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HomeMy WebLinkAbout16287 (663) � ____�._,.. _..�_.w.._ _ _ . ..._.. , ._ . ,,y. __ . ���`�/ � �� _ CITY OF DIAMOND BAI+t ��,��d�-/ - DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES �=''(i' 21660 E.Copley Drive Suite 190 � .W (909)860-3195 Fax(909)861-3117 PRE$$ �..�y�'.., BUILDII�G PEYtM1T APPLICATI�l� , ,. . ����. _ _ .,.., _. o� JOBSITE � /� y APPLICATION PERMIT P!C ADDRESS e`7 rS 7+ ��L gd-�1.-f�P Q`.� DATE � � NUMBER�� # � ISSUE � � TYPE OCC APN LO� C TRAGT _ DATE CONST. GROUP p OWNER � I.f�t"�°Y'r'J'S• ' o ADDR SS. ZONING SETBACKS RW ❑ � CITY ZIP �TEL.`�LDy W'�1°B(]_i!3 REART ❑ APPLI ANT TEL. SIDE/SIDE STREET RW ❑ � CONTRACTOR SIDE ❑ � CIIY ES� ��ZIP >�TEL. PROPOSEo us� ['�P Q�,y''_�'� �7�i�f� o ARCWENG/ j��-� ^� ,�,, DESIGNER NO.DWEL. NO. NO. � ApDRESS UNITS STORIES BEDROOMS = CITY ZIP TEL. rn vs DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-BUILOER DECLARATION SFR/ADDlREM O � 1 HEREBV AFFIRM UNDER PENALTY OF PERJUNV THAT�AM EXEMPT FROM THE CONTRACTORS LI� G2f89B/C81[70(I � CENSEL4WFORTHEFOIIOWINOREASON(SEC.7o39.58USINE53ANQPPOFE3310N9CO0E:ANYC17YOfl (J� GQUNTYWHICHREWIRESAPEflMRTOCONSTRUCT,ALTER,IMPROVE,DEMOLISH,ORREPAIRANVSTiiUC� W patio/DBCk NRE,PRIOH TO ITS IS3UANCE,AL50 REW IRES THE APPLIGANT FOR SUCii PERMIT TO FII.E A SIGNEO W � STA7EMENT 7HAT HE OR SHE IS LICENSm PURSUANT 70 THE PROVISIONS OF THE CONTRACTORS U� � � CENSE UW�CHAPTER 9(COMMENCINO WITH SECTION 700D)OF�IVISION 30P TNE BUSINESS AND PRO� POOVSpB FESSpNSCOOE)ORTHATHEORSHEISEXEMPTTHEREFpOMANDTHEBASISFORTHEALLEGEDEXEMP� C7 TION.ANVVIOLATIONOFSECTION7031.58YANYAPPUCANTFORAPERMITSUBJFCTSTHEAPPLICANTTO Z Re-Roof � A CIYIL PENALTV OF NO7 MORE THAN FIVE HUNDRED DOLIARS IS56o).j: ^ ❑I,ASOWNEROFTHEPROPERTV,ORMYEMPLOYEES`MTHWAGFSAS7HEIfl5OLECOMPENSATIOk, COIIlfI1BlCI81 - L WIIL DO THE WORK,AND THE STRIICTURE IS NOT!N7ENDED OR OFFEFE�FOR SALE(SEC.704�,BU51• � � NE55 M'D PROFESS�ONS COOE:THE CONTRAGTORS LICENSE LAW DOES NOT APPLV TO AN OWNER OF � PPOPEPTY Y/HO BUILDS OR IMPROVES THEREON,AND WHO WES SUCH WOflK HIMSELF OR HERSEIF Ofl CC THRWCiH HIS OR HERONM EMPIOYEES,PR6VIDED 7HAT SUGH IMYROVEMENTS ARE N4T INTENOEDOR m � OFFEqEDi'ORSALEIF,HOWEVERNEBUIl01N000.1MPFOVEMENTI5SOLDWRHINONEYEAROFCOMPLE- � Z TION,THE OWNER-BUILDER WILL NAVE 7HE BURD@1 OF PROVING THAT HE OR SHE DID NOT BUILD OH = IMPRDVE FOH THE i'URPOSE OF SALE�. w ❑I,ASOWNEROFTHEPROPERTY,AIAC%CLUSIVELYCONTRACTINOWITHLICENSEDCANTRACTORS (� TO CONSTRUCT THE PRaIECT(5EC.7ou.BUSINE55 ANO PR(JFESSIONS CODE:THE CO47RFCTORS LJ� Valp2tlOn ADJ.AREA W CENSELAWDOESNOTAPPLYTOANOWNEROFAPAOPERttWH09UILD50RIMVRDYES7MEREON,AN� — � N'FIOCONTMCTSFORSUCHPflQIECTSWiTHA�'ANTRACTOR�S)UCENSEpPURSUANTTOTMECONTHAG QUANTITY DESCRIP710N FEE � 70R5 UCENSE UW.�. � ❑I AM EXE/APT UNDERSEC. _B.8 P.Q FOR THIS REASON Q 'T! _ _ V Lf.. -- � DATE OWNER _, , � Z W Q LICENSED CONTRACTORS DECLARATION � � IHEREBYAFFIRMUNDERPENALTYOFPERJURVTNATIAMLICENSEDUNDERPROVISIO450FCHAPTEF � a, 9(COMMENCINOWITHSEGTICN7o00jOF01VI510N30F1NE9U51NESSANDPPOFE5510N5CO�E,ANO Z X MY LICENSE IS IN FULI FORCEAND EFFFCL � LtJ �q � UCENSE CL�ASnS�_-_ 3�. , UC.NO.��C✓ � V OATE�;�r�Q�__ CONTRAC?OR�L��q���Cg����— d W � WORKERS'COMPENSATIOM DECLARATION Q � IHEREBYAFFIHMUNQERPENALTVOFPERJURYONEOFTHEFOLLOWMGDECLARATIONS: Z � _,_IHAVEANDWILLMAINTAINACERTiFICATEOFCONSENTTOSELF-INSUREFORWORKEPS' 2 COMQEIVSA710N,AS PROVIOE�9Y SEGTION 3�u0 PF TME LABOfi CODE,FOR THE PERFORMANGE W Q OF THE WORK FOH WHICH THIS 7ERMIT IS ISSUEO. � � �I HAVE AND WiU.AIAI�RAIN WORKERS'COMPENSATlON INSURANCf,AS RECUIRE'J BV SECT!ON Q� 37o00FTHELABORCOpE,FpRTHEPERFOfiMANCEUFhiEWORKFORWHICryTHISPERMiTIS ISSUE�.MY WORKERS'COMPENSATION INSUftANCE CARRIEfl AND PCI.'�CY NUMBEfl ARE: CONSTRUCTION jCARRIEH���.� : ��9 PLAN REVIEW � POLICYNUMBeA���(�. U C'�x.�C��5�_—__ ELECTRIC Q (fHISSECT%7NNE�NOTRECCPAPI.£TFDOFTI-iEPERMffISWH(NJEHIANJRW�C%.l.AFiS(5100)OPLESS} PLUMBING W I CF:RTIFYTMAT INTHE FERFOHMANGE OF THE WORK FOq WHICH 7H15 PERMITIS ISSUED,I MECHANICAI. Z (,� SHALL IVOT EMPLOY ANY PEFi50N IN ANY MANNEN 50 AS TO BEGOME SUBJeGT TO THE .�.�„„� (/j WORNERS'COMPENSATIONLAWSOFGAUFDRRIA,ANDAGREETMATIFiSHOtILORECOME INSPECTIONFEE S SUOJECT TO THE WORKERu'CrJMPENSATION PROVISIONS OF SECTION 370D OF 7HE LA�OP .� f . � _„ , — CA�E,I SHALL FORTHWITH CAMPLY WIT HOSE PROY�S. // ISSUANCE � �`�—�L�+ .4��'.4'2-� SMIP �, —�� ^ p �ATE: APPLICA�%�S%�C���� "___' J WAHNING:FpR.URE TO SECURE WORKER MPENSATION COVE GE IS UNUWFVL,AND SHALL BE ENERGY P/C a W SU&IECTANEMPLOVERTOCRIMINALPENAlTIESAN�CIV�LFINESUPTOONEHUNDRE�THOUSAND ENEFlGYPERMIT ���(S1o0,o00),IN AUDITION TO7HE COST OF CAMPENSATION,OAMAGES AS Pfi0V10E0 POR IN � SECTION37oeOFTHELp80RCODE,IN7EHE5T.AN0ATTOflNEV'SFEES. RETENTIONFEE: � CONSTRUCTION LENDING AGENCY PRE-ALT FEE: � M� T�T O � I HEREBV APFIRM UN�ER PENALTV OF PERJURY THA7 7HERE IS ACONSTRLC710N LENOING AGENCY FOFTHE PERFORMANCc OF THE WORK fOR WHICH THIS PERMIT IS ISSUED(SEC.3087,CiV.C.). Z W � LENDER'SNFME__ F— LENDER'SA�OftE55 � TOTALFEES ��� �_ � I GEFTTIFY Tl1AT I HAYE REAO THIS APPLICATIONAND STATE THAT THE ABOVE MFORMATKKJ IS CAftRECT. W I AGREE TO COMPLY WITH ALL CIN AN�COUNTY ORDINANCES PNO STATE LAWS RELATING TO BUILDING � COPJSTRUCTION,AND HEREBY AtITHOR:ZE REPAESENTATIVES OF 7HIS COUN7Y 70 EN7ER UPON THE ZABOVE-MEN7IDNED PP09ERTY FOR INSPECTION PURPO5ES. Q / COMMENTS �J ---�..r.t.�.l��--�'�-'-°��v�'`• -------- — QPERMITTEENAME(PRINT) t _ � � �"" t �. . . � Uj - NATUREOFPERMITf E �ATE � � = RECPT.NO. 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