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` _!�� CITY OF DIAMOND BAx
� DEPARTMENT OF COMMUNITY d�DEVELOPMENT SERVICES
I 21660 E.Copley Drive Suite 190
� (909)860-3195 Faz(909)861-3117 J - PRESS
��-����^��W BUILDING PERMIT APPLICATION � FIRMLY
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o ADDRESS I��O V�II� V�3'I'� 5-I�C. 10v DATE�l.,� `-'� NUMBER I�AJ� #
� ISSUE TYPE OCC
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� ADDRESS ZONING SETBACKS
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� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION
� OWNER-BUILDER DECLARATION SFR/ADD/REM
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p I HEREBV AFFliW UNDER PENILT/OF PERIURY THA7 I AM E%EMM FHOM THE CONTRACTO{iS LI� GflfeCJO/CefpOft
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� TURE,PRIOR TO ITS ISSUANCE,AL50 REW IPES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED W
STATEMENT THAT HE OH SHE IS LICENSED PURSUANT TO THE PROVISIONS OF 7HE CONTRAC70RS LI�
� CENSE lAW(QUPTER D(COMMENCINO WI7H SECTION)000)OF DIVISION 3 OF THE BUSINESS AND PRO- � PooUSpa
FESSIONS CODE)OR THAT HE OR SHE IS E%EMPT hiEREFROM AND THE BASIS FOR THE ALLEGED EXEMP•
TION.ANYVIDLATIONOFSECTION7031.6BVANVAPPLICANTFORAPERMITSU&1ECTSTHEAPPLICANTTO Z Re-Root
� A CIVI�VENALTV OF NO7 MORE THAN FIVE HUNDRED OOLURS(i5oo).):
� OI.ASOWNEROFTHEPROPERTV.ORMVEMPLOVEESWITNWAGESASTMEIRSOLECOMPENSATION, � COrtIfilOfCifll . �
MALL DO THE WORK,AND THE STRUCTURE IS NOT IHTENDED OR OFFERED FOR SALE(SEC.7011,BU51- J
NESS AND oROFESSIONS CODE:7HE CONTRACTORS LICENSE UW DOES NOT APPLV TO AN OWNER OF
� PROPERTYNhiOBU11DSORIMPROVESTHEREON,ANDWHO00E5SUCHWORKHIMSELFORHERSELFOR �
Q THiqUGH HIS OR HER OWN EMPLOVEES,PROVIDED THAT SUCH IMPROVEMENTS AHE NOT INTENDED OR m
0 OFFEREDFORSQEIF,FIOWEVEF�7HEBUILDINGORIMPROVEMENTISSOtDWITHINONEYEAROFCOMPLE ,
Z �'TION,hIE OWNER�BU�tDER WILL HAVE THE BUR�EN OF PROVINO THA7 HE OR SHE DID NOT BUILD OR
� IMPROVE FOR THE PURPOSE OF SALE). �
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[[ TO CONSTRUCT THE 7RQIECT(SEC.)ON,BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI- V81U8I1Of1 ADJ.AREA
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DATE OWNER V
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� LICENSED CONTRACTORS DECLARATION w
� I HEREBV AFFIRM UNDER PENALTY OF PERIURV TNAT I AM LICENSED UNDER PROVISIONS OF CHAPTER �
� Y(COMMENCIN(i WITH SECTION 7000)Of DIVISION 7 Of THE BUSINESS AND PROFESSIONS CADE,AND Z
��� MY LICENSE IS IN FULL WRCE AND EFFECT. m
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� � Z'Y� WORKERS'COMPENSATION DECLARATI N Q Z �� �,
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� I HEREBV AFFIRM UNDER PENAI.TV OF PER1UftY ONE OF THE FOLLOWING DECURA710N5:
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� _IHAVEANDWILLMAMTAINACE{iTIFICA7EOFCONSENT705ELF-INSUREFORWORKEHS' 2 ��� ,/ 1� /�C ' C �
COMPENSATION.AS PHOVIDED BY SECTION 37000F THE UBOR CODE,FOR THE PERFORMANCE U N /Y V
� OF 7HE WORK FOR WHICH 7HI5 PERMIT IS ISSUED. �
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W �I HAVE AND WILL MAIMAIN WORKERS'COMPENSA710N INSURANCE,AS REQUIRED BY SEC710N
Q 37000F THE LABOR CODE,FOR THE PERFORMANCE OF THE WORK f-0R WHICH THIS PERMIT IS
ISSUED.MY WORKERS'COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE: CONSTRUCTION
� , CARRIER oI c, . .-�R PLAN REVIEW
� POLICYNUMBER r/Cx5'L],v�a20oo (I ELECTRIC
0 (IHSSECf10NNE�NOT8E00MPLEfIDOFi}¢PEFifXTSFi�HaNEFiIN�DREDWILPAS(f10D)OqLESS) PLUMBING Q
Z I CERTIFY THAT IN THE PEHFORMANCE OF THE MIORK FOR WHICH THIS PEPMIT IS ISSUED,I MECHANICAL � U
(,�} SHALL HO7 EMPLOV ANY PERSON IN M1Y MAtJNER 50 AS TO BECOME SUBJECT TO THE INSPECTION FEE
� WORKERS'COMPENSATION LAWS OF CQIFORNIA,AND AGREE THA71F I SHOULD OECOA�E __
S SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 3700 E"GBOR � - ' �
COOE,ISHALLFORTHWI7HCOMPLYWI7NTH05 P I QO ISSUANCE �
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p DATE: � d� APPLICANT: SMIP �
w ENERGY P/C
� WMNINO:FAILURE 70 SECURE WORKERS'COMPENSATION CO RAGE IS UNUWFUL,AND SHALL BE
� SUBJECT AN EMPLOVER TO CRIMINA�PENAL71E5 AND CIVIL FINES UP 70 ONE HUNDRED THOUSAND ENERGY PERMIT
DOLIaRS(i100.000).IN ADDITION TO THE COST OF COMPENSA710N,DAM�GES AS PHOVIDED FOR IN
J SECTqN 3708 OF THE LABOR CODE,INTEFEST,AND ATTORNEV'S FEES. RETENTION FEE: -�
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d CONSTRUCTION LENDING AGENCY PRE-ALT FEE:
� I HEREBY AFFIRM UNDER PENALTV OF PERIURV THAT THERE IS A CANSTRUCTION LENDING AGENCV
� FOR THE PERFORMANCE OF THE WORK FOR WHICH 7HI5 PEFMIT IS ISSUED(SEC.7D87,CIV.C.). - �
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� LENDER'S NMIE
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� ICERTIFY7HA71HAVEREPDTHISAPPLICATIONANDS7A7ETHATTHEABOVEINfORMATIONISCORRECi TOTAL FEES 4 ���
w I AGREE TO CAMPLV N77H ALL CT'AND COUNTV ORDINANCES AND STATE UWS RElA71NG TO BUILDING
� CONSTRUCTION,M1D HEREBV AUT}10RIZE REPRESENTATIVES OF THIS CWNTY TO ENTER UPON THE �
ZABOVE-MEN710NED PROPERN FOR INSPECTION PURPOSES. COMMENTS �
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� RECPT.NO. PAID BY VALIDATION
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