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� . ��p�r�,�' ^ _�� CITY OF DIAI4TOND 8A1� /�,�� dl0� , DEPARTi�IENT OF COMMUNITY&DEVELOPMENT SERVICES � 21660 E.Copley Drive Suite 190 (909)860-3195 Fu(909)851-3117 �G� PRESS '�'A�' BUII,DING�'ERMIT APPLICATION __.. FIRMLY o DDR'ESS���� � l/"I//�r�� � DATEICATION /�f �� � NUMB R�� �/C l ISSUE � APN LOT TRAC DATE � � �� �J pNST. GROUP p OWNER G!� p ADDRESS ZONING SETBACKS W CITY ZIP TEL. FRONT RW ❑ � APPUCANT� T L. ... AEAR � � SIDE/SIDE STREET RW O � CONTRACTOR SIDE C; ADDRESS � � CITY ' ZIP TEL. `� PROPOSED USE � ARCH/ENG/, � DESIGNER NO.DWEL. NO. NO. � ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � rn DESCRIPTION SQ.F'f. FACTOR PSF ADJ.AREANALUATION Q OWNER-BUILDER DECIARATION _ SFR/ADOlREM O I HEREBV AFFRM UNOER PENALTV OF VERJURY TNAT I AM EXEMPT FROM THE CONTRACTORS LI- Ga�a9BICa(�OR W COJSELAWFORTNEFOLL0IMNOREASON(SEC.7031.68USINESSAN�PROFESSIONSCODE:ANVCINaR (n V COUNTYWHIp{p[-0UIRESAPERMITTOCONSTHUCT.AL7ER,IMPROVE,DEMOL!EH,ORREMIRANYSTHUC- W PatiO/DBCk W 7URE,PRIDR TO ITS ISSUANCE,ALSO REOUIRES THE APPLICANT FOR SUCH PERMI7 TO FILE A SIGNED W � 9TATEMENT THAT HE Oq SHE IS IJCENSED PURSVANT TO THE PROVISIONS OF THE CONTRACTORS ll� LL CENSE UW(CHAP7ER 9(COMMENCINO NMTM SEC710N 7000)OF DIVISION 3 OFTHE BUSINESS AND PRO- POoUSpa FESSpNSCODE)OR7H�TMEOflSHE15EXEMPT7HEREFROMMATHE0A515FORTHEALIEQEDEXEMP- (!3 TpN.ANYVIOLATI0NOF5ECTION7031.58YANYAPPLICANTFORAPERMITSU&IECTSiHEAPPLICANTTO Z Re•Raof F„_ ACMI VENAI.TV OF NOT MOfiE THAN FIVE HUNDRED DOILAHS(SSaa�J: � �I,ASOWNEROFTHEPROPERN.ORIAVEMPLOVEESWITHWAGESASTHEIRSOLECAMPENSA710N, Comm6fCial - WILL DO h1E WORK,AND 7HE STRUCNRE IS NOT INTENDED oq OFFERED FOR SALE(SEC.7044,BUSI- � � NE55 ANO PPoDFESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES NOTA7PLV TO AN OWNER OF � PROPERTY M/Ii0 BUILDS OR IMPROVES THEREON,AND WNO OOES SUCH WORKHIM&ELF OR HERSELF OR 2 T}iROU(iHHISORHERONTlEMPLOYEES,PROVIOEDTHA7SUCHIMPROVEMENTSARENOTINTENOEDOFl m QOFFERWFORSALEIF,I�IOWEVE0.7NEBUILDIN(30RIMPROVEMENTISSOfDWITHINONEVEAROFCOIAPLE- z TqN,THE OWNEfl�BU1LDER WILL HAVE THE BUR�EN OF PROVING THAT HE OH SHE�ID NOT BUIID OR � IMPf�VE FORTHE PURPOSE OF SALE). � OI,ASONMEROF7HEPROPERTY,MAE%IX.USIYELVCONTRAC7MGWI7HLICENSEDCONTRACTORS TO CONSTRUCT THE PRQIECT�SEC.�a44,BUSINESS AND PROFESSIONS CODE:THE CONTFACTORS LI- VelU2tiOn ADJ.AREA CENSE UW DOES NOt APPLV TOAN OWNER OFA PROPERTYMl110 BUILOS OR IMPROVES THEREON.AND � WFIOCONTMCTSFOflSUCHPHQIECTSWITIACONTRACTOP(S)LICENSmPURSUANTTOTHECONTRAG QUANTITY DESCRIPTION roas uc�sE uw.�. FEE O ❑I AM O(EMPT UNpER S�C. B.8 P.C.FOFi THIS REASON Q � U �'i" DATE OWNER ¢ � W � LICENSED CONTRACTpRS DECLARATION W � I HEREBV AFFIRM UNDER PENAIN OF 7ERJURY THAT I AM LICENSED UNDER PROVISIONS OP CHAPTEP Z � � 9�COMMENCINOWITHSECTION7000)OFDMSION30FTHEBUSIN_ESSAN�PROFESSIONSCOOE.9ND �� MV LICENSE IS IN FULL FOfiCEAND EFFECT. ��� m � LICENSE CIASS LIC.NO. � � V DATE ���?�"`� CONTAACTOR_ a W � WOflKERS'COMPENSATION�ECLARATION ¢ � I HEREBV AFFIRM UNDER PENALTV OF PERIURY ONE OF THE FOLLAWING�ECLARATIONS: Z G IHAVEANDWILLMAINTAINACERTIFICATEOFCONSENTTOSELF-INSUREFORWORKERS' a Q PENSATION,AS PROVIDED BV SECTION 3700 Of 7HE UBOR CODE,FOR 7HE PERFORMANCE U Q -OFhIE WOHK FOH WHICH THIS PEAMIT IS ISSUEO. � � I HAVEAND WILLMAINTAIN WORKERS'COMPENSATION INSUFANCE,AS REOUIRED BYSECTiON Q 37ooOF7HELABOflCODE,FOR7HEPERFORMANCEOFTHEWORKFORWMICHTHISPERM1715 ISSUED.MY WORKER�S'C,O/M��PE..N,S�ATION INSUFANCE CAqRIER AND PO UMBER ARE: CONSTRUCTION jCARRIEH�Lr������j- PLAN REVIEW � � POLICYNUMBER ELECTRIC � �{, (i}i455ECiKY�4E�NOTBECOFPIEfEDOFhEPEMqTISFCRONEHUt�DREDDq1ARS(S100JORL6S� PLU�dBING ' � '- Z ICERTIFI'THATINTHEPERFORMANCEOFTHEWORKFORWHICHTHISPERMITISISSUE�,I MECHANICAL. ____ �JY��� Cj3' SHPLLNOTEMPLOYANYPERSONINANYMANNERSOASTOBECOMESUBJECTTO7HE �� �� � WORKERS'COMPNSATIONLAWSOFCAUFORNIA,ANDAOHEETHA7IFISHOULDBECOME INSPECTIONFEE SU&IECTTO TH NbRKEAS'COMPENSATIO VISIONS OF SECTION 370o OF THE LABOR �j CODE,1 HALL OR Wlhl CAMPLY WITH OSE IONS. ISSUANCE LJ� � a p DATE: Q APPLIGANT: SMIP W J WAHNINO:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFIIL,AND SHALL BE gyy�t �y SUBJECTANEMPLOYERTOCAIMINALPENAI.TIESANDCIVILFINESUPTOONEHUNDREOTHOUSAND ENERGYPERMII""�' DOI.I ARS(ft OO,oOo),IN AD�ITION TD THE COSTOF COMPENSRTION,DAMAGES AS PROVIDED FOR IN i n � SECT�DN 3708 OFTNE LABOR CODE,INTEREST,ANO AT70RNEV'S FEES. RETENTION FEE�^'��-`-"'�' �' ' '- �`' •�✓5. .� OCONSTRUCTION LENDING AGENCY PRE-ALT FEE: � INEREBVAFFIRMUNOERPENALTVOfPERJURYTHATTHEflEISACONSTRUCTIONLENDINGAGENCV FOR THE PERFORMANCE OF THE WORK WR WHICH THIS PERMIT IS ISSUED(SEC.3087,CIV.C.). Z W � LENDER'SNAME F-� LENDER'SADOFESS � TOTAL FEES �� I W I CERTIfV THAT I HAVE REAO THIS APPLICA710NAND STATETiATTHEA60V'c INFORMATION IS CAHREC7 d IAGREETOCOMPLVWITHALLC�TYAN�CX7UN7V RDINANCESANDSTATEfAWSRELATINGTOBUILDING � CONSTRUCTION.AND HEREBV AUTVIORRE REPR SENTATIVES OF THIS COUNTY TO ENTER UPoNTNE Z A80�NEOPROPERTYF RI SVECT PURPOSES. C T � J � m FERMrtTEE (PRINn � � �� � SI�NANPE EHMITTEE OA E � RECPT.NO. 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