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Home My WebLink About17233 CTI'Y OF DIAIvIOND BAR � EXPIRED � - "�� ---� DEPARTIvIENT OF COMMUNITY&DEVELOPMENT SERVICES Ziszs E.cop►ey��e , �U(d 19 1002 (909)860-3195 Fax(909)861-3117 PRESS �� BUILDING PERMIT APPLICATION FIRMLY � JOBSITE APPLICATION I ,}PERMIT 1 p/C o ADDRESS I_ 3��S 1/Ur��i� ��l-/ L DATE � �� I��v 1 NUMBER I—/� g � APN LOT TRACT �SSUE TYPE OCC � —y-/ ---�--- DATE CONST. GROUP OWNEF M 1�� 1 P 1� 1�� p ADDRESS - ZONING SETBACKS �"' CITY I�P�j� TEI. FRONT RW ❑ APPLI NT � TEL. REAR � � SIDE/SIDE STREET RW O � CONTRACTO F SIDE � � ADDRES � GTY ' ZIP TEL�IL'4 I�7 PROPOSED USE � • C''''• � oARCH/ENG/ z DESIGNER a ADDRESS NO.DWEL. NO. �•4 ,(' �1�]�N . � CITY ZIP TEL. UNITS STORIES BEDROOMS � DESCRIPTION SQ:FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER DECLARATION O SFR/ADD/REM p 1 HEREBV AFFIRM UNDER PENALTV OF PERIURV TMAT I AM EXEMPT FROA/THE CONTRACTORS U� G8f8JB/CBfPOR W CENSEUWFORTHEFOLLOWINGREASON(SEC.70.71.SBUSWESSANDPROFESSIONSCODE:ANYCITYOR (n ZCOUNTVWHICHREOUIRESA7ERMITTOCONSTRUCT,ALTER,IMPqOVE.DEMOLISM,ORREPAIRM7YSTRUC- W P8I10/D6CI( w TURE,PRqR TO ITS ISSUANCE.AL50 REOUIRES THE APVIICANT Fpq SUCM PE{iMIT TO FI�E A SIGNED w � STATEMENT THAT ME OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI� � CENSE LAW(CMMTER D(COMMENCINO WITH SECTION 7000)OF DIVISION 7OF THE BUSINESS qND PRO- � POOUSPO � FESSIONSCODE)ORTHATHEORSHEISE%EMPThIEREFROMANDTHEBA515FOHTFIEALLEGEDE%EMP• � TION.ANV VqLATqN OF SECTION 70]1.5 BV ANY APPLICANT FOR A PERMIT SU&IECTS THE APPLICM7T TO Z Re-Roof O � A CIVIL PENALTV OF NOT MOqE T11AN FNE MUNORED DOLUAS(f600�.): � ❑I,ASOWNEROFTHEPFOPERTY,ORMVEMPLOYEESWITHWAGESASTMEIRSOI.ECpMPENSATION, COrtIrt10�CidI Z 'WIIL 00 TME WORK,M!D THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC.7W�,BUSI� � � � NE55 MID PqpFES510NS CODE:TME CONTRACTORS LICENSE LAW OOES NOT APP�V TO AN OWNER OF � PROPERTY WHO BUILDS OR IMPROVES THEREON,AND NT10 DOES SUCH WORK HIMSELF OR HERSELF OR w THROUGH HIS OR MER ONRJ EMPLOVEES,PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENOED OR m � � OFFEREDFORS�LEIF,HOWEVERTMEBUILDINGORUAPROVEMENTISSOIDWfTHINONEVEAROFCAMPLE- Z TION,THE OWNER�BUILDER WILL HAVE THE 6URDEN OF PROVINO TMAT HE OR SHE DID NOT BUILD OR , � IMPROVE FOR THE PURPOSE OF SALE). ' , ' � �y,� ❑I.AS OWNER OF THE PROPEHTV,AM EXCLUSNELV CONTRAC7IN0 WITH LiCENSED CONTRACTORS Q TO CONSTRUCT 7HE PRQIECT(SEC.70u,BUSINE55 ANO PROFESSIONS CODE:THE CONTRACTORS U� VaIU8�I0f1 ADJ.AREA L11 CENSE UW DOES NOT APPLV TO AN ONRJER OF A PROPERTV WHO BUILDS OR IMPROVES TMEREON,AND � y N?1000NTRACTSFORSUCHPq0.1ECTSWITHACONiRACTOR(S)LICENSEDPUHSU�VITTOTHECONTqAG QUANTITY DESCRIPTION FEE Y TORS LICENSE UW.�. . . � ❑�AM EXEMP7 UNDER SEC. -� Q B.8 P.C.FOR TNIS REASON � � U � � DATE OMMER ~ U � LICENSED CONTRACTORS OECLAFATION � w . � � � I HEREBV AFFIRM UNDER PENALTV OF 7E0.1URY THAT I AM LICENSED UNDER PROVISIONS OF CHAGTER � . d Y(COMMENCIN(i WITH SECTION 7a00)OF DNISION 3 OF THE BUSINESS AND PROFESSIONS CODE.AND Z w MY UCENSEISINFULLFORCEAND EFFECT. O C { �J m � LICENSE CLASS �� LIC.NO. ✓� ! � � . � � wD4TE / ) CON7AACTOR � / � a . . �. � ORKERS'COMPENSATION DECLARATION � � I HEREBV AFFIRM UNDER PENALTY OF PENURV ONE OF TME FOLLOWING DECLARATqNS: U � Z � _1 HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR V/ORKERS' a � _ � COMPENSATION,AS PqOVIDED BY SEC710N 37000F THE LABOR CODE,FOR THE PERf-0RMANCE U� � OF THE WORK FOR WMICH THIS PERMIT IS ISSUED. W � � � w _I HAVE AND WILL MIJNTAIN WORKERS'COMPENSATION INSUILWCE,AS REOUIRED BV SECTqN Q 3�0o OF THE LABOR CODE.FOR THE PERFORMANCE OF THE WORN FOR WHlpi THIS PERMIT IS , � � . � ISSUED.MY WORKERS'COM ENSAATION INSUfLWCE CARRIER AND POLICY NUMBER ARE: CONSTRUCTION ' � ,a��+�+ � CAARIER •/ �T ��j�1�-�• PLAN REVIEW � � Pq.ICY NUMBER ' �7�_3-�`_t�)� � Z �r----- ELECTRIC ¢ o (iH1S5ECTqNNE�NOT8E00MPLEfmpFT1#pEqM{IS{i�qp,tEHUpqEpppU3iS(flpplpq�ESS� PLUMBING Z �CERTIFV THAT IN THE PERFORMANCE OF THE WORN FOR WHICH THIS 7ERMIT IS ISSUED,I MECHANICAL U' SHALL NOT EMPLOY ANV PERSON IN ANY MANNER SO AS TO BECAME$U&IECT TO THE ' (/� WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHW�D BECOME INSPECTION FEE � SUBJECT TO THE WORKERS'COMFENSATION PROVISIONS OF SECTION 37000F THE LABOR ��— S CODE,I SMALL FORTHWITM COAIPLY WITH TH0 PROVIS�. ISSUANCE o �.`p OATE: IL� C �, APPLICANT: � � Z�L�I L, ' SMIP �i J ENERGY P/C J WARNING:FAfLURE TO SECURE WORKERS' PENSATIUY CAVERAGE IS UNUWFUL.AND SHALL BE � SUBJECT AN EMPLOVER TO CRIMWAL PENA�TIES AND CIVI�FINES UP TOONE HUNDRED THWSAND ENERGY PEFMIT � DOLLARS(ft00.0o0),IN ADDITION TO THE COST OF COMPENSATION,DAA/�GES AS PROVIDED f-0R IN � SECTqN�7oe OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. RETENTION FEE:� � � ' W O CONSTRUCTION LENDING AGENCY � PRE-ALT FEE: � I MEREBY AFFIRM UNDER PENALTV OF PERIURV THAT THERE I$ACONSTRUCTION LENDING AGENCV FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.70G7,CIV.C.�. Z W � LENDER'S NAME � . . � ~ LENDER'SADDRE55 w I CERTIFV THAT I NAVE READ THIS APPLICATION AND STATE THAT TME ABOVE INFORAIATION IS CORRECT. TOTAL FE ES 1 1�J 1 � 4� � I AGREE TO CAMPLV WITH ALL CITV AND COUNTV ORDWANCES ANO ST�TE UW$RELATINC TO BUI�DING 1 —` \,� J � CANSTRUCTION,AND MEREBV AUTHORIZE REPRESENTATNES OF THIS COUMY TO ENTER UPON THE � . Z ABOVE-MENTIONED PROVEFTV FOR INSPECTION PURPOSES. COMMENTS O � —' � �v<<`.. �-� � m PERMI Q � � SIG E � . DATE ' � � � RECPT.NO. PAID BY VAUDATION � WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENR D--File Copy,GREEN—Applicant's Copy � 5�(e,a�"1�� C� �a � (Z'a � ��%�