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CITY OF DIAMOI�TI3 BAYZ - -��� -- DEPARTMENT OF COMMUNI7'Y&DEVELOPMENT SERVICES I I � 21825 E.Copley Drfve ^ (909)860-3195Fax(909)861-3117 PRES$ '"%yr>�\ BiTILDINGPERMITAPPLICATION FIRMLY o DDRESS� / �'��! ������! J�A�O�'°' C�Il��" �APEICATION "��""�-��NUMB R-�i� #/C oro ISSUE NPE OCC � APN LOT—�---� TRACT DATE CONST. GROUP p OWNER C L. � � I� �d ADDR S � J� -��Z /� �- ZONING SETBACKS gCITY � i ZIP �'�� T . 5-��- '�/ip�/ �� FRONT RW ❑ APPLICANT �-� }�� r TEL. REAR ❑ Z 'f''"`"`f� ' SIDE/SIdE STREET RW ❑ ¢ CONTRACTOR SIDE ❑ � ADDRESS � CITY ZIP TEL. PROPOSED USE o ARCH/ENG/ W DESIGNER NO.DWEL NO. NO. � ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER•Bl11LDER DECLARATION SFR/ADDlREM � O p 1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI- � Garage/Carport W CENSELAWFORTHEFOLLOWING�iEASON(SEC.7031.SBUSINESSAN�PROFESSIONSCODE:ANYCITYOR U COUNTYWHICHREWIRESAPERMVTTOCONSTRUC7,AlTER,Pv1PROVE,OEMOLISH,ORREPAIRANYSTRUC- W P&tio/DeCk Z TURE.PfiIOR TO ITS ISSUANCE,ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT 70 FILE A SIGNED W 'STATEMENT'THAT HE OR SHE IS LICENSE�PL1fiSl1ANT TO THE pppVI510N5 OF THE CONTRACTORS LI- W � CENSE LAW(CHAPTEft 9(COMMEt�CING',WITH SECTION�000)OF DIVISION 3 OF hiE BUSINESS AND PRO- V' POOUSP2 FESSIONSCDD�)ORTHATHEORSHEISEXEMPT'RtEREFROMAND7HEBA5ISFORTHEALLEGEDEXEMP- � '� TION.ANYVIOLATIONOFSECTION7o31.58YANYAPPLICANTFORAPEFMiTSUBJECTSTHEAPPLICANTTO Z Re-Foof A CIVIL PENALTY OF NOT MORE TF,P.N FIVE HUNORED DOLLARS(SSao).): � a ❑I,ASOWNEROFTHEPROP€RTY,ORMYEMPLOYEESYlITHiNAGESASTHEIRSOLECOMPENSATI�N, 0 CpmmerCidl -' WICL DO iHE WORK,AN�THE STRUCTUFlE IS NOT INTENDED OR OFFERE�FOR SALE(SECJ044,BUSI- J � �NE55 AND PROFESSIONS CODE:'IiiE CONTRACTORS UCENSE LAW DOES NOT APPLY TO AN OWNEii OF � PROPERTY WHO BUILOS OR IMPROVES THEREON,AND NhiO DOES SUCH WORK HIMSELF Ofl HERSELF CR � 'THROUGHHISORHEROWNEMPLOYEES,PROVIDEDTHATSUCHIMPqOVEMENTSARENOTINTENDEDOR m w OFFEREDFORSALE.�F,HOWEVER,7HEBUILDINGORIMPflOVEMENTISSOLDWITHINONEYEAROFCOMPLE � T�ON,THE OWNER-BUILDER WILL I1AVE THE BUR�EN OF PROYING THA7 HE OR SHE DID NOT BUILD OR Z . IMPROVE FORTHE PURPOSEOF SqLE).', _ ❑I,ASOWNEROFTHEPROP�RTY.AMEXCIUSIVELYCONTRAC7INGWITHLICENSEDCONTRACTORS W � TO CANSTFUCT THE PROJECT(SEC.7044,BUSINESS AND PROFESSiONS CO�E:THE CONTRACTOPS LI- Valuati011 ADJ.AREA W CENSELAWOOESNOTAPPLVTOANOWNEROFAPROPERTVWH09111LDSOPIMPPOVESTHEREON,AN❑ � WHOCONTRACTSFOPSUCHPROJECTSWITHACONTRACTOp(5)UCENSEDPURSUANTTOTHECONTRAC- QUANTITY DESCRIPTION FEE � Y iOpS LICENSE LAW.�. � ❑I PM EXEMPT UNDER S�C." B.&P.G.fORTH15 FEASON Q � U -. � � � DATE � . OWNER U Z W � LICENSED CONTRACTORS DECLARATION W � � I HEREBY AFFlfiM UNDEH PENALTY OF PERJUflV THAT I AM LICENSEC UNDEFi PROVISIONS OF CHAPTER � 4 9(CDMMENCMG WITH SECTION 7Q00)�F DIVISION 30F THE 6USINE55 AND PROFESSIONS CODE,AND z �X MY LICENSE IS IN FULL FORCE ANp EFFECT. m � LIGENSECLASS LIC.NO. � - - F J V DATE CONTRACTOR a W �� WORK�RS'COMPENSATION DECLARATION Q � IHEREBYAFFIRMUNOERPENALTI`OFPERJURYONEOFTHEFOLLOWINGDECLAFATIONS: z Z _I HAVE AND WILL MAINTAIN A CEPTIFlCATE OF CONSENTTO SELF-INSURE FOR WORKERS' _ � CAMPENSATION,ASPfiOV�IDE�BYSECTION37000FTHELA00RCODE,FORTHEPERFDRMANCE W Q OF THE WORK FOR WHICH THIS PERMIT IS ISSl1ED. - � � F I HAVE AND WILI MAIMAII�WORKEflS'COlAPENSAiION INSUriANCE,AS RE�UIRED 6V SECTION Q 370oOFTHELABORCO�E.FOR�THEPERWRMANCEOFTHEWORKFORWHICHTHISPERMITIS J ISSUED.FAVWORKEFS'COMPENSATIONINSURANCECARRIERANDPOLICYNUMBERARE CONSTRUCTION j cnaaieR PLAN REVIEW j � ZaoucvNUMeEa � ELECTRIC �10��� ¢ 0 (iHISSECTiCNNEmNOTBEO�MPLETEDOFhiEPERMffISWRONEHUNDREDCIXLARS1310�ORLESS). PLUMBING Z I CERTIFYTHAT INTHE PEIiFORMANCE OFTHE WOPo(FOP WHICHTHIS PERMIT IS ISSUEO,I MECHANICAL 3,4 ^+a ��_�'M1^t--.'�+ ^--^�-'�� '(..3 SHALLNOTEMPLOYANYPERSONINANYMANNERSOASTOBECCMESl1BJECTTOTHE ��_��"`,1'°�'"'==�,��.I � �I �� ' � WORKERS`COMPENSFTIdNLAW50FCALIFOftNIA,AN�AGFEETHATIFISHOUL06ECOME INSPECTIONFEEff --`"�'� = SUBJECTiOTHEWORKERS'COMPENSATIONPROVISIONSOFSECTIDN37000FiHELABOR CODE,I SHAL�FORTHWITH COMP_Y WITHTHOSE PROVISIONS. ISSUANCE � �R � � SMIP � �' � �'� p DATE: ApPLICANT: � , � ' ENERGY P/C � A7 ' � WAANING FAILUFE TO SECUFtE WORKEFS'COMPENSAT{ON COVERAGE IS UNLAWFUL,AND SHALL BE � SUBJECTANENPLOYERTOCRIMINALPENALTIESANDCIVILFINESUPTOONEHUNDREDTHOUSANO �'LL�+��e � DOLLARS(S1o0.0aaJ.INAODITIONTOTHECOSiOFCOMPENSATION,OAMAGESASPRWIQE�FORIN ENERGYPERMIT��M��M`„ ^ �� � SECTION37080FTHE LABORCODE,INTEREST,ANDATTORNEV'S FEES. RETENTION FEE:��"�' ��� oCONSTRUCTION LENDING AGENCY PRE-ALT FEE: � I HEREBYAFFIRM UNDER PENALTH OF PERJURV THATTHERE IS A CONSTRUCTION LENDING AGENCV FOR THE PLRFORMANCE OF TH[�A'ORK FOA WHICH THIS PERMIT IS ISSUED�SEC.309],CIV.C.). . Z W � LEN�ER'S NAME 1'- IENDER'SA�DRESS �, WICERTIFYh1ATIHAUEREAD7HISAPPLICATIONANOSTATETHATTHFABOVEINFORMAiIONISCOF{RECi. TOTALFEES ��� O d 1 AQFiEE TO COMPLY WITH ALL CITY ANO COJNTY ORDINANCES AND STATE LAWS ftELATING TO BUILOING CONSTRUGTION,AN�HEREBYAUTHORIZE REPRESENTATIVES OFTFiiS GOUNTYTO EIYiEFUPONTHE ABOVE ENTIDNE�PROPERTYr�oR INSPECTION PURPOS � � Q � /� F^�A� {��� COMMENTS J 1� � l�O Sr ��.i. y _ m PERMITT ENAIdE1PRINT) a � � ) � i � si E onrE = RECPT.NO. PAID BY VALIDATION ~ WHITE—De ahment Co YELLOW—Finance Co PINK—Assessor Co GOLDENROP—File Co GREEN—A IicanYs Co P PY� PY� PY� PY� PP PY . .. .. , ., _ - . ,.,. _. , ,_ ., ;::. - . . .. ., '',:�.;: - .' 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