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HomeMy WebLinkAbout15133 (34) V �� �� _ CITY OF DIAMOND BAbt � DEPARTMENT OF COMMUNTTY dc DEVELOPMENT SERVICES 21660 E.Copley Arivo Suiu i90 (909)860-3193 Fax(909}661-3117 PRE$$ ^^"f� BLJII.DING PERM[T AFPLICATION FlRMLY y JOBSITE « � APPLICATIO�t'_ PERMR P!C 0 ADDRESS DATE �lJ�'o�.� NUMBER i $ APN LOT T ACT �SSUE / w�O_�� TYpE p�T DATE L� CONST. (3ROUP � OWNER p ADDRESS ZONING SE7HACKS CITY ZIP�� TEL. FRONT qyy p APPUCANT TEL. REAR p SIDFJSIDE STREET pyy ❑ CONTRACT R SIDE p ADORESS � g C�1'1f ZIP Lf�nO�_. TEL �' PROPOSED USE ARC �'���P y 3 � . DESIGNER NO.DWEL. NO. NO. ADDRESS UNRS STORIES ___,�_BEDROOMS CITY ZIP TEL.^T_` � OWNER-BUILDHR DECIARATqN DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION O SFWA��/REM I HEREBY AFFlRM UHDER PENALTY OF VEIUUFY TIfAT I AA1 E%EhmT FROM TNE CONfMC70RS LI� G9f8gdC81pOlt CENSEU1WFOqiNEFOILOWNOREA,40N(SEC.7031.6BUSINESSAN�PFIOFESSIOIVSCOpE:ANYCRYOR (n COUNTYWHIdIREODUiESAPEAMRTOppNSTiIUCT,AI,TERLLfPHOVE,OEMOl1SH,ORREMIRANYSTqUG. W P8210/DBCIf T1RE.VRqR TO R8 IBSUANCE.AL80 REOUIRES THE APPIICANT PoR SUG1 PEfiM1T TO FlLE A BKiNED W � 6TATEAIEHf TMAT ME OR 9HE IS LICENSE�PURSUMIT TO TFIE VROVISIONS OF TME CONTMCTORS ll. CFTI9E LAW(diMTER 0(OpAA1ENCINO N7TH gECTION T000)OF DIVI810N 7 OF THE BUSINESS M10 Pq0- � POOUSPp FE85�ONSODDE)ORIW�TMEOHBHFISEXEMPT7HEREFN0/6ANOlMEB�518FORh1EhU.K3EDEXFMP• (' TION.ANYNOU1TqNOF6ECT10N7D31.6BYANYAPPLICl1tlTFORAPERMITSUBJECTEh1EAPVlICANTTO Z Re-Fioof � ACML CEN/�LTY OF NOT MORE TIM1 FNE NUN�REO DOLURS tt600).): .. O4i1BOWNEROFTIEPHOGENTY,ORMYEMPLOYEEBWIiHriMiESASiMEIR90LECOMPEN91lTIpN, A L`pmm6rCi01 M7LL OD 11E WORK ANO h1E 9THUCTURE IS NOT INTENDE�OR OFFEREO FOq 6ALE(SEC.7oH,BUSI- J lESS ANb PFOFFSSION6 CODE:TME CpYiMCTOR6lICENSE UW CDES NOT APPLY Tp 1W pWI�Ep pp ? � iNDPFAtYWH�BUILDSORYVROVESTNEREOIv,ANDYMO00E99UCMWORNNINSEIFpRNERSELFOp TfR10U0HMISORHEROWNEMPLAYEES.PNOVI0ED711AT8UCMYJPRpyEMENfSMEN�TMITENDEOOq m OFFENED PDR B/LE IF IqWEVER7ME BUILDINOOF MAPROVEMFNTI9 SOLD WITIdNONE YEMOf ODIAPLE �TION,THE OWNER-0UttDER WLL FUVE Tl1E BURDEN OF PROYWO iMAT HE OR SME DU NOT BWID OR MPROVE iON TIIE PURPOSE OF BM.E). O 1,l�,pYMEA OF TFiE PROPERiY,AM EXCLUSIVELy COMRACTINO NfI7F1 LICEN9ED CONTMCTORS TO CONSTlX1GT TME PRO,IECT(BEC.7oN,lUSINESS 1W0 PpOFESSION5 CODE:TME CONTRACTORS LI• '91U811011 ADJ.AREA CENSE lAW DOEB NOTAPPLY iOAN U�M1ER OF A DROPENTY YYFIO BUM.pS OR IMPROVES 7MEiiEON,AND N7/00ONTMCTSFORSUCIIPAOJECT8WITH�OOH7MCTOp(g)LICENSEDPURSUANTTOTHEIbAITpAG UMITITY DESCRIPTION � tons ucprse uw.). FEE ❑IAM E%ENP7 UNDER BEC. B.i P.C,iORTH18 REIISON � U + D�TE OWNER � � U ss[[ LICENSED CONISiACTORS pECLARATION W � �MEREBY AFFKUI UNDER PENALTY OF PERIURY THAT I MA LICENSEO UNDEH PROVISION6 OF CHAPTER � �(COMIJENCNN3 N7TH SECTqN 700D�OF CNISION 9 OF THE BUSINESS AND PROFESSpNS COpE,ANp Z W UCENSE 18 IN NLL AND EFFEC7. m 0 LICENSE CLASS LIC.NO. � � wr��,p^�--Q� coriTnncsoA �' WORKERS'COMPENSATION DECLARATION � I MEREBY AFFIRY UNOEq PENALTV pF PEiUURV qJE OF 7HE FOLLOWING DECUMTlONg: �/ � z � _INAVEAlOWILIIMMTAINACEqTIFICATEOF�ONSEMTOS�LF-INSUREFORWORKERS' _ . CdiPENuAT10N,A9 PROVIDED BY SEC770N J7pp Oi 1NE L!BOR COOE,iOR THE 7EIIfORMNlCE U O OF h1E WORK FOR WHICM THI9 iERMR IS I65UE0. , . � I NAVE AND W41 MAhTAIN WOPNERS•COMPENSA710N NJSURANCE,AS REQUIREO Bv SECTION Q 9T00 pF T{E 1A80H CODE.FOR THE PERFORMANCE OF 7HE WORK FOR W W pi TNIS PERMIT IS I�� 156UEU.MY WORKE ' MPENS TION I IRANCE C IER A!A VOLICY NUMBER ME� C�JNSTRUCTION I �� � CARPoER �.�_�� PIAN REVIEW ► POLICYMJAABEq ELECTRIC ��r� �!"p^ d (ndSSECf10fJNE�MOTeEaxaErEoacnEaEaaTs�oaaNEµr-DRE�oaUwsR+mloatEssi PLUMBING �_��'l"� � 1 CERTIFY 7MAT M 7ME PERFORMANCE OF THE WOHK FOH WHlql TFIIS PE WAIT IS LSSUED,I MECHANICAL 6WLLLNOTEG�PLOYANYPERSqJN1ANY4ANNERSOASTOBECOME6UBJECTTOTHE � , Cn WOHKERS'COMFEHSATIDNUWSOFCALI ,MAA�REEIF7ATIF18NOUL�BEODME INSPECTIONFEE 6U&lECTTOTME WOFiKERS'OOMGENSAT VISIONS OF SECT N 97oa OF THE 1A90R ��� �• - �� s coo�,isww.wnn�vnn+caao�rwini r owsar�s. ISSUANCE �. � � ��t'�i.iifl��.�ii3 � p OATE� APPLICANT: SMIP ��. � ENERGYP/C ' �-:•:'��-�+,.:i.f��:t�Y WARNINI3:FAIUHE TO SECURE YN�RKERS'COMPENSATION COVEMOE IS UNLAWFU�,LND SH �y, BUBJECTANEMPLOYERTOCRIMINALPENAL7IESANOCIVLFWE9UPTpONENUTARED � ENERGYPERMIT � OOltAR51f1o0,0ao),WA�pI110NTO7MECA5TOFGOMPENSATqN.UAMAQESl�SPROVIDED RIN SECTION 170!OF 7HE LABOq COOE,INTERE3T,AND ATTORNEV'8 FFFS. � RETENTION FEE: f CONSTRUCTION IENDING AGENCY PRE•ALT FEE: I HEREBYAFFIRM UNDER iEN,LLTY OF DERlURV 71uT THERE IS ACONSTRUCTION LENOWG AOENCY � FOR THE PERFORMANCE OF TXE WORN FOR WMICH THIS PEAMIT IS IBSUED(SEC.7W7,CIV.C.j. � LENOEH'S NM1E LENDER'S�DDqE55 � ICERTIFY7NrtTIXAVEREIIDTHISAPPLIGTIONANDST117ETlM7TiEABOVE WFOR1AATqNISOORRECT. TOTAL FEES �D IACiREETOCOMVLVN7THALLCT'ANpCOUNTVORDINANCESIJIDSTATEIAWSREUTINOTOBUIDING � CONSTRl1CT10N,AN HEREBY AUTFqRRE REPRESENTATIYES OF 7NIS COUNTY TO ENTEN VPON 11iE /�BOVE•MENTONFD qTY FOR INSPECTION PUHP0.5ES. 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