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_ _ _ CITY OF TIAM�ND BAR ^- ��'``-- DEPARTM�NT OF COMMUNiTY&DEVELOPMENT SEItVICES I I 21825 E.Copley Drive " (909}860-3195 Eax(909)861-3117 PRESS ""-y�u� BUILDING PERMIT APPLICATION FIRMLY � JOBSITE �'�� �/ ��� ����1 a APPLICATION � �� �'I NUMBER ��o� #/�v� o ADDRESS_ v DATE o ISSUE -� ,D TYPE OCC APN LOT TRA�T_ DATE � CONST. GROUP °C OWNER O ADDRESS ZONING SETBACKS oCITY ZIP��'/�"�TEL. � FRONT RW ❑ APPLICANT TEL. REAR ❑ � SIDE/SIDE STREET RW ❑ z ¢ CON7RACT0 ,,� � SIDE ❑ � ADDRESS � CITY ZIP L. PROPOSED USE I o ARCMlENG/ z DESIGNER w NO.DWEL. NO. NO. a ADLIRESS UNITS STORIES BEDROdMS � CITY ZIP TEL. cn � DESCRIPTION SQ.FT. FACTOR PSF ADJ.ARE/UVALUATION p� OWNER-BUILDER DECLARATION SFR/ADD/REM - O 0 I HEREOY AFFIRM UNDER PENALTV OF PERJUflY THAT I AM EXEMPT FAOM THE CONTRACTORS LI- � Garage/Carport � W CENSELAWFORTHEFOLLOWINGiiEA50N(SEC.�a31,56VSINESSANDPflOFE5510NSCODE:ANYqTYOR U COUNTYWHICHREOUIRESAPERMITTOCIXJSTRUCT,ALTER,IMPROVE,DEMOLISH,ORREPAIfiANYSTiiUC-' W Patio/Deck W � 7URE,PRIOR TO ITS ISSUANCE,ALSO RcaUIRES THE APPLICANT FOR SUCH PERMI7 i0 PILE A SIGNED W � � STATEMENT THAT HE Ofi SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI- � � CENSE LAW(CHAPTER 9(COMMENCING WITH SECiION 7aaa)OF DIVISbN 3 OF THE 8LISINESS ANO PRO- u" POOVSpB FESSIONSCOD�ORTHATHEORSHEISEXEMPTTHEREFflOMANDTHEBASISFORTHEALLEGEDEXEMP- (� � TION.ANVVIOLATIDNOFSECTION7a31.5BYANYAPPLICANTFORAPEflMITSU6JECTSiHEAPPLICANTTO Z Re-Roof A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS(5500).)�, Z ❑I,ASOYYNEROFTHcPPOPERTY,OFMVEMPLOYEESWITH]^fAGE5H5THEiR50LECOMPENSATION, � �mmercial -� WILL DO THE WORK,AN�THE STRUCTURE IS NOT INTENUE�OR OFFERE�FOR SALE(SEC.7046,BU51- J � NESS AND PROFESSIONS CO�E:THE CONTFACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF � PROPERTY WHO BUILDS OR IMPROVES THEREON,AND WHO�OES SUCH WORK HIMSELF OR HERSELF OR a THRDUGHHISORHEROWNEMPLOVEES,PROVIDEDTHATSUCHIMPROVEMENTSARENOTINTEN�EDOR m QOFFEREOFOPSALE.IF,HOWEVER,7HEBUILDINGORIMPROVEMENTISSOLDWITNINONEYEAROFCOMPLE- Z TION,iHE OWNER-BUILUER WILL HAVE THE BUR�EN OF PROVING THAT HC OR SHE DID NOT BUILD aR � IMPROVE FORTHE PURPQSE OF SALE�. �� �J,J Ll I,AS OVJIdEROF THE PROPERTY,AM EXCLUSIVELY CONTRACTING W{TH LICENSE�CONTAACTOP,S . [L TO COWSTRUCTTHE PROJECT(SEC.7�44;BUSINE55 AND PROFESSIONS CCOE:THE CONiRACTOAS LI- VHIlJBIlOI1 ADJ.AREA lLl CENSE�LAWDOESNOTAPPLYiOANONMEROFAPROPERTYWHOBU1LD50RIMPROVESTHEFEON,AND � WHOCONTRACTSFORSl1CHPROJECTSWITHACONTRACTOR(S)LICENSEDPIJRSUANTTOTHECONTRAG QUANTITY DESCRIPTION FEE � TORS UCENSE LAW.). . /� @ . o ❑I AM EXEMPT UNDER SEC. B.&P.C.FORTHIS REASON Q (/ �T Tv � � ti 4' �ATE GWNER U z L— c`J6!/�7' ti�tS � � LICENSED CONTRACTORS DECLARATION W � . d � I HEFiEBYAFFIRtd UNDER PENALTY OF PERJUFiY THAT I AM UCENSE�UNDEft PROVISIONS OF CHAPTER � , ' a, 9�COMMBVCINGWITHSECTION70o0)OFDIVISION30FTHEBUSINESSANDPROFESSIONSCODE,AND Z ��� �X MY LICENSE IS IN FULL FORCE AN�EFFECT. �� m a ' � � � LICENSE CLA S _LIC.NO. � � J � V DATE � _ CONTRACTO a W � WOFKEflS'COMPENSATIOM DECLARATION a = U '� � 1 HEREBV AFFIRM UN�ER PENALTY OF PERJURY ONE OFTHE fOLLOWING DECLAR0.TIONS: Z � _IHAVEANDWILLMAINTAINACERTIFlCATEOFCONSENTTOSELF-INSUREFORWORKERS' _ COMPENSATION,AS PFiOVIDED BY SECTION 370o OFTHE LABOR CODE,FOR THE PERFOqMANCE C� QOFTHEWORKFORWHICHTHISPERMITISiS5l1ED. � W _IHAVEANDWILLMAINTAINWORKERS'COPAPENSA710NINSUaANCE,NSPE�VIREDBYSEGiION �s�1 Q 37o00FTHELA80RCODE,FORTHEPERFORMANCEOFTHEWORKFORWHICHTHISPERMITIS � p �/!. ISSUED.FAYWORKFA'COMP NSATIONINSURA�CECARRIE AN�PO'JCYNUMBERARE� CONSTRUCTION p �„d6.,f� ¢ ]� CARRIER ��i PLAN REVIEW �� � POLICVNUMBER � ELECTRIC 0 (iHISSECfIONNEmNOTBEO�MPLEfEDOFTHEPEr'1MfTISFORQIEHUJDPEDCOLfARS�510C)ORLESS). PLUMBING Z I CERTIFYTHAT INTHE PERFORMANCE OFTHE WORK FOR WHICH THIS PERMIT IS ISSUED,I MECHANICAL CJ SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUOJECTTOTHE (J� WORKERS'COMPENSATIONLAWSOFCAUFOflNIA,ANDAGREETHATIFISHOULOBECOME INSPECTIONFEE � SUBJECTTOTHEWORKERS'COMPENSATIO.V�ROVISIONSOFSECTION3�ooOFTHELABOR Q � CODE,ISHALLFORTHWITHCOMPLYWI7HTHOSEPROVISIONS. ISSUANCE � �. p �ATE: APPLICANT: SMIP � � S \ J� WqqNING:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL BE ENERGY P/C. � �—y� SU&IECTANEMPLOYERTOCRIMPJALPENALTIESAN�CIVILFINESUPTOONEHUN�REDTHOUSAND ENERGYPERMIT '� DOLLARS(E1MI,OOO�,INA��ITIONTOTHECOSTOFCOMPENSATION,�AMAGESASPROVIDE�FORIN J SECTION3]oeOFTHELABORCODE,INTEREST,ANDATTORNEV'SFEES. RETENTIONFEE: � � d CONSTI�UCTION�ENDINGAGENCY pRE-ALTFEE: O � 1 HEREBVAFFIRM UNDER PENALTV OF PERJURV iHATTHERE IS ACONSTRUCTION LENDING AGENCV FOR THE PERFORMANCE OF THE WORI<FOR W HICF,'iHIS 7ERMIT IS ISSUED(SEC.3oB7,CIV.C.�. Z W '.i ? LENDER'S NAME '. I F_— LENDER'S AODRE55 ��e v �' � TOTAL FEES �C��.�P� � ', W ICERTIFYTHATIHAVEREADTHISAPFLICATIONANCSTATETHATTHEABOVEINFORMATIONISCORRECT. ��, � I AGREE TO CAlAPIY WIiH ALL CITYAND COUNTV OR�INANCES AND STA7E LAIVS RELATING TO BUILOI�G ; � CONSTRUCTION,ANDHEflEBYAUiHORIZEREPftESENTATiVE50FTHISCOUNTYTOENTERUPONTHE ��v �� z ABOVE�MENTIONE�PROFERTYFORINSP POSES. / � i � COMMENTS P���'�`_ ��" � - r� ��, ¢� PER iTEE NA�IP N � G� � 1 f I�c c�d. � � SIGNATURE F P RMI E � . D E , � = RECPT.NO. PAID BY � VALIDATION ~ WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy,60LDENROD—File Copy,GFEEN—Applicant's Copy � ;:� � y y � , .� . . . �°.. ,� �.� � ., �� #� _ � . . � ., _ t �W a�vs��' "� u"y, �� : k .� § � } 5 " '. 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