �OUN}YYlMi1CMpEWIRE6APERMITTOCONSTRUCT.AL7ER,IMPR9VE,0FMOU6H2ORHEPAIRANYSTRUC- ' �fJ pall0/DBCK �' NR�PRIOR TO ITS ISSUANCE,ALSO REOUIFES THE AVPIICANi fOR SUCH PERMIT TO FILE A SIGNED w STATEMEN7 THAT ME OR SHE IS LICEMSEO PURSUANT TO TNE PRONSIIXJS OF THE CONTRqCTOHS LI- ' �S CENSE LAW(CNAPTEfl e i�MENCING WI7H SECTION 70D0)OF OIVISION 3 OF THE BUSINE55 AND PRO• � W PootlSpa 7!' FESSpN500DE)OflTHATHEORSHEISEXEMPTTHEREFROMANpTHEBASISFORTHEALLEGEDEXEMP- a (� V 710N.ANYVIOUTqHOFSECT10N7091.6BVANYAPPUCANTFORAPEPM17SU8JECTSTHF,APPLICANTTO ' � Re-Hoof � qC1VILPENAL7YOFNOTMOPETHMIFIVEHUNORE000L1AH5(3500).f: ❑I,ASOWNEROFTHEPROPEflTY.ORMYEMPLOYEESWITHWAGESASiHEIflSOLECAMPENSA710N, : CO1tITBiCIfiI �.:. YALL 00 THE WOflK,AND THE STflUCTUpE IS NOT INTENDED OR OFFEFED FOR SALE(SEC.709<,9U51- ' a � NE6£AND PROFESSIONS CODE:THE CONTRACTORS IICENSE LAW DOES NOT APPLY TO AN OWNEfl OF � PROPER7V WFIO BUILDS OR IA/�qpYES iHEREON,AND VhlO OOES SUCH WORK HIMSELF OP HERSEIf OR Q THRIXIGHHISORHEflOWNEMPLOVEES,PflOVIDE0Ti/p75UCHIMPqOVEMENTSAflENOTMTENDEDOq . � n .OFFEHWFOHSALEIF.HOWEVERTME6UIlDINGORIMPROVEMEN'fI550t�WITHINONEYEAflOFCOMPLE- � Z �TION,TME OWNER-BUILDEA WRl HpVE THE BUROEN Of PROVING THAT HE Ofl SFiE DID NOT BUILO OR - �� IMPROVEFORTHEPURPOSEOf3ALEJ, f7 I,ASONTIER OF THE PFiOPERTY,AA1 EXCAUSIVELY COMMCTINO WITH LICENSED CONTRACTORS �� TO CONSiRL1CT iNE PRQIECT(SEC.lW4,BUSINE55 M70 PflOFE5510N5 COUE.THE CONTRAGTORS LI- � V811J8110II _ _ ADJ.AREA_..__ W CEN3E lAW UOE9 NOTAPPIY 70AN OWNEfl OFA PflOPERTV WF10 BUIL�S OFi IMPROVES THEREON,PND ' � — - ---�'—' �' 'WFIOCONTflACTSFOflSUCNPRQIECTSWITHACONTRRCTORIs1LICENSEDPIJRSUANT70THECONTM0. ' QUANTITY DESCRIPTION F�E TORS IJCENSE UW.). �"� ' ❑IAM E%EMP7UNDER SEC. 8.&P.C.FOR THIS REASON �' Q O' -- U � -- — ----- � LL� DATE _OKTlER___ z - - - -- W � UCENSEP CONTRACTORS DECLARATION W � I HEREBV AFFIRM IJN��R PENALiV OF PERIURY?HAT I Ali�ICENSF�LlNUEfl PROVISIONS OF CHAPTER � d� e(COMMENqNQWITHSECilON7000�OFDIVI510N30FTHE8USINE55AND7flOFE5510NSGODE.AND , X�n MY LICENSE IS IN FULI FOflCEAND EFFECT, � � IJJ //� r- / � /�y�']/� m i j �� IfCENSE CJLA55 l�-�-+,�\ L��, �IC.NO. ��`\L 3�?-��U ,_ �'�� � V� DATE_-LJr''2/^7� _,CONTRACTOR c''._..' �7i a ; W'� � WORKERS'COMPENSATION DECLARATION -� � 4 � IHEflEBYAFGIRMUNOEHPENALTYOFPER1l/qVIXJEOFiHEFOIIOWINGOECLARATIONS 7 �; _IMRYEAF1�WiLlMAiNiM1INAGERTIFICA'fEOFCONSFNTTOSELFINSUREFORWORKEfiS' _ LOMPENSAYION,AS PROVIDEO BV SFCTIIXJ 97oa OFTHE LABOR COpE,FOR THE PfRFORMANCE W OF THE WORK(OR WHICH THIS PEflMiT IS ISSUEU. � . W Y �i HAVE AND Wl�l MAINTAiN WOflKERS'COMPENSATION INSURANC[,AS REQUIREb BY SECTION Q 370UOFTHElAE30qCODE,FORTHEPERFORMANCEOFTHEWORKFOqWHICHTFIISPERMITIS ISSUEO.MY WOP.NERS' P^ATKKJ INSURANCE CARqIERAN�POLICV NUMBER AflE�, CONSTRUCTION ' � CARRIER���� til ,�� --—.----- PUUJ REVIEW `_— __-_---__.--_----- ' � voucvNUMeEA-�� -K1-q- 1./as1-�'-C;�.,�,j- --- ELECTFIC 4 '— '—'_ ' ' � ;,� � (fHISSECfpNNE�NOTBEW1.NlEfED�FlHE7EPo�tlrISFOHQJEfRX�AHEDDOLLq[iS(510�)Of1LES5� PLUMBING ,____________..__, __.��-c ��- ZICERTIFYTHATINh1EPERFOflMANCEOFTHEWONKFOflWHICNTHI5PEfiMITISI55UE0,1 MECHANICAL _ _____`..______ ___, � ('J SHALLNOiEMPIAYMIYPERSONINANYMMINERSOASTOBECOMESl18JECTTOTHE � WORNERS'COMPENSATIONUWSOFCALIFOflNIqANUAOREETNATIFISHOUL�BECOME INSPECTION(EE _,. _ +�/' �' r SUBJECPTO7HF.WORKEfluCOMPEN6ATIONPROVISIONSOF5ECT10N37aoOFiHEIABOR 1�� � C/ODE,ISNALLiFORTH�WjI�T'MCOMPLVWITHTHOSEVROVISIONS. __ __. _.__ __. ISSUANCE _J _.__ � _(._O_L/`�" APPLICANT:�_ '�°�..�__ SMIP p OATE: _�—_�"—._...__—__ .-- . W � "'� WAflNING:FAILURETD SECUflE WORKERS'COMPENSATION COYF.RAGE IS UNIAWFUL AND SMALL BE ENERGY PIC �y}�-(�i,� ��-py�!�/� _ ! � 5t161ECTANEMPLOYEfiTOGfiIMINFLPENALTIESANDCNILFINESUPTOONEHUNURGDTHOUSANU ENERGYPERMIT _o^`��� '�`�� DOLUNS(S10D,aao�.INAO[11710N70THECOSTOFCOMPENSA710N,pAMACESASPROVIDEOFORIN - �— -- ---------� -- �� � SECTION97080FTHLI.ADORCODE,INTEflEST,ANDqTfORNEV'SFEES. RETENTIONFF(�`� ,__ d CONSTRUCTION LENDING AGENCY PHE-ALT FEE:'"'�T�������— CL 1 HEREBYAFFIflM UNOEq PENALN OF PEIWURY iHATTHERE IS ACONSTPUCTION LENDING AGLNCY �r"�"'����� � FORTHEPER�AHMANCEOFTHEWORKFOFWHICHTHISPERMITISISSUED(SEC.3097.CIV.GJ. --� —���— ' —'— Z W — ' � LEN�ER'SNAME__'_'_ _ __ _"- '__ '__ "_ _'_' _i_ __ W LENOER'S.1DDflF55 ___ __ _ _— � �`�� � � ICF.RTIFYTHATIHAVEREA�THISAPPUCATIONANDSTA7ETHATTHEABOVEINFORMATIONISCORflECT. TOTAL FEES p IAGi7EETOCdMPLVWITHALLCITVANDCOUNTYOflDINANCESANDSTATELAWSRELATINGTOBUILDING , � CONSTRUCTION,ANDHFREDYMfrHOHREPEPR6SENTA71yE50FTHISCOUNTYTOENTERUPONTHE Z ABOVE-MENTIONED PROPEHTY FOR INSPECTION PURGOSES. COMMENTS__ __ ._„__ � � " _ � '__ _ _ m PERMITfEE NM1E(PHIM) c�. c� ��"�^'_-� %Q�7^j`s O — �—.�•� - � SIGNANHEOFPENMITTEE DATE `� � RECPT.NO.___ PAID BY �, VALIDATION. WHITE--Departmant Copy,YELLOW—Finence Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—ApplicanYs Copy ... �. ... . .,e.._, __., .. _ , , . . __._ � � � �� �:� ' ,� � � � � �,; a �f ! � ` ,; ; !. , .� J � ' `.i �, t ` �� . ,.: . i . i _ 1 # �' € x� ' �.� � , i ; " '� ,i , � i =� � � � � a t 1 • 7 ! i � � ' , I � ,� � " � . , , � � „ ; , � �- , � ,�:' � . , � � i I � � � .,, ,:�� . � �. � � ' i � ' �. � - � � ,_.. � � � � � ' , � , i . 1 i ��' . ..., ..... .... _ . ..; -F � , i _ . ! I E ' 1 � , x j� I . �°�-:� ..�.. . , � ..., � �� � � ' � ' � � �� i i � I i � � ... ... �� �„. • . � . 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