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HomeMy WebLinkAbout15916 (659) CITY OF DIAMONB BAFt � - -1�--- DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVYCES 21660 E.Copley Drive Suite 190 (909)860-3195 Fax(909)861-3117 PRESS �� ���H�°� � BUILDING PERMIT APPLICATION FIRMLY � JOBSITE � APPLICATION `_ PERMIT I 5�I� P/C p o ADDRESS•.+ DATE � � ��' NUMBER # � ISSUE TYPE OCC APN LaT TRACT DATE CONST. _ GROUP p OWNER �'��1iQ_�, ~J.�rY��� � AQDRE}�S � ` � ZONING SETBACKS z CITY tJ��m I' ZIP��I TEL -- RE�RT -- RW � g APPLICANT TEL._ SIDEJSIQE STREET RW � � CONTRACTOR � •, � C_..;� SIDE � ADDRESS �G/ _ • c� g � e ;}� � CITY �,�t�t(�a (`� � ZIP���2T L'�O�1= -S�'7'37 PROPOSED USE � �F_ �_ K-F"� — �� ARCH/ENG/ f^ .,�n F Cei-f-ty'1"�S'�3:.��Cr�ti ,rt ..•' FZ r � /7 c,i , r,�..... Z DESIGNER -`3 f �- d ADDRESS NO.DWEL. NO. NO. � CtTY ZIP TEL. UNITS STORIES '�V"�_BEDROOMS � v� DESCRIPTION SQ.Ff. FACTOR PSF ADJ.AREANALUATION � OWNER-BUIL�EF DECLARATION � SFR/ADDJREM I NEREBY AFFIRM UNDER PENAL7Y OF PEfiJURV THAT I AM EXEMPT FROIA TME CANTRACTORS LI- G2f8 J0/CdfpOR W CENSELAWFOFTHEFOLLOWINOREASON(SEGT03t.50U51NE35AItDPROFES5l0�9CODE'ANVdT/OR (n� � _ C7 COUN7YWHICHRC-0UIHESA?ERMITTOCONS7RUCT.AITER.RAPFiOVE.DEiJ�OLISH,ORREPAIRANV57qUC- WI P8f1a/DOCk NRE.PRIOR TO 1T5 ISSWUJC'c.ALSO RE�UIRES THE APPIICANT FOq SUCH?ERUI7 TO FILE A SIGNED �� STATEMFNT THAT HE OR SHE IS IJGENSFD PUFSUAN i TO 7HE PROVISIONS OF THE CONTRACTOR$�I� W CENSE LAW(CFU�TER 9(f,OMMENCINO WITH SECTION 7DGa�OF DIVI3IDN 30F THE BL'SINESS AND PRO� U'" POOUSpe FE5610NSCOOE)OR7HATHEOASHEIFE%EMPTTHEREFROMIW�TMFBASI.SFORTHEALLEGEDE%EMR � �+� V TION.ANYVIOIATIONOFSECT�ON7a31.5BVANVAPPLICAfJi FORhPERMITSU&IECTSTHEAPPLICANTTO Z Re-Hoof � ,f(-d � AGYIL PENALTV OF NOT A10RE THAN FIVE HUNORED OOLLARS(SSaa�.)� �� � C�.RSOWNEROFTHEPROPERTY,ORMVE4IPLOVEESWITHWAGESASTHEIRSOLECOMPENSATION, � COfTIffIBfC181 _ WILL DO THE WOAK,AND THE STFUCTUaE IS NOT INTENDm OR OFFEREJ FOR SALE(SEC 7G<4,BUS:� J � NESS pND PROFESSIONS CODE:THE CONTRACTOPS IICENSE UW OOES NO7 APPLV i0 AN OWNER OF � PflOPERTY VAiO BUiLDS OR IMPRW ES rHEREON,AND WHO DOES SUCH WORK NIMSELF CR HEFSELF OR CC TMROUQH HISOR HEROWN EMPLOYEES.PROYIDED 7FIAT SUCIi IMPROYEMEMSARE NOT INTEPIDEO OR m OOFFEREOFORSALE.IF,HOWEVER7HEBUILDINGOAIMPROVEMEN'ISSOIDWRHINONEVEAROFCOMPLE- z TION.THE OWNER-BUIL�ER WILL HAVE THE 9URDEN OF PROVINCi THAT HE OR SHE OID NOT BUILD OR IMP�YE FORTHE PURP0.5E DF SAIE; - w •^_I.ASOWNEROF'HE9ROPERT`l,A/AEXCI:JSIVELVCANTRAC�I�GWRHLICE'�S'eDC04TRACTOAS � (� TO CONSTRUC'i 7HE 7flP:EC7(SEC.7044,BUSINESS ANO PROFESSIONS CODE.THE COY7RACTORS LI� V81U8li011 ���i�� ADJ.AREA W CeNSEUW00E5NOTAPPLVTOANOWNEROFAPROPER7YY6'Fi09UtLD50RIMPqOVESTHEREON,AND -- -----'-- � NM1IOCONTRACTSFORSUCHPRQiECTSWIT?iAC9MRACTOR(S)LICENSEOAURSUNJTTOTNECOMMC QJANTITY DESCP.IPTION FEE � TOHS IJCENSE LAri'J. ____ � G I AM E%EMPT UNDER SEC.� ___,__ B,&P.0 FOR THIS ReASOu � � _ '_________-___'_"..__ � ' DATE OW!�IER____ _ � z ---- — c� w _ � LICENSED CONTRACT09S DECLARATION � W— OC I HEREBY AFFIRA{UNDER PENALTY OF PERIURY TY.AT I AM LICENSED UYDE+�GROV:SIONS OF CNAPTER � d 9�COMMENCINGWITHSECTION7000?OFDIVISION30F?Nr'_9USINESSANDPROFESSIONSCC.^.E.ANp Z ___ ___ ?C MY LICENSE IS!N FULL FORCE AND EFFECT. m l3J o LICENSE CLASS���___ LIC NO � j _����� J' W �e �Z. � CONTRACTOR s ��- � a!— -- U�. I��,� WORK��ENSATION DEL'LARATION -J = U�-- � t NEREBV AfFIFAI UNDER PENALTV OF VER.:URY CTiE CF THE FOLLOWIh:G�ECLARATIONS � Q __ � _IHAVEANDWILLMAINiAINAC'eNTtFICATEOFCGNSENTTOSELF-INSUREf-OIiWORKe'FS' _ � COMPENSATION,ASPROVIDEOBYS£CTION3]WOFTiE:ABORCOOE.FCRTHEPER'ORMANCE �U _ _ . OF THE WORN FOR WiiICH THIS PERMI7IS I55UEC � d ; � ____ � 4'THAVEANDWILIMAIM,AINWORKERS'CONiPF45ATIONINS::ftANCF,ASREOJIREDBVSECT:ON !��� Q � �700 OF THE LABOA CODE,fOR THE PEPFORMANCE GF 7HE WCRK FOR WN'CH T415 PERMIT IS I � � y� �SSU'cD.1AY bVORq`-RS'OOMPENSATION INSI:N.RNCF GAFR:`cR ANO 70lICY R'UMBC-a Aft_ CONSTRUCTION � O 7 CARRIER�`�`�.-��+ _.�1 ----- --- PLAN REVIEW _ ..-----_--. ZP(RICYNUMBER...%��7 ���-- --- ELECTP.IC _... p��ry/��-- ¢ '__-���V V � (�1+IS5ECTlf%VNEmWTar(x7APLE?EDOFTHEPEFV.9Ti5FOFGNEkuY]REOWI.WASEtoalORL55:. PLUA481�iG __..___.__— _ �yy _— � ���F--d--i:lF��-!�s i A I�If C7N� Z ICEF.?I�YTHRfINTHEPERFGRMaNCECFiME'vJORKFORWHICHTH15P' T�SISSuE�.I MECHANICA.L � �t'ATl (�j �HALL KOT EMo��,7Y ANY FERSON IN AhV A1f.�dCl�9.�AS?O BECO 118.1E ?C THE .�+�� Vj WORKERS'COM?EYgAT:ONlAiN50FCICLiFORN1A,Ah ,RFET !F.SHOU 9ECOME INSPECTIONFEE _������'����11 7 - SU&ECTTO7HE WORKERS'COMP NSATION FROVISIO.�'S ' C�ION 3]CG THE'_A90R \ OCODF,I SHAL!.FO//R��TFS..,,NITN COMP' WI?H"'OSE PROVI51 . ISSUANCE _________._____.___,______ 6�l-.S��� p DAT...,J��L.� /�j APPLICANT. _-- '— '-__- _. '.'SMIP .. ... ..... ._-____— —_ • V - W I EYERGY P/C � WARNING:FAILUAE105ECUREWORKERS' IONCOVERAGEIS'JNLAWFUL,ANDSHALL9E ----"-------� ---- --� LL SU&IECTANEMPLOY�RTOCRIMINALPENALTIEgA�DCIVILFINESUPTOONEHUNGFEDTHW5A4D ENERGYPERMIT DOLLAHS(S��.�).�N ADDITION TO THE COST OF COMPENSATIOh',DAMAGES AS PROVIDED FOR IY --'---------�--- � SECTION S]UB OF TNE Lf$OR CODE.IMTEiiEST,0.ND ATfORNEV'S FEES. _- RETENTION FEE: ___,_____� _ a CONSTRUCTION LENDING AGENCY PRE-ALT FEE: ___...______,... _ O � I NENEBYAFFIRiA U40ER PENALTV OF PERJURY THAT YHERE IS A CONSTqJ�IIXJ LEtiDING AGENCV __ ___ _____� ____ _ FOR'HE PERFORMANCE OF THE WORK FOR WHICH THIS PFRMIT I>ISSI;ED(SEC.3091,CIV C.�. Z LL! - - . .. _ . . ., . � LENDERS4PME_ __-__—`_--'__'_'—'-" -� . F- LENDEP.SADDRESS___'_'_'__""___'__'-_" ... . ,. � � TOTAL FEES � ICERTIFVTHAT7MAVEREPDT.IISAPFLICATIONANDSiATETHATTH[ABOVEINFORMAT�pN�SCORREC'. 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