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CITY OF DIAIv10N1��AR "� ''� `'� �' " �\� � -�� - DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES 21660 E.Copley Drive Suife I9D _ . - �;f w PRESS (909)860-3145 Fax(909)8b1 3117 . , BITII,DIa'�iG��R21%TTt`A�'�Y.°ICA'TIbI� ; +� ... , ,_.._ ,: ,. � , � ...,�,..�. w :� °� _ ;� ;: , � � . . , . . �� �. . tF ., � �, , ,. u,�...�, . . ... „. ... ., v_: ,,...�_ ,:,� � JOBSIT� '���""i t "��.l..r�a,Q � 4 ..':; DATECA710N `�..-[-�--,_ ' NUMBER �� L-�-'C.� r. . .:. o AOORESS � � APN LOT TRA �s , DATE CONST. GROUP p OVVNER 1 !L�( C' �� � �� LL ZO . , _ _.. .. - o AC�DFtESS � ,': .",. ' NING SETBACKS � GITY r�- �R� ��-�- ZIP f t�C'��I'EL �. '-- "E� * REART RW ❑ , AFPLICANT - - - TEL. SIDEISIDE STREET RW ❑ � CONTRACTOR � L 1,� ' „ .i �.� 51DE ❑ ADDRESS G, � C17Y ZIP��_�TE�. 'a PROPOSEDU5E o AFICH/ENG/ z DESIGNER _ � AdDRESS NO.DWEL. NO. NO. � CI'fY ZIP TEL. ' UNITS STORIES BEDRQOMS � a> DESCRIPTION SQ.FT: FACTOR PSF ADJ.AREANALUATION � OWNER-BUIIDER DECLARATION SFR/ADD/REM O I HEREBY AFFIRM UNDER PENALTY OF PERJUM THAT I AM EXEMPT FROM ThIE CONTRACTORS LI� G8f8JB/C3R101'[ W CENSELAWFOR'MEFOI.LOWINGREASON(SEC.7o31.fi8USINE55ANDPROFESSIONSCODE:ANYq1Y0P (J� COUNTYWHICMR�UIHESAPERMITTOCON§TRUCT,AITER,iMPR4VE,DEMOLiSH,OPREPAIRANV5TRUC- W P3f10/DDCI( � NRE,VRIDR TO ITS ISSUANCE,AC50 REQUIflES THE APPLICANT FOR SUCX PEFiMIT TO FICEJi$lONEO - - W STATEMENT THAT HE OH SHE IS UCENSED PURSUANT TO THE PqOVISIONS OF TNE CONTNACTORS LI� W � CENSE LAW(CHAP7Efi 9(COMMENQIN�WITH SECTION 7000)OF OIVISION 3 OF THE BUSINESSAND PRO� � POOVSpB � FESSIONS CODEJ OR THAT HE OkSHE IS E%EAIPTTHEREFROM AN�THE BASIS fORTHE ALLEGED EI(EMP� TION.ANVVIOLATIONOFSECTION7037.6BYANYAPPLICANiFORAPERMITSU&/ECTSTHEAPPII�ANTTO Z Re-Roof � ACIVIL PENALTY OF NOT MORETHAN FlVE HUNDRED OOLLARS(SSoo).): �� � � �I,ASOWNEROFTHEPROPEfiTV,ORMYEMPLOYEESWITHWAGESASTHEiR50LECOMPENSATION, � C0011116PCiHl � WILL DO 7HE WORK,M!D TNE STRUC7URE�5 NOT INTENDED OR OFFERED FOR SALE(SEC.7o4d,BU51� _1 � NE55 AN�PROFESSfONS COOE:THE CON7RACTORS UCENSE I,AW DOES N07 APPLY TO AN OWNER OF � PROPERTY WhiO BUILDS OR IMPROVESTHEREON,AND WHO DOES�SIICH WORK HIM5ELF OR HEpSELF OP � THRdJOHHISORHER�OWNEMPLOVEES.�PROVIDmTHATSUCHIMPROVEMENTSARENOTINYEND'EDOR m Q OFFEREOFORSALEIP.HOWEVE0.TME8UILDING001MPROVEMENTISSOfDNATHINONEVEAROFCCMPLE � � �TION,THE OYlNER-BUILDER WILL HAVE THE BURDEN OF PROVINp THAT HE OR SNE DID NOT BUILD OR . . , = IMPROVEFORTHEPURPOSEOF6ALE). �� uy ❑I,ASOWNEROFTHE PROPEHN AM EXCLUSNELY CANTRACTING WITH UCENSED CONTRACTORS � TO CONSTRUCT TFIE PFiO.IECT(SEC.7044,BUSINE55 AND PRbFE5SION5 CO�E:TNE CONTRACTOFiS LI� V811J8SIOP1 A�J,AREA L13 CENSELAWDOESNOTAPPLYTOANOWNEROFAPFOPERTYWHOBUII.OSORIMPROVE5THEk'ECNJ,ANO �L WHOCONTRACTSFORSUCNPRQIECTSWITFlACONTRACTpR(S)UCENSEOPURSUANTTOTHE(bNTRAG QUANTITY DESCRIPTION FEE � TGIiS LiCQlSE LAW.). _ ❑I AM EXEMPT UNDER SEC. B.&P.C.FOR THIS REASON �T ' - o Q � _ � , ; •� """.✓R �•.;;,, LL . DA"a EE OYJNER______,_____._ F- -- � -_ W �.e[ LICENSED CONTRACTORS OECLARATION � W Cr . 1 HfREBVAFFIfUJ UNDER PENALTY OF PERIURV THAT IAAA LICENSEfI UNOER PROVISIONS OF CHAPTER � . � � B((XkAMENCINQ'MTH SECTION 70a0)OF DINSION 3 OF THE 6USINESS AND PPOGESSIONS CADE,AN� � MY UCENSE IS M FULL FOftCE AND EFFECT. y LLI � �./�,i-i-�� � tp LICENSE CLASS�.�_ LIC.NO. ����" J wC DA7E h�=_�� CONTRACTOR' �;.: 5,,�°f c� d � S � � VdORKERS'CpMPENSATION DECLARATION � � � IHEREBYAFF�RMUNDERPENALTYOFPEFilUR1'ONEOf"(HEF011O`MNGDECLARATIONS:` ' ' � z � _I HAVE AND WILL MAINTAIN ACERTIFICATE OF CANSENT TO SELF-INSURE FOR WORKERS' _ COMPENSATION;ASPROVIDEDBYSECTION37000FTHELl�80RCODE,FORTHEPERFORMANCE W OFTHE WORK FOR WHICH TNIS PERMIT IS ISSUED. ,� � � _I HAVE AN�WILLMAINTAIN WORKERS'COMPENSATION INSURANCE,AS REqUIRED BV SECTION � 37CO OF THE LABOR CODE,FOR THE PERW RMANCE OF THE WORN FOR WHICH THIS PEfiMR 15 � ' rvuMe�anae _ CONSTRUCTION _.. ISSUEO.MY WORKER' PENSA710N I S RA A OL _.... ...__.�. �— CARRIEn_ r��i."fj4� . , PLAN REVIEW.. � _ _'_'___.—��______._.�. .'_,____ —"_..._._' _ ....._.__. > �y � pP � � POLICYNUMBER._���,�„��.,,_�lL . ELECTRIC �. � �et�. ���,�+�_-,-,--- o (I}-0SSECf101dNE�NOTBEf7JIlPLEfEDOFTHFPEWtqTISFQ:7(#JENIIMREDf70lLAR5(S1o0)ORLSS). �t�IJJpAt3ld�.i--^7 . _� l '-�' W Z � I CERTIFY THl�T IN YHE PERFOFMANCE OFTHE V/ORK FOR VJHICH THIS PERMIT IS ISSUED.1 MECHANICAL ����L (,'J SHALL NOT EMPLOY ANY PERSON IN ANY MAhNER SO0.S 709ECAME SU&IECT TO THE � � WORKERS'COMPENSATIDN LANS DF CALIFOflNIA,AND AGREE THAT IF 1 SHOULp BECOME INSPECTION FEE = Sl/&IECTTOTHEWOfiKERS'COIAPENSATIONPROVISIONSOFSECTIDN37�oOF7HEI.ABOR CA�E,ISHALLFORT�/IT CAMPLVWITHTHOSEPROVISIONS. ISSUANCE � -.gg `� —�-��1 � � � p DATE:�A LICANT: �-�.n.�+.- 1�C'�'G�-' SMIP F°Y W 2� f7 F Q J WARNING:FAILURE TO SECURE WORKERS'COM?ENSATION COVFRAGE IS UNLAWFUL,AND�HAL BE ENERGY P/C m1 7-� ,pp,��,,f� �-y.,q,�hi � SU&IECTANEMPLOYER70CRIMINA�PENALTIESANOCIVILFINESUPTOONEHUNDREOTHOti3ANL1 ENERGY PERMI��4.7�SlILS1Yt'�1A�V.L.d Y.`.t�Se � DOLLARS(5700.000),IN ADDITION TOTHE COSTOF CAMPENSATION,1]AMAGES AS PHOVIDEO FOR IN �y''��7�'p'�'p��('� 7y,� '} 6ECTION37000fTHE LA00P CODE,INTEREST,AND�TTORNEV'S FEES. RETENTION FE�'�1d�.ad.9.&1W4..J�S f�� .rQ$��'L:'r�a�Y:�1� � CONSTRUCTION LENDWGAGENCY PRE-ALT FEF: O � I HEREBV AFFIRM UNDER PENALTV OF PERJURV THAT 7HERE IS 0.CONSTRUCTION LENOMG AGENCY FORTHEPERFORMANCEOFTHEWORI(FORWHICHTHISPERMITISISSUED�SEC.3o9t,CIV.C.), , , Z W . � LENDER'S NAME F- LENDER'SADURESS . / � ICERTIFYTHATIHAVEREADTHISAPPUCATIONANDSTATETHRTTHEABOVEINi'ORMATIONISCORRECT. TOTAL�CES � �/'� � I AGREE TO COMPLV WITH ALLdTV ANO CAUNTV ORDINANCES AND STATE LAWS RELATING TO BUILDING � CCMdSTRVCTION,PND HEREBY AUhYJRRE REPRESENTATIVES O(THIS COUNT'TO ENTER 11PON THE �� � � Z AfiOVE•MENTIONED PROPERIY FOR INSPECTION PURPOSES. - � ,- , '- COMMENTS �w+' � _ �c�... tti=^a-c.�i. �7 E�x..�.. i�i i��' , m PEHMITTEE NAME(PRItiT) . � �F R/A1 EE � 4� .� � —__'._ _ —_' � ... . ,�..��� �, I �,,. {q SI^NAT � REQPT.NO. � PAID BY c�_����IALIdAT10N � 2 °— � � � -� '��� WHITE�—De artment Co YELLOW—Finance C PINK—Assessor Co GOLDENROD—File Co GREEN— IicanPs Co - P PY� �PY, PY, PY. APP PY „ .., , .,. .... ,� , ,<. . , ,,, ... . . ,,, ... �� , _ ;,<, . . '” �; � � 1 w..._1' ,,:. � ,_: � � ; '. .. ;. , -� . . _ �Tt ,�.: _. ,. _ ... ......: .... :�,� :-..,.� ,w..�.a �y4 9 '..... ..... .. ._ . . . ,.:,;�t fhg' .. � . . . ... . . ... .. ,. , . , .. .. .:. .� .. . - �. . .. .. . . .. .. . . °a � � .�..� �. � � � . 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