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- '� I — CITY OF DIAb40ND BAR COMMUNITY DEVEI:OPMENT DEPARTIvIENT R *';,.�; 21660 E.Copley Drive Suite 190 (9D9)860-3195 Fax(909)8G1-3117 � PRE`SS �''�" BUILDING PERMIT APPLICATION FIRMLY o DDR'ESS ��� _�C�S c� �/�� e,. ,,,i . pAPEICATION �� R NUMB R #/C o ISSUE TYPE OCC °O APN LOT TRACT DATE CONST. GROUP p OWNER � , � C. �4'P�.�S o ADDRESS ��j-�tC, ZONING SETBACKS QCITY D �9; ZIP�C���;� TEL.����� �RONT _ RW � APPLICANT TEL. REAR ❑ � SIDE/SIDE STREET RW ❑ QCONTRACT R � �.b�bt`�: °�� SIDE � ❑ o ADDRESS_�l; -��- �^y�"CR�_ PROPOSED USE CITY �-d.-Q ZIP 7 7� TEL. ��%''I' ,�"� o ARCH/ENG! W DESIGNER NO.DWEL. NO. NO. � ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-BI:IL�Eft DECLARATION SFR/ADD7REM Q I HEREBY AFFIRM UNDcR PENALTY OF PERJURY THAT I AM EXEMPT FROPA THE CONTRACTORS LI- � Garage/Carport W CENSELAWFORTHEFOLLOWINGREASON(SEC.i031.5BU51NE55ANCPROFE5510NSCO�E�.ANYCITYOR C? COUNNWHICHRE-0UIaESAPEFMITTOCONSTRUCT,ALTER,IMPROVE,DEMOLISH,ORREPAIRANVSTRUG W Patio/Deck z TURE.PRIOR TO ITS ISSUANCE,ALSO REDUIReS THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED w W STATEMENT THAT NE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS O�THE CONTFiACTOflS LI- � CENSE LAW(CHAPTER 9(CCMMENCING WITH SECTION 7C0o)OF DIVISION 3 OF THE At1SINE5S ANn hHO- u' POOUSp2 � FESSIONSCADE)ORTHATHEORSHEISEXEMPTTHEREFROMAND'HEBASISFOFTHEALLEGEDEXEb1P- (� � T�ON,ANYVIOIATIONOFSECTION7031.50YANYAPPIICANTFORAPE�MITSU6JECT5TH[AFPLICANTTO Z Re-Root ACNILPENALTVOFNOTMbRETI1ANFNEFiUNDREDDOLLARS��5500).j:�� �-�"�" �" ZQI.ASOVlNEFOFiHEPROPEFiiY,ORMYEMPLOYEESWiTHWAGE5A5TMEIRSDLECOMPENSATION, � Commercial WILL DO THE WORK,AND THE STRUCTURE IS NOT IN7ENDED OR OFFERED POR SAI.E(SEC.7044,BUSb J NE55 AN�PROFESSIONS CODE:THE COMRACTORS LICENSE lAW DOES NOT APPLY TO AN OWNER OP � PROPERTYWHOBUILOSORIMPROVESTHEREON,ANDVlHO�DESSUCHVJORKHIMSELFORHERSELFOR � C[ THROUGHHISORH[ROWNEMPLOYEES,PROVIOEDTHATSUCHIMPROVEMENTSARENOTINTENDEDOR m W OFfEREDFORSALE.IF,HOWEVER,THEBUILDIN(30RIMPROVEMEN?I5SOlDWITI�{�NONEYEAROFCOMPLE- � TION,THE OWNER�BUILDER WILL HAVE THE EUR�EN OF PflOVING THAT HE OR SHE DID NOT BUI�D OR � IMPROVEFORTHEPURPOSEOFSALE�. _ ❑I,ASOWNEROFTHEPFiOPERTY,AMEXC:.US'�VcIYCONTRACTIVGWIiHLICENSEDCONTRACTORS OWC TO CONSTRUCT THE PROJECT(SEC.7044,BUSWESS AND PROFESSIONS CO�E:THE CONTRAC70RS LI- Valuaf:on ADJ.AREA W CENSELAWDOESNOTAPPIVTOANOKRJEP.OFAPROPEftTYWHOBUILDSORIMPROVESTHEREON.AND � WHOCANTRACTSFORSUCHPROJECTSWITHACONTRAC`OR($�UCENSEDVURSUANTTOTHECONTRAC- QUANTITY DESCRIPTION FEE Y TORS IICENSE LAW.). � J O ❑I AM EXEMPT UN�ER ScG B.&P.C.FOft THIS qEA50N Q � � � � DATE OWNER r Z U W � LICENSED CONTRACTOR$DECLARATION W CL IHEREOYAFFIRMUNDERPEVALTYOFPeRJURYTHATIAMLICENSEDUNDERPROVI510NSOFCHAPTER � �+ p. 9(COMMENCING W'RH SECT'.ON 7000)OF DIVISION 30F iNE BUSINESS AND PROFESSIONS CODE,AND Z P S "f I � C X MYLICENSE IS IN FULL FORCEAND EFFECT. O �"�?, -� LIC.NO. ��� �� � ! m ,.... ._ . . . .. � UGENSE GLA55 s �7 � ~ DATE ��'I�'C� � COMfthCTOR I'�. '�1�.���(^�_ ��Z. 0- V � �'���� /� � � WGRKERS'COMPENSATION DECLRRATION —� + ¢ � IHEREBYAFFIRMUNDERPENALTYOFPERJUftYONEOfTHEFOLLOWINGDECLAPATIONS I '�1 Z V Q 0 IH0.VEANDWILLMAMTAINACERTIFICATEOFCONSENTTOSELF�INSUREFORWORKERS' _ COMPENSATICN,AS PROVIDED BY SECTION 3�oa OF THE�ABOR COOE,FOF THF PERFORMANCF, U Q OfTHE WORK FOFl WHICH THIS PERMIT IS ISSUED. - � � W �I HAVEAND WILLMAINTAIN WORKERS'COMPENSATION INSURANCE,AS REOUIRED BYSECT.ON Q 3�OOOFTHELA80RCO0E,FORTHEPERFORMANCEOFTHEWOfiKFOflWHICHTHISPFRMITIS ISSUED.MV WORKERS'COMPENSATION'�INSJRANCE CARRIER AND POLICV NUMBER ARE: CONSTRUCTION Q / �. CARRIER �S"���y��s� etlq`'l<`r11.4�I� PLAN REVIEW zPOUCY NUMBER W'V.[_�a I-�°�� ______=� EL� � Q � (IHISSECTIONNEmNOTBECO��dPLE7'EDOFTHcPERMfTISiORONEHUt�DRF.�ObL1AR5(E10�ORIESS). P�UMBI � z f CEHTIFY THAT INTHE PERFORMANCE OF THE WORK FOR WHICHT:-IIS PERMIT IS ISSUED,I MECHANICAL (,'3 SHALLNOT EN�PLOYANV PERSON IN ANY MANNEP SOAS TO BECOME SUBJECTTOTHE � WORKERS'COMPENSATIONLAWSOFCAL'�FORNIA,ANDAGFEETHA'I-'ISHOULDBEC061E � INSPECTIONFEE - � SUBJECTTOTHEWORKERS'COMPENSATIONPRCVISIONSOFSECTION37000FTHElA80R '�+�y� 111►, s�.� [,,-.� � CO"O�E,ISHAf'�_pLF{ORTHWITHCONPLYWITHTHO}�EPROVIS�ONS. ISSUANCE ��*a. _l._ ._.._..._._____ _Jl � �d`l E��P 47 APPLICANT: .Jv' '""^'^'+.—�^^^'" SMIP �IM�" p DATE: J WARNING:FAILURETOSECUREWORKERS'COMPENSATIONCOVERAGEISUNLAWFUL,ANDSHALLBE ENERGYP/C LL SUBJECTANEMPLOYERTOCRIMINALPENALIIESANDCMIFMESUPTOONEHUN�REDTHOUSAND �! DOILARS($1oa,Coo),INADDITIONTOTHECOSTOFCOMPENSATION,DAMAGESASPROVIDEDFORiN ENERGYPERMIT �� � SEGTION 37G8 OF THE LABOF COOE,INTEflEST,AND ATTORNEY'S�ees. RETENTION FEE: �� � a CONSTRUCTION LENDING AGENCY PRE-ALT FEE: O � IHEREBYAFFIRMUNDEFPENALTYOFPERJURYTHATTHEREISACONSTFUCTIONLENDIN�AOENCY � FORTHEPERF09MANGEOFT�-IEWORKFORWMIGHTHISPERMITISISSUEO(SEC.309],CIV.CJ, Z W � LENDER'S NAME _ . . . F— LENDF_R'SADDRESS w ICERTIFYTFATIHAVEflEADTHIS/1PPLIGATIONANDSTATEI'NATTHEABOVEWFORMATIONISCORRECT. TOTAL FEES � �/� � �, 7 � I AGREE TO COMPLV WI7H ALL CITY AND COUNT'f ORDINANCES AND STATE L4'NS REIATWG TO BUILDING � . `.-� �„ CONSTRUCTION,ANDHEFiEBYAUTHORI2EREPRESEN7AT!VESOF7HISCOUNTV70ENTERUPONTHE , ; . z ABOVE-MENTIOM1E�?ROPERTYFORINSPECTIONPURPOSES. COMMENTS � � �7 — � k� ✓�a9"S � m PERMITTEE NA��RINT) { Q ��a _-- . - -I!�'. Cn /4_ /��p � SIGN REOFPERMITTEE � �� � DA7e� �' ' � �� - s P r�(T,,� ) _ �� • � - � RECPT.NO. PAID BY ` �ATI��� l/�� ~ WHITE—De artment Co YELLOW—Finance Co PINK—Assessor Co GOLDENROD--File Co GREEN—A IicanPs Co ` �' '�' ��'�'�' �,�"'�' -'�� P pY. PY. PY• PY. PP PY�.. .. „ .. . . h, .,,. , ;. , ,: . . . . .. . 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