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� � � �ITY OF DIAMONb$AI� DEPARTMENT OF COIVIIVIUNITY&DEVELOPMENT SERVICES 2166Q E.Copley Drive Suite 194 � (909)$60-3195 Fat(904)8613117 PRESS :� � BUILDING PERMIT APPLICATLON FIRMLY � JOBSI7E APPLICATION ff j PERMIT ��,' (p P!C � ADDRESS ��(� ''f–i+�l.(�.c�_ ��� DATE ' 1 ��` NUMBER � � � ISSUE TYPE OCC APN LOT '�_ TRA T DATE CONST. GROUP p OVIINEA ' ` Ca "- qppR ,,,, , �, ^. ZONWG SETBACKS 0 z CITY Z!P '"7 ' TEL�if'l��y�i���i'Srt �RONT FiW ❑ p APP�lCANT I TEL.�� S DE/SIQE STREET_ RW�❑ � CONTRACTOR SIDE ❑ � ��DDRES$ ZIP TEL. PROPOSED USE '� � ,t.,3'4 .3 Q ARCWENG! z DE$9GNER NO.DNIEL. NO. NO. � /�1DDRESS � UNITS � STORIES � BEDFi00h1S�,� � ClTY ZIP� TEl, cra — DESCRIPTION SQ.FT. FACTOR PS� ADJ;AREANACUATION p� OWNER-BUlLDER DEClARA71QN 5FR/ADD/REM O I HEREBY AFRRAI UNDER PENALTY OF PERJURY THRT I AM EXEMPT PROM THE COMRAC70R5 LI- G8fEg8/C9rpaIl W� CENuEL4WFOR7HEFOLIONlIN6'�REASOlV�SEC.709�.i6U51NESSANDPflOFES510N9CODE:ANYCITYOR (n UI,�COUNIYWHICHREWIRESAPERMYfTOCONSTflUCT,ALTE�9,IMPftOVE,DEMOLlSH,ORREPAIRANYS7RUG �jJ �j0/DECIC ;���., TURE,PRIOR TO ITS ISSUANC£,�L50 REQUI0.ES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNEO W � � STATEMENT hiAT HE OR SHE IS LIC9JSE�PURSUANT TO THE PFIOVISICN5 OF THE WNTRACTQRS LI- '..��"���CENSE'LAW(CHAPTER 9(COAIM7ENCING WliH SEC710N 70Q3)OF�IVISI4N 3 OF THE Bl1SINE55 AND PRO- U' POOUSp3 � � � � � F '. FESSIONSc:O�E�t�RTHATHEOR��.SHEISEXBdPTTHEHEFROMAN�THE8A515FOflTHEALLE�EDIXEMP• (� �y' TION.ANYVIOLATIONOF�SECTION7039.5BYANYAP�JCANTFORAPERMITSU&IECTSTNEAPPLICAN7T0 Z RE-ROof - � .�� . . . . t„� AqVI PENALIY OF NOT MOPETHRN FNE HUNDRED�OL'u1q5(45ao),j: � �ASOWN6ROFTHE7ROpERTY,ORMVEMPLOYEESWITHWAGESASTH61RSOLECA°APENSATION, COmfitefCldl . -' '� ' � WlLL 00 THE WORK,AN�TME STRl1CTURE i5 NOT IfdTEN�EO OR OFFEREO FOq SALE(SEG 7044,6U51- . a �� NE55 ANO PROFE.SSIONS CODS:�THE CCNTRACiOPS LICENSE IAW DOES N07 APP�Y TO AN OWNER OF � . �� , , , � �PROFERTYVM06VILp30qIMPROVESTHEflEON,�dDWHO00ESSUCHlNOHKHIMSELFOftHERSELFOq .�:. ��THROUGH H65 OR HER OV✓fJ EMPLOYEES,PROVIDED TFiAT SUCH iMPF1011EMENTS ARE P10T INTENDE�OR � � W',`: OFFERED FOHSALE IF,HOWEV6R,iHE BUILDING ORiFAPROiIEMENT ISSOI.�YdITHINONE YEAR OFCAMPLE � �'�. ��TION,THE OWPlER�Bl11L�ER Wdl HAVE 8HE SURDEN OF PRCVING THAS HE Oq SH£DID NOT BUILD OR ��� MPROVEFORTNEPUPPOSEOF'.SALE). . . . ' �y„�,� ❑I,ASOVdNERQFTltEPROPERIY.AMEXGLl151VELYCpNTRM1CTfNCaWfYFiL9CENSEDCONTRACTORS ,'.��,' YO CON3TRUCT THE PRDJECY(�4EC,7044,BU91NESo PND PROFESSIONS:AUE:TH@ CONTRpCYOR3 LI- V21Ue�i0R ADJ.AREA � � � LLJ�'.,CENSEL9WDOEEN07APPLYTOANOWNEROFApROVERTYWFIQ6UiLO50RIMPROVESYHEREON,AH� '�,'��, wF�ocoNrw.cr�Foasucts�rAo�Ec7sworsincor�rcucroa�s�uceNssoauasuqrrtro�saE�hrano- qUllNTIIY DESCRiPTtlQN �FEE � � . �, 7ORSLICENSEIAW.�. o ❑i AM EXEtA?T UNDER SEC.�� _.__�.�6.m P.0.FOR TNIS RE0.56N d I � ' � � � �' U � i'i`, o,�r� ' �`� ovme�J�&� ��a,�°Ar�'f��; V Z � a�� LECENSED CChVTRkC?OP.5 DEGC.ARATION w � . Q I HEREBtlRFFlRM UNCER PENA6.TY OP PERJURY THAY I AM LICFNSELI UNDER PflOVI510k5 OF CHAP'Efl � �, 9(COMANENCINQWITHSEC7'ION�700o)OfDIViSi�N30F7HEBU51NE5SANDPHOFES510NSCODE,ANP Z ' ' MY LICENSE IS IN FIAL:-0FCE hN�J EFFECT. � o; LICENGE CUS^a LI0.NO. � � DA'fE _ C�7RACYOR � -�- W � WORKERS°COMPENShTION DECLARATION Q � 1 HEAEBYAFFSRM UND£R PENPLTY OF 7EfldURY�9NE OfTHE FOLLOWING DECLAflATICNS: � I � _�_tHRVEANO"NILLMAINTASNACEPTIFIGF7E6FCL)PoSENTTOSELFINSUFEFORWOflKERS' � ` �CAMPENSA710N,ASPi}OYIDEOBYSEGTION37oaOFTHElA60RCOpE,FOATMEPEflFORMANCE � � C3F7NE WORK F�wF�iGH 7HIS PEFiMIP IS ISSUED. , � . �� _..�IliflbEAND'NIISMAINTAtNYIQRKERS'COAnFEN5A7fONiNSURANCE,ASHEflUIREDBYSECTIOfd ppp��y 37o00F7HELRBOR�DE,r�ORTHEpERFCflMAi`9CEOFPHEWORKFOflWHICIiTHlSPER�AITIS �� � � 158UED.MY bN6AKER5'CbMPNISA'170N 1Id5UFfi�4GE CARRIER tiND POUCY Nl1M8Efl ARE: CO�ISTFIUCTION _,__ .A� ;� I � cn�aiEa_,_, pLANREVIEIh' ZPOLICYNUMBER �� � � ELECTRIG � iTF'JS3ECi1CNJNEEDNO'(C3EOD4rl'�.EfEDOFTHEPER6LTi5FORC1rEHUND?iE�C'JLW75�81G0)ORLESSF PLUMBING Z . ICERTIFYTkATiN1'PiEPERFORMHNCEOFTHEeV9RKFORWWGHTHISPERMITI515SUED.I MECHANICAL ���-,�.� _ (;f SFiALLN07EfAP�6YF;�4YPEflSONP�ANYMANNERSOASTOBECOMESU&ICCTTOTHE ���g ,� �. ` - yj) WORK6RS"COAqPEN5/+710N1AW50FCALifORNIA,ANOAGpF.EiNATIFISHOULDBECOME INSPECTIONFEE SL�JECT70 TH6 WOqKERS'COMPENSATION PROVISIONS OF SECTION?Too OF THE Ld,BOR �p�.� � � COOE,I SFiAI'LFOHTHWITFI GOM1AP�Y W11H TH05't PHDViSIOMS. ISSUANCE H D 9' ���89'1AiTT.y�y�y0 �-'�1• �t- � , �y'p r�t�Z3�_. .a,.\� tp CATE:�_.,,� APcLICANT. SMIP -� ' dAr.n� ' n .� WARN7NG:FAIWRETOSECUREWORKER3'COMPENSATIONCOVEFAGEISUNLAWFU�,ANOSHALL9E ENERGYP/C ���' LL SU&IECTANEMPLOYERTOCAIMINALPENALTiESAN�qVIIFINESUP'fOONEHUNORECITHOU5AN0 ENERGYPERMIT DOLLARS(51oa,MiOj.INADDIPION TOTHE CAST nF COMPENSATtON,DAMAOES AS PROVIDED Pofl IN � SEC710N37000FTI{ELABOr�CODE,INTEREST,AN�ATTORNEV'Si-EES. P.ETEPITIONFEE: i_ _ � ''�CONSTRUCTlQN LENDING AGENCY PRE-ALT FEE: � '�� �HEREBV AFFiRAA UNDER PENALT/OF PERJURV THAT?HEflE IS ACGNSTRVCTIDPJ LENDING AGENCY FOR-iHEPEflWRRhANCEOFkHEYIOP,KFORWHIGFITHISPERM17151551IE�(SEC.309i,CIVC.). - , � l[J � LEt�ER'SN0.4hE« '� ,__. 8"-- LENOER'Sp�DPoE55_ ' _ _ � ICERTIFYPHA71H0.VEFIEADTHISAPPLICqTIONANOSTATETHAiTHEABOVEINFORMAT10NI5CORRECT. TOTAI_FE�S ' ��>�� �� IAGq[ETOWMPLtlM7TMAlLCITYANDCOl1NTYORDIIVANCESANDSTATEUWSRELA7INGTOBUILDING �'i , °����� � CON5TRUCTION,MI�HEREBYAUTHOp12'cREPRESENTA71YE50FTHI5COUNTYTOEN7EflUPONTHE ' ; � ABOVE-MENTIQNE6PPAPERTYFORfNSPECTIONPURPOSES. COMMENTS - � � n � .. D P's`�� f`�- ��fJ�.Cl'St.oC.; , _ '� PERMITTEEN ' �� �s �. C t"� SIG ATUR . DATE i I ' RECPT.NO. �S PAI�BY r ` �. 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