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HomeMy WebLinkAbout13704 � � 1� CITY OF DIAMOND BAx DEPARTMENT OF COMMUNITY&DEVELOPMENT SBRVICES 21660�.Copley Drive Suite 190 � �� (909)860-3195 Fax(909)861-3117 PRESS ���H�'��� BUILBING PERMIT APPLICATION FIRMLY } JOCiSITE L �"�� � ; ' " �� �t APPUCATION r� ERMIT ./'� U • /C o ADDRESS• �c a���__��°1 C�,i�l �C�I DATE_ C.•.� UMBER C'�,� # c� ISSUE TYPE OCC APN LOT TRACT_ DATE CONST. GROUP p OWNER ''" �. Y�i�-�-i� �ifld� ADD SS a.�`iR ,)•.I 61YL«'�1 �.�I l'fS �� ZONING SETBACKS z CI'fY� 1�]�y3 �• �1 � �.=/ ZfP TEL. �1 � , FRONT RW _ ;�` g APPUCANT _ TEL.e����� " SIDE/SIDE STREET_ RW U` � CONTRACT � . � '� <:t� ��'i.�±ir'1-t 1 SIDE fl__ Q ADDRE ' '�y. � a CITY a"1^�.�,��_4iL' 21P ` '�� TEi.,- 1•J' I.�I•1 Z•�I � PROPOSED USE 0 ARCI-UENG/ –"-- _ � DFSIGNER _ NO.DWEL, NO. NO. � ADDRESS UNITS STORIES _ BEDROOMS � CI7Y ZIP TEL. N — DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION Q OWNER-BUILDER DECLARATION 5FR/ADD/REM O (� I HEREBY AFFIRM UNOER PENALTY OF PERJUflY THAT I AM EXEMPT FROM THE CONTRACTORS LI� G&fdQO/CflfPOft W CENSELAW!-0RiHEFOILOWINOREAuON(SEC.70.91.50USM[SSANDPROFESSIONSCOUE:ANYCITYOR (n _ U CWNTYWHICHREWIqESAPEPMRTOCONSTRUCT,ALTEFy4AVFiOVE,DEMOLISH,ORRF:PAIRANYSTRUC- W PBt10/DBCk W NqF.ORpp TO ITS ISSUANCE,AL50 REOl11HES THE APPLICANi FOR Sl1CH PERMIT TD FILE A SIGNED W .� STATEMEM TNAT HE OR 5HE IS LICENSEU PUiiSUANT 70lFiE PNOYISIONS OF THE CONiRACTORS LI� � CENSE lAW(CWIPTEH e(COSMMENGINO WITH 5[CTION'Ia70�OF DIVI510Y a OF 7HE BUSINE33 AN�PRO- U' POOUSpO FESSAN900DE)ORTHATHEORSHEISEXEMPTTHEREFf10MAN�THEBA515FOqTHEALLEG[UE%EMP- (3 V TpN.ANVV101.ATNNlOFSECTION7o3t.5BVANVAPPIICANTFORAPERMITSUBJEC7STHEAPPLICANT70 Z Re-Roof r ACIVILPENALTYOFW]TMORETHANFIVEHIJNDREDOOLtARS(f50o).): F ^ ❑I,ASOWNEROFTNEPqOPER7Y,CRMYFMPLOYEESWIThIWAG[SASTHEIRSOLECAMPEN5ATION, O COf11f11BfC18I _ � WILL DO THE WORK,AND T1iE 5'fqUCTURE IS NOT INTENOED OR OFFERFD FOH SALE(SEC.7odd,BU51- J � NESSMA PflOFESSIONS CWE:THE CONTRACTORS IICENSE LAW�OES NO7 MPLV i0 AN DWNER OF = Pq�ERTY WFiO BUIL�SOR IMIPROVES THERE04,AND VhiO DOES SUCN WORK HIMSELf OSi HERSEIF OR � iHROUGNHISORHEROWNEIAPLOYEES,PfiOVIDEUTHATSUCF1ii�PROVEMEkTSAREhOTINTEN0E00R m w OFFEHEDWRSALE.IF,110WEVERP7EBIJILOINGORIMPqOVEMENTI55IX�WITMiP10NEYEAflOFCOMPLE- �, T%1N,YHE OWNER$UILDER WILL HAVE THE 6UROEN OF PROVING TiAT HE ON ShIE UID NO7 BUIID OR .� IMPpOVEFORTHEPURPO3f.OF5ALE). 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' z _-_ __"'. _- U W a LICcN°iED COYTRACTORS DECLARATION u� . �` � �HEREBYAFFIflMUNDERPENALTVOFAF�iJUNVTHA7IAM�ICENSEDIINUt:ftPROV75101SOFC1iAPTER � . ` 6� B(COMMENCINGWITHSECTION7uao�OF�IY1510N30FTH'cBUSINES5A4DPROFE5510.MSC0�[,AND Z _ _ X� M1'LICENSE IS IN FULL FOAC,E pND EFFECT. �/ '� � j, � ���}.� m q 7 i � LICENS CLAS�,__�_ _�)� LI�.NO,�_��� . � �� r � � � °(F i(" -__-_ ��� r � �{ C -i DATE_�_�� _ cOYrRA,CTOR��IY._.{'_�p �Y-:s7 ^�d � � WORKERS'COMPENSATION DEdCA�ATI6N`�LY b��3��� J �' `� _..�.� _ � U �„ IHEfiEBYAFFINAitIN�ERPFIr0.1.TYOFPERJUFYONEnFTFSEFOLIAWWGDECIARATl0Y5: Z I a - (1 IHAVEANDWILLFIAINTqINACER7IFICA;EOFW45ENTTOSEiF•!NSUR�:FOHWUHKFHS' Y � C�APENSA(iON.�5 PROVIDED BY SECTION 9�w OF iM:LAOOR CODE,FO�THC PLR�ORAIANC'e S��_ - OF7HE WOFiK FUFl NTIII;H THIS PEPMIT 18ISSU[�. f� - W i HAVE AND WILL MNl1'!MN 1YORKERS'CAMPENSATiCN INiURAMCE,AS RE�IIIREU HY SECTION _-__ Q a�WOFTHEW30RCWE,FOHTHEPEFFORn1.oNCEOFTHFWOAKFOFIWNICF171i;5PERMITIS , � IS9UEU.MY�v�� c•EFRSCOM SATIONINSURANCECANRIERPNDPOLICYNUMUERARE: ' CONSTRUCTION ._____ _____ __„_..__ _...._,.. _____ � yd, \•!.;� ��i�1�1`l - -- --- PLAN REVIEW -----.. _- ...__. ..- - CAFlRIEN �'__ , . ._ __'_" � POLICYNUA1BEfi�`:,[.�_ 1 ` ------ ----- ELECTRIC :^'%!?':s"�'*. Q �-°'��'`�� i� p (IFi�55FCIpNNE�NJT(IECp,AF:TF.DOFn1EPEFMTSWRCNENUNx7ED[%%LVLS(ft00)OR�ESS). PLUMBING ..--- '-..- '-�----' � ICcR71FV7HATINTHEPERFORMANCECFTHEWOF.KFURWH;CHTHISVEHMITI5155UE0,1 MECHANICAL � '_-" "__" ___ _-' SHP:INOT EAIPLO�ANV PERSON IN ANY MANNER<O AS 70 CIECUMF SUUJEC7 TO TME - WoqNENS'GOMVENSATION LAWS UF LALIFO 'IA,ANU AGREE TMAT IF I' Ul�BECOME INSPECTION rEE � . "' ,_ ___ f/)� •� ,.�, t . � r .. S110.1ECTTOTIiEWORKERS'COMPENS TION OVISIONSOFSECTION ]a0 THELAB � ' ISSUANCE �� '`� 3�� GODE.ISHALLfORTHWITHCOMPIYWI( EPNOYISIONS. ;'ta✓� ,- f ,, � " •� .C_, SMIP •._,�1. .' . . _.---.....- ---- � W DATE:1fi� APPLICANT: f _ � � ..,�. .- . .� � _'____ -_'"_ ".-___..__' .._.. - l,.,.1"_ . -J WAfiNINO:FAILURE TO SECURE WOIiK[flS'CUMPENSATION COVEflAGE IS UNIAWFUI,ANO ShIAL BE ENERGY PIC "_._,__„_—...__._ _...__... _ _.. ._.-_ J �,�, SUBJEC7ANEMPt.OYERTOCRIMINALPENAlTIESANDCIVILFlNESl1PTOONEHUN�RE�THOIJS ENERGVPERMIT _ ,. _ _,__ . _ _ .__ ___ DOILAflS�S100,00D),INADUITIONTOTHECOST�FCOMPENSATION.DAMAGESASPROVIDED�OHIN - - � SECTION3708oFTHEtR00nCOU[,INTEHEST.FNDATfORNEY'SFEES, RETENTIONFEE: _..._._ _, _._. _. __ � CONSTRUCTIONLENDIYGAGENCY PRE-ALTFEE: ____.______.__ __ _ 4 IHEHE9YRFFIRMUNOERPENALiYOFPEflJURVTHATTHEFlEISACONSTRUCTIONLEN�INCAGFNCY ___. ___ __ __ _ FORTHE FERFORMANCE OF THE WOPK FOR WHICH THIS PEfiMIT IS ISSUED i5EC.30B7.CIV.C.). � '_'_ ___' "_'_' _ W � LENDEfl'SNAME_...._"'____-__"_'� -'--_"'_' '-_ F- LEN�FR'SAD[)RFSS.. -_..�._...._ --"- WICERTIFYI'HATIHAVERE�DTNISAPPLICATIONANOSTATE7HATTHCABOVEMFORMRiKKJI5COFiR[CT. TOTAL FEES �� � d I AGFlEE TO COMPLY WITH ALLCITY AND COUNTV ORDINANCES ANU STATE LAWS RELATWC TO BUIl�IN6 CONSI FUf.110N,AND HEREBV AUTHORIZE REPRESENTATIYES OF THIS COUNTY To ENTER uPaN THE Z ABOVE-MENTIONED PROVFHTY FOR MSPECTION PUFPOSES. _ _ __ ;'� COMMENTS_._ � _t1 Y,_ti fa�f� C ✓'_� 6--�_-._...--- — - ----- ---- — MITrEE NMIE(PftIM) �,,i� _. --- f�A� Le C �1.�.�--:�'--- — r j !�_._ .._ -- IG FTUHEOFPERMITTEE DA1E = w RECPT.N0. __PAID� __VALIDATION__,__ ~ WHITE-Department Copy,YELLOW--Finenco Gopy,PINK-Assessor Copy.GOLDENROD-File Copy,GREEN-ApplicanYs Copy ._ _ , , _ , �_.... .. . . i i � ;. � . � „� . k f .. . . ' � ' , , i' . . , � � i ' 1 3 - .. ' - " ... � ' , .' f - , . , , . . . � 7�� ' . ` . ' , . � . . . ' r 1 . '�.� . ' . ' ' ', ' . ' I .. " k �� � ' . �I � ��� f I � . I" �. I ! �I , ' I " . i' : � ' , '��' � � _ t < ' :.., ''. • ' : ' , � , „ .... . > — , . " . . .. . . , . i . , . I, � ,�..A ( �' . ! 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