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1 � CITY OF DIAMOND BAB >�'��' -��`� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES >�� _ � . 21660 E.Copley Drive Suite 190 (909)860-3195 Fax(909)861-3117 PRE`SS ����'� � BUILDING PERMIT APPLICATION FIRMLY � J0681TE � "��� � --� APPLICRTIONe' �3 ``�` ' ` � o ADDRESS �`���� �'�s'�Y=�g t=�- � �. �� PERMIT � C A( P/C DATE � NUMBER ��f9 # � ISSUE 'TYPE --�� OCC .- APN LOT�— TRACT - DATE______. CONST GROUP p OWNER �.--�-�t"'3 5"1; ::��*'��'4_�.��"�"'`�_�,� LL ����y;��. '� ZONING SETBACKS ADDRESS�a'`"�: .� ,'�: _:�a-� W CITY ----�-��� � +�f,��IP'�i� ft.�:�.TEL. FRONT RW n � APPLICANT „ � .,,�: �.3'�st TEL. "'$� i�'�t-y�t+,t� S DAE/SICE STREET RW O � � z;` � x:_-. „ SIDE ❑ CONTRACTOR . n�""�_� �-.�d` .,--,E1 '�:��..C-. Q ADDRESS ' �i \ � r-- �.:.,-. y'.�- --:-�.� �-=-s� � CITY__ ' �,= s r` PROPOSED USE �C�.� . � ZIP d �a._. TEL. � w ARCH/ENG/ ^��'.`��. z DESIGNER �?:'��va ��_^--��=�'�`� —� NO.DWEL. NO. NO. � ADDRESS�=-�E � /P C-�3 ±,�� ��:-� � _�-� UNITS STORIES BEDROOMS � � CI7Y i-f"�:�tif�4� ' �; �IP �S�l:��-, r.'�; � _�g�;�.w- y N DESCRIPTION SQ.FT. FACTOR PSF ADJ,ARENVALUATION � p� OWNER-BUILDER DECLARATION 0 SFRIADD/REM i HEPEBV AFFlRAI UNDER PENPI7Y OF PERNRY TNAT�AM EXEMPT FROM THE COUTRACTORS LI- Ga(a9EJCa�On W CENSEUWFOflThiEFOIIOWINGREASON�5EG.703t.38U5iNES5RNDPROFESSIOkSCODE:ANYCITYOR (n � - �- .U-. COIINfYWHiCHREIXIIRESAPERMITTOCONSTRUCT.ALTER.IMPflOVE.DEMOLISH.CRREPAIPANYSTRUG - W PatiolDeck ` � ���a� S � ���7 i L: �- TURE,PRIOR TO ITS ISSUANCE,ALSO RE4UIFES THE APPLICANT FOP SUCH PEPIAIT TO FILE A SIGNED W � �- \. _ 5�:� _� STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO iHE PftOYI51IXJ5 OF THE CANTflACTOPS LI- � -_� CENSE LAW(p1APTEfl 9(CDMMENCING WITH SECTION 7000)OF OIVIS!ON 30F THE BUSINESS AND Pft0- POOUSpd FESSqNS CODE)OR THAT HE OR SHE IS E%EMPT7HEREFqOAi ANO THE BASIS FOP THE AILEGEO EXEMP- TION.NiVVIOLATI0NOF5ECTIO�i7031.5BYANYAPPUCANTFOflAPEHMIT5U3JECTSTHEA°PLICANTTO z. RB-RWI -� ACIVILPEN/LLTYOFf�JTMORETHANFIYEHUNOREODOLLARS(5500).): ❑I,ASOWNEROFTHEPROPERTV,ORiAVEMPLOYEESWITHW0.GE5A5THEIR50LECOAIVEN5AT10N; 0 Comm0fCi81 - -�� NALL DO THE WDR1C,AND 7HE STfiUCTIiRE IS NOT INTENDED OR OFFERED FOfl SALE(SEC.7044,BUSI- J :�- NESSAN�PPOfE6SiONS CODE:THE CUNTRRCTORS iJCENSE UW OOES NOT APPLYTO AN OWNEfl OF _ _ . . Of�PENiY WIiO BUIIDS OR IMPRQVESTHEREON,AN�SYHO'JOES SUCH YJORK HIMSELFOR HERSEIF OR � 7HROUGHHISORHEROWNEMPIOVEES,PHOYiDEDiNATSUCHIMPROVEMENTSARENO5INTENDEDOA % m _Q. _OFFENEOPoRSALEIF,HOWEVER7NE8UILDINGORiMFqOVEMENTISSOtDWi1'HMONEYEAROFCOMPIE- - ._ ,Z_.�TION,THE CkYNER-BUItDEH YYILL HAVE 7HE 6UR�EN OP PqOYING THAT HE OR SHE 010 NO7 BNLD OR _ . . __ �MPROVEFORTHEPURPOSEOFSALE). - � : �JJ C I.AS OVfNER OFTNE PROPENTY,AM IXCLUSNEIY COMHAGTING WI1H LICERSED CO�TRACTORS �CC: TO CONSTRUCT THE PflQIECT(SEC.70�{,BUSINESS AND PROFESSiOhS CC�E 7Y.E COhTMCTOflS U- V9il12lltl'1 1/�i.� 5� A0.1.AREA W< CENSELAWDOESNOTAPPLVTOANOWNERQ'rAPROPERTY6VHO8UIlO50RIMPROVE'aTH'eFEON,AKD — :�' YdF1000MMCTSFORSUCHPROJECTSWITiiAGONTRACTOfl(S)LICENSEDPURSUPNT�orHeo�nna QUANT!TY �ESCAIPTION FEE ,Y_ 70R5 LICENSE LAW.). _ ,g` � �71 AM EXEMPT UNOER SEC. 8.&O.C.FOfl THIS flEA50N _ � -�1- 3�J5-...'$` ' ' �.� �: . � ' DATE OWNEA -_ J - Z; � ;�' IICENSED CONTRACTORS DEClARA?ION � , - - - � � - - - - � --�� I HEPEBYAfFIRM UN�ER PENAL7V OF PERJURV THAT IAM LICENSEQ UNDER FROVISIONS OF CHAPTER � V, I � ;d' Y(COMMENCINO WITH SECTq47o00)OF OIVIS!ON 3 OF THE BUS.tiESS AND PROFESSIONS CADE,aN0 . � -�X_ MY LiCEN3E�S 1N FULL FOFCE RND EFFECT. m LLJ � , �� . ��>.. -�`� �,..a?d '�""s -.o LICENSECUISS��'- ��L C.NO �,��� :�j = � � - � i .^'� p' � . . 'U: �A7E"�� "�+%"'-�- � CANTR4CT0�� : d �,_ � ��- WORKEAS'COMPENSATION DECLARPTION ._ Q : _ - _.� . . . . . .. . . . . _ . � '.�-_ INEREBYAFFIRMUNDERPENALTYOFPERJURYONEOFTHEWLIOWINGDECLARATlOt:S - � I - _ - � — �L ; � It{AYEANDWIiLMAiN7Ai4ACERT(f:CATEDFCONSENTTQSELF-INSUF.EFORWOARERS' -: y -� �'.�:_ COMPBVSATION.RSPROVIDEOBVSEC};qy?7pppF?HELPEONWOE,t-CR(HEPEHPoRMMC � ;: � ��� - OF THE ViOf1K FOR WHiCFi iHi6 PERMIT IS ISSUED . � �:� 1 � �1 HAVE AND N7LLMAIMlJN�110RKEiiS'COMFENSAT'ON INSURANCE,AS PEOIJIR£�9YSECTIOY �f'`' � f' .�- 57o00F7HE1180RCODE,r'ORTMEPERFOAMANCEOF}A�WORKFORWHICFITH:SPEPMITIS — C�� � ISSUE�.MVWOA S`�PENSk NSURANCECA[tRIE'(iANDPOLICYNl1MBEAAR"e: CONSTRUCT�ON , -� �� � /�� � ;j�- CAflRIER �� `T�� � ��- �.,4� PLRN REVIEW - - .- _ - ��.�e" POLICY NUMOEfl -�'�� � �.'.�1 '� �� � "- '�`��:� Z,_ ELEGTRIC .�_ �'��� :e: - �sEcnaaru��mo78Eco�.��rIDo'it�aExwrswa oawts�sao)oa�Essa PLUFABING �W� � MECHANICAL �,.�'" <.�£ •�Z. �CERTIFY TMA7 M THE PEflFOPMANCE OFTHE WOflK fOR Wf GHTHI�S PERMIT IS ISSUED,1 a� � �; --�'' �;(J-; SNAILNOTEMPLOYANYPEHSONINANYMANNERSOA5T06 MESUBJECTTOTHE `'�'"$^�^-� - �- - � "Vj^ WOflKERS'CS3MPENSATIONlAWSofCAL1FORN10.a4DAGREE -iFISHWL�BE�ME - INSPECTIONFEE SU&IECTTOTMEWORKERS'COMPENSATIONVftOVI510N5 E -�ION370oO�HE'IABOR .�qt�����; � � ' j 3-..' - /- ,=F _�� CADE,ISHALLFOFlTNWITHCOMPIYWITHT}10SEP O IONS�.. _,,..f'� IJ'SUAINCE -� - - ��[i o"'—� o_ '�e�f.`�i aaalCArar:` - SMIP ��Lx.�'.���-a�-_.:d�� n-.-n,-.:� � f'"�_ . ,:p; DATE� - . . �.�- ` : "� � '�...� ENERGYP/C •J-. WARNINGFAIiA1RETOSECUREWORKEftS'C�� PENSATIOYGOVEnAG UN..AWFiIi, SHALLBE -:.�_ SUBJECTANEM�LOVFATOCAIMiNALPENAL IESANDCIVILFINESUP OONEHUN�ReOT SAND ENERGYPERMIT • pOLLAR3(St00.OD0),INAODITIONTOTHEC0.STOFCOMPENSATION,DAMAGESASPROVIDEDFOaIN __-�-; SECTION37080FTHELABORCO�E,INTEREST,ANDATTORNEY'SFEES. - RETENTIONFEE: -:��� CONSTRUCTION�ENDING AGENCY PRF-ALT FEE: 0: ��"� IHEflEBVAFFIflMUNDERPENALTYOFPERJURYTHATTHEREISACONSTflUCT10NLENDINGAGENCY ��-�- FORTHE PERFORMANCE OFTHE WORK FOR WHIGHTHIS PERMITIS ISSUEO(SEC.30W,CIY.C.). 2 t'= -.w`_ _-"'3., �'a .% - _ _% IENDER'S NAME � � /' '�°�--;-� : '-�i-. _'__".'— — — __._ —_ -1_-- LENDEP'SADDRESS ���� 1 CEftTIF`/THAT I HAVE fi[A�THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. - TOTA L FE�S �<��� �$�� �..�: IAGREETOCOMPLYWITHALLCITYANDCOUNTYORDINANCESANDSYATELAW9RELATIVC+T09UIlDINO .-� ti� .� CONS?RUCTION,PN�HEPEBYAUTHORIZE REPRESENTA7IVES oF 1HI5 COUNTY TO ENTER UPONTME _ �: AeOVEMENTIONE�AROPEHTY FJR INSPECTION PURPOSES. COMMENTS � � + � � ..�. f .>` _ .�4-i - ��� m- PERMI TEE HAME(PRINT) � �� ' �-' :Q-. " s' /� 'Z'@'�-� ' - ./ � •, ./ .� �.-y"''� ,.. 1 ✓ � f...�.�-'� /' .�� ' � i s°`�.,%. �� � 3 / -�, SI�NATUflE �PFAMITT . ��— _.._� `.� 7�a�� . ,` - . --, . .; �arE �� RECPL� F`��� t_•f 1 � �- ALIDATION � .�'.r � � �~ . . - .. --"� •-- WHITE--[5apartment�Copy�i`ELLOW-Finance Copy,PWK-Assessor Copy.GOL�ENROD--Fiie Copy,GREEN-ApplicanPs Copy � � �_� _� .;, . --- �� �� � ;� �� - q�� � ,���`�-`��,�r ������� � "_ �=e=�'; �9� � ' ' � � � � �, � ,3.'� � ' i , i — } �`��k��� ��� �� � � � ' t � � . € � �� }�� .€��� �..�� � �. �y.y j 7 E _ �''1 7�,� , �'�i � �� ��� ��' _ # �' ��f � E� . �' � � � � t ` � � � �a 3�+z.'� "6 � k . � 3 � �*�' ' r' - 1 � � ! -.a' _ ,��°�..3 ��h ,� - I � ,. E, � -� I , � 1 . � � � �n � vs� , 1 .,,.�.. ; � �� � � .i � � ' { i �- . 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