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HomeMy WebLinkAbout13191 (109) CITY OF DIAMOND BAb� �\�'� -- -- DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES J �� 21660 E.Copley Drlve Suite 190 (909)860-3195 Fax(909)861-3117 PRESS ��°�. BUII.DWG PERNII'T Al'P�.ICATION FIRMLY � JOB5ITE / 9 APPLICATION RERMIT51 /`'�y� P ,� � ADDRESS ( ��S �'�I/�-LO Lc/ A�� DATE � �-' NUMBER`�� "� It � ISSUE TYPE OCC APN LOT T ACT DATE CONST. GROUP _ . g OWNER � A' ADDRE S S^ �� t� ZONING SETBACKS CITY ZIP TEL� " FRONT RW ❑ APPUCANT T��. REAR ❑ SIDE/SIDE STREET RW O CON7RACTOR Ci4 P�+� S✓.VRQ�A-t5 SIDE ❑ ADDRE � PROPOSED USE 0 G�+ "tCD G�� g CfTY IP Z TE '� � ARCH/ENG! DESIGNER NO.DWEL. NO. NO. ADDRE55 � UNITS STORIES BEDROOMS CITY TEL. y DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION Q OWNER-BUILOER DECLARATION SFRIADD/REM O I HEAEBV�FFlRN tAJDER PENALT'OF PEN.AIRY THAi 1 AM EXEMPT FNOM TIE CONIRACTORS LI• Qg�Oq/(;BlpOR CENSEIAWFORTNEiOLLOWIIXIHE�.90N19E0.70.9t.5BUSINES3ANDPROFE5510N5CODE:ANVCI7YOR (n COW7Y1NHK7iREOlIIflESAPERMRTOCONS7'RUCT.KTEP.N1PflOVE.UEMIOLISH,ORREPMflANYSiHUP W patidDeck iUpF.PRIOR TO ITe ISSUANCE,AL50 REIXIIREe THE JIPCLICMff FOR SUCN PERMIT TO FILE A SIGNED W 6TATEMENT 7}MT HE OR OHE IS LICENSED NRSUMIT TD THE PROVISION9 OF THE COl7TMCtORS LF CE}13E UYY(GMAPTER Y(CdAMENCIN�WfTH SECTION T000)OF DIVISION 9 OF THE BIJSINESS ANO Piq• � PaO�Pe FE6SpN5 OO�E)ON TWT HE Ofi SHE 16 EXEMPT 7liEREF1iOM AND TNE BASIS FOR THE ALLEOED E%EM0. 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B.L RC.PoR THIS RE��N 4 2 � �1� � � OATE OWNER V � LICENSED CONTRACTORS DECLARATION W J � W 1 NEREBYAFFlRl1 UNDER PENAL7Y OF PERNRY TFUT 1 AM LICENSED UNDER PROVISIONS OF CHAP7ER � 0(OOMMENCINO IM1niN SECTION 7000)OF OIVISION 9 0F 7HE BUSINESS ANO PROFESSIONS COOE,AN0 MT lK�NSE 18 NI FULL FOR�AN�EFFECT. `I � � ucE�a�ss � r+o. � p�� conrnacroa D ORK RS'COMPENSATION DECLA NTION �n� � / � 1 HEREO`�AFFlRM UNDER PENA�TV OF OERIUflY ONE OFTHE FOLLOWINO�ECIARATIONS: � � ��III�VEANDWILLWRITAINACERfIFICATEOFCONSENTTOBELf�INSUREFORWORKF.NS' Q GOLNENSATION.ABPROVIO�BYSECTION97000FTHEUBd1CODE.FORTHEPERWRM.�NCE OFTFIE WORI(FOR WHICM 1Fi13 PERMR IS ISSUED. 0 __11111VE ANO WILL YAIMAIN WORKERS'OOMPENSATION INSUFIANCE.AS REW IRE�BY SECTiON /')Q � 87000F7HElABORCODE.FOR7HEPERFOflMANCEOFTHEWORKFORWHICHTHISPEAM1715 CJ 0 ISSUED.MY WOHKERS'COMPENSATION iNSUHANCE CARRIER AND POLICY NUMBER ApE. 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