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_. .�.., ,. P.. _�..r..-.=�_��--�-�,.�.��-��__�����;;� " _�� CITY OF DIAIviONT1 BAR . � : DEPARTMENT OF C�MMUNITY&DEVELOPMENT SERVICES :� 21660 E.Copley Drive Suice 190 . (909)860-3]95 Fas(909)861-3117 PRES$ „��+�,.., ` BUII.DING YERMIT APPLZCATION� - f ;;` :zFIRMLY } JOBSRE � ,.: 3 APPUCATION,-< *-�� �� PERMIT � � � •� P/C o ADDRESS` b_ - � DATE �t' _ �� � �•� NUMBER z=x��'.�! # �` APN LOT TRACT DA EE ��� ��� �� ONST. GROUP � OWNER ;'� .� "�` ADDRESS ZONING SETBACKS ` , , ,;_+ ;. � CITY ZIP TEL. R ART RW_ O : � APPUCANT TEL;` SI�EJSIDE STREET RW ❑ : � CONTRACTOR r; -,, s= " ; SIDE 0 - "'t , t oj CDDRES3 , § : �ZIP= . �' TEL - PROPOSED USE �� t�� � .T�'�.r � � ARCH/ENG/ + �, � DESIGNER £ NO.bWEL. N0. NO. £ ADDRESS UNITS STORIES BEDfi00MS � ; � CITY ZIP TEL. � a � � � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION £ -OWNER-BUILDER�ECLARATION - -- - � - - '� �..��. .. .. . SFR/AOD/REM . . . . . . . :_ '"': .� I NEREBY AFRRM UNDEH PENPLiY OF_PE0.A7HY 7HAT7 AM E)fEMVT PROM THE CONTMCTORS LI-: � --G8f3ge/C2fpOR� - �- �� � � - � - - S =_-+ �� -CENSEIAW.FONTNEFtXLOR'MIGREASON(SEC:'703t:58USitJESSANDPROFE3310NSOOpE:ANYCITYOR ' � COUtiFYNhi1C}{REWIRESAPEBMRtOCONSTpUCT,AITER,RAPROVE.�EMOlI5H,0AflEPAIRANYSTRUG :W patidDeck. y TURE,PRIOR'N ITS ISSVANCE,ALSO REQUIRES THE APPLICANT FOR SUCH PEPMIT TO FILE A SIGNED ?� � -�. �. STATEMENT THAT HE OR 3HE�IS UCENSED PURSl/ANT TO THE PROVISIQYS OF THE CONTRACTORS ll- . . . ,- ��. i _� CENSE4AW{CHAPJERG�COFIMENCIN4WITHSECTION700D)OFDMSION3OFTHEBUSINESSANDPPO• � ,'�` POOUSP3 - � -� ' ' .FESBIONSWOE ORTIIATHEORSXEISIXEMPT7HEAEfRDMANOTHE9A31SFORTHEALLEGEDEXEMP - - ` � ,�� .., , x -. �� l. TpN.AqYVIOtATIQYOFSECTION7031.50VANYAPVUCANFFOftAPERMiTSU&IECTBTHEAPPLICAhT70 � �� ��' ;`�' � - � fls-Foot.- �. ... '� � ` F , ACMLPBJAIT'OF:NOLMONETHANFIVEHUN�PEDDOLLAflS(5500).): - �- ' � . ;- � . _ .� ❑4�`OWNEHOFTNEPROPERiY,ORMYEMPLOYEESWITNWA6ESASiHE1R50LECOMPENSATION, F Q COf11fOBfCial - -' • WILLDO 7HE WORK,MD THE STRUCTi1pE IS�pJOT INTENOED Oq OFFEflED FOF SALE(SEC.7o64.BU56 � J _j � "-�`3-�� NE3S AND OfqF�510NS CODE:THE CONTMCTOH9 LICENSE lAW DOES NOT APPLY TO IW OWNEfl OF �. � . . ' _j q WiOPERiYWl108UILDSORIMPROVES7HEREIXJ,ANDWHOOOESSUCHWOHKHUISELFORHERSEIFOq 4s, � .THROUGHF930RHEflOWNqIPLOVEES,OROVIDED7HATSUCHIMVROVEMENi3ARENOTiN7EN�EDOR � m - - � OFFEHED WRSALE:iG,NOWEVER7FIE BUIIDIN(iORIMPROVEMENT1556LD WITHINONEYEAROFCOMPLE- �� `TION,THE OWNER-8i1�iDER WIl1:HAVE iHE BUflDEN OF PROVIKG TMAT HE OR SME O!D NOT HURD OfF� � � �� - . � . IMPHOYEFOHTHEPURPOSEOFSALEL. � . � - �' : :. ; . . . .. . :� - OI,ASONMEROFTHEPROPERTyAMIXCLUSIVELYCONYRNCTIN6WffHLiCEt�EACOf�RMCTOHS ���TO CbNSTRUCT hIE PRO.tECT(SEC.7CM,BUSINE55 MIO PROFESSIUIS COOE.THE CONTPACTOAS tl; V6lueti0lf ADJ.AREA� � :-CENSEIAWDOESNOTAPPLYTOANOWNEflOFAPROPEHTVWHOBUILOSORIMPPOVES�iHEflEON,AtJD. ' - - ;:i -WHOCONiHACTSfOflSUtliPRQIECTSWITHACONTRACiOR(5}UCENSED_V,l7HSUANTTOTMECONTMG � QUANTITY OESCRIPTION� � - � - FEE � - � �.TORS LICENSE UW.�. . . � � � ..-- I :�� ❑IAM EXEMPT IN�EP SEC.. . &6 P.C.FORTHIB REASON Q - - - � .. ,.- . � - U .. � �. �.. :. fL. . . £..: �.,k ��,�'�DATE OriNER � . U: . . . . . . _ :.�?? � :W i �` �,,� -� y, LICENSED_CONTRACTORS OECLAFATION - -� - - � r` � W � iF{eflEBYflFFIRMUNDEflPENALTYOFPERJUflYTHAT1AMLiCENSEDUNDERPROV1510N50FCHAPTER � � �_ ,`. _ � B(COMMENCiN(iWiiHSECTIONZ000)OFDIVISION30FTHEBUSINESSANDPPOFESSIONSCODEAND � Z - j_: .MY LI�NSE IS M FULL FORCE AND EFFECi. . m �; . � e�A� �` � _ . � I.fCENSE CLA53�' LIC NO. -� � � ..� � . _ � . ��i - �' �'� DATE COMRACTOR T ~ �-... ..a _ � �5 .� _�., .. �� � WORKERS'COMPENSATION DECL4RATION � Q : , � , U � IHERFSYAFfIRMUNDEAPENALh'OFOEIUURYONEOFTHEFOLLOWINGDECUMTIDNS � Z � ; .St .� . . . . . . �. . - . �� IH�VEANDWILLMAINtAiNACERiIFICA7EOFCONSENTTOSELf-INSUREFORWOflKEflS' ���� 2� � ��•s COAiPEN8AT10N,ASP1iOVIDEOBYSECiION37aDOfTHEiA90RCaDE.�WRTHEPERWRMANCE - .W � '�� ' OFTHEWOAKFORWHICHTHISPF.HMRISISSUED. - � i-- u � ���� - . . . � � . � :5� � , � � _IMAVEANDWILLMAMTAINWORKERS'CbMPENSATiONINSURANCE,ASFEQUIREDeVSECTIIXd � � - - � - i- � Q. 97000FTHELABORCODE,FORTMEPERF4IiMM10EOFTHEWOPKFORWNICHTNISPEHMfriS � -+°`'' �t���� � � �'� t.t-_ � �S. ISSUED.MY WOHKEflS OOMPENSATKKi INSURANCE CARNIER AND POLICY NUMB£RARE: ��CONSTRUC�L� � . �`�� �='� ;� af. '.Ji: - 'E - �t@wwY•-s'Y'"" . . � 7-. � � � ��j:� c�aatea " t �`;. ,. -. -- - PIAN REVIEW � - �_ . p PaiCY NUMBER '.. �� ' �' ' _ ''! EIEGTRiC ' � ��, Z . "xs a` (nuss[crpnr�Noreeoa+a�r�oFtrE�warsw�ar�Fnx�nr�oa.ttas(s+co�orttFss� PLUMBWG �� �: _ w:'. . : Z:; I GERTIFY THAT IN THE PEflFOfiMANCE OFTHE WORK FOfl WHICH TNIS PENMIT I5155UED 1 ��:� - -MECHANICAL .� � � �J ' SHAllNOT-EMPLOYMlYPEflSONINANYMANNER50AS70flECAMESU&IEC770THE � . . . . . - - � ; YIOW(ERS'COMPENSATqN LAWS OF CPLIFOANIA,AND AGREC 7NqT tF i S'rIOULU BECAME � iNSPECTION FEE� _. '` ' ��*; SUBJECTTD 7HE WORKERS'WMPENSATION PROVIS1P,y$,OFSECTION 37a00F 7NE LABOR �:�Y - ��" - � , - - � '- .�S'' � CO�E.ISNqI.{.FOHiHWiTHCOMPIYWIiHTHQSEPHOV1514NJS.. � �� „�S�ANCE � _ �6z� f� <�-��,�� j o, : ` � ��� f :➢ATE r � '� -��� APPI:ICANT. �._�_ >�,,.a.- r..,.-. � , ;p. . ._ . . — �:._ :. ..x= . ; W'- ENERGY P/C i �. � �WARNINO.FAILUflETOSECUREWOPKERS'COMPENSATI�NCOYERAGEISUNLAWFUL,ANDSHALLBE _ �(� T " _ . " �. � :SUBJECTANEMPLOYERTOCPoMINALPENALTIESAN�GVILFMESl1PTOONEHUNOREDT.iOVSANO '-ENERGYPERMIT -YA�■1 � � � -OOLURS(5100,0oo�.�NPD017�ONTOTHECOSTOFCOMPENSATION,DAMAGE5A5PROVIDEDFORM _ . -- - . j "�� �J:-SECTION97080F'I}7ELA80RCODE.�NTEFEST,ANDATTORNENSFEES. � --RETENTIONFEE: - *� �Y -_.�' -� d;. CONSTRUCTIONLENDINGAGENCY � 'PRE-ALTFEE: - � �� �� NOY 71 ' IHERE9YALFlRMUN�ERPENAL7YOFPERIURYTHATTHEPE'ISACONSTRUCTIONLENOINGA6ENCY � � - d� FOflTHE PERFORMANGEOFTHEYJbRK FOR WNICHTNIS PERMIT IS ISSUW fSEC.30W.CIV.C.) � � �, ��oEA�S N�,E CITY OF DIAM ; � - � !_� LENDER'SAUDHESS - �. � � �- ICERTIFVTHATIHAVEREADRiISAPPLICATIONqNDSTATETHATTHEA80VEMFONMATIONI3CORRECT �- TOTAL�FEES � ; < � �' IAGRE�TOCOMPLYWITHALICiTYANDCOUNT'ORDINANCESANOSTATELAWSfltUTINGTOBUILDING ' - - .�'t"� �. CONSTRUCTKKI.N'�0 HEREBY AU7MOHIZE REPRESENTATIVES OP THIS COUlJTY TO EN7FR UPON THE . �� k* '• �' ABOVE•MEMIONEO PROVERTY FOR MSPECTION PURPOSES, �, � � - � fc� Z _ � COMMENTS — � v = � %: o. -.` ,. �:£ I 1r } 1 �j - - - ..�. :�: . �` � ' ' f " �£ � - . �;-i : ...' m-. PERANTTEENAME(PAIIlT) � � 4 �� '. 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