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'�'� CITY OF DIAMOPiD BAR
; � • PRESS
. -.-" ' DEPARTME BUluLDINC E'RIVIIT�SAFETY FIRMLY
JOBSITE � APPLICATION , - --
� ADDRESS 'h 6� ' DATE ��;(��-' NUMBER � � OS E
ISSUE 'n(p� C.
� � APN LOT TRACT DATE _ �\� �� CONST. GROUP
� CROSS STREET ZOPiING SETBACKS ��ms
OWNER FRONT Ryy [j
LL ADDRESS REAR []
W GITY C) ZIP TEL.i ' SIDE/SIDE STREET Ryy Q
iAPPLIGANT ��� TEL. SIDE []
Q CONTRACTOR � �r �
o ADDRESS SEWAGE O PUBLIC PMT#
DISPOSAL � PRIVATE SQ.FT./100 GAL
W CITY ZIP TEL.
= STATE
y LIC.NUMBER GRADING 0 CU.YDS.EXC. CU YDS FILL
1 y ARCH/ENG/ � TY�E. SQ F�'-FACi7�.'}f� F�S A���AREAtVRLl1�AT#E�N `
= DESIGNER .t�tz 1
o ADDRESS - -�` 2
z GTY ZIP TEL. +�r g
� PROPOSED USE��1F���§� �' 4
� �; 6ARAGE
o NO.DWEL. NO. NO. �'"'°
y UNITS_�_STORIES�BEDROOMS� � P�RCH
� LOT DIMENSIONS � VALUATION ADJ.AREA
c NO.OF BLDGS HOW ti?t�A�T3T�t 1��SrGF;��T�� . -���; ';, "'_ `
W ON LOT USED �
� �.
� � �, �
r=- tr.
-� LICENSE�CONiRACTOflS DECLARATION:1 M1erehy affinn�hat I am licenud under pmvuions of ChaDler 9 Itommercing �:_ � -
-� 'nAh Sec4on!O(l0)oi�ivision 3 o(ihe Business and Praiessinns Code,and my license is in fuli torce and effeet � -
3O ;1 ( <
..- OWNER-BUILDER�ECLARATI04�1 herehy affirm thal I am ezempt hom the Comrazmr's Lirense taw fa�he idlowing �� � �' -�""
Z reasan i$Ec.7031.5,Business and Professions Code-Any ciry or caunry which requfres a permil�u wnsfiu[t -Z}: � � ��:.1.(/ -
�- alter,impmve,demolisR,m re air an stmcN�e.prior ta fts issuance.also re uiies Ihe a licam for much �;��"
D V 9 DV permit ��- �fi ��
Q: to file a signed statement[hat he is!irensed pursuant to the prwisions of the Contractor"s license Law(Chapter „�. �v .
.p�- 9(commwcing wnh Secuan 7000)of Oivisbn 3 of the Busineu aM Pmfeulons Code�w that he is exemp�Nerelmm ;�: _ -
_ X and the lasfs ter the a:leged exemption.Any vlWatfan ot Sectiun 7031.5 by any applicant tor a pe�mit su6jec[s �; ����j -� � �
W ihe zpD��cant io a cml 0?nalry of net more than five hundred dollars�550�;.�� f J�-. ��
!L.'
- �- ❑1,as o�vrcr at IM property,or my empioyees witA wages as Ihefr sale compensalion,-will do the work.antl
r: ihe Slmtlura Is not fntended or uffered far sale(Sea 7044,Business znd Profesvons Coded The Canuactm"s licenx �, ) �" ( �
V-: lew does-not app�y to an awner ol prapeny who Luiids ur impmves IAneon,aiM who-Oces SUch work himsetl (,): �� y'�� 0,.,>�
•..: or thmugh his own employees.pmvided that such improvemenu are nm intended or-oflered Mr sale.If,howevn /� ,I�
m- the h iLiing or improvement is sold within one year oS campletion,the owner6ui�der will have tlie hnrden of prming "� 4 �� �s� - � ��.�� - bj � �
. y--�hat he did nm huild or impmve for the purpose of sale.) - ,�,.
_ eii- ❑I,ax o��,•r.er ol the propeny,am e.clusively can[ractiny witM1 licensed conrcacmra W wnstruct�he projat�Stt ,}�; -
�-_ 7044,Busiress antl Professions Cade:The Contrattor's License Law does noI apply to an awner ot property who �` _
Q2: huilds w impmvas ihereon,and who contracis fo�such pm�ects wiPo a[onhactw�s�licrosed purtuant to the Cm[rac�w s
�icer.se taw.� ;CONSTRIICTlC)N
0
� ❑I am exem0t under Sec. .B-fi V.C.lattach Ceriificate! '���,�Eti/�EW
= o Oate pwner �
� E �
-�- K9RKEflS'COMPENSATION DECIARATION:I here6y aifirm thai I have a certificate a(consent ro self�insure.a . -�^
a certifkate of Nfirkers'Compensatinn in:urance,er a certitied copY therzof(Sec.3800.La6.C.L �
-.Qc u
- ❑CerUGed cupY ie hert6y funished_ -.ME��y�!/�N�CyJ�L , �'
C- �Certdisd capy�s filed with the Buiiding�nspection Oeparimem or peparimen� �;GRAD W G �����—�—
�.r.
�: CEAi1FICATE Of E%EMPTIINi PflOM WUHKERS'COIt�ENSATION INSUflANCE:This aec�wn need not he compktai ;�SSUAr N�-' ,�� � (
y- �f ihe permii is kr one hunMed{51001 a�ess.I certify tlat In the perfo�merce o(Me wak for whicN ihis
�: permit rs issued,i shall not emplay any perwn in any manrer so as ro hecome whject to ihe Nbr4ers"Compensatron ''� (y��P
= Laws at Calrforma.
� - - � PARK FEE
p:_ �ate - .".: ejpp6ant �---�.._.;
�: NOTICE TO APPIICANT_If,after making thii CertiFiCate af E�remptron,you shoulA hecame su6ject to the WdYer': �:SCHOOL FEES
—+. Compensanon p�ovfsions of the La6or Code,yau must Fathwith cortpiy wilh such prmisinns or Mis permii sM1aN
LL�- he deemee rewked.
a- -
W._ OIVISION OF IND�STflIAL SAFETY PE�91�qTIFIC�TqX1- ,,.,sy� �
0: ❑1 herehy cenrfy ihat no escavatwm five�5)or-.uwre Yeet n,pepjh.�to which a penon is�rquired�o descend
e- wifl ha made in cannection with work auMmized 6y tha permit,a�that�ro 6uildi�q suunure,scatfalding,falsework
� or demoGtian or dismanUnq thereof,will 6e mae than th'ary-six i36)feet hiph.(Chap.9.1,Gry 2.Art 2,See
_� 341.Title 8.C A C-1. -�
: r__� .... ,_ ..._. . . ..._. , ,.: :.
w
-_ .�:: -: .._ :..-. . r:,;-.
3 ❑As owner�huilder I will not�empby airyn��to dG wnrk-�whkh w6u1C repuire a pamit hom dx tiuuion M
H Induslrial Saiety,as noted a6ave,'uniess such'parson has B peimit t0 do�such`Wark I�om thc division.
� ':
I t -y�j ❑Urision of Indusv�al Salety Pcrmrt No TOTAL FEES t
� � CQYSTHIICTqN LENOItKi AGEIVC�'.I herehy aNirm that tkre is a wMtruction k�inp ager¢y fa tice performance 1 `
x ot thx xrork la which tMs permn rs fssued�Sec.3097.Gv.C.1. - -
= Leneer's Name COMMENTS �
m Lender's AAd�ess
. 4 CEPTIFICATE OF COMPtIANCE AND AU11pINIATION NiflV.I catify 1 haK read Mis appic�tion and stak
v� that ihe infamatian given is ca� to tom �M1 all stale laws md riry ordinynces reydp in yuilding .
I ��. y construction,and autAor¢e a rexnwtrve f�e� tmem of BuilAirq and Sakry(o mgr�ppi yK prpqeny
� � for which I have permit fa t � of inekmp i�upxeetimc
fx X -
a� a�np w Apcnt r � �� RECPT NO.--1`3��-�y�PAID BY VAUDATION
WHITE—De rtment Copy.YELLOW—Finance Copy,PINK—pssessor Copy,GOLDENROD—File Copy,GREEN—qpplicants Copy
' 8S1o8-11/89
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