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�' CITY OF DIAMOND BAIt - - ��'� DEPARTMENT OF COMMUIVITY&DEVELOPMENT SERVICES � � 21660 E.Copley Drive Suite 190 (909)86t}-3195 Fax(909)861-3117 PRESS A�'�� BUII,DINGPERMITAPPLICATION _ FIRMLY . o� JOBSITE �(1� Q' p'� ��,� APPLICATION � PERMIT �� P/C ADDRESS � 0 �� _ DATE NUMBER # � APN L T CT ISSUE TYPE OCC �� �+����\ DATE CONST. GROUP p OWNER `�-- p ADDR SS R% , 1�('t�-. � ZONING SETRACKS W CITY � ZIP '� d�fEL?' � O -�l=1� '- FRONT _ RW ❑ � APPLICANT ..kTEL:'? � � '� REAR ❑ SIDE/SIDE STREET RW ❑ � CONTRACTQ� -T; "_ SIDE ❑ ADDRE S � �"a '�( � CITY ZIP ' d�cTEL���' PROPOSED USE w ARCH/ENG/ �z DESIGNER NO.DWEL. NO. NO. a ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � v� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION ¢ OWNER•BUILDEq DECLARATION SFR/ADD/REM O Q 1 HEREBY AFFlRM UNDER PENILLTY OF PERJURV THAT 1 AM E%EMPT FROM THE CONTRACTORS LI- G8f890/CetpOft W CENSELAWf-0RTHEFOLLOWINGREASON(SEC.70315BUSINESSANQPROFESSIONSCODE:ANVCITYOR (n U COUNT`/WHICHREOUIRESAPERMtTTOCAN57RUCT.ALTER,IMPROVE.�EMOLISH,ORREPAIRANYSTRUC- W Pg110/DBCk TURE,PRIOR TO ITS IS&UANCE,PLSO REDUIRES THE APPLICAN?FOR SUCH VERMIT TO FILE A SIGNED W STATEMENT 7HAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS U- W c CENSE UW(CHAPTEH e(COMMENCINO WI7H SEC710N�000)OF DIYISION 3 OFTHE 6USINESS AN�PFO- LL PooUSpa _ y PESSpNSCODE)ORTMTHEORSHEISEXEMPTTHEREFROMANDTHEBASISFORTHEALLEGEDEXEMP- � TION.ANVVIOU710NOFSECTION7031.66VANYAPPLICANTFORAVEFMITSU&IECTShIEAPPLICANTTO Z Re-Raof � A dVIL PENALN OF NOT MORE THAN FNE HUNDRED DOLLARS(SSoo).): � ❑I,ASOWNEROFTHEPROPERTV,ORMYEMPLOYEESWITHWAGESASTHEIRSOLECOMPENSATIDN, � Commarcial - VALL 00 THE WOAK�1D THE STRUCTURE IS NOT IMENDED OR OFFEfiED FOF SALE(SEC.7044,9U51- J � NESS AND PROFESSiONS CODE:hIE CONTRACTORS IICENSE LAW OOES NaT APPLY TO AN OWNER OF ? PNOPERTY WHO BUILDS OR IM7ROVES TMEREON,AND WHO OOES SUCH NbRK HIMSELF OR HERSELF OR � THqOUGHHISORHEROWNEMPLOVEES,PROVIDEOTHHTSUCHIMPROVEMENTSARENOTINTENOEDOq m GOFFEHEDFORSALEif,HOWEVER,THEBULDINGORIMPPOVEMEMISSotDWITHINONEVEAROFCOMPLE- Z TION,THE OWNEfl�BUItAEfl WILL HAVE THE BURDEN OP PROVING THA7 HE OH SHE DID NOT BUILD OR � IMPROI/EFOR7HEPURPOSEOFSALE). W ❑I,ASOWNEROFiHEPROPERIV,AMEXCLU5IVELVC�NTRACTINGWITHLICENSEDCONTRACTOPS � TO CONSTRUCT THEPROJECT(SEC.)OM,BUSINESS AND PROFESSIONS CADE:THE CONTRACTORS l4 V01U8tI0f1 ADJ.AREA � CENSEUWDOESNDTAPPLVTOANOWNEHOFAPROPERTVWHOBUILDSORIMPROVESTHEREON,AND WFiOCOMRACT5FOR5UCHPROJECTSWITHACONTRACTOR(S)LICENSmPURSUANTTOTHECONTRAF QUANTITY DESCRIPTIO FEE � TORS LICENSE LAW.). � ❑I AM E%EMPT UNDER S�C. _8.8 P.C.FOR THIS REASON U �� u�� , � � . �ATE OWNER � � LICENSED CONTRACTORS DECLARATION W � I HEREBV�FFIRAI UNDER PENALTV OF PERJUFY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER � � 9(COMMENCINO WITH SECiION 7000)OF DIVISION 3 OFTHE BUSINESS AND PROFESSIONS CODE,AND z ��� MY LIGENSE IS IN FULL FORCE ANO EFFECT. m 0 UCENSE`C�L.ASS " LIC.NO._�-;2�� j V DATE '�C�� �` ��� � CONTRACTOR d W � WORKERS'CQMPENSATION DECLARATION Q � IMEREBYAFFIRMUNDERPENALTVOFPERJURYONEOFTHEFOLLOWINGDECLARATIONS: U � 4 � I HAVE MI�WILL MAIN7AIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOH WORKERS' 2 PENSATION,ASPROVIDEDBYSECTON37ooOFTHEIABORCA0E,F00.THEPERFORMAHCE U Q OF THE WORK FOH WHICH THIS PER�11T IS ISSUED. � � W I HAVE ANb WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REOt11RED BY SEC710N Q 370o OP THE LAAOR CODE,FOR THE PERFORMANCE OF THE WORK FOFi WHICH THIS PERMIT 15 ISSUED.MY RS' PENSATION {1RANCE CAqj�/R AND POLICV NUMBER ARE: CONSTRUCTION � CARRIER�`� � �� ,---+ �c,lS PLANREVIEW � /9 r' QPOLICYNUMBER ���""� ' �l1 ' 6� ELECTRIC � � 0 (tHl55ECTI0NNE�NOTBE00bPLETEDOF7HEPEFU.MTISFORONEHUNDRmD01.LAR>(5100)ORLESS� PLUMBING Z I CERTIFV hiAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I MECHANICAL �,j' SHAIL NOT EMPLOY ANV PERSON IN ANY MANNER 50 AS TD BECOME SUBJEC7 TOTHE i ; � WORKERS'COMPENSATIONLAWSOFCALIFORNIA,AN�AGREETHATIFISNOULDBECOME INSPECTiONFEE S , SUBJECT TO THE WORKERS'COMVENSA'ION PROVISIONS OF SECTION a7o00F THE LABOR s�� CODE,I SHALL FORTHWITHCAMPLY WI7H TH4SE PROVISIONS. ISSUANCE � SMIP p , OATE: APPLICANT: . ���(�� . J WARNINd:FA1LURETDSEGUREWORKERS'COMPENSPTIDNCOVERAGEISUNLAWFUL,ANOSHALLBE ENERGYP/C .1.\.LLN__ � SU&IECTAN EMPLOVERTO CRIMIN/LL PENALTIESAND CIYIL FINES UPTOONE HUN�REDTHOUSAN� ENERGV PERMIT v v•- DOLLARS(f 100,000�,IN A�DITION TO THE COST OF COMPEN SATION,UAMAGES AS PROVI4E�FOR IN � SECTION 3i08 OF THE LABOR CODE,INTEREST,AND ATfORNEY'S FEES. RETENTION FEE:� a CONSTRUCTION LENDING AGENCY pRE-ALT FEE: �U� � IHEREBYAFFlfiMUNDE PENAL7YOFPERJURYTHATTHEREISACONSTRUCTIIXJLENDINGAGENCY FORTHEPERFOHM C OFTHEWORKf-0RWHICHTHISPERMITISISSUEo�SEC.3o97,CIV.C.). Z w f.�1f'��i � LENOER'S NAME 1= LENDER'S ADDRESS � TOTAL FEES � 1 CERTIFV THAT 1 HAVE REAUTHIS APPLICATION AN�STATE TMPTTHE ABOVE MFORMATION IS CORFECT. � �,� W I AGREE TO COMPLV W1TH ALL CIN AND COUNTV ORDINANCES ANO STA7E UWS RELA7ING 70 BUILOING � CONS7RUCTION.AN�HEREBVAUTHORIZEHEPRESEN7ATIVESOFTHISCOUNTVTOENTERUPONTHE ZABOVE•AIENTIaNED PROPERTV FOH INSPECTION PURPOSES. COMMENTS ��, �,.�f c aE EE NAME.(PR �„ p"�7 �- N SI6 EOFPERMITTEE OATE � RECPT.NO. � PAID 8Y � VALIDATION WHITE—Departmant Copy,YEILOW—Finance Copy,PINK—AssessorCopy,GOLDENROD—File Copy,GREEN—ApplicanP Copy ��`� 1 �� --'' � "�� . _ _ � . _ � � •� , , � � ; m � � _ � . q � � � _ , . , :. � . �, _:: �. � � u ��. �. � ... ��`� ��,�,� ' � � _ : 3 �� . - � � [ Ft t�C:?Ft J.J�;��" �..� �_�._ t.� ;� F�"t=��t%—(���2�r�F`�EL __ ' i F6-�A�?�t�Et!:S � __. - � i _a.��__�__m__ _ ,. �E..����"I�.£`.��`ai.I�J� �. i _____._W _._�._.�._ �;�lJ�l��t� FLxt��€���?CT"�� � _� _ �r�,_,:.J°`�`� �`_�iit�;�i����� �' i � ��_` i �<_.��_�. i� , �1h1C��� �=L��?��c:1h.I�}�JIT _,. � . �'s yy �y �^' _.._..,._�___.___._ g�''q}'''g �y �.L p ti��f-'�'� V:11'$�'@�..m ..._._._...._ .............__..._,...��m..� f-_-I (`-L�""�31:..1'71..d�$�4..✓'�ItlI..BP°I s':..dEV ''1 ....{T � . _ ...p , '.�.. ..,y+a' - � ..� .__._�.,.... � .�^ p� ��p/'*y � . 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