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CITY OF DIAMOND BAB �� --�1� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES - ' 21660 E.Copley Drive Suite 190 (909)860-3195 Fax(909)861-3117 PRESS `'���� BUII,DING PERMIT APPLICATION FIRMLY � JOBSITE ��� /a.��:'� �(IRGp`� JU� APPLICATION PERMIT � P/C o ADDRESS ��`` �"`" DATE NUMBER � � # � ISSUE y �}�/; TYPE OCC -- APN LOT TRAC DATE �""�4��-'-�1`''1. C�NST. GROUP p OWNER v ADDRESS�.�� �} � ZONING SETBACKS Z CITY� • �i ZIP TEL �'�.� '�� FRONT RW ❑ � APPLICANT ' ( T�L. REAR ❑ SIDEJSIDE STREET RW L CONTRACTOR I�� SIDE ❑ p� ADDRES - � CIN ZIP �S TEL. P PROPOSED USE � o ARCHlENG/ �z DESIGNER NO.DWEL. NO. NO. a ADDRESS UNITS STORIES BEDRODMS � CIN ZIP TEL. y DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � � OWNER-BUILDER DECLARATION SFR/ADD/REM p t HEHEBY AFFlRM UNDER PENALTV OF PEPJUAY THAT I AM EXEMPT FROM THE CONTRACTORS LI- G2f298/Cfll'poR � W CENSELAWFONTHEFIX.LOWINGREASON(SEQ3031.SBUSINESSANDPROFESSIONSCODE:ANYCITYOR (n _ V COUNfYYYHHxiREWIHESAPERNITTtlCONSTRUCT.ALTER,�MPROVE.DEMOLISH,OflREPAIRANYSTRUC- W P3ti0/DeCk WTURE,PRIOR TO ITS ISSUANCE,hLSO RC4UIRE5 THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED W � STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO lHE PROVISIDNS OF THE CONTRACTORS LI-� � CENSELAW(CHAPTERB(COMMENCW�WITHSECTION700o�OFDNISION30F7HEBUSINE55ANDPRO- u' POOUSPfl FES910N5 CODE�ORTHAT HE OR SHE IS EXEMPT7HEREFflOM AND THE BASIS FOR THEALLEGm E%EMV- TKKJ.ANYVIOLATIONOFSECTION7031.SBYANYAPPLICANTFORAPERMITSU&IECTSiHEAPPLICANT70 Z Re•Root � A CIVIL PENALTV OF NOT MORE lHAN FIVE HUNDRED DOI.LARS(5500J.): � ❑I,ASOWNEROPTHEPROPERTY,ORMYEMPLOYEESWITHWAGESMS7HEIFlSCLECOMPENSA7pN, � CoRlmefCiHl � VALL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OH OFFERED FOR SALE(SEC.7044,BUSI- J NESS AND PNOFESSIONS CODE:THE CONiRACTORS LICENSE LAW DOES NOT APPIY TO AN OWNER OF � PROV9iTYWHOBUILDSORIMPPWESTHEREON.AN�WHODOESSIICHWORKHIMSELFORHERSELFOR = � THROUGHHISORHERONTIEMPLOYEES,PfiOVIDEDTHATSUCHIMPROVEMENTSAHENOTINTEN�EOOR m Q �OFFEREDWRSKEIFHOWEVERI'MEBUIL�BdGORIMPROVEMENTISSOLDWITHINONEYEAROFCOMPIE Z 'TION,THE OWNER�BUILDER WILL HAVE 7HE BUROEN OF PflOVING hIAT HE OR SHE DID NOT BNID OR = IMPROVE FOR TFIE PURPOSE QF SALE} w ❑I,ASOWNEROFIHEFFiOPEHI'Y,AMEXCLUSIVELYCANTRACTINGWIIHLICENSEDCONTRACTOR3 p[ TO CONSTRUCT THE PRQIECT(SEC.70M,BUSINE55 ANO PROFESSIONS COOE:THE CONiRACTORS LY- 2I118LI0 ADJ.AREA LLI CQtlSEUWDOESNOTAPPLYTOANOWNEROFAPROPERTYWH08U1LDSORIMPNOVE57HEREON,AND � WFiOCONTMCTSFORSUCHPROJECTSWfTHACANT9ACTOR(5)LICENSEDPURSUANTTOTHECONTRAG ('�UANTI7Y DESCRIPTION FEE . Y masuc�sEuw.). ¢ ❑IAM EXEMPTUNDER SEC. B.&P.0.FORTHIS NEASON U S � u' DATE OWNER V W � IICENSED CONTRACTORS DECLARATIOSJ �j � 1 HEREBYAFFINM UNDER PENALYY OF PE0.1llRV THAT I AM LICENSEO UN�ER PROVISIONS OF CHAPTER � � 9(COMMENCIN6 WRH SECTION 7a0U}OF DIVISION 30F THE BUSINESS AND PPOFESSIONS CADE.AN� z X MY IICENSE IS IN FULL FO CEAND EFfEC7. (`/ 0 LICENSE CL4S5 � 11C.NO. � v�� r � V DATE'�A'� CONTRACTOR �- W "� � WORKERS'COMPENSATION DECLARATION Q y IHEREBYAFFIRMUNDERPENALTYOFPEAJURYONEOF7HEFOLLOWING�ECLARATIONS: v ' y i 4 L] _INAYE/WDW1t.lMAINTAINACEiffIFICATEOFCONSENTTOSELF-INSUREFORWORKEflS' 2 � COMPENSATION,ASPROVIDED9YS6CTON370oOFTNELABORCODE,FORTHEPERF6RMANCE � OF THE W9flK FOR INHICH THIS PERMIT IS ISSUEO. � 0 W IHAVEANDWILLMAIMAINWORKERS'CD6A7ENSATIONIN5URANCE,ASREOUIREDBYSECTION Q 370o OF761E LABOp CODE,FtlRiHE PERi'ORMANGE OPTNE WORK FOR WHICH TMIS PERMIT IS �C`Ya � (I1t ISSUED.MY�j EAS'COMP NS T!IO�WSURPNCE CA IEFAND ROLI V NUMBER,,,ARE: CONSTRUCTION L, 1� Q �► I� (�C, S CQ PUlNREVIEW '`.��� � CARRIER � ^"',`:..' `�� _ 0 ralcv NUMBER ELECTRIC "' " Q ,. ,o� k.:. � � (fNISSECIIONNE�NDTBECOMPLEfIDOF'77�EPBiFAffISWF10t�EHUPARED00LLNi5(5�ao)oa�Ess). PLUMBING `VP°."-` �� w ����,s� z' ICEPTIFVTHATINTHEPERFOHMANCEOFTHEWORKFORWHICHTHISPERMITISISSUED,I MECHANICAL __ n '`r S�t:,'���;_ � WO KER TCOMP ENSATIONELAWS OF CAtJ ORN A AND AGREE H TEF SBHOULD BECAME INSPECTION FEE _��� < � �� �'� � SU&IECTTO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 370o O�BOR � � '�s t � CODE,1 SHALLF THCO THOSE OV�NS.� �SSUANCE �����"1`` ��s O p � nM-y �_,o. �� p DATE�LJL�I APPUCA � �� SMIP -�:� �"�*�� . W `. S 'n" J WARNINGFALUflETOSECUREWORKERS'GOMPENSATIONCOVERAGE9 NLAYYFUL,AIJ03HAlLBE ENERGYP/C s.,��'�'ti,r�'�� �y SU6JECTANEMPLOYEflTOCRIMINALPENALTIESANOCNILFINE5l1PTOONEHUNDREOTHOUSRND ENERGYPERMIT �R�" DOLLARS(5100.000).IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PHOVIOE�FOR IN - � SEC710N37osOFTHELAeOHWDE,iNTEREST.ANDATfORNE`/'SFEES. RETENTIONFEE: d CONSTFiUCTION LENDING AGENCY PRE-ALT FEE: � IHEREBVAFFIFMUNDERPENALNOFPERJUAYTHATTHEREISACONSTRUC710NLENDINGAGENCY Z FOR TF�PERFORMANCEOFTHE WORK FOR WHICH 7HiS PERMIT IS ISSUEO(SEC.3097,CIV.C.). W � LENUER'S NAME � F— LENDER'SAD�RESS WICEFfiTIFYTHATIHAVEREADTHISAPPIJCATIONANDSTATETHATI}1EPHOVEINFORMATqNISCORRECT. TOTAL FEES d 1 AGREE TO COMPLY W1TH ALL CITV AND CAUNiY ORDINANCES ANO STATE LAWS RELATiNG 70 BUILDING CONSTRUCTIDN.AN�HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ZABOVE�MEN710NED PROPEFTY FOR INSPECTION PURPQSES. COMMENTS � j�'�'�'�� = ld.r.� � a -0 M�TTE NAM fllNn .„�'� . ��1 c� �J � SI NA FPEH EE �A� = RECPT.NO. PAID BY VALIDATION ~ WHITE-6epartment Copy,YELLOW—Finarxe Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—Applicant's Copy , ., . , ..,, ._ __ . .,, , ,. , ,_, :ut ,,7-;...:.-r ...�;;ro�. �..;'�'Y w �.-�.,v d 7'.., ,a�. . . 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