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CITY OF DIAMOND BAI� ----- � DEPARTMENT OF COMMU1vITY&DEVELOPMENT SERVICES �" c/ : W 21660 E.Copley Drive Suite 190 , � � � (909)860-3195 Fax(909)861-3117 PRESS �..��.�`. BUILDING PERMTf APPLICATION . . --: . . .. ,p FIRMLY _ ;:w�=.., � JOBSITE e,�,� � t, ' APPUCATION I PERMIT f� !C a ADDRESS��1 ?�'�'��2+� /"�- DATE 4 ����� NUMBE � # � APN LOT��r� TpACT 7 S S �SSUE TYPE OCC d/`I T (.�u DATE CONST. GROUP p OWNER U►" � �1� " ADDRESS�7�-� � � Jl t�� ZONING SETBACKS � CITY EI�r-�H O ZI P �S'��TEL. . ,�S/��� FRONT RW ❑ APPLICANT TEL. REAR ❑ � SIDE/SIQE STREET RW ❑ � CONTRACTOR �� � SIDE ❑_ p� ADDRESS PROPOSED USE 7`C/� 6J " � C y¢�'/C� � CITY ZIP TEL. o ARCH/ENG/ z DESIGNER NO.DWEL. NO. NO. � ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � y DESCRIPTION SQ.Fi. FACTOR PSF ADJ.AREfWALUATION p� OWNER-BUILDER DECLARATION SFR/ADO/HEM O 0 I HEREBV AFFlRM UNOER PENALTV OF PERJURY THAT I AM E%EMPT FROM THE CONTqACTOliS LI- G8f8(JBIC2fpOfl W CENSELAWFOR7HEFOLLOWINOREAf>ON(SEC.1o31.58USINESSANDPROfESSIONSCODE:i1NVCITYOR (n U COUNT`/WMCHRC4UIflE3APERMITTOCON3TRUCT,ALTER,IMPflOV�DEMOLI9H2ORREPAIRANY3TRUC- W PB�1O/DBCI( � NRE,PRqR TO ITS ISSUANCE,ALSO REOU�RES iHE APPUCANi FOH SUCH PERMIT TO FILE A 516NED W STATEMENT THAT HE OR SHE 15 UCENSE�PURSUMIT TO THE PROVISIONS OF THE CONTRACTORS LI- � CENSE UW(CHAPTER B(COMMENCING NA7H SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO- � PoOVSpa FES510N5 CODE1 OR 1HAT HE OR SHE IS EXEMFT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP- TION.AHYVIOUTIONOFSECTION7031.SBYANYAPPLICANTfORAPERMITSU&IECTSTHEAPPLICANTTO Z Re-Roof � ACML PENAL7Y OF NOT MORE THAN FIVE HUNDNED DOLLARS(SSaO)J: � ❑I,ASOWNEROFTNEPROPERTV,ORIAVEMPLOVEESWITHWAGESASTHEIRSOLECAMPENSATqN, � COR1f11BfC12I -� WIIL DO THE WORK,AN�7HE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC.7ola,BUSI- J � NESS/J7C1 PROFESSIONS CODE:THE CONTRACTOqS LICENSE LAW DOES NOTAPPLV TO AN OWNER OF = PflOPEHiY NM1iO BUILDS OR IMPROVES THEREON,ANO NMOOOES SUCH WORK HIMSELF OR HERSELF OR � TNROUGHHISORHEHONMEMPIOYEES,PROVI0E0THAT5UCHIMPROVEMENTSARENO71N7ENDEDOR m QOFFEREDFORSALEIF,FIOVYEVER7MEBUILOMGORIMPROVEMENT550LOWITMINONEYEAROFCAMPLE- Z TION,THE OWNER�UILDER WILL HAVE TNE 6UROEN OF PROVING THAT HE OR SHE OIO NOT BUIL�Ofl = IMPRqVE FOR THE PURPOSE OF S�. ❑L AS ONMEfl OF THE PROPEHIY,AM E%CLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS � TO CONSTRUCT h1E PRQIECT(3EC.704l.BUSINE55 AND FROFESSIONS CODE:THE CONiRACTORS LI- VBWetiOfl ADJ.AREA W CENSEUW�OESNOTAPPLVTOANOWNEROFAPR07ERTYWHOBUILDSORIMPHOVESTHEREON,AND � WFiOCONTRACTSFORSUCHPPOJECTSWi'fHACONTRACTOR(5)LICENSEDPURSUANTTOTHECONiRAC- QUANTITY DESCRIPTION FEE � TORS LICENSE LAW.). Q ❑I AM EXEMPT UNDER SEC. B.8 P.C.fOR THIS REASON � LL DATE '� / OWNERI �1 .t.."� (r'C„�'�'�". � �. . . � W � LICENSED CONTRACTORS ECLARATION W � 1 HEREBYIIFFIHM UNDER PENALTV OF PERJURV TNAT IAM LICENSFD UNOER PROVISIONS OF CHAPTER � � D(COMMENCWO NATH SECTION 7oao)OF OIVISION a OF THE BUSINESS ANO PROFESSIONS CODE,AND Z �� MY UCENSE IS IN FULL FORCE AND EFFECT, m � LICENSE CLASS LIC.NO. j � J V DATE CON7RACTOR_ n- w � WORKERS'GOMPENSATION pECLARATION Q = U � IHEREBVAFFlRMUNDERPENAI.TYOFPEpJURYONEOFTHEFOLIOWINGUECIARATIONS: Z Q � _IHAVEANDWIIIMAINTNNACERfIFICATEOFCONSENTTOSELF-INSUFEFORWOFKERS' _ COMPENSATION,ASPROVIDEDBVSECTION7/a00FTHElABORCOOE,FORTHEPERfORMANCE U � OFTHE WORK FOR WHICH THIS PERMIT IS ISSUED. � � w _INAVEANDWILLMAINTqINWORKERS'COMPENSATIONINSURANCE,ASREOUIREDBYSECTION j _ ��,/'�� Q 37000FTiElABORCODE,FOflTHEPERWRMANCEOFTHEWONKFORWHiCHiHISPEHMITIS �� I ISSUED.MYWORKERS'COMPENSATIONINSURANCECARRIERANDPOLICYNUMBERARE: CONSTAUCTION J j cnaaiEa � PLAN REVIEW Z vaicvNUMeER_ ELECTRIC Q � (IH65ECT10NNE�N�TBEOOI+PLEfEDOFhIEPEPMT�SF'bRONEHINDRm00L1AR8�5100)ORLESS). PLUMBING Z I CERTIFY iHAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I MECHANICAI (,� SHALLNO7EMPLOYANYPERSONINANYMANNERSOASTOBECAMESUBJEC7TOTHE � WORKERS'COMPENSATIONLAWSOFCALIFOiiNIA,AN�AGREETHATIFISHOULDBECOME INSPECTIONFEE � SUBJECTTO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 370DOF THE LABOR CODE,I SHALL FORTHWITHCOMPLV WITH THOSE PROVISIONS. ISSUANCE i � SMIP � U�� 0 oarE: nP�icaivr p'�7 �'���-! e � WAPNMa:FAIWRETOSEIXIREWO(iKERS'COMPENSATIONCOVERAGEISUNlA1NFUL.ANOSHALLBE ENERGYP/C 1�JTi--`.��" ����'aT^P�7J II � SU&1ECTAN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINFS UP TOONE HUNOHED THOUSAN'� ENERGY PERMIT � DOLIARS(5100.000�.IN ADDITIONTOTHE COST OF COMPENSATpN,OAMAOES AS PROVIDEO FOR IN . � SECT�ON37080FTHEU180qCODE,INTEREST,ANDATfORNEY'SFEES. RETENTIONFEE: ` d CONSTRUCTION LENDING AGENCV PRE-ALT FEE: O C� I HEREBV AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING A,C,ENCY FOR THE PEFFOPMANCE OF TNE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.3097,CIV.C.). Z W � LENOER'S NAME . F— LENDER'SADDHE55 � I CEHTIFYTHAT I HAVE NEAD THIS AP7LICATION AN�STATE THATTHEABOYE INFORMATqN IS CqRqECi. TOTAL FE ES � � I AGREE TO CAMPLY WITH AlL CRV AND COUNTV OROINANCES AND STATE UWS RELATING TO BUILOINO � � CONSTRUCTION,ANDHEREBYAUTFiORIZEREPRESENTATNE50FTHI5CDUNTYTOENTERUPONTHE Z ABOVE�MENTKKJED PROFERiY FOR INSPECTION PURVOSES. �. COMMENTS � �.G,P �.,�t�L/ f�L,KJCIL r � m P RMITT NAME(PRI . . � ���C dv� /% �'' �� � SIONATUflEOFPE ITTEE OATE � '-"'-'-' ' = RECPT.NO. 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