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. � -- CITY OF DIAIvfONDBAR COMMUNITY DEVELOPMENT DEPARTMENT -;..0 2166D E.Copley Drivc Suite 190 c9o9�a6asi9s Fax�909>a6i-3ri� PRESS �'""'� BUILDING PERMITAPPLICATION FIRMLY � � J08Sl7E o ADDRESS ZCd�Z�°�� ���"�'�""� � ��• DATECATION Q / ��� NUMBER' '�SF��q�C c� 6 � APN LOT TRACT �SSUE ��� ,,�� TypE OCC S OWNER � DATE Ci �� CONST. GRQUP � ADD SS� p ZONING SETBACKS a ; z CITY �IP_�l�S TEL.�.GoYJ-C�S Z FRONT RW ❑ o APPLICANT TEL. REAR � � — SIDE/SIDE STREET ❑ � � CONTRACTOR SIDE � ADDRESS � � CITY PROPOSED USE �'��P�'�� ��'��'`�� �� �'��'P�-�7 ZIP`� TEL. w ARCWENG/ =��� `��"-' �� " � ��. z: DESIGNER ..s�«-.� �r.ti- trsw- J �`J��.✓�.a�°t � �� aW. ADDRESS NO.DWEL. NO. NO. `� C�ry Z�P TEL UNITS STORIES BEDROOMS �� . �� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION O� OWNER•BCfLDERDECLARATION SFR/A�D/REM - _ Q: �HER'cBY pFFiRM UNDER PENALN OF PER.A/RY THAi I AA1 EXEN.PT FHOA1 THE CQVTRAC70flS L6 .. �-�W CENSEIAWFOqTHEFOLLOWINGqEASW.�(SEC.7031.SBUSINESSAN�PftOFES51qN5CWE:ANYCI7VOR � Garage/Carport _ �- CWNTVWHICHpE0U1FESAPERMITTOCONSTNUGT.AL7Efl.IMPqOVE,DEMOLISH,ORREP0.IRANYSTRUC- TUflE,PRWft TO iTS ISSUANCE,ALSO qEQU1RE5 THE APPLICANT FOfl SUCH PENMR TO FILE A 91GNED w Pd110/DBCI( � STATEMENT TNA7 NE OR SME IS LICENSEO PURSUANi TO THE PROYISIONS OF THE CONTMCTORS l�� CENSE lAW(CHAPTER 9(COMMENCING WITN SECTION 760n)OF D��I510N3 0F THE BUSMESS/�ryD Pqp- � PooUSpa FE5910NSC01)E)ORTHATHEORSHEiS[XEMPTTHEqEFROMANOTHEBA5ISFOPTHEALLEGEDEXEMP- -(� - '.^���.. TION.ANYVIOIATIONOFSECTI0N7031.5BYANYAPPLICANi FORAPERIUITSUBJECTSTHEAPP��CANTTO z pe-Roof - - . � AC!VILPENALTVOFNOTMONETNANFIVFNUN�RED�OlIARS(SSoo)J� ❑I,ASOWNEROFTHEPqOPERTV,OqMVEMPLOVEE5WI7HWAGE5A5THEIRSOLECOMFENSATION. . COfl1M9761�I �- W�LL 00 THE WORK,AN�THE STqUCTUq�IS NOT IHIEN�ED OR OFFEflED FOR SAI.E(SEC.]04d.BU51� -� - �_ NESS ANO➢RpFESS�ONs GODE�TNE CAN7RAC70R5 UCENSE�AW OGES NOTAPP�Y TO AN OWNER OF � � _ GROPERTY WHO BUILAS OP IMPROVES THEflEON,AND YPAO DOES SUCH YiORK HIMSELf Ofl HERSELF OR . ' �. TMHWGHHISORHEqOWNEMPIOYEES.PROVIDEDTHATSUCNIMPRWEMENTSARENOTiNTENDEDOR m- j OFFEflE�FOR 5A1'c.iF,HO WEVER THE9LILGING ORIMPROVEMENTIS SOID W1iHiN ONE YEpqOFCOMP�E- t,, TIDN,TNE OWNER-6UILDEft WILL HAVE THE 6URDEN OF PROVING THAT HE OF SHE 01�NOT BUIID OR � � �MP�FORTHEPUqPOSEOFSALE).. � I,ASOWNEROFTHEPNOPERTY,q�IE%CLUSIVELVCONTRACTINGWITHLICEN5EDCOMRACTORS , �s '_- TO STHU4T THE PROJECT(SEC.7oa4,BUSINESS AND PROFESSIONS CO�E:iHE CqMRAC70fl5 LI - V8II181tOf1 • ���N � ADJ.AREA__ , g,W-- CENSELqWDOE6NOTAPPLYTOANOWNEROFqPpOVEANWHpBU1LD90RIMPROVESiHEREpNA11D � �� WMOCONTMCTSFORSUCHPR0.1ECT9WITHACONTRACTOR�S)LICENSEDPUflSUANTTOTHECp MO �� QUANTITY DESCRIPTION FEE TOPS UCEYSE LAW.). Y 1 �1 AM EXEMPT UhDER SEC. B.A qEA ���.:�i� � V �.':. :LL ATE OWNER ;�+„^'�' . .� S ' Z � U � _:� LICENSED CONTRACTORS DECLARATION� W -.�-- � IHEREBYAFFIRMUNDERPENALTVOFPERJURViHA7�AMLICENSEOUNDEFPflOVI510N5CFCNAPTEq � � ' -� B(COMMENCING WITH SECI'ION]opo)OF pNI510N 30FTHE BUSINESSAND PflOFESSbNS CADE,PND z �x MYUCENSE IS IN NLl FORCEAND EFFECT. � � ' `� LICENSE CLASS LIC.NO. � - - � - -U �ATE COMRACiOq-____ _ p, . : W ._-� WORKERS'COMPENSATION DECI.ARATION � T� : � � I HEflEBYAFiIpM UNOEfl PENAL7V OF PERAIRY ONE OF TME FOLLOWING OECLAflATiON$; U - (n Z ...-..d 4 � . . _Z �IHAVEAMOWILLMAMiAINpCEHTIGtCaTEOFCpNSENTTOSELF-iNSURcFOflWOqKERS' S . . __¢ COMPENSA710N,ASPfiOVIpED8Y5EC�lON3�0DOF7HElA8oRCO�E,FOATHEPERFOflk1ANCE U -_-.q OF THE WORK FOR WHICN TNIS VEFlAiIT IS 155UE0. � - j .y..W_ ._�I HAVE ANO WILi MAINTAIN WORKEflS'CA.V.PENSATION INSURANCE.AS PEOI11F1ED BV SECTIOM `� j � _q 370o OF THE IABOfl CODE,FOR THE PEqFOAMANCE OF 7HE V.'OFK FOR WHtCH iHIS PFRMITIS �-�---�—'-��'-- L/'� �� *; �. . � ISSUED.MY WOflKERS'COMPEN&qTION INSURANCE CARRIER AND POLICV NUMAEPAFE: TRUCTI� � � � � ? CARaIEA _ ` PIAN REVIEW : � -Z POLICVNUMBER ELECTRIC �� SC S: . -_� (IHLSSEC7KiNNE�NOTBEWMREfEDOFhEPEPAMiSFOAONEli1NAREDD011AR5(5/00)ORLFSS4 PLUMBING �- � LLl _— -- --Z 1 CERTIFYTHAT IN TNE PEflFORMANCE OF THE WOPK FOR WHICH THIS PEHMITIS ISSUED,1 MECHANICAL � � `C�S SMALLNDTEMPLOYANYPEHSONINMIYMANNERSOASTOBECOMESUBJECTTOTHE �" -:-.(n WOIiKEfl3'COMPENSATION LAWS OF CA�IFOHN10.�0 AGREE THAT IF I SHOULD BECOME INSPECTfON FEE ��. SU&IECTTO THE WORNEflG'CAMPENSATION PROVISIONS OF SECTION 3�OOOF THE IAEiOq � . .�� - CO�E,I SHALL FORTHWITH COMP�V W11H TNOSE PROViSIONS. UANC ' � -.p �ATE:____ APpLiCANT: SMIP A �CD _ :W - ' -- s.. . .� WAqNING:FAIWqETOSECUFEWORKERS'COMPENSATIONCOVERAGEISUNLAWFUL,ANDSH0.LlBE ENERGYP/C _` � �y 9U&IECTAN EMPLOVEfi TO CRIMINAL OENALTIES AND CIVIL FMES Uv TO oHE MUNURED THOUSpNO ENERGY PERMIT {���� � � � �� � � OOLUflS(51aa,000�.IN ADDITION TO THE COSTOF COMPENSqT1oN,DAMAGES AS PROVIDED FOq IN g. t. . - 'J 3ECTiON370BOFTHELABOflCODE,MiEqEST.�NDRT�ORNEY'SFEES. - t9�E����c�r—±�'- � (-: _ -w � RETENTION FEE: - :p CONSTRUCTION LENDING AGENCY PRE-ALT PEE: - - � .-� IMEFEBYFFf�RMUNDERPENALTYOFPERJURYTHATTNEFEISACONSTHUCTIONLENOINGAGENCY � FOqTHEPERFORMPNCEOFTHEWORKWRWMICHtNiSPERMITISIssuED�SEC.ao9�,qY.C.1. Z . - ENDERSNAME . LENDER'SMDRESS � „W I CERTIFYTHAT i HAVE HEAA�THIS APPIICATION AND STR7E THAT THE ABOVE INFOqMATION�5 CORRECT. �OTAL FEES ��.�� � IAGREETOGOMPLYWITiIALLCITYANDCOUNTVORDINANCESANDSTATEIAWSPELATINGTOBUILDING - � CANSTNVCTION,ANDMEflEBYAU7MORIZEREPRESENTA71VE50FTHISCOUNTYTOENiFRUPONTNE . 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