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Home My WebLink About10513 (5) -- - CITY OF DIAMOIVD BAR � COMMUNITY DEVELOPMEN'I'DEPARTMENT .,,.� 21660 E.Copley Drive Suite l90 (909)860-3195 Fax(909)861-3117 PRESS '""°J BUILDING PERMIT APPLiCATION FIRMLY � JOBSITE ..-,, '{ r APPLICATION - �/ ,� PERMIT Z P/C o ADDRESS � � ��✓ DATE t NUMBER �-� # c� ISSUE TYPE OCC APN LOT TRACT DATE CONST. GROUP � OWNER p ADDRESS " �� ' ZONING SETBACKS Z CITY ZIP_ TEL. FRONT RW U , g APPLI "I T TEL. REAR � I SIDE/SIDE STREET RW f_i I � CONTRACTOR SIDE ❑ a ADDRES r , � CITY ZIP TEL. OPOSED USE�F �c� J�� ' o ARCH/ENG/ , s'�`/ �� Z DESIGNER NO.DWEL. N . � 3�"r• NO. �� a ADDRESS UNITS_ STORIES � � BEDROOMS � CIN ZIP TEL. � N DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION ig p� OWNER-BI:ILDER DECLARA710N SFR/ADDlREM [ O � p t HEREBY AFFI0.M UNDER PENALTY OF PERJURY 7HA71 AM EXEMPT FROM 7HE CONTRACTORS LI� G9r8gB/CeryOrt W CENSEUWFORTHEFOLLOWMGREASON(SEC.7o]1.6BUSINESSANDPflOFESSIONSCODE:ANVCITYOR (n � V COUNNWHICHREOUIRESAPERMITTOCONS7qUCT,AL7ER,IMPROVE,DEMOLISH,ORREPAIRANY57RUG W Pati0/D6Ck � Z TURE.PHIOR TO ITS ISSUANCE,ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED W STATEAIENT THAY HE OR SHE IS LICENSED PUPSIIANT TO THF.VROVISIDNS OF THE CONTMCTORS L�� W � � CENSE LAW(CHAPTEH 9(COMMENCING WITH SECTION 7000)OF DIVISION 9 0F 7HE BUSINESSAND PRO� V" POOVSPB ? fES510N5CODE)OR7HATHEORSHEISEXEMPT7HEREFROMANDTMEBASISFORTMEALLEGEDEXEMP� (� � � TION.ANVVIOLATIONOFSECTION703i.56YANYAPPUCANTGORAPERMITSU&IGCTSTHEAPPLICANTTO Z Re-Roof A CIYIL PENALN OF NOT MORE THAN FIVE HUNDFlFA DOLLARS(7500).): � ❑I.ASOWNEROFTHEPflOPEHTY,OHMYEMPIOYEE5WITHWAG[SASTHEIRSOLECAM�ENSA710N, � Commercial Z WILL DO THE WORK,PND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC.70dd,BU51� � � NE55 AN�PROFES510N5 CO�E:7HE CANTRACTORS LICENSE LAW OOES HOT APPLY TO AN OWNER OF � i 7ROPERTY WHO BUILDS OR IMPROVE5 TMEREON.ANO WMO DOES SUCH WORK HIMSELF OR NERSELF OR � THRWGHHISORHEROWNEMDLDYEES,PHOVIDfDTHATSl1CHIMPROVEMENTSARENOTINTENDE00R CL� � � OFFEREDFORSALE.IF,HOWEVERTNEBUILDINGOHIMPROVEMENTISSOLDWITHINONEYEAROFCOMPIE- � Z TION,7HE OWNER�BUILDER WIIL HAYE THE BURDEN OF PROVINO TMAT HE OR SNE DID NOT BUILD OR � IMPNOVE FOpTHE GURVOSE OF SALE). ❑I.A&OWNER OF THE PROPERTV,AM EXCLUSIVELV CONTRACTING WITH UCENSE�CONTMCTORS /�� e f Q TO CONSTRUCT THE PROJECT�SEL.7044,BUSINE55 AND PROFESSIONS CODE:7HE CONTRqCTORS LI� V21U8t100 _ �y a.a-.�' ADJ.AREA f LU CENSELAWDOESNOTAPPLYTOANOWNEROFAPROPERNWHOBUILDSORIMPROVESTHEHEON,AND � YJHOCONTRACTSFOFSUCHPROJECTSWITHACANTRACTOR(S)UCENSEDPURSUANTTO7HECANTRAC- QUANTITY DESCRIPT�ON FEE 6 Y TORSUCENSELAW.) FF � ^1 AM E%EMPT UNDER SEC. �.8 P.C.fOR THIS HEASON Q � � _ U Ll.. � �ATE OWNER___,_____ � � Z W fr � LICENSED CONTRACTORS DECLARATION W f� � I HEREBY AFFIPM UNOER PENALTY OF PERJUflY TMAT IAM LICENSFA UNDEH PROVISIONS OP CNRPTEfl � 9�COMMENCING WIiH SECTION 7000)OF�IVISbN 3 0F THE BUSMESS AN�PROFESSIONS CODE,AND Z � X MV LICENSE IS M FULL FOHCEAND EFFECT ? W �-�,rG� � q � UCENSE CLA55�� LIC.NO. � J � V DATE__��CONTRACTOR _ _ a � W � � WORKERS'COMPENSATION DECLARATION Q j = U � � 1 MEREBY AFFIRM UN�EN DENALN OF PERJURV ONE OF THE FOLW WINa DECIARATIONS: (_� Z � Z __IHAVEANDWILLMAINTAINACERTIFICATEOFCONSENTTOSELFJNSUPEFORWORKEflS' _ COMPENSATION,ASPROVIOEDBYSECTION37000FTHELABORCODE,FORTHEPEflFORMANCE U { ¢ OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. � # � F w I HAVEANO WILL MAINTA�N WOqKERS'CAMPEN5ATION INSURANCE,AS REQUIRED BY SECTION �•']�� r�]J f Q 37000FTHELABOHCODE,fOflTHEPERFORMANCEOFTHEWOflKFOflWHICHTHI3PERM1T13 �l� � (� � d ISSUED.MY WORKERS'CAMPENS TIO NSl1RANCE CARfiIEH AND P ICY NUMBER ARE: CONSTflUCTION f E j cnr�aieA----.-.— PLANREVIEW ------------------ � Z POLICYNUMBER_ _ � w/ �P��_ ELECTRIC ¢ Rwss[cnaiNE�t�oieEoornRerEocFn��awr�sroRa+E�ax�000upas�sioo�oatFs51 PLUMBING = � -- - . w 4:.7,� �..�, Z 1 CERTIFY THAT IN TME PEflFORMANCE OF THE WORK FOH WHIGM 7NI5 PERMIT IS ISSU ,I MECHANICAL __ .{' •.s � SHpILNOT FMPLOV ANY PERSON IN ANY MANNER SOAS TO BECAME SUBJECT TO •. ,�. � WOPoCERS'COMPEN9ATIONLAWSOFCAUFORNIA,ANDAGREF.THATIFISHO � E INSPECTIONFEE ,______ = SU&IECTTOTY.EWORKERS'COMPENSATIONPftOISIONS SECTI N3 F. E fl j CODE,ISHALLFOR'HWITHCOMPLYWITHTHOS i s- �� ISSUANCE —�'�— � �a�� - SMIP ---�: � �� — '--/ ' p �ATE: APPLICANT: _ W ENERGY P/C J WARNIN6:FAILURETOSECUREWOFKERS'COMPE IONCOVERAGEI WFU4' DSHALL9E `- --- LL SU&IECTANEIAPLOVERTOCRIMINALPENALTIES CIVILFINESUVTOONEHUN OTHOUSPND ENERGYPERMIT �OLLAR5(5700.000),INADUITIONTOTMEC03TOFCOMPENSATION,�AMAQESA VIDEDFORIN — — � SECTION37U90F THE LABOR CODE,INTEflEST.ANDATTORNEV'S FEES. RETENTION FEE: __ _ � CONSTRUCTION IENDING AGENCY pRE-ALT FEE: ___ O � I MEREBY A�FIflM UNDER PENALTY OF PERJURV THAT THERE ISACANSTflUCT10N LENDINC AGENCV � GOR THE PEHWHMANCE OF THE WORK FOR WHICH T1i1S PEfiMIT IS ISSUED(5EG 3097,CIV.CJ. -��— - Z W — — � LENDER'SNPME """__"'_"_ _'_'_ __ F- LENDER'SA�ORESS_"" __"'_'—"_'—"' W� TOTAL FEES � � I CERTIFY THAT I HAYE READ THIS APPLICATION ANO STATE THAT TNE ABOV INFORMATION IS CORHECT. � IAGREETOCOAAPLYWITHALLCITYANOCAUNTYOFOINAN ESAN�STAT WSRELA7INGTOBUILDING I CANSTf1UCTION,ANDHEREBVAUTHORIZEREPRESENTATI S 7NI5 UNTVTOENTERUPONTHE �/ (1�,, �[//7 � ABOVE•MENTIONED PflOPEflTY fOR INSPE ION PURPO f� COMMENTS_ �/��`� `�- � �C.%F. _._ 0 J _ _ _ ¢ PEHMI (P T) �.-+� 1 I N � v N SIG R OFP MI DATE � � = RECPT.N0. �D BY VALIDATION ~ W —Department Gopy,YELLOW—Finance Copy,PINK—Assessw Copy,GOLDENROD—File Copy,(3flEEN—Applicant's Copy � �� _.- _..___ ._:__ ____. _ __ - _ _.__..__. 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