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y.� . CITY OF DIAMOND BAI� �� ;�% --�°� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES '� w 21660 E.Copley Drive Suite 190 (909)860-3195 Fax(909)861-3117 PRESS A�"� BUII.DING PERMIT APPLICATION , ' _ FIRMLY � JOBSITE �.�t�l���� d?��.- �,�� ' d DATEICATION NUMBER,��-�.� #JC��� ¢ ADDRESS� 5 (� ��- V $ APN LOT TRACT ISSUE i TYPE OCC d DATE �� l �~�� CONST. GROUP p OWNER � L- �'' ' � `�-' oADDR S.���,� r:�i: ,t� JF , ZONING SETBACKS W ��' �—��� ' RW ❑ z� CITY a oc r� u t � �TE�I��R'�'`'`i''G�� REART ❑ � APPUCANT TEL. SIDE/SIDE STREET RW ❑ � CONTRACTOR �J � ��I SIDE ❑ p� ADDRESS �`-f� ,. : 'it =�:= Q CITY �C,O e•{�:.5 ZIP ��'�� TEI��i.�rl�f'�lk:`�- PROPOSEDUSE `: ��'=' `C,�cL6a% G'tY�JI� f`{r j1- w ARCWENG/ r u a � z DESIGNER ` � � � ' �'� � � ADDRESS NO.DWEL. �' �a . C.a.'��• �K:n�� NO. �° tn UNITS STORIES BEDROOMS � CITY ZIP TEL. ' � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION Q OWNER-BUILDER DECLARATION SFWADD/REM � O , p 1 HEREBY AFFlRM UNDER PENALTY OF PEFUURY TNAT 1 AM EXEMPT FROM 7HE COMRACTORS LI- G8t8A0/C81pof[ W CEN5ElAWFORTHEFOILOWINGfiEA50N�5EC.)031.SBUSINESSAN�PROFESSIONSCODE:MIYGTVOfi (n � COUNTYNMICHREq11RESAPEiiMITTOCON9TRUCT,AITER,IMPROVE,DEMOUSH,ORREPAIqANYSTAUG �tJ patio/Deck � W TURE,PRIOR TO 1T8 IBSUANCE,ALSO REQUIRES THE APPLICANT POft SUCH PEPMIT TO FILE A SIGNED W � STATEMENT THAT HE OR SHE IS LICENSE�PURSUANT TO THE PHOYISIONS OP THE CANTRACTORS L4 � C CENSE lAW(CHAPYER 9(COM/AENCIN6 WITH SECTION�000)OF DIVISION 3 OF THE BUSINESS AND PPO- POOUSpe � 4l FESSfONSCODEjORTHATHEOR5HE1SEl(EMPTTNEREFR6MAN�TiEBA3iSFORTriEALIEGE�EXEMP� V TqN.ANVV�q,l�7lpNpFSECTION7031.5BYANYAPPLICANTFORAPERMITSUBJECTSTHEAPPLICANTTO Z Re-Roof ���� � ACMLPENAITYOFNOTMORETHANFNEHt1NDRE�DOILqRSjSSOD).): ' � OI,ASOWNEROFTHEPROPERT',ORMYEMPLOYEESWITHWAGESASTHEIflSOLECOMPENSATION, , CommBfCi81 - Wlll DO THE WOfl!(,AND THE STRUCTURE IS NOT INTENOED OR OFFERED FOH SALE(SEC.7044,BUSI� � , � NESS AND PF�FESSIONS CODE:THE CbNTRACTORS LICENSE LAW DOES NOT APPLV TO AN OWNER OF PROGERTVWHOBUH.DSORIMPROYESTHEREON,PNDWHOOOE65UCHWORKHIMSELFORHERSELFOR � MN '4'I ' � hIROUGHMSORHEROWNddPLOYEES,PROYtDE6THA75UCHIMPFlOVEMENTSARENOTINTENDEDOR m � 0 ,OtFEHEDFORSILLE.IF.NOWEVER,THEBUIlU1NGORIMPROVEMENTISSOLDWITHIN�NEVEAROFCOMPIE- - � z 'TION.THE OWNER-BUILDER WILL HAVE 1FiE BURDEN Of PROVMG THAT HE OR SHE DID NOT BUILD OR , � IMPROVEFOpTHEPURP03EOFSALE). � - � [71,AS OWNER OF THE PROPER(Y.MA EXCLUSIVELY COMRACTMG WITH WCENSED COMRACTORS . Q TO CONSTRUCT THE PRQIECT(SEC.7044,BUSINES3 AND VHOfESSIONS CODE�.TIiE CONTRACTORS LI� VaIUdY10l1 � ADJ.AREA W CENSELAWDOESNOTMPLYTOANOWNEROFAPROPERTYWHOBU��DSORIMPROYESTHEFEON,AND , � WNOfANTRAGTSfORSUCMVROAEGiSWITHACONTRACTOHIS}LICENSEO_PURSUANTTOTHECONfRAG QUANTITY DESCRIPTION FEE � TOPS LI�CENSE UW.). o tMMA E%EMPT UNOEfl SEC. B.S P.C.FOR THIS REASDN Q. 3 c> . �'i' DATE OWNER H � W � LICENSED CONTRACTORS DECLARATION W � . � IHEREBYAFFIRAIUNDERPENALTYOGPERJURYTHATIAMLICENSEDUNDERPROVISIONSOFCHAPTER � p� e(COAIMENCINOWITHSECTION7000JOFDIVISIONJOFTHEBL131NESSANDPROfESSIONSCADE.AN� Z 11J MY LICENSE IS IN fUll fO/RCE AND EFFECT. ,�+�ry m . � UCENSE.CLASS���IIC.NO. , . 6-�✓�.`� � �j UATE�� G�Ca CONTRACTOR_ � a. � W � WOAKERS'COMPENSATION DECLARATION ��,�� � ¢ � IHEREBYAFPIRAIUNDERPENQNOfPENJURYONEOFTHEFOLLOWINGDECLARATIONS: � Z � �_IHAVEINOW1lLMAMTAINACERiIFIGATEOFCONSENTTOSELF-INSUHEFORWORKERS' �_ ' � COMPENSATlON,AS PROVIDED BV SECTION 370o OF THE LABOR CO�E,FOR THE PERFORMANCE � U Q OF iHE WoqK FOR WHIGt17HIS PEqM1T IS ISSUED. � � � � _I HAVEPND WILLMAINTNN WOHICERS'COMPENSATION INSUFANCE,AS REQUIflED BY SECTiON QQ 37000FTHELABOR�E.FORTHEPERFORMANCEOFTNEWORNWRWHIqHTHISPERM1T15 ��.� � ISStiED.MY WORKERS'COMPENSATION IN6�RANCE CARRIER AND PO�ICY NUMBER ARE: CONSTRUCTION j CARRIER ._- __--_-.—_----.-- PLAN flEVIEW � �� "{ �l. � �A � � �� POLICYNUMBER ELECTRIC " __ ____ � 0 (fFNSSEC(IONNE�NOTBECObiVLEfFDOFTF�PEiU.4TSFOFlONEiA1FAREDOC11A17S(5100)OqLESSa PlUM81NG Z �CERTIFYTHAT INTHE PERFORMANCF.OF THE WOPK fOR WHICH THIS PERMIT IS ISSIJED,l MECHANICAL � SHALLNOTEMFLOYPNYPERSONINANYMANNERSOA5T0.B MESUB C E � (n WORKERS'COMPENSRTIONLAWSOFClLLIfOR IA„MJFY,4G TH LO COME INSPECTIONFEE SUBJECT70THEWONKERS'COMPENSATI S OF T ooOF EI.A80R �j CADE, SH FOFiTHW�THCOMPLVWITH EP I51 ISSUANCE A�� .�j� ��� �� cd��� SMIP °� °� �.&� ��� DATE: �� APPLICAN. �-'{(. WW0.flNING:FpILI1RETOSECUREWORKERS'COMPENSATIO �VERAGEISLINIAWNL,ANDSH0.LLBE ENERGYP/C --� y�F�" ' �y SUBJECTANEMPLOYERTOCRIMINALPENALTIESANDCIVILFMESUPTOONEHUNDR[DTHOUSAND ENERGYPERMIT � s� � DOLLAR5(S1 a0.W0),IN AODI710N TO THE COST OF COMPENSATION,DAMRGES AS PflOVIDED FOH IN � p, � SECTN1N37U80FTHELABORCO�E.MTEREST,AN�ATTORNEY'SFEES. - RETENTIONFEE: ���.q�{`�_X�'1_ , . . O CON5TRUCTION LENDING AGENCY PRE-ALT FEE: �� �� � IHEREBYAFFIRMUNOEFPENALTYOFPEFJUHYTHATTHEHEISACONSTFUCTIONLENDINGAGENCY � FORTHE PERFORMANCE OF THE WOFK FOR WHICH THIS PENMIT IS ISSUED�SEC.3097,CIV.G�. � �� W � LENDER'S NNAE F-- l�1DER'SADDRE99 g TOTALFEES � ICEflTIFYTHATIHAVEREADiHISAPPLICATIONANDSTATETHATTMEA80VEINFOFMATIONISCORRECT. W IAGREETOCAMPLYWITHALICINAN�CAUNTYDR0INANCE5AND5TATELAWSRELATIN6TO8UILDINO � � CONSTRUCTION,ANDHEHEBYAUTHORIZEREPRESEMATIVESOFTHISCWNNTOENTEfiUPONTHE ZENTIONEDPROPEflNFOflINSPECTIONPUflPOSES. 0 CAMMENTS _' � � �-�,..' -i � , m ru+rrr ae f + �1. 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