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��/����� �4 �/�Y Ui � �� _�� CITY OF DIAIVIOND BA& ! DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES �G�3 4�U� , � , 21660 E.Copley Drive Suite 190 (909)860-3]95 Faa(909)861-3117 PRESS `�`�����J BUII.DING�'ERMIT APPLICATION ___ FIRMLY '�Aelb ..... ..... . . .: ,: .. . . -. o� JOBSITE � �°�1 � �„'�y, t�"�.,I� �i� DATE CATIOIS� �/� PERMIT'� � P/C ADDRESS vJ� r vco ii! V � NUMBER # w4 ISSUE Q� TYPE OCC APN LOT T ACT DATE_(Z � CONST. GROUP p OWNER p ADDRESS UN !A� ZONING SETBACKS w CITY ZIP E FRQNT RW ❑ � APPLICANT TEL. _ REAR ❑ � SIDE/SIDE STREET RW ❑ � CONTRACTOR SIDE ❑ AD�RESS � CITY ZIP !.�'EL. '— L PROPOSED USE o ARCWENG/ ��,, DESIGNER NO.DWEL. NO. NO. � ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � tn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER DECLARATION SFRlADD/REM O p 1 HEREBY AFFWM UNDER PENALTV OF PEfUURV THAT I AM IXEMPT FROM THE CONTRACTORS LI- G8�3ge/CdtpOR W CENSELAWFOR7HEFOLt.OWINGREASON(SEG7o31.5811SINESSANDPROFESSIONSCODE:ANYCITYOR (n U COUNTVWHICHqC-0UIRESAPER�II7TOCONSTRUCT,ALTERIMGROVE,DEMOL!SH,ORREPAIRANYSTi7UC- W P8fi0/DBCk � NRE,PRIOR TO RS ISSUANCE,ALSO RE�UIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIONED W STATEMENT THAT HE OR SHE IS LICENSEO PURSUANT 70 7HE PROVIS�ONS OF THE CONTMC70RS ll• � CENSE LAW(CFiAPTEfl 9(COMMENqNO W1T}7 SECTION 7WUJ oF�IVI510N 3 0F 7ME BU51NE55 ANO PR0- �'L' POOVS�3 FESSqNSCODE)OHTHI�THEORSHEISEXEMPTTHEREFROMANDTHEBAS�SFOR7HEALLEGEDEXEMP- (� TION.ANYVIOLATIONOFSECTION7031.68VANYAPPIICANTFORAPERMIT5U&lECTSTHEAPPLICANTTO Z Re-Roof � 11 CML PENALTY OF NDT MORE THAN FlVE HUNDRED DOLURS�35ooJ.): � ❑I,ASOWNER�THEPROPERTV,ORMVEMPLOYEESWITHWAGESASTHEIRSOLECOMPENSATION, O ComRIBfCi01 - YALL 00 THE WORK,AND THE STi1UCTURE IS NOT INTENDED OR OFfEFED FOF SALE(SEC.704a,Bu51- J � NES:AND PROFESSIONS CD�E:h1E CANTRACTORS LICENSE LAW DOES NOT APPLV TO AN OWNER OF � PIIOPERTY W/p BUILDS OR IMPROVES 7HEREON,PND WHO DOES SUCH WORK HIMSELF OR HERSELF Oli Q THROU(iHHISORHEROVMBdPLOVEES,PRONDEDTHATSUCHIMPROVEMEMSAFENOTIMENDE00R m QOfFEREDFORSilLE1F,HOWEVERTMEBUiLDINGORIMPqOVEMEN�IS50lDWITHINONEVEAROFCOMPIE- Z �TION,THE OWNER�BUILDER WILL HAVE 7HE BUHDEN 6F PROVING THAT HE OR SHE�ID NOT BUILD pR = IMPROVE FOR7HE PURPOSE OF SALE�. W ❑I,ASONMEROFTHEPROPEHTY,AMEXCLUSIVELYCONTRACTINOWITHLICENSEDCONTRACTOFS � TO CONSTRUCT THE PqOJECT(SEC.7044,BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS U- V81U8fiOn ADJ.AREA CENSE U1W DOES NOTAPPLY TO M!OWNER OP A PROPERTV WHO BUILDS OR MPROVES THEREON.AND � WFIOCONTRACTSFORSUCHPRQIECTSWIhIACONTRACTOR(S)LICENSEDPURSUANTTOTHECONTRAG QUANl1TY DESCRIPTION FEE � tt1RS UCENSE lAW). ❑1 MI FJ(EMPT UNDER SEC. B.&P.C.FOP THIS pEASON 4 U �= DATE OWNER � � W LIGENSED GONTRACTORS DECLARATION -� � w I HEREBYIIFFIRM UNOER PENALTV OF PERJURv THAT I AM LICENSED UNDER PROViSIONS OF CHAPTER Z � r � e(COMMENCIMO WITH SECTION 7000)OF DNISION 30F THE BUSINESS ANO PROFESSIONS C^^`.AND V� MY IICENSE IS IN FULL FORLE D E�T. 0 m �� y � LICENSE CLASS �� LIC.NO. � � +� J V DATE L.' CONTRACTO�' W � WORKERS'COMPENSATION DECLARATION Q � I HEREBYAFFlRM UNDER PENALTY OF VEitIURY ONE OF THE FOLLOWING DECLARATIONS: z O IHAYEMIDWILLMAINTAINACEHfIFICATEOFCONSENTTOSELF-INSUREFORWORKERS' _ Q COytPENSATION,AS PROVIDED BY SECTION 37ooOFTHE LABOR CODE,FOR THE PERFORA�ANCE �U O � /OFTHE WORK FOR WHICH THIS PEAMIT IS ISSUED. ,� � ~ I MAVE NVD WILL MAINTNN WOHKENS'COMPENSATION INSURANCE,AS REOUIFED 0Y SECTION 0 97000FTHE LABOR CODE.FOR THE PERfORMANCE OF THE WORK f-0R WHICH THIS PERMIT IS ISSUED.MYWOFKERS'CO�MPE�NS1.A,T�ION.IN URANCECARRIERANDPOLICVNUAIBERAPE: CONSTRUCTION jcnnaiw ��L./�d�-� ' PLAN FEVIEW � POLICVNUMBER�q_�t f l.� , ELECTRIC /V L�f Ljf' 0 (fHSSECiIOMNE�NDTBECOA�PLETEDOFTI#PEPoXTISFORIXJEl1lIMREDD01.lAR5(E1a0)ORIESSy. PLUMBING ' _ Z I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I MECHANICAL (� SMALL NOT EMPLOY V PERSON IN ANV MANNER SOAS TO BECOME SUBJECT TO THE (/� WORNERS'COMPE ATIONLAWSOF IFORNIA,ANDAGREETHATIFISHOULDBECOME INSPECTIONFEE _ �'SR. - � SU&lEC TOTHE RKERS'COMP SA FlOVISIONSOFSECTIONa'ICOOFTHELABOfl , HALL WITMCOMPL WITNT O ROVISIO ISSUANCE O �L. p DATE: APPLICANT: SMIP J WARNINO: AILURETO SECURE WORKERS'CAMGENSATION CAVERAGE IS UNL4WFUL,AN�SHALL BE �'-� +�( � �y SUBJECTAN EMPLOVER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRE�THOUSAND ENERGY PERMIT �J-.t �a � } DOLlARS(SlOo,00Oy,IN ADOITIONTO THE COSTOF COMPENSATION,DAMAGES AS PROVIDED FOR IN � �^q J� SEC7�ON 3708 OFTriE LA90R CO�E,INTEqEST,ANO ATTORNEV'S FEES. RETENTION FEE: � � 11 OCONSTRUCTION LENDING AGENCY PRE-ALT FEE: �_�s�,_p � t HEREBVAFFIAM UN�ER PENALTV OF PERIURY THATTHERE IS ACONSTRUCTION LENDING AGENCV �5'�a�a. FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED�SEC.ao97,CIV.C.�. Z W � LENDER'S NAME � F— LENDEWSPDORESS wICERTIFVTNATIHAVEREMTHISAPPLICATIONANDSTATETNATTHEABOVEINFORMATIONISCOHRECT. TOTAL FEES � y� Qi AGREE TO COMPLV WITN ALL CITYAND COUNTYORDINANC AND STATE LAWS RELATING TO BU�LDING ��//��/� �� � � � CONSTRUCTION,AN�HEREBV AUTfiORRE REPRESENTATIV OFTMS COUNTY TO ENTER UPON THE �� Z ABOVE�M�`EDGROPER7YFORINSPECT NPUflPOSE COMMENTS i J �. � m PERMITTEE N E( / Q 'f / . 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