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HomeMy WebLinkAbout13416 CITY OF DIAMOND BAx ��'�� --J� - � DEPARTMBNT OF COMMUNITY&DEVELOPMEl\TT SER\�ICES r w , 2166Q E.Copley Drive 5uite 190 (909)860-3195 Fax(909)561-3117 PRESS ���Y�°� BUII..DIIVG PERMIT APPLICATION FIRMLY � JOBSITE / C- � APPLICATIO PERMIT "• P/C o ADDRESS;Lj � � ��✓r �o ��f U�"C'��� DATE �j � ����_ NUMBER� ��4 # � ' iSSUE TYPE OCC � APN LCT TRACT DATE CONST. GROUP p OWNER (�,1 l�i�/r/t�_�l: S SE�_ p '�ODRE S %�'� � � aa.'�-1 !�I���'!U C,-� U�L- ZONING SETBACKS Z CITY ,� i I�MLy�Z1P C��T� .I��_��� FRONT RW '] g APPLICANT r`�• _ TEL. — SID SICE STREEI' FW ❑ � CONTRACTOR � e t. SIDE ❑ � CITY ES �.��L�� . ZIP��j�E� r+� �!S d.��/ PROPOSED USE �lN���"�[ Q ARCH/ENG! - "� � DESI3NER NO.DWEL. PJO. NO. a ADDRESS UN1T5 :iTOR1ES BEDROOMS__ N CITY ZIP TEL._ - cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION �r OWNER-BUILDER DEC�ATION SFR/ADOlREM O --• I HENEBY AFFIRM UNOER PBJpLTV OF PERJURV THAT I AM L%FMPT FROA1 THE CONTRACTOPS LI- G8f2Q8/CdIPOIT W CENSELAWFORTHEFOILOWINGREASON�5EC.703t.58U51NE55NNDPROFE5510!�SCODE'ANYCINOR (n U COUNTYWHI�HpE0U1RE5APERMRTOWNSTpUCT,ALTEF,IM7RWE.DEMOLISH,ORREPAIRANYSTRUC- w 7URE,PFUOR TO ffS IS3UANCE,ALSO REOUfRES THE NPPLICANT FOR SUCH PERMI'TO FILE A SIONE� W Patio/Deck _ � STATEMENT THAT HE OR SHE IS LICEkSEU PURSUANT TO THE PROVISIONS OF THE COfiTP.ACTORS LI� � -- CENSE LAW(CHAPTER B(COMAIENCINCi WITM SECT!ON 7000)OF DiVI510N 3 OF 7HE BUSINESS AND PRO- PoeUSpB FESSpNSCODE)OflTHRTHEOR5F7EISEXEMPTTIIEREFROMM7DTHEBA515FORTN[ALLEGEDEICEMP• (� TqN.ANVVIOI,ATIONOFSECTIDN7p;t.58VANyAPpLICAPiTFOHAPERMITSU&i[CTSTHcAPPLICANTTO Z Re-Roof � ACINL PENALiY OF NOT MORE TFiAtd FIVE HUVDRED OOLLqRS�5500).J: ❑I,ASOWNEflOFTHEPROPER'.Y.OFMY�MPLOYEESYdITNWAGE5A5THF.IRSOLECO?APENSATION. L� Cummercial � WILL 00 THE WORiC,AND THE STRUCTURE IS NOT IN7ENDED OP OFFERED FOR SALE(SEC.7oa4,BUSI- J � NE55 AND PqOFE551QY&COOE:THE CANTRACTORS LICENSE LAW UOES NO?APPLY TO AN OYJNER OF � , PqOPEHfV'YhlO B WL�S OR IMVItDYES THEREOf�,AND WHO�OES SUCH 4JORK HIA�SELF OR HERSELF OR H � THqq1CJiHISORHERONRJEA1PlAYEES,PROVIDEOTHATSUCHIMFROYEMEN?SARENOTIN*,ENDEDOR � m QOFFERWFORSALEIF,FIDWEVERTHEBUILOINGORIMPROVEMENTISSDlDW17116VONeYEA90FCOMPLE- ! Z TbN,THE OWNER-BUILDER WILL HAVE THE BUROEN OF PpOVING THAT HE OR SHE DID NOT BUILD OR � = IMPROVEFORTHEPURPOSEOFSALE} � � ❑I.ASO`NNEN OF THE PROPERT;FM EXCL'USIVELY CONTRACT!NG YViT4�ICeNSED IX)NTY3AC7OR5 �-- � TO CONSTRUCTTHE PRO,IECT iSEC.7048,BU31NE55 AND PROFESSIOkS CODE:YNE COYTPACTORS LI- VdIU8t10� _ ADJ.AREA W CENSEUSVDOESNOTAPFLYTOANOWMEROFAPROPf.RTVWNOBUIL�50R!MPFOVESTHEREIXJ.ANCI _ -------- � NFIOCOMRACTSFORSUCHPRQIECTSWITHACONTRACTOR;S�LICENSEDPUASUANTTOTH.CCNTRAP aua:vTir DES�RIPT!OY FEE Y TpqS LICENSE LMY.). `_, � �I AM E%EMPTUNDER SEC.` B 8 P.C.FOR TMIS REASON �Q __ _ � - — — — � � -- — fS -- CATE OWNEH "„_-�— W� � — _ LICENSED CONTRACTORS DECLAFiATIQN` -� � W I HEREBYAFPIflM UiJGER PENALTY OF PERIURY THAT 1 NA I.ICEYSE�UNOER PP.OVISIONS OF CHAPTER y' �/ � B(COMMENCINO Wlhl SECTION 700D)OF DIVISION 30FTI;E BUSINESS AND r ROFESSIONS CO�'c.AN� z � �'! E:�/� L� �� Xu MY UCENSE IS IN FULL FORCE AND EFFECT. '_J� � LL /�{ g —. �_LYNGr-L-" G>eJ T � IfCENSE CIASS ��a�� LIG.NO. " ���1� 'f �' �_� —� � � V OATE s � 5 cor�Tr��roa . � �'x _ � a . u' ,,// ---�— � WORKER5'COMI�ENSATiON DECLARRTIOPI f�J}' .ti Q 4� � � I HEREBVAFFIRM UN�ER PENALTY DF PERJURY ONE OF7HE FOLLOWING D[CLARA'�(O�IS.�� U � _I HAVE/ND WILL MAINTAIN A�E.'i11FICATE OF�IJSENT TO SELF-INSURE FOR WORKfR' S ` — — COAAPENSATfON.AS PROVIDEO BV SEC710N 370a OF THE IABOR COOE,FCR THE PERFORMANCE !`U OFTHE WORK FOH WHICH"HIS PERMIT IS ISSUEU. �� � � �1 HAVE AND WILL MAINTAIN WURKERS'CAMPEhSNTION,NSURANCE.AS RCdUIRED BY^uECTION —~ Q 37000FTNELABORCWE.FORTHEPEFiFORMAMCEOF?HEWORKFORWHICNTHiSPERMITIS . ISSUED.MY WORKE!RS'�M�PENSRTION INa'UFANCE CARRIERAND PO'.ICY tvUMBER APE: � CONSTRUCTION _ � CARRIER 7 I�L� �d'��� ___ PLAN REVIEW _ __ _ � roL�cVNUMOER � EI_EC7AIC ,__. � —�------� Q Q (IN�SSEC�IONNE�NOiBECOMREf�OFiYL-YFF+MfI6FURONEI-Ut�%iE�D:::J.AAS(a100�CRLESS�. PLUMBING _ __ � ICFRTIFYTHATiNTMEPERFOPMANCEOFTr1EWOflKFDRWHICHTHiSPEFhi1T!SISSUE0.1 ( P�9[CHAMCAL _ __ __ __ (} S/LV.LNOTEMPIOYAF:\'PEFl50'NINANYMANNF.q50/ISTO COFAESUBJFCTTOTHE (/j WORKERS'COM?'cNSATIONlAW50FCALIFOR41q,AfW7A TMATIFISHCX/LD ",.OMC- � INSPECTIONFEE __._.,. �•�•���. . • _ SU&IECTTOTNEWORKERS'CONi�ENSATKKJ%POV!SI FSECTION37Cc.0 'cLA80R ,�',j-��� ,� ~j COOE,ISHALIFORTHWIIHCOMPLVWITHTHOSEPfD ions. i' ISSUANCE _�,____ �� p DAYE:��.'t/_ AFPLICAhT. c _-_���_, SMIP .. __� ________ J � �� � ENERGY P/C -�`�`''`•�° ` �c.,�.. Y/AflNING:GpILURE TO SECURE WOP,KEftS'COMP ATIO ERAGE IS UNLAWFUL,AND SHALLBE --- �y 54fl1ECTANEMPLOYERTOCRIMINALPENPLTIESANDC:V ItJESUPTOONEHUNDRED7HOUSANO � p } ""� r `,f �i,!'e�.+� DOLLARS(S1aD,000),INADDITIONTOTHECOSTOFCOM?ENSATION.DFMAGESASPROVIDE�FCRIN ENERGYPERMIT °"' �� � SECTION37080FTHELABORCODE.INTEREST,RNOATTORNEY'SFEES. _ _ RETENTION FEF.: ","rYx rj'�� � '��s��z;1"�„'i''.:V ' s /;)'? W "�-q�T��`-^^�`'yi_<..V.. a CONSTRUCTION LENDING AGENCY PRE-ALT FEE: - �-:i�'T'ST 0 - - - _ �. � IHERE9YAFFIRIAUNOERPENALT'/OFPERJURVTHATTHERFIS�CONSTRUGTIONIeNDINGAGENCY � FOR THE PERFORMANCE OFTHE WORK FOR WHICH THIS PERIAIT IS ISSUED{SEC.3oB�.CIV C j. -------- � . . .. Z W I —� .,— . .. . � LENDER'S NAFAE_ __ __ _ _ . F= LENDEfl'SADDRESS __ ____ _ , , � TO�P,L FEES ~�,e � I CERiIFY THAT I HAVE READTHIS APPLICATION AND STATE THATTHE P80VE INFORFAATION IS COFPECT. � IAGREETOCOMPL�WITHAL�CITyqN�COUNTYORDINqNCESANDs7ATElAWSRELATWGTO&11LDING � CONSTHUCTION,ANDHEREBYAUTHORIZEREPRESGNiATNE50FTHI5COUNTYTOENTERUPCNTHE A60VE-AIENTIONE�PROP TYFORINSPECTIONPURPOSES. COMMENTS _ — ,t3 / C..�- ��wJ!'� --- - . .. , m ¢-�.�Y PERMfTTEE NAME�PR�f � � :�G �'ra -l� --- --- -- . �/y SIGNATUREOFPER . E! DATE = R PECPT.NO. �f'AID BY , �%' _VALIDATION ~ WHITE—Department Cepy.YELLOW—Finance Copy,PINK—A;sessor Ccpy,GOLDENROD—File Copy,GREEN—Applicanl's Copy , �. • ' .. . . . . . ' . .�• . . 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