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HomeMy WebLinkAbout13874 (16) - ..---._.. .,._,_... . . .,,�----,.�. :i CITY OF DIAMOND BAht - J� —� DEPARTMENT OF COMMUNITY dY DEVELOPMENT SEFIVICES � w , 21660 E.Copley Drive Suite 190 (909)860-3195 Fax(909)861-3117 � PRES$ :•..,vM BUILDINGPER11�dITAPPLICATION`�,A'.. i , _FIRMLY ��„�, JOBSITE � ./- � APALICATION PERMIT`-,':���� :.'^. �'/C o ADDRESS � f O�( � DbTE g-3-4� _ NUMBER�*:�fr' ���# � APN �OT TRACT �SSUE TYPE f OCC —�—;- DATE _CONST. GROUP p OWNER .��QGK �-h.(�/� p ADDRESS�O 6�� ZONING SETBACKS Z CITY__�#�`��E�f S ZIP � TEL. _ REOART RW n g APF�LICANT TE . SI�E/SI�E STREET RW ❑ a� CONTRACTOR C�-f+�RKFNA $�� SIDE `__ ❑ p� ADDRESS .3'.� S . AV E. � ( � � CITY �/ .�p��,�'_T__ ZIP�__ TEL. 0 =�f PROPUSED USE� n F �G t f_F w ARCWENG/ ��'�'�^�� � � �- z DESIGNER — w NO.DWEL. NO. NO. n. ADDRESS UNITS � STORIES BEDROOMS = CiN ZIP TEL. � rn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � . GWNER•BUILDESi DECLARATION i SFFUADD/REM 0 � --- I ilEREBY AFFlRM UNDER VENALTY OF PERJURY THqT I M9 EXEMPT FROM THE CONTRACTORS L:- Gff�dgB/CBfPOfi W CENSELAWFOR7HEFi�ILOWINGREA50N(SEC.7W7.59USINESSANDPROFESSpNSCODE:ANYCITYOfi (J) U COUNTYWFIIqiREdIIRESAPFAMITT6CONSTRUCT,AITER�MPROVE,DEAIOLIS4{ORREPAIRANVSTRUC- W P31i0/�BCk TUflE,PRIOH TO RS ISSUANCE.AL50 RE�UIRES THE APPLICAN7 FOR SUCH PERMI7 TO FILE A SIGNED W STATEMEN7 THAT HE OR SHE IS LICENSED PURSURNT TO 7HE PROVISYJNS OF THE CONTFiACTORS LI� W � CENSE UW(CHRPTER e(OJMMENCINO WITH SECTION 7000)OF DIYISION 30F THE BUSINESS AND PRO� � PoollSpa FESSIONSCODE)ORTHATHEOflSHEISEXEM?T'fHEREFROMANDTHEBASISFpRTHEALLEIEDEXEMP- (� V TION.pNYYIOUTIONOFSECTION7o31.5BYANVAPPUCANTFORAPERM�TSUBJEGTS7HF0.PPLICANTTO Z Re-Root F IICINLPENALT'OFNO7MOREl71ANFIVEHUNORED00LUR5�S50o).): O ❑1A50WNEROFTHEPFiOPERTY.ORMVEMPLOVEESWITH'NAGESASTHEIRSOLECDMPENSATION. � Commercial _ Z WILL 00 THE WORK..W�THE STRUCTURE IS NO7INTEN�EU OR OFFERED f0�SALE(SEC.7oN,BU51- J � NE55 ANO PROFESSIONS COOE:iHE CANTRqCTORS LICENSE!AW�OES NOTAPPLY?O AN DYJNER OF = PROPERTY WHO 6UIIAS OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSRF OR HERSELF OR A d THidOUCJiHiSOHHFAOWNEMPLOYEES,PROVIDEDTHATSIJCHIMPROVEMENTSAflENOTINTENDEDOR L� OOFFERmWRSALEIF,HOWEVEf�7HEBULDINGOR�MPqOVEMENTI550LDW17HINONEYEAROFCOMPLE- Z TION,THE OWNEXAUIL�EH WILL HAVE THE BURDEN OF VROYIfdG iHAT HE OR SHE OIO N�T Blll��OR = IMPROVEFORTHEPURPOSEOFSA�E�. W 71,ASOWNENOFTHEPROPERTY,AME7(CLUSNELYCONTRACTINGWI7HLICENSEOCAIJTRACTORS � TO CONSTAUCT THE PFQIECT�SEC.70M.BUSMiESS RND PflOFESSIONS CODE:THE CONTRACTORS U- UdI118I10� ADJ.AREA W= CENSEUWDOESNOTAPPLVTOANOWMEROFAPROPER7YWH08UILOSOA!AAPRDVESTIiEREON,AND - --- � WFIOCONTMCTSFORSUCHPH0.)ECTSWiTHACONTRACTOR(5)LICENSEDPURSUAkTTOhIECAMRAG QUANTITY �ESCRIPTlOW FEE Y TORS LICENSE LAW.). � ❑I AM EXEAIPTUNDER SEG 2.8 P.G FOR'H:5 REASON Q � _ � � � �ATE OWNER --_. U Z w � LICENSED CONTRACTORS DECLARATION w � 1 HEREBYAFFIRM UNDER PFNALTV OF'PENJURV THAT I AM�ICENSED lRr'DER PROVISIONS O�CHAP'ER � n„ e(COMMENCING WITM SECTION 7000)OF DIVISION 3 OF THE BUSI4ESSAN'J PAOFESSIONS COOE.A%� � _ � X MV UCENSE IS IN FUIL FORCEAND EFFECT. p � p ' '�- �T —� _'L � O LICENSE CU155 G/ C I UG.MO. ��9�_ � OATE�9 9 GONTRAC70R�,+�/YJQ�. 0. W � WORKERS'COMPENSATION DECLARRTION a = U � IHENEBVAFF6iMUNOERPENALTVOFPERJUFYONEOFTHE�LOWINGDECLAFATANS: Z L_l �IHAVEAfvOWILLA7AINTAINRCER7IFICATEOFCONSENTTOSELF-INSUREFOR4YDRKE�S' 4 � � — I%�JPENSATION,/S7ROVdlED9VSEC710N370oOFTNELA90qCO�E.FOFTHEPERFORMANCE W OF T7E WOR%FOR WMICH THIS PERMIT IS ISSUED. � 0 w �IHAYEANDWILLMAINTAINWORI�RS'COIAPENSA?IONINSUflANCE.ASREOUIREDBYSECTIDN f'��., p 37oa OF THE LA80R CODE.FOR 7HE PERFORI.i)�lCE O�THE WORK FOR WHICfi THIS PERMIT 15 --_— t f��, �,J�� {SSUED.MY WO ERS'COMPENrSAT'iO,N INSURANCECARRIERNJD POLICY NU'rABERARE�, CONSTRLiCTION y CARRIER_�.������--. W�•��;--- PLAN REVIEW —� � POLICY NUMBEH_Q�_�3 0�(_� _— ELECTAIC _____ _ � RrussEc�or�N�HoreE�n+v��mcFn{cacawr�sFc:aoraeNuraaF000w��saoioa�Ess� PLUMBING ------ .Z I CERTIFY THAT IN THE PERFORMA4CE OF TNE WORK FOR WHICH TH�S PEfiMI'IS ISSUED,I MECHANICAL _ ��-�-4 d}a'�'___ V SNALINOTEMPL.OVA7JYPER50.41NANYMANNERSOASTOBECOMESU6JEC7TCTFtF i " (/j WOflKeRS'COMPENSATiONUW50FCAL1-0RNIA.ANDAGPEETNATIFISHOULOBECOME I INSPECI'IONFEE � SU&:ECTTO iHF.WORNFRS'COMPc'NSATON PROVISION�OF SECTI Y 3]0o OF h1F.LABOR I ; ,.,>�T 2 � cooE,�sr+au coarnwiTH coMr�r wini Tn e a v�sioNs ISSUANCE _ �„ �✓''� � �–�_ APPLICAM. SMIP _'__�� k���;e.A.+ p DATE: � ENERGY P/C _ '��I �•- �- . y ,.-��- .��,� .rY:s�'-- J WARNINC:FAILURETOSECURcVJORKERS'C ENSATI . 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