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HomeMy WebLinkAbout16987 (892) CI'TY OF I11AMO1�1D�AR -----�'�``——�) IIEPARTh�LENT�F�;�I��v1�JNTt'Y�Bc DEVELOPMENT SERVICES � - 21825 E.Copley Drive � (9l39)860-3195 Fax(904)861-3117 ' PR ESS ��;»ri�'�' B��,nnvGPE�a�ra�PL�CaTioN FIRMLY y, JOBSITE � � APPLICATION �w^�,,�� PERMIT 9 �(� y P/C a ADDRESS DATE `�l�f NUMBER �� S # ' o� ISSUE TYPE OCC , -- APN LOT', TRACT DATE CONST. GROUP ¢ OWNER I O `'- ADDR ZONING SETBACKS z CITY -- ZIP��,� T .�'���0 FRONT RW ❑ o APPLICANT � TEL. REAR q z SIDE/SIDE STREET RW ❑ a CONTRACTOR �"'� SIDE ` p �I � CIT`(/� �.- i ZIP�� TEL.G 2 l� PROPOSED USE� �� -' I ? l ' w ARCH/ENG/ I w � � Z pESIGNER ' NO.DWEL. I N . O. I� ADDRESS I UNITS_ STORIES BEDROOMS �' CITY I 7_1P TEL � � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANAIUATION p� � ' OIWNER-BUILDER DECLARATION SFR/ADD/REM �� O ,p'� ,I HEREBY AFFIRM UNDER PENALTV OF PERJURY THAT I AM EXEMPT FROM THE COMqACTORS LI- � Garage/Carport 'W'�. 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CAMPENSATION,AS PROVIDED BYSECTIDN 37000F THE LABOR CWE,FOR THE PERFORMANCE U 4 ' OFTHEWOPKFORWHICH�ITMISPERMITISISSUED. � � w .__IHAVEANQWILIMAINTAMIIWORKERS'COMPENSAiIOYIN5l1qANCE,ASPEOl11RE06VSECTION { d'�p �. �� Q 3�OOOFTHELA90RCODEFORTHEPERFO�MANCEOFiHEWORKFORWNJCHTHiSPERMITIS . 1 � ISSUEq.MY PENSATIO SURANCEC RIEFiANDPOLICYNUMOERARE: CONSTRUCTION i Q � CARRIER''�� PLAN REVIEW �' �' POLICYNUMBER ELECTRIC Q I � (MISSEC�ONNEmNOTBE�PLEfEDOFTHEPERMITISFORONEHUMRED0011AR5(5700�ORLESS�, PLUMBING � � 1 CERTIFY THAT IN 7HE PE FORMANCE OF THE VlORK FOR WHICHTHIS PERMIT IS ISSUED,I MECHANICAL �J' SHALLNOTEMPLOYANYP�ERSONINANYMANNERSOASTOBECOMESUBJECTiOTHE � �WORKERSCOMPENSATIO�ILAWSOFCALIFORNIA,ANOAGREETHATIFISHOULDBECOME INSPECTIONFEE ri = — _ SUBJECT TO THE WORKEp,5 COtAPENSAiION PROVISIONS OF SECTION 370o OF THE LABOR y t r`"F,! � �y ISSUANGE ""�r���� ' �J=� COOE,I SHPLL FORTHWIT COM'LY WITH THOSE PROVISIONS. � . � � ` " '� � I � [] DATE:._ APPLICANT: SMIP � _t����� 7 W � ' ENERGY P/C �8..6 L7 �q'�?•u .0 l I d 1� � � WARNING:FAILURE�Td�SECUREW�RKERS'COMPENSATIONCOVERAGEISIINLP.WFUL,ANDSHALLBE S �. �� SUBJECTANEMPLOYEflTOCRIMIf�ALPENALTIESANDCIVILFINESUPTOONEHUNDflED7HOU5AND ENERGYPERMIT � r OOLLARS(S10o.o�0),IN ADDITION Ti0 THE COST OF COMPENSATION,DAMAGES AS PROUI�ED FOR IN a yJ 'SECTION 3]a6 OF THE LABOR COO,INTEftEST,AN�ATTORNEY'S FEES. 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