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_��� CITY OF DIAMOND BA�3 DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES � 27;660 E.Copley Drive Suite 190 PRESS ��`'�"�W BUQ.DING PERMIT APPLICATION FIRMLY _ � JOBSITE ��i(_ >t""�,`�?T�,_-. � ) �� APPLICATION _ t , .C� PERMIT /C o ADDRESS T "t'"�"��_���"" DATE NUMBER # c� ISSUE TYPE OCC APN-----��T TRACT DATE CONST. GROUP p OWNER �c-'.�-��" p ADDRESS %�'�- ��b _ ZONING SETBACKS Z CITY IF�M- ��- ZIP TEL " qEART RW ❑� g APP�I ANT L t Z� TEL. �=�_� SIDEISIDE STREET RW U � CONTRACT R m�"`�"1�Y--�'l"���--�'! SIDE ❑ � AD�RESS J,.7 liJ i�7���nJ7"��'---�-"7" pROPOSED USE ��� � I� �D��S�"/� O CIT�"'z,.��-�701'"(AJL,�."�►`�ZIP G�2�3f,�iTEL.`�St��� SSI� _ w ARCH/ENG/ �9�St' �'�t�... �' G� s z DESIGNER ~ �- � NO.DWEL. - NO. NO. � d; ADDRESS UNIT5 �� 'STORIES �BEDROOMS � CITY ZIP TEL. �`: � N' DESCRIPTION SQ.FL FACTOR PSF ADJ.AREANALUATION N; Q OWNER-BUILDER DECLARATION SFRIADD/REM g O � p, 1 HEREBV AFFlRM UNDER PENALTY OF PER.Il1RY 7HAT I AM EXEMP7 FFOM THE CONfRAC70FlS U- Gat3gBlC8IEWrt W 'CENSELAWWRTNEFOLLOWIN�REASON�SEC.7031.SBUSINESSANOPROFESSIONSCODE:ANYCITYOR - (/) , U �:�OUNT'/WHICHREQUIRESAPERMP(TOCONSTtiUCT,ALTER,IMPROVE,OEMOLISH,ORREPAIPANYSTAUG . W P3l'10lDBCk �� �-�NRE,VRIOR TO ITS ISSUANCE,AL50 iiEQUIFiES THE MPLICMlr FOR SUCH PERMIT TO FILE A SIGNEO W � '$TATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS li- S, CENSE UW(CFNPTEfl e(COMMENCMO WITi SECTION 700oj OF�IVI6ION 30F THE BUSINESS AN�PRO V' POOVSPO � �C; FESSIONSCODE}Oq1NATHEORSHEISEXEMPTTHEREPROMANDIHEBASISFORTHEALLEGEDEXEMP- � �TION.MIVVIOLATIONOF6ECTION�031.5BYANYAPVIiCANTFONAPERhUTS�&IECTSTHEAPPIICANTTO . R8-fl00} r: ACML PENALN OF NOT MORE THAN PIVE NUN�RED OOlLARS�55oD)): � ❑I,ASOMMEROFTHEPROPERT;ORMYEMPLOYEESWITNWAGESASTHEIPSOLECAMPENSA7bN, Camme(CiHI '" .N7LL 007HE WORIf,AND 7HE STRUCTURE IS NOT IN7ENDED OR OFFEqEO FOR SALE(SEC.7044,BUSI .J - NE6$AND OqOFE3810N5 CODE:7NE CONTflACTORS LICENSE LAW�OES�OT AVPLY TO AN OYINER OF � .PROPENTYNRfOBUILDSOAIMPROYESTMEREON.MlDWHODOESSUGHWORKHIMSELFORHERSELFOR � � �- �:�THROUGM HIS OF HEH OWN EMPtAYEE3.PHOVIOED THAT SUCH IMPPOVEMENTS ARE NOT INTENDEO OR Q .OFFEAWFORSALEIF,NOWEVEFI.THE6UILDINGORIMPROVEMBJ715SOlDWffHINONEVEAROFCOMPL6 . Z_ �TION,THE OWNER�BUIIDER NliLL HAVE THE BUROEN OF PROVIN6 7HA7 HE oR SNE�lo NOT e�I1D Oa _ __ IMPipVEFOHTNEPURPOSEOFSALE�. - ❑1.AS 01YNER OPh1E PROPEflTY,PM EXCLUSIVEIY COMRACTINO WITH LICENSED CONTR/CTORS � �'�TO CONSTRUCT THE PflQIECT(SEC.70M,BUSINESS AND PROFESSiONS WDE:THE CON7RACTOHS LI- � glU8tl ADJ.AREA W CENSEUWDOESNOTAPPLYTOANOWNEHOFAPROPERNWFIDBUILDSORIMPROVESTHEqEON,AND '. �- MR7000NiRACTSFORSUCNPRO.lECT5WITHACONTRACTOR�S�LICENSEDPURSUANT70TMECONTHAG � �UANTI DESCRIPTION FEE ��_ TOHSUGENSEUW.). �- �-. O I AM IXEMPT UNDER SEC. 8.8 P.C.,FOR THIS FE450N -Q ' �. ��� V . .. , �. � u'�- �ATE ONMER - � V � W �, LICENSED CONTRACTORS DECLARATION � �: `,�.IHEREBYAFFIRMUNOERPENAITYOFPEfUURYTMATIAML�CENSEDUNDEflPROVISIONSOFCHAPTER � (L' �-8(COMMENCINOWRHSECTION7000)OFOIVISION30FTHEBUSINESSANOPFOFESSIONSCAOE,AND .Z X, MY LICENSE IS W fl1LL FOFCrANQ EF ECT. �� m LLI FL, � � �-UCENSE CLAS l LIC.NO.` � J V :�pq7E � � CONTRACTOR w�� a W G����' � WORKERS'COMPENSATION DECLARATION � U � � .IHEitEBYAFFIRMUNDERPENALTVOF7EpJURYONEOFTHEWLIOWM�OECLARATiONS: N Q . O _�_IHAVEANDW�LLMAMTAINACERYIFICATEOFCONSENTTOSELF-INSUqEFORWORKERS' _ � CDMPENSATION,ASPNOVIOEDBYSEC'TiONel000FTHELABORCODE,FORTNEPERFORMANCE W OFTiEWOflKFORWHICHTHISPENMITi5155UEU. _ � � � �IHAVEAN�WILLMAINiAINWORKEF.S'COMPENSATIONINSURpNCE,ASREOUIREDBVSECTiON - '� r q 37000FTMELABORCO�E,FOflTHEPERFORMANCEOFTHEWORKfOflVhIICHTHISPEFIAITIS �� �f �� '- ISSUE�.MYY/DAK S'WMPENSATION INSUMNCE CApRIER AND POLICV NUMBER APE: CONSTRUCTION �� � �pqiEq '. D��.D�/J �,.�_C,...�� PLAN REVIEW � POLICYNUMBER � �D ""-- ELECTRIC � 1 Q (�5g[-C�pF�NE�ppTgE�LETEppF7FffpE{p,qilSFOpONEHIN�REO�OLLFPS(SIW A x PLUMBING . Z 1 CERTIFYTHAT IN THE PERFOflMAfVCE OF THE WORK FOft WHICH THIS PERMIT IS ISSUED,I -MECHANICAL (�j SHALL NOT EMPLOY ANY PERSON IN ANY MANNER 50 AS TO BECAME SUBJECT TO THE � WORKERS'CAMPENSATION LAWS OF CALIFORNIA,ANO AGREE TNAT IF I SNOULO BECAME INSPECTION FEE � SUBJECTTOTHEWORNEHS'COMPENSATIONPROVISIONS FSECTIWd3�ooOfTHELAeOR � CAD I SH FORT�H/WI�TN COMPLY WI7H THOSE P ISSUANCE � � C}7� SMIP � q OATE�_�.dsi APPLICANT. _ - , —� --� . W ENEflGY P/C � WARNING:FAIWpETO3ECUPEWORKEHS'COMPENSATIDNWVERAQEISUN L,ANDSHALLBE � SU&IEGTANEMPLOYERTOCRIMINAI.PENALTIESAN�CIVIIFINESUPTOONE U qEDTHOUSAN� ENEAGYPERMIT OOLUR3�5100.oaD),INADUITION70TMECOSTOFCOlAPEN5ATION.OAMAGE AS NOVIOEDFORIN ¢ SECTI�N37DBOFTHELABORCOOE,INTEREST,qNUATTOPNEY'SFEES. flETENTIONFEE: � CONSTRUCTION LENDING AGENCY PflEALT FEE: — - �. IHEREBYAGFIPMUNDERPENALTlOFPENURYTHATTHEREISACONSTRUCTIONIENDINGAGENCY � a-� FORTMEPERFORMANCEOF?HEWOFiKFORWHICHTNISPERMITISISSUED(SEC.309],CIV.C.). � � W � LENDER'SNM1E � k—- LENOER'6ADDRES3- -- ' b��)'��'`/J ¢- ICERTIFYTHATIHAVEREADTNISAPPLICATIONPNDSTATETHATTHEA60VEMFORMATIONISCORRECL TOTAL FEES - �✓ j � � I � IAGREE7oCAMPLYWITHALLCITYANDCOUNTYOR�INANCE5AN�5TATELAWSRELATINQTOeUILDING - ! � COtJSTFUCTION.ANDNENEBYAUTHORIZEREPRESENTATNE50FTNISCOUNTYTOENTERUPONTHE . �� z ABOVE-MENT ED PROP FOR IN9PECTION PURPOSES. COMMENTS � o _ /�--�'�:'�/��,�-�-�--� m PERMITTE /'`� ---- � ---�/: c � N 3Ni EOFPEHMIT7EE ATE = RECPT.N0. PAID 8Y � VALIDATION��. - �~ � � - WHITE-0epartment Copy,YELLOW—Finance Copg PINK—Assessor Copy.GOLDENR D—File Copy,GREEN—ApplicanPs Copy i..�. 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