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HomeMy WebLinkAbout15122 (653) � �i`�l`'� CITY OF DIAMOND BAIt � �� DEPARTMENT OF COMMUNTTY&DEVELOPMENT SERVICES ��j/ ���` '- _ w 21660 E.Copley Drivt Suite 190 / (909)860-3195 Fax(909)861-3117 PRES$ '9�" BUILDING PERMIT APPLICATION __ FIRMLY a ADDRESS I I�Y v �� 1 4, �l C GC� L,'�s �_'�jj `� "'► , � � } � ,� � APPLICATION PERMIT � P/C p � DATE �� NUMBER # � ISSUE / TYPE pC� APN LOT /�ACT DATE L'7"-'I��� � CONST. GROUP p OWNER .F� �A.'Y1f 1'�"irv (1 LLp ADDRESS � ;f ZONING SETBACKS � CITY � . ZIP I IU- TE �` REART RW �❑ APPLICANT TEL. SIDE/SIDE STREET RW ❑ � CONTRACTO �` / �;a SIDE ❑ ADDRESS � CITY ��a�'\Rf.�$��i v ZIP �W°�'3 TEL. _��M�i`'�� PROPOSED US ��� -�- C��h � ��i+ ARCWENG/ z DESIGNER NO.DWEL. NO. NO. k' ADDRESS �5 UNITS STORIES BEDROOMS � CITY 21P__ TEL. cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUIL�ER DECLARATION $FR/ADD,�fiEM O � I HEREBY AFFlRM UNDER FENALTY OF PERJURY THA7 I AM EXEMPT FROM THE CONTRACTORS U- GflfBJB/C8f(.lOf[ W CENSELAWFORTHEFOILOWNGREASON(SEC.7o31.58U31NE35AN�PROFESSiONSCADE:ANYCI7YOR (n � COUNTYWHICHREOUIRESAPERMITTOCONSTRUCT,ALTER,IMPROVE,DEMOLISH,OHREPAIRANYSTRUG W PdtiO/DBCk W 7URE,PRqR TO ITS ISSUN7CE,AL50 REQUIRES THE APPLICANT FOFi SUCH PERMIT TO FILE A SIGNE� W � STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF iHE CONTRACTORS U� CENSE UW(CNAPTER D(WMMENCINO WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO- LL' POOUSpd FESSqNSCODQOPTHATHEORSHEISEI(EMPTTHEREFROMANDTHEDASISfORTHEALLEGEDEXEMP� (�J V TION.ANVVIOLATIONOFSECTION7o31.5BYANYAPPLICANTfORAPERMITSUBJECTSTHEAPPLiCANTTO z Re-Roof F A CMl PENALTY OF NOT MORE THAN FNE HUNDRED DOLLARS�SSOD).): � ❑I,ASOWNEROFTHEPROPERTV,ORMYEMPLOYEES`MTHWhGESASTHEIRSDIECAMPENSATION, O COR1MBfCl81 - WII.L DO 7HE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERE�FOR SALE(SEC.7044,BU51� J � NE55 AND PflOFE3910N3 COOE:THE CONTRACTORS UCENSE LAW DOES NOT APPLY TO AN OWNER OF = - PROPER7Y WFiO BUIlDS OR IMPROVES TMEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSEIF Oq CL lHROUGHNISORHEROWNEMPIOYEES,PROYIDE0h/ATSUCNIMPAOVEMENTSARENOTINTEN�EDOR m � OFFEREDFORSALEIF,HOWEYE0.TMEBUIL�INGORIMPRQVEMENTISSOLDWITHINONEYFAROFCOMPLE � TION,THE OWNER-BUILOER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHF.�ID NOT BUILD OR IMPROVE FORTHE PUFPOSE OF SALE). W ❑I.ASOWNEROFhIFPROPEHTY.AMEXCLUSIVELYCANTRACTINGINTHUCENSEDCONTRACTORS � TO CONSTRUCTTHE PRQIECT(SEC.70t<,BUSINESSANO PPOFESSIONS CA�JE:TNE CONTRACTORS LI- V�II18SI011 _ADJ.AREA W CENSEL�WD9ESNOTPVPLYTOANOWNEROFAPROPERT'WH60U14DSORIMVRDVESiHEREON,AND F WFbCONTRACT5FOF5UCHPR0.1ECT5WI7HACONTMCTOR(S�LICENSEDPURSUAM70THECONTRAG QUANTITY DESCRIPTION FEE � TORS UCENSE UW.f. ❑IAM EXEMPT UNDER SEC. 9.8 P.C.FOP THIS REASON Q 3 _ � ,� a DATE ONMER U � W LICENSED CONTRACT4RS DECLARATION —� � w �HEREBVAFFIRAIUNDERPENAI.TVOFPERJURYTHATIMIIICENSEDUNDEFPROVIS10N50FCHAPiER � �y � B( ENqNO WITH EECTIOId 7000)OF DIVISION 3 OF THE BUSIHESS AND PROFESSIONS CODE,ANO z (/ X MY LIC NSE IS IN NLL FOPCE AND EFFECT. � Ltl ��,///���^^^ 1 � CEN CLASS� LIC.NO. � � +�� � V � � CONTRAC d � !� ���CUMPENSATION DECLARATION —r „C � ¢ � I HEREBY AFFlRM UNOER PENALTY OF PERIURY ONE OF THE FOLLOWING DECLARATIONS: Z � _INAVEANDWkLMA1NTAINACERTIFICATEOFCONSENTTOSELF-INSUAEFORWORKERS' _ �� COMPENSRTION,AS PROVI�ED 9Y SECTION 37o00F THE LABOR CODE,FOF TNE GERFORMANCF �U O �OFIHEWORKFORWHICHTHISPERMITISISSU£D. � W I VEMIDWILLMAINTAINWORKERS'CAMPENSATIONINSt1RnNCE,ASRE�UIRED8Y5ECTiON Q 37 OFTHE LABOR CODE,FOHTHE PERFORMANCE OF THE WORK F4R WHICH7HIS PERMIT IS IS ED.MY WO�ARS'��/oo MPE�y�p,TlON INSURFNCE CARRIER AND POLICY NUMBER ARE CONSTRUCTION jc �Ea_���;.�1`4�> �a��qj-y^{�-�'�� PLAN REVIEW z �cv NutasEA—��'1=t SL:?�.��14 •—'� --- — ELECTRIC Q -�` /�`, 1 � SEGTiONNE�NOTBEWMfLEfEDOFhiEPEfgMISFORqVENUNDRWDOI,lARS(510o)OpLESS� PLUMBING �(d.!�-[..�l.R, .C.�..[. lA'_.� �i.r .:T �r : �, 'r Z I ERTIFYTHATINTHEPERFORMANCEOFTHEWORKFOqWHICHTHI5PEHMITISISSUED.I MECHANICAL � ALL NOT EMPLOY ANV PERSON IN ANV IAANNER SO AS TO BECAME SU&I'eCTTO THE � ORNERS'C0IAPENSATIONL.lWSOFCALiFOR ANDAGREETHATIFISFIOULDBECOME INSPECTIONFEE `fe UBJECT TO THE VJORKERS'CCMPENSA ON �ISIONS Of ECTION 370o OF THE LABOR �'r,d d� —�j � CODE,1 SHALL FORTHWtTH COMPLY WITIi 2'PFlOVISI ISSUANCE _p���]-_:_ �r T -� � ��-�7 O DATE: ����' G�� APPLICANT: .. :��"` ��.. SMIP 41c {aT� r, `'� ��a w WARNING FAIWF'c TO SECURE WORKF.RS'COAIPENSATION COVERAGE IS UNLAW�LIBE ENERGY P/C {9�'�,�� � y�N�_ LL SUBJECTANEMPLOVEPTOCRIMINALPENALTIESANDCIVILFWESUPTOONEHUNOREDTHOUSAND ENERGYPERMIT �a�'°jh�R��¢���Y�w OOLURS(510o.0a0).IN ADDITION TO THE COST OF COMPENSATION,OAMAOES AS PROVI�EO FOR IN J SECTION37oeOFTHEL080RCODE.INTEREST,ANDATTORNEI"SFEES. �±.�§"' F��'j p� RETENTION FEE: aif�a„sz�➢ � CONSTRUCTION LENDING AGENCY PRE-ALT FEE v��� � I HEFEBV AFFIRM UN�ER PENALTY OF PEAJURY iHAT THERE IS ACONSTPUCTION LENDING AGF_NCY FOP THE PERFORMANCE OF THE WORK FOR WHICH TH:S GERMIT IS ISSUEO(SEC.3097,CIV C). Z LL — � LENDER'SNAME F— LEtiDER'SAODRESS W ICERTIFYTHATIHAVEREADTHISAPPL'CA710NANDSTATETHA7THEABOVEINFORMATIONISCORflECT. TOTAL FEES � IAGREETOCAMPLYWITHALlCI7VAN�COUNTVOR01NANf,ESANOSTATELAWSRFUTINGT08UIL�ING � CONSTRUCTION,AND HEREBY AUTHOqIZE REPqESENTATNES OF TNIS COUNTY TO ENTER UGON THE Z ABOVE-MENTIONEDPROPERTYFORINSPECTIONPUPPOSES. COMMENTS � ` � ,�f��r"L�r'p.7.-�. - {�.:'+..� m PE I7TEENAME(PflINTI . cdn � -�..�� � GNAT R E A7E FECPT.NO. PAIO BY VALIDATION � WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDEN OD--File Copy,GREEN—Applicar�t's Copy . . .....:' . -�'.. . �....'.L,. ,. �.- ...i.�::. 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