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CITY OF DIAMOl`I13 BAR �� � - ��``�---� DEPARTARENT OF COMMUNITY&DEVELOPMENT SERVICES �_ _ � 21825 E.Copley Driee (909)560-3145 F�(909)861-3117 PRE$S '"z,%Ka�' �UILDINGPEitMIT APPLICATION FIRMLY o� JOBSITE C� �K`�� �+ APPLICATIQ PERMIT ��j�� P/C �� ADDRESS I�I� � �C1I�ASS DATE � ¢°l NUMBER �_[�" 1�lJ1��_._ � ISSUE f ,� TYPE OCC APN LOT "fRACT DATE a CaNST. GROUP � OWNER �� GA-Ql.SO�l OO p ADDRESS �LS LOOKINL�i C�pl'..Ia,SS ZONING SETBACKS Z CITYDtqM0�+10 CatAS� ZiP�.�_1_fD� TEL.�S- -A1�-i(D FRONT RW ❑ � APPLICANT TEL. S DE SIDE STREET RW p I � z m CONTRACTOR G�AUTtI I�WME E�E2~aR SIDE ❑ oADDRESS 1`i'l�fl Gn3TuqA(3W7. PROPOSEDUSE �txx33B� i,s17M�ta�°�' CITY(f�Obl�At3h t��t,.tr� ZIP F3b TEL.�il`�,'932- bll"� Q ARCH/ENG/ z DESIGNER — NO.DWEL. ND. NO. 0. ADDRESS UNITS STORIES BEDROOMS � CITY ZIP�_ i'EL. cn j � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREA/VALUATION p� OWNER-BUILDER DECLARATION SFR/ADD/REM O ' � I HEREBV AFFIRM UNDEft PENALTY OF PERJURY THAT i AM EXEMP7 FROM THE CONTRACTORS LI- GdfdQEICdYPO(F 'i W 'CE7JSELAWFORTHEFOLLOWINGREASON(SEG.]631.5d1151NE55ANDPROFE5510NSGO0E:ANYCITYOR (/� U C�UNTYWHICNREQUIRESAPERMITTOCONSTRUCT,ALiER,IhRPqOVE,DEMOLISH,ORREPAIAANYSTRUC- W Patio/Deck . � Tl1qE,PRIOR TO ITS ISSUANCE,AL50 REOUIqES THe A7PLIGANT FPR SUCH PERMIT TO FILE A SIGNE� � STATEMEN7 THAT HE OH SryE IS LICENSED PVRSUANi TO TNE PROVISIONS OF TNE CONiRACTORS LI- � CENSE LAW(CHAPTER 9(COAAMENCMG WITk SECTION 7000)OF�NISION 30F iHE BUSINcSS AND PftD- �'L' PooUSpa � FESSIONSCO�E)ORTHATNE'ORSHEISEXEMPTTHEREFROPAANOTHE9ASISFORTHEALLEGEDEXElAP- (!J '. � TION.ANYVIOLATIONOFSECTION7o37.5BYANYAPPLICANTFl]RAPERMITSUB,.'ECTSTHEAPPUCANiTO Z Re-Rnof � • r, ACIVIL PENALTY OF NOT MORETHAN FIVE HUNORED DO�LA:qS(ESOD�.�: �� � ❑I,ASOWNEROFTHEPROPER7Y,OFMYEMPIAVEESWITHiNAGESA57HEIR50LECOMPENSATION, � �COfYlfft07C121 ' � Z WILL Do THE WORK,AND THE STRUCTURE IS NOT INTENDE�oR OfFERED FOR SA'_E(SEC.ia44,BUSI- ,_I - � NESS AND PflOFESSIONS CO�E:THE CONTP.ACTORS LICENSE LA4V DOES NOT APPLY TO AN OWNER OF � I . PflOPERTYWFbBUILDSORIMPROVESTHEFEON.AN�WHODOESSUCHYlOflKHIMSELFORHERSELFOR . � 'THROUGHHISORHEqOWNEMPLOYEES,PROVIDEDiHATSUCHIMPROYEMENT5ARENOTINT'eN�EDOR m ' Q .OFFEREDFORSALEIFHOWEVER.THE9UILDMGORIMPROVEMENTI350LDWITHINONEYEAftOFCOMPLE- Z iION,THE OVJNER-BUILDEfl WILL HAVE THE BURDEN OF PROVING?hIAT ME Ofl SHE DID NOT BUILD OR � IMPROVEFORTHEPURPo$EOFSAIE�. ❑I.AS OYM'ER OF iHE PROPERTY,AM E%CLUSIVELY GON7RACTING WI7H LICENSED GONTRACTORS ��. TO fANSTRUGT iHE PFlOJEC7(SeC.7044,BUSINE55 AND PROFESSIONS CODE:THE CON7RACiORS LI- VdIllflllOfl � ADJ.AREA W CENSELAWOOESNOiAPPLYTOANONMEROFAPflOPERTYWHOBl11L�50NIMPROVESTNEPEON,AN� F WHOCOMRACTSFORSL1CHpROJECTSWITHAGOMRALTOR(5)LICENSEDPURSlJAN7iOTHELONTPAC- QUANTITY DESCRIPTION FEE Y TORS LICEN5E IAW.). � ¢� ❑IAM EXEMPi UN�ER SEC. B.&P.C.FOq THIS REASON � � U � � �'�"' OATE OWNEfl U Z w � LICENSED CONTRACTORS DECLARA710N W Q Q IHEREBYAFFIRMUN�ERPBNALTYOFPERJURY7HA71AMLICENSEDUNDEflPPOVISION50FCHAPTER � � , _ d s(COMMENqNG WITH SECTION 7000)OF DIVISION a OFTHE BUSINE55 AND PROFE5510Ns CO�E,AND' Z X MY�IC[NSE{S IN FULL FORCE AND EFr'[CT. � . � LICETlSEpCLpSS �� LIC.NO. 9��y��R �. _ . j _ . �j' DATE l�"��`�� CONTRACTORrC✓L� .. ��' a . W � WORKEFS'COMPENSATION DECLARATION a I � � IHEREBVAFFlRMl1NDERPENALiYOFPERJURYONEOFTHEFOLLOWINGDECLARATIONS: Z - Z _IHAVEANDWILLMAINTAINACERTIFICATEOFCONSENTTOSELF-INSUREFORWOflKERS' _ ¢ COMPENSATION,AS PROVIpE�BY ScGTION 3�0o OF THE LABOR CO�E,FORTHE PERFOpMANCE � OF THc'W�RK FOR WHICH THIS PERMI7IS ISSUED. � � W _IMAVEANDWILLMAINTAINWORKER3'COMP'cNSATIONINSURANCE,ASRE�UIflEDBYSECTION . Q 3�u00F TH`�LABOR COOE,FOR THE PERFOflMRNCE 0F 7HE WORH FOR WHICH THIS PERMIT 15- ,�p�' g,l� �' ISSUE�.MYWORKEAS'COMPENSAiIONINSURANCECAFRIEFiANOPOLICYNUM3ERARE CONSTRUCTION Sd' J j c,qpqiEq PLAN REVIEW ' Z POUCYNUMBER, ELEGTRtC Q � � (iHFSSECTKKJNEmNOTBEL17A1PLEfEDGf71iEPERMI7ISWRONEHl1NOREDDOLIARS(51o7jORLESS). PLUMBING W . � ICEflTIFVTHATINTHEPERFORMANCEOFTHEWORKFOR'NHICHTHISPERMITISISSUE�,I MECHANICAL . . , �j' SHALLNaTEMPLOYANYPERSONINANVMM'NERSOASTOBEGOMESUBJECTTO7HE �� N WORKERS'COMPENSATIONLAWSOFCALIFORN��:A,ANDAGREETHATIFISHOUL�BECOME INSPECTIONFEE _ __ _ ' SLIBJEGTTOiHEWOflKERS'COMPENSATIONPROVISIONSOFSECTION3] THEL490R ISSUANCE �� ` '�� � CO�E,I SHALL�FORTHWITH COMPIV WITH'7��,rl95E PROVISION$,/ p DATE:��–A���°"���� APPLICAM:� y'���y �-��-� SMIP . �IL� . � J WAANING:FAILVRE i0 SECURE VlORKERS'COMPENSATION COVERAGE IS UNLAWFIJL,ANO SNALL BE ENERGY P/C � LL SUBJECTANEMPLOVEftTDCRIMINALPENALTIESAN�CIVILFMESUPTOONEHUNDREUTHOUSAN� ENERGYPERMIT ' DOLLARS�Et00,000�,IN.A�Ol71aN'(OhiECOSTOFCOMPENSATION,�AMAGESASPpOV70EPFORIN � ' � SECTION 3]080FTHE Lh60R CO�E,INiEREST,AND ATTORNEYS FEES. RETENTION FEE: W a ���' �CON6TRUCTIpN LENDING AGENCY PRE-ALT E: --���. � IHERE6YAFFIRMUNDERPENALTYOFPERIUPYiHATTHEREISACONSTftUCT10NLEN�WGAGENCY �� �',�� , Z FORTHcPEPWRMANCEOFTHEWDRKFORWHICHTHISPEqMITISISSt/E�[SEC.3os],qV.G). � ^ �, . � �w '7(s/�S� I LENDER'S NAME F– LEN�ER'SADDRE55 - � TOTAL FEES �°�� G C� � I CEfl71FY THAT I HAVE HEAO iH15 APPLICATION AND STATE THATTHEA60VE MFORMAiION IS CORRECT. � �� �. � IAOREEiOCOMPLYWITHALICITYANDCOUNTVORDI.VANCESANUSTATELAWSREtAiING708UILDING - �. CONSTRUCTION,AM1OHEREBYAUTHOP2e"REPRESENTATNESOFTHISCOUNTVTOEMERUFONTHE '- � Z ABOYE�MENTIONED PROPERTV Wfl INSPECTION Pl/RPOSES. COMMENTS � � �a..,9'�'to . +Y[I�C.�,'� ' m PERM NAME(P �) � ¢ , eP r ', � ' �•," ��A � Uj f�ftEOFPERMITTEE � �ATE � _ � � RECPT.NO. PAID BY � VAIIDATION ~ WHITE—De artment Co YELIOW—Finance Co PINK—Assessor Co GOLDENROD—File Co GREEN—A IicanYs Co � P PY, PK PY. PY. 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