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^ _��� CITY OF DIAMOND BA� � DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES ,�� , 21660 E.Copley Drive Suife 190 �� ;,,,., (909)860-3195 Fax(909}861-3117 ,�i PRESS s�°. BUII,DING P�R'1�T1'�A1��LICATION � _ _... i1 , ; _' �f FIRMLY a DDRESS_.�2�j_9---�����C� 11 K � �,.... '' SSUE A .` " ' , ,..,., TION ��� ��� PERMIT I�`7 P/C o DATE NUMBER��# � APN LOT�_ TRACT ��q��� DATE ONST. GROUP p OWNER V " ADDRESS ZONING SETBACKS 0 � CI'PY ZIP 91���- TEL��,� FRONT Ryy � APPLICANT TEL. )Sr'2�3k�.k' REAR r-J SIDE/SIDE STREET RW � � CdNTRACTOR���i��f'1Fl_(',,�-O�U� SIDE � � ADDRESS gb*, t��(�.. (�p ��p2. � CI�Y /�{Z(�Q'�� ZIP�j nO'� TEL(.��g����'Q P�OPOSED 11SE o ARCWENG! z DESIGNER a AdDRESS NO.DWEL. NO. NO. cn UNITS STORIES BEDROOMS � CIIfY ZIP TEL. � DESCRIPTION SQ.Fl: FACTOR PSF ADJ.AREANALUATION pC OWNER-BUILDER DECLARATION p SFR/AODlREM � I HEREBY AFFIHM UNDER PENALTV OF PERJURY THAT I AM EXEMPT FROM THE CANTPACTORS lb Gafe B/C2 Ort W CENSELAWFORTFIEFOLIOWMGREASON(SEC.7o31.5BUSINESSANDPROFESSIONSCO�E:ANYCiTYOF (n 9 � U COUMYyyHICMPEOUIRESAPERMtTTOCONSTRUCT,ALTER;IMPFlOVE,DEMOUSH,ORREPAIRANYBTRUP W Pdtlo/Ded( W IURE,PRIOii TO Ii5 ISSUANCE,AI.50 REQUIRES THE APPLICqNT�FOR SUCH PERMIT TO FlCE A 51�NED W � � � � STATEMENT THAT HE Ofl SHE IS L�CENSEO PUIiSUANT�TO THE PRDVIS�ONS OF THE CONTRACTOitS U� � CEtJSE LAW(CHAPTEH 9(COMMENGYNO WITH SECTION 7000)OF OIVISIQN 3 OFTHE 9USINE3S AY,VD PRO- POOUSPd FESSIONSO�DE)OHTiA7NEORSHEISEXEIAPTTHEREFqOMANDTHEeASISFURTNEALLEGEDEXEMP- (� TKKJ.ANYVqLA710NOFSECTION7031.5BVANYAPPUCANTfOflAPERMITSU&IECTSTHEAPPLI�ANTTO Z Re-Raof � ACIVILPENALIYOFNOTMORETHANFIVEHUNDflEDDOLLAFi5�S5ao).J: � � � � � DI,ASOWNEROFTHEPROPEHTY,ORMYEMPLOYEESWITHWAGESASTHEIRSO�ECOMPENSATION, � COfItR1BfC13I . - Wlll.DO hIE WORK�ND THE STRUCTURE IS NOT INTEPDEO OR OFFERED FOR SALE(SEC.7041,BUSI- J � NESS AND PROFESSIONS CODE:THE CONTRACTORS LICENSE UW OOES NOT APPLV TO AN OWNER OF � PRQPERTY NRiO BU0.DS OR IMPROVES THEPEON,AND WHO�OES 5UCH WORI(NIAISELF OR HER5ELFOq ' � THROl1fiFIHiSORHERONMEMPLOVEES,PROVIDEDTHO.tSUCIi}�pROVElAENTSitRENOTIMENDED�OR m O OFFEREDFOqSALEIF,HOWEYER7NE8UiLAINGOpIMPROVEMENTISSOL�W1iHINONEYEAROFCOMPLE- � TION,THE OV/NER�UILDER WILL HAVE TiE BURDEN OF PROVING THAT HE OR SHE DID NOT BUIID OR IMPROVEFORTHEPURP09EOF3ALE). � � w ❑I,ASDWNEROFTHEPROPEHYY,AMEXCLUSIVELYCqNTRACTWGWITHLICEN5E0CQNTflACTORS � TO CONSTRUCTTHE PROJECT(SEC,7a4,BUSWE55AND PROFESSIONS�COD�:THE CONTpACTORS U- ValUBtiOn ADJ.AREA W GEk5EUW00E5NOTAPP4YTOANOVYNEROFAPROPEHTYWHOBUILDSOR�IMPROVESTHEREON,AND � WNOCONTfiACTSFORSUCHPR0.IECTSWITHACANTRACTOR(5)LICENSE�PURSt1ANTTbTHECONTRAC- QUANTIT' DESCRIPTION roRs ucEwsE uw.>. FEE - �� ❑IAM E7(EMPT IINDER S�C. p.8 PC.FOR THIS qEASON Q � U �'A' DATE OWNER }– � O W �q LICENSED CONTRACTORS DECLARATION W OL 1 HEREBYAFFIRM UNDER PENALTY OF PERJURV THAT I AM LICENSL�UNDEF PROVISIONS OF CHAPTER � p� B(COMMENCINQ WITN SECTION 7000)OF DIVISION 3 OFTHE BUSINESS AND PROFESSIONS CqDE,AND Z �ti� MY lICENSE IS IN NLL FORCE AND EFFECT. � o LICENSE ClASS__� LIC.NO.�C]�� /� � v DATE IZ-'�"�,O='�'T� CONTRACTOR-�� �L _�r.�Q �� w � WORKERS'COMPENSATION DECLARATION ��–�j(�ZOO Q � I HEREBYAFfIRM UNpER PENALTV OP PERJURY ONE OF TNE�FOLLOWING DEClARATIONS:� � �Z � �IHAVEANDWILLMAINTAINACERTIFICATEOFCONSENTTOSELF-INSUqEFORWORKERS' _ COMPENSA710N,AS PROVI�ED 8Y SEGTION 3�a00f THE tABOR CODE,FOF THE PERFORMANCE .U Q OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. � � __I HAVE AND WILL MAINTAIN WOqKERS'COMPENSATION INSURANCE,AS REOt11RED DY SECTION Q 3700 OF THE LABOR CODE,fOR THE PERFORMANCE OF hIE WORK FOR WNJCH THIS PERMIT IS ISSUED.MV WOflNEflS'COMPENSATION INSURANCE CAFRIEF AND POLICV NUMBE{i ARE: CONSTRUCTION J .... . ....__..... ................... y caRR1ER _.___ P REVIEW ZPOLICY NUMBER TR Q � (trisscclaNe��woreema�rmoF'r��raar�swnon�eraroFle�oounas�Eim�oaiess�. PLUMBWG Z i CEHTIFYTHAT INTHE PERFORMANCE OFTHE WORK FOR WHICHT415 PERMITIS ISSUE�,i MECHANICAI. (!S SHALL NOT EMPLOYANV PERSON IN ANY MANNER SOAS TO 9ECOME SUBJECT TO 7HE � WORKER5 COMPEtSATION LAWSOF CALIFORNIA,PND AGREETHAT IF I SHOULD BECOME INSPECTIqN fEE SUBJEC7 TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR CODE,�SHALLFOqTHWITNCOMPLYWITHTHOSEP OVI310NS. ISSUANCE � p �ATE:_�.�Q=�� APPLICANT: --_�,,� . SMIP �I}' J WAflNING:FAILUAE TO SECURE WORKERS'COMPENSATION CAVERAGE IS UNLAWFUL,AND SHALL BE ENERGY P1C W SUBJEC?ANEMPLOYERTOCRIMINALP�NALTIESANDCIVILFINESUPTOONEHUNOREDTHOUSqND �NERGYPERMIT � DOLLARS(5100.000).IN AODITION TO THE COST OF COM?ENSATION,DAMAGES AS PROVIDED FOR IN SECT70N37oeOFTHELABORCODE,INTEREST,ANDATTORNEI^SFEES. RETENTIONFEE: OCONSTRUCTION LENDING AGENCY PRE-ALT FEE: � I HEREBYAFFIRM UNDER PENALTY OF PERJURY TMAT THERE IS ACONSTRUCTION LENOING AGENCY FOR THE PERFORMANCE OF"fHE WORK FOR W IiICH TMIS PERMIT 15155UEO(SEC.30 W,CIV.CJ. Z W � LEN�ER'S NAME - ' I— LENDER'S0.DORESS � ICERTIFVTNATIFWVEREA�7HISqPPLICATIONANDSTATETHATTHEABOVEINFORMATIONISCORRECT. f TOTAL f EES W 1 AGREE70 CAMPLV WITHALL CIN AN�CDUN7Y ORDINANCES AND STATE LAWS RELATING TO BUILDING - .' � � CQNSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF7HIS COUNTVTO ENTEfi UPON THE Z ABOVE-MENTIONED PROPEHTY FOR INSPECTIDN PURPOSES. - - . . . , � COMMENTS - � �4 �L.. ��lU ¢ VEFAIRTEE NAME(PRINT) ' .., .' ... . � 9�-a��l�, 12-10-y&' � SIOWANqEOFPERMITTE OATE . � � . . RECPT.NQ. PAID BY _VALIDATION WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENROD--Fie Copy,GREEN—Applican¢'s Copy ...�. ...;,,. . .... .... .: .. . . . ,... . .. ..� . .'��:r, y _,. ,..... .:,,.. ., .�... .. __ ._. ..1,� ,. �� � � ,:.. � � ���"� . �, .� .. .:�... . . , _ _ , .. . � � � � � � � , � � � �x ,. g _ ,. �. � � � ;,�=����~� � ` i �=t�����c����' _� �� � ,-� ��a � �,� �;��,� ,,�-��, _;_ �_ _$_ _ _; ��;����r��-� � � � � —,��.-�— �---- �:���.�i�i!;��a"��.;�'���_. � _._ _d�i ..�..____.�..__��_��� ��a�$��-t-t' �_,�'�'°�E��?�.1'�'i ` �____�___�` �T � s _._. . _..E.,.. �.. - �gp� �w,g���r. �i^_^q^y""'� . _ } ....,.�_v�t„"'^"^.4m^'�"'""..^,_.w.^..'^.,..,^'� 1�'_�,�.,p��-t b.e ��.�la�d�� ; ..-......�- t V'73�$"'3 ��,iL.,::"i 1.d'���iC,.�34J_��g�... ��e...a--..:�`` �. 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