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� C_.t��l v'�-�%7'� _1�_ CITY OF DIAMOND BAIt GUl � r DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES 3 �U� ' � . 21660 E.Copley Drive Suite 190 (909)860-3195 Fax(909)861-3117 � PRESS `�'^^" BUII,DING PERMIT APPLICATION -:.,- M ', PeaMir :.... .:,• ,Prc' , . FIRMLY .. . : ,. .. QJOBSITE •� �� � ��j+„` { R�� DATEICATION � � �i NUMBER I � # ¢ ADDRESS sJ �,.�°°N � D TEE NPE OCC APN LOT TRACT CONST. GROUP p OWNER LL ADDRE ZONING SETBACKS 0 W - FRONT � CITY f ZIP � �EL. REAR RW � APPLICAN"f �. ���.� ❑ z�. SIDE/SIDE STREET RW O � CONTRACTQ SIDE � ADDRESS ` O PROPOSED USE p CITY �` � • ZIP EL. L o ARCH/ENG/ z DESIGNER w NO.DWEL. NO. NO. o„ ADDRESS v� UNITS STORIES BEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER DECLARATION SFR/ADD/REM 0 p I HEREBV AFFIRU UNDER PENALiY OF PERJURV 7HA7 I AM EXEMPT FROM THE CONTRACTORS LI- Gefa98/CeR70R W CENSEUWFORTHEFOLIOWINGREASON(SEQ7037.58USINESSANOPROFESSIONSCODE:ANYCITYtlp (n U COUNTYWHiCHREWIRESAPERMRTOGON5TAUCT,ALTER,R,APROYE,OEMOLISH,ORREPAIR0.NYSTRUP w TURE,PFIUH 70 ITS ISSUANCE,AL50 REW IHES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED w Pdtio/DBCk S7ATEMENT THAT HE OR SHE IS LICENSEO PURSUANT TO THE PROVISIONS OF THE CONTRACTORS Ll� '�� CENSE UW(�PTER 0(CQMMENCINO WITH SECTION 7oo0)OF�IVISION 3 OF THE BUSINESS AND PWO• �'1' PoOUSpa FESSIONSCODE)OPTHATHEORSHEISE%EMPTTHEREFROMANDTNEBASISFORTHEALLEGEDEXEMP- (� V TION.ANVVIOI_ATIONOFSECTION7�31.5BYANYAPPUCANTFORAPERA.IITSU&IECTSTHEAPPLICANTTO Z Re-Roof r �CIVILCENALTYOFNO7AIORETHMIFNEHUNDREDDOILARS�S500j.): � ❑I,ASOWNEROFTHEPROPERTV,ORMYEMPLOYEESWITHWApESASTHEIR30LECOMPENSATION, C.] COmmefCial �� NALL DO THE 1NORK,AND THE STRUC7URE IS NOT INTENDE�OR OFFERE�FOR SALE(SEC.7o44,BUSI- J � NE93 AND PROFESSIONS C�E:7HE CANTRAGTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF = PROPERTY NRiO BUIL0.S OR IMPqOVES THEREON,JW U YVFiO DOES SUCH WORK HIMSELF OR HERSELF Oq � TFIRDUGHHISORHEflOWNEMPLOVEES,PROVI�EDTHA7SUCNIMPflOVEMEMSARENOTINTENDE00R m 0 OFFEREDFORSALEIF,HOWEYEFi,1HE8UIL�INGORiMPROVEMENTISSOIDWITHINONEYEAROFCOMPI.E Z TION,THE OWNER-BUILDER WILL.HAVE THE BURDEN OF PROVIN6 THAT HE OR SHE 010 NOT BUILD OR = IMPROVE FOH 7HE PURPOSE OF SALE). W ❑I.ASONMEROFTHEPROPER'iV,AME7(CIUSWELVCANTRACTINGWITHLICENSEDCONTFACTORS (r TO CONSTRUCT TiE PROJECT(SEC.7011,BUS�NE65 AND PROFESSIONS CObE:THE CONiAACTOR3 LI- V8IU8IIOf1 ADJ.AREA � W CEN6ELAWDOESNOTAPPLYTOANOWNEROFAPR07ERTVWHOBUILD90RIMPROVESTHEREON,AND � WFIOCONTMCTSFORSUCHPROJECTSWITHACONTRACTOR(5)LICENSEDPURSUANTTOTHECONTMG QUANTITY DESCRIPTION FEE TOfiS LICENSE LAW.). 0 ❑I AM EXEMPT UNOER SEC. B.d P.C.fOR THIS REASON Q 3 � � � �ATE OWNER F– � W � LICENSED CONTRACTORS DECLARATION W � INEREBY0.FFIRMUNDERPENAI,TYOFPERJURYTFIATIAMIICENSE�UNDERPHOVI510N50FCHAPTER � � 9(COMMENGIN(i WITH SEC710N 7o0D)OF DIVISION 3 OFTHE BUSMESS AND PROFESSIONS CODE,�N� Z ��� MY IICENSE IS IN NLL FORCE AND EFfECT, } m � LICENSECL.)�1 SS w��.�+'��..� _ LIC.NO._ 4� � � U DATE +'' G�ff 'I� � GONTRACTOR a W � WORKERS'COMPENSATION DECLARATION Q � I HEREBV AFFIRM UNOER PENALTY OF GERIUFtt ONE OF THE PoLLOWING DECLAFATIONS: Z � IHAV ANDWILLMAINTAINACERTIFICATEOFCONSENTTOSEIF-INSUREFORWORKEFS' _ �t ENSATION,AS PROVIDEtl BYSECTION 37o00F THE LABOR CODE,FOR THE PERFOqMFNCE `U O iHF WDRK FOR WHICH THIS PERMIT IS ISSUED. � � _I HAVE AND WILL MAIMAIN WORKERS COMPENSATION INSURANCE,AS REOUIRED BV SECTION Q 37000FTHELA90RCODE,FORTHEPERFORMANCEOFTHEWORKFORWHICHTHISPERMITIS ISSUED.MV WORKEAS'COMPENSATIO INSURANCE CAR ER AND P/$�ll UM6ER ARE: CONSTRUCTION jCARRIER Ld ` PLAN REVIEW � POIICVNUMBER � „� ELECTRIC 0 (nissECi�oNNE�No78EC06AEiEDOG7rEpEp,w�FSwaauEHurDaEDDa.v3tslEtao)oRLEss). PLUMBING � � W Z 1 CEA7IFYTHAT IN hIE PERFORMANCE OF 7HE WORK FOR WHICH THIS PERMIT IS ISSUE�,1 MECHANICAL C,7 SHAI.L NOT EMPLOY ANY PERSQN IN ANY MANNER SOAS TO BECOME SUBJECTTO iHE J� (p WORKE 'COMPENSATIONLAWSOFCALIFORNIA,ANDAGqEETHATIFISHWLDBEC INSPECTIONFEE S SU&!E TOTHE RKERS'COMPENSATIO VISIONSOFSECTION370DOFT R M1 CO E, HALLF HWITNCOMPLYWITH EP ISIONS. ISSUANCE g�}q�� ) p DATE: APPLICANT. SMIP ._)T4B� fG � L�0 J WAFNIN AILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AN�SHAIL BE ENERGY P/C �y.r..�,� �„/rs'"^ATe.Tl��� � SU&IECTANEMPLOYERTOCRIMINALPENALTIESANDCIVILFINESUPTOONEHUNDREDTHOUSAND '��g� Z'��� �� "�� ..! } DOLLARS(5100.0007.IN AODITION i0 THE COSTOf COMPENSA710N,�AMAGES AS PRONDED FOF IN ENERGY PERMIT �� r� J� SECTION37DBOFTHELABOPCODE.7NTEREST.ANDATTORNEY'SFEES. RETENTIONFEE: �"'� � 4� ' OCONSTRUCTION I.ENDING AGENCY PRE•ALT FEE: � I HEREBY AFFIRM UNOER PENALTY OF PERJURY THAT THEqE IS A CONSTRUCTION LEN�ING AGENCV FOR THE PERWRMANCE OF iHE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.3097,CIV.CJ. Z W — � LEN�ERSNAME 1— LENDERSADDRESS / � TOTAL FEES � 1 CEFTIFYTHAT 1 HAVE FlEAD THIS APPLICA710N AND STATE iHAi THEABOVE INFORMATION IS CORRECT. d IAGREETOCAMPLYWITHALLCITVAN�CIXINNOR�INANCESAND$TATELAWSRELATINGTOBUILDING � CONSTRUCTION,AND HEHEBV AUTHORIZE REPRESENTATNES OF IS COUNTY TO ENTER UPON THE ABOVE-MEN7IONED PROPERTY FOR INSPECTIO PURPOSES. COMMENT O �. J � m PERMITTEEN � Q � � SIGNATUREOF ' MIREE ATE /, = RECPT.NO. PAID BY v �VALI�ATION=J,�� ~ WHITE-0epartmant Copy,YELLOW—Finance Copy,PiNK—Assessor Copy,GOLDENROD--File Co GREEN— py, Applicant's Copy .. �� , :,::a A .,s, ...�iu, . ��c, \ e .�,b, ��,x r S ,:�H::.0 t�F.. :`h . :.A . . . ,.� _ ..: � . . •� � r .'` . , . . � - .. , . � , , S 0 T � �.AA �i� .. 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