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HomeMy WebLinkAbout13323 (123) �. ' , . f� CITY OF DIAMOND BAIt - DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICSS �� 2166D E.Copley Drive Suite 190 (909)860-3195 Fax(909)861-3117 PRESS ���9N°�� BUILDING PERMIT APPLICATION FIRMLY Q DDRIESS��tO�y�_�f�fG.i�� � �^� DATE CATIO� / ,q NUMB R����#'0 -I � ISSUE ' TYPE OCC � APN LOT 2� TRACT DATE CONST. GROUP p OWNER Z�U.f�i�i� � C ��L-E o ADDRESS�� WO(��.�•2I►��'�? C�' ZONING SETBACKS z CITY D-l�f(3hCO 1��ZIP TEL.�gC)-�IzSfl FRONT RW � gj APPLICANT��wlL?"�,,z_GNS�?'t7lvl-�/�� TEL.�.�-qFiOS�' SIDE/SIDESTREET FaW ❑ � CON7RACTOR �t�t,�-�S ��S'T�OM ��9D�3 SIDE p iy ADDRESS `2,22-�`J !l� dE PROPOSED USE �'AUf�1 f E {%(bOI� '1/�L'F �-�A o cirr�incr� � ziPq��tv TEL.�(o¢-9C�0g' � o ARCH/ENG/ aDESIGNER ��'� �^Q��"�_�• ND.DWEL. NO. NO. ADDRESS��Af _l�_I•'�C.LST1�f A�L� - - UNITS_ STORIES BEDROOMS � aTv aN.dF�f�/M zia�j.2.�� TEL. �U-Lp/n 0 � DESCRlPTION SQ.FT. FACTOR PSF ADJ.AREA/VALUATION OOWNER-BUILDER DECLARATION SFR/ADD/REM p I MER�'/AFFIRM UNDER PENALTY OF PERJURY THAT I AM E%EMM FROM THE COIJTFACTORS U- � Garage/Carport W CENSEUWFORTHEfOLLOWINGREA50N(SEC.7031.58USINESSA4DPROFESSIONSCODE:ANYCI'VOR _ C) Cp(RlfYWHICHREWIRESAPERMITTOCONSTRUCT,ALTER,IMGqOVC,DEMOIJSH,ORREPAIRANYSTRUC- W patio/Deck WTURE.PRIOR TO IiS ISSUANCE,ALSO RC4UIRE5 THE APPIiCANT FOR SUCH PERMIT TO FILE F SIGNED � STATEMENT THAT HE OR SHE IS LICENSED PURSUMiT TO THE PROVISIONS OF THE CONTRACTORS ll� ` CENSE LAW(CHAPTER s�COl/KiENCING NATH SECT16N�e0o)OF DMSfON 3 OF 7HE 9l'151NES5 AN�PRO- V' POOL�SpB S FESSIONSCODE�ORTHRTHEORSHEISEXEMPTTHEREFROMANDTHEBAS�SFOFTHEALLEGEDE%EHIP- V TIOtd.NNVYIOL/1TqNOFSECTiON7o31.50YANVAPPIICANTFORAPERMITSU&lECTSTHEAPPLICANTTO Z Re-Root � NCIYIL VENALTY OF NOT MORE TMAN FNE HUNDRED DOLIAR3(SSCo).): � ❑I.ASONMEROFTHEPflOPERN,ORMYEMPIOVEESWITH'NAGESASTHEIRSOLECAMPENSATIDN, � Gommercial • WILL DO THE WORN,AND THE STRUCTUqE IS NOT INTENOED OR OFFERFD FOR SALc(SEC.7044,BUSI- J' NESS AND PROFESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES NOT APW Y TO AN OWNER OF � p1�VEATYNhiOBUILDSORIAIPROVESTHEREON,ANDWHODOESSL'CHWOFKHIMSELFORHERSELFOR � � iHROUQHHI50FlHEROWNEMPLOVEES.PROVI0EDh1ATSUCHIAAPROVEUENTSAP.ENO?INTEN�EDOR m QOFFEflEDFORSALE�F,HOWEVER7HEBUIL�INGOHIMPROVEMENTISSOLDWITHIN04EYEApOFCDlAPLE- Z TION,THE OWNER-BUIIDER WILL HAYE h1E BUflGEN OF PROVING THA:HE OR SHE 010 NOT BUILD OF IMPROYE FOR TNE PURPOSE OF SALE�. W '�I,ASOWNEROFTHEPROPEHiV,NAAE%CLUSIV'cLYCANiRACTI.YGWITHLICENSEDCONTRAGTOFS � /�\A � TOOONSTRUCT THE PN0.IECT(SEC.70�C,9USINE55 AND PROFESSIONS CODE:THE CONTRAC?ORS L'� aW8110f1 ____�_=��,k;�J��DJ.AREA____ _ CENSE UVr DOES NOi APPLY 70 Ml OWNER OF A AROPERTY WHO BUIL�S OH IMPROVES THEflEON,ANQ � 1MIOCONTHACiS�OR5UC71PAOJECTSWIiFiACONTFACTORIS)LICENSEDPURSUANTTOTHECONTHAG QUANTITY DESCRIPTION FEE � TORS LICENSE UW). — -- ❑I AM EXEMPT UNDER SEC._ B.8 P.C.FOR 7415 RERSON Q � _ -�-------- i � o � c c � DA7E OwNEa___.__...—_ V Z iy i � LICENSED CANTRACTORS DECLARATIO'1 i j{ � IHEHEBYAFFIqMUNOERAENALTYOFPERJURYTHATIAMLICENSEDUNDERPROVISION50FCHAPTER � � a(COMMENCWO WITH SECTION�000)OF DIVISION�OF h1E BUSMESSAND PRDFESSIONS COOF.,AND z MY LICENSE IS IN FULL FORCE AND EFFEGL m LlJ �' � LICENSE CLASS �r",�3__110.NO �/`. ���,��, 5,� j V DATE���_._— CO�I�RACTORC�(d�--/J�S��j/L)M-�� d . W � LVORKERS'COMPENSF�TION UECLARPTIDN a —_ — � I HEREBY AFF{RM UYDER PENALTV CF PERJURV ONc OF THE FOLLO'MVG DECURA710NS: �Z � �� 2� � Q _ � _IHAYE1IYDWILLRiAINTAINACERTIFICATFOFCONSENTTOSELF-INSUREFORWORKERS' S � COMPENSATION.AS P�OV�DEO 8Y SECTIGN 37co OFTME LA60R CADE,FOR THE PER=09MANCE W ._ — —_ OFTHE WORK FOR WHICH THIS PEFlM:T IS ISSUED. � W r �I HAVEANO WILL MAINTAIN'NORKERS'f:OMAENSA710N INSI;RAkCE,AS REOUIRED BV SECTION Q 3�00�F TME l.ABOR OODE.FOR THE PERFCRMANCE OF THE WORK FOR Wr�ICH hi15 FERMIT IS . �y ISSUED.MY WORKEFS'CIOM?ENSATKKJ INS•U,R,A�NCE GARFUER AND POLICY M1UMBER ARF.: CONSTRUCTION g 7S�2_ � CARRIER C'.��/�✓ J p�'��L}-�-----------.---.-- PLANREVIEYJ ��- ---------- - ZPOLICYNUMBER"��,.,, ..l_��s---.-------------- ELECTRIC ____ � �O a -� . Q (iH155ECfK7NNE�NDTBEWN�A.EfIDOFhIEPERNT�FORCTI:NUNDRFD�R'�iORLESS� ?L'JMBING -----.._..----..— -� _—Id. W MECNANICAL �� �� � ICEflTIFYTHA7iNTHEPERFORMANCEOFTHEWORKFORWHICHTHISPERMIT'SISSU`<D.I ---.---.--.-- (!j SHAlLNOT FMPLOY ANY PER50Y IN ANY MANNER SO�S TO BECOME SUBJECT TO T4E RT�,�,p�� .� � WORKERS'COMVENSATIONLAW50FCALIFORNIR.AN�AGREETHATIFISHOL'LDBEAME INSPECTIONFEE _______._._._,,._—_—_`��� SUBJECTTOTHE WOFKERS'COMP1lSATIONP(10VISIONSOFS'cC'fION]]oCOFTkELAEOR �y sCODE,I SHALL FOflTHW:TH COMPLY WITH THOS'e PROVISI S. ISSUANCE _________ ^"� �•�' �*A O ��v�y0* �`,�a.i� �E'y'' p DATE:���__ APPLICANY: �' � �f--�� SM!P .__"_"—_' .-� ' r"' h-' '.' _ _" __ __ t' .-..�;Y'Y"v . w FNERGY P/C '+�°��' �`h•�` J WARN�N6:FAtLUFETOS'cCUFEWORKERS'COMPENSAT'.ONCOVERAGEISUNLAWFU�,ANOSNALLBE --'"-"""`—' � � LL SVBJEGTANEMPLOVEFTOCRIM:NALPENALTIESANDCIVILFMESVPTOONEHUNDREDTHOL'SAND [NERGYPERMIT _ �_��A•S > 'f"'«' D�LURS(SiW,00a�,IN ADDIT!ON TOTHE COST OF COMPENSATION.DAMAGES AS PflOV!DFD FOR IN '-- M./' gi� 'i.,�"'� (� � SECTp437080FTHELABORCODE,INTEREST,ANDATTORNEv'SFEES. �ETENTIONFEE: __.___.__ '�jSy'�� v w .9 O CONSTRUCTION IENDINGAGENCV PRE-ALT F(Ff,E:�� � IHEREBYAFFIRMUNOERPENALTYOFPENURYiHATTHEAEIS.4CONSTRUCTEONLENDINGAGENCY I� � FOR THE PERFORMANCE OF THE WOFK FOR WHIGH TH�S PERMR IS�SSUED(SEC.3097,CIV.G}. � W � ^��- — �.Z LENDER'SNAME___""_--'_'_'_—"____"'__"—'_'" "--'—' �— � _l - F- LENDER'SAOORESS _--— -- c W I C'eRTIFY THAT I HAVE REAU TH�SAPPLICATION Pt��STATE TNAT THE A60VE INFORMATKNJ IS GORREGT. TQTA�FEEJ � I AGREE TO COMPLY WRFI ALL CfT`.'AND COUNTY ORDINANCES AND STATE:AWS RELATING TO BUILDING CONSTRUC71CY1 AND HEPE9Y AUTHORIZE REPR'eSENTATIVES OFTHIS COUN'fYTO ENTER UPON T!+E Z A60VE�MENiIONED PROPERTV FOR INSPECTION PURPOSES. COMNiENTS__ —_.,_.__ _ � !_=� �. �'�('C��- ---- ----- ,�_ . . . ... .. .. .. . - ._ - - ------ m PERMITTEE NAME i?RIMI� � �/ --'--- . .... Q 1 �__�/` ��1/�I� —' ... . .. . ... .. . .... . .. Cn �_ _.._ -- � SIGNA7UREOFPERMIT7cE � y �A�— _ 2 RECPT.NO. __ PAID BY VALIDATION ~ WHITE—Department Copy,YEILOW—Finance Co PINK—Assessor Co GOLDENROD—Fla Co GREEN— IicanPs Co PY. 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