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-----�``ei--- CIT'Y OF DIAIvIOND BAR , � � DEPARTMEN"i'OF COMMUNITY&DEVELOPMENT SERVICES a. •. „ 21825 E.Copiey Drive (909)860-3195 Fax(909)861-3117 PRESS '"-�ri�'�' BUdLDING PERMIT APPLICATION FIRMLY o DDRESS��/ �r//�,�J�- DATE CATION�--��"� NUMBE�� � [ #/C o ISSUE TYPE OCC APN LOnT� TR`A,CT DATE CONST. GROUP p OWNE�/7,GIa�b//ah ^'/TG.G'O�A p ADDRESS 0�3/ Bv�h t/.0 ZONING SETBACKS Z CITY��,�� o�- ZIP 9/?Ir� TELS9y �j�O_ FRONT RW ❑ � APPLICANT TEL. REAR ❑ � SIDE/SIDE STREET RW ❑ z m CONTRACTOR F � C SIDE ❑ � CITY9i�r�i ZIP 5'/7D/ TEL. S2 PaOPOSED USE oARbWENGI W DESIGNER NO.DWEL. N0. NO. a A��RESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREA/VALUATION p� OWNER-BUILDER DEGLAAATION SFR/ADD/REM O � I HEREBV AFFIRM UNDER PENALTV OF PERJURY THAT I hM EXEMPT FflOM THE CANTflACTORS LI- � �yrage/Carpon � W CENSELAWFORTHEFOLLOWINGREASON(SEC.7C31.5BUSINESSANDPROFESSIONSCODE:ANYCITYOR U COUNTYWHICHRE�UIRESAPERMITTOCONSTRUCT,ALTER,IMPROVE,DEMOLISH,ORREPAIRANYSTRUC- W patio/Deck w TUflE,PRIOR TO ITS ISSUANCE,AL50 REOUIRES THE APPLICANT FOR SUCH PERMIT i0 FILE A SIGN� W STATEMENT THAT HE OH SHE IS LICENSED PURSUANi TO THE PflOVI51DNS OF THE CONTRACTORS LI- �' CENSE LAW(CHAPTER 9(COMMENCWG WIT4 SECTIDN 70a0)OF DIVISION 3 OF THE BLASINE55 AN�PRO- � PDOVSpB FESSIONS COD�OR THAT HE Ofl SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE AIIEGm EXEMP- �'� 710N.ANVVIOLATIONOFSECTION7031SBVANVAPPUCANTFORAPERMITSUBJECTSTHEAPPUCANTTO Z Re-Roof A CIVIL PENALN OF NOT MOfiE THAN FIVE HUNDRED OOLLARS(E500).): �Z ❑I,ASOWNEFOFTHEPROPERTY,ORMVEMPLOYEESWITHYJAGESpSTHEIR50LECOMPENSATION, � COfIlfIlBfC18I ` WILL DO iHE WORK,AND THE STRUCTURE IS NOT IN7ENDED DR OFFERE�FOR SALE(SEC.7�44,BU51- J N� NESS AND PROFESSIONS CODE:THE CONTRAC70P5 LICENSE LAW DOES NOTAPPLY TO AN OWNER OF � PflOPERfY WHO BUILDS OR IMPROVES THEREON,AN�WHO OOES SUCH WOFK HIMSEIF OR HEaSELF OR ��� �THRDUGHHISORHEROWNEMPLOYEES,PROVIDEDTHATSl1CHIMPROVEMENTSARENOTINTENDEDOR m �Q; OFFEREDFORSALE,IF,HOWEVER,THEBUILDINGOfliMPPOVEMENTIS501DWITHINONEYEAROFCOMPLE- ' Z TION,THE OWNER-BUIL�ER WILL HAVE THE BUROEN OF PROVING THAT HE OFI SHE DID NOT BUILD OR �„� IMPROVE FORTME PURPQSE OF SALE�, �w, ❑I,ASOWNEIiOFTHEPROPERTY,AMEXCLU5IVELVCONTRACTINGWITHLICENSEDCONTAACTOftS ���', TO CANSTRUCT THE PROJECT(SEC.7044,BUSINE55 AN�PROFESSIONS COOE'7HE CONTftACTOFiS LI- VflltlHtlOfl ADJ.AREA � W, CENSELAWDOESNOTAPPLYTOANOWNEROFAPROPERTYWHOBUP�DSORIMPROVESTHEREON,AND ���. WHOCONTRACTSFORSUCHPROJECTSWITHACIXJTRACTOR(S)LICENSEDPURSUANTTOTHECONTPAC- QUANTITY DESCRIPTION FEE Y TOFS LICENSE LAW.). � � ❑I AM EXEMPT UNDER SEC. 9.&P.C.FOR7NI5 REASON U � � � DATE OWNER U Z w � LICENSED CONTRACTORS DECLARATION w Q � I HEREBY AFFIFM UNDEfl PENALTY OF PERJURYTHAT I AM UCENSE�UNDER PROVISIONS OF CHAPTEfl � ',� 9(COMMENCWGWITHSECTION7000JOFDIVISION30FTHEBUSINESSANDPROFESSIONSCODE,AND Z �X MY IICENSE IS IN FULL FORCE AN�EFFECT. m � Q IICENSE CLASS �2 O LIC.NO. � W. DATE��r CONTRACTOR � n- - � � WORKERS'COMFENSATION DECLARATION - Q ��r � '�'� � � I HEREBV AFFIPAA L1N�ER PENALTV OF PERJl1RV ONE OFTHE FOLLOWMG DECLARATIONS: z � � _I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENTTO SELF-INSUflE FOR WORKERS' _ CAMPENSATION,ASPROVIOE�BYSECTION37000FTHELA90RCDOE,FORTHEPERFOflMANCE U ¢ OF THE WOFK FOR WHICH THIS PERMIT IS ISSl1ED. � � � _IHAVEANDWILIMAINTAINWORKERS'COMPENSAiIONINSURANCE,ASREQUIREDBYSECTION Q 37000FTHELABOflCODE,FORTHEPERWRMANCEOFTHEWOFKFOftWHICHTNISPERMITIS ISSUED.MYWORKERS' OMPENSATIONINSURANCECARR/IER�AN�POLICYNUMeERARE: CONSTRUCTION ¢ �+ ] CARRIER Iyli�� ..,L t�e• PLANREVIEW Z� aoucvNUMeEa �,�� ,���f yy I ELECTRIC ¢, �� (IHISSECTIONNEEONOTBEDJiAPLEfEDOFTHEPERMfTISPJRONEHUNDFEOCOLLARS�57oC)OqLESS). PL�8IPIC'i. Z1 CERTIFYTHAT INTHE PERFOPMANCE OFTHE WORK FOq WHICHTHIS PERMIT IS ISSl1ED,I MECHANI � � SHALLNOTEMPLOYANVPERSONINANYMANNERSOASTOBECOMESUBJECiTOTHE ��� �'� WORKERS'COMPENSATIONLAWSOFCALIFORN10.AN�AGFlEETHATIfISHOULDBECOME INSPECTIONFEE - �I ,�� SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTIDN 37oa OF THE LABOfl /" �� �' C��E,I SHALL FORTNWITH COMPLV WIT��VIS��� ISSUANCE _ """� � SMIP �]� DATE:� APPLICANT:( J' WAflNINGFAILU ETOSECUflEWORKERS'COMPENSATIONCOVERAGEISUNLAWFUL,ANDSHALLBE ENERGVP/C . � �' SUBJECTANEMP�OYERTOCRIMINALPENPLTIESAN�CMLFINESUPTOONEHUNDREDTHOUSAND ENERGYPERMIT OOLL4RS�5700,000�,IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN �I �' SECTION37060FTHELABOfiCODE,INTERESiHNDATTORNEY'SFEES. RETENTIONFEE: � 1 � d CONSTRUCTIONLENDINGAGENCY PRE-ALTFEE: Q IHEREBYAFFIRMUNDEPPENALTYOFPERJURYTHATTHEREISACONSiRUCTIONLENDINGAGENCY ' /� a- FDRTHEPERFORMANCEOFTHEWORKFDRWHICHTHISPERMITISISSUED(SEC.3097,CN.C.�. Z W � LENDEft'S NAME F LENDEH'SADDRESS w ICEFlTIFYTHATIHAVEREA�THISAPP�ICATIONANDSTATcTHATTHEABOVEINFOPMATIONISCORREC7. TOTAL FEES �, � I AGREE TO COMPLY WITH ALL CITYAND COUNTV OPDINANCES AND S7AiE LAWS RELATING TO Bl11LDING ��� � � CONSTRUCTION,AND HEREBY AUTHORIZE REPRES_NTATIVES OFTHIS COUNTV TO ENTER UPON THE Z AODVEMENTIONE�PROPERTV FOR INSPECTION PURPOS[S. COMMENTS ' � e � r,� - _. m PERMITTEENAME(PRIN / � � T E F EPMITT E � � d'9�I M'1 -----'-'�- — = RECPT.�O. `�G, �� PAID BY VALIDATION ~ WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—ApplicanYs Copy . _.; .. ,... .. , �. . .�-... , ,r.�'.:�. ...._. , -...- �. :., y wC" ...t,r�^r� e{ . r .. . . .: . , .. . . ':.rf� �: . , .�- .°,.. ..,,... ..<..,,_ , ... ..... . .. � . . " (3 , ? � a r- � ' � r. . ,:. �:.. . ,.`� .: . h �.. .. 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