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� CITY OF DIAMOND BAht DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES / �w 21660 E.Copley Drive Suice 190 � (909)8603195 Fax(909)861-3117 PRESS ����A�� � BIJILDING PERMIT APPLICATION FIRMLY vi JOBSITE APPLICATIDN � f� PERMIT l �j P/C 0 ADDRESS �� `ri�"�",����_.,��, , DATE "- NUMBER r� ^� Ii c� ISSUE i (� TYPE OCC APN LOT TRACT DATE ( t� CONST. GROUP °C OWNER O � ADDRES ZONING SETBACKS � CITY�t��3��, ZIP TEL. REART _ RW � APPLICANT TEL. SIDE/SIQE STREET RW ❑ � CONTRACTOR � SIDE ❑ o� ADDR�SS 1 PROPOSED E Q CIT(�If,t�� ZIP TEL. . — ���� ► � ARCH/ENG/ DESIGNER NO.DWEL. N . NO. ADDRESS UNITS STORIES BEDROOMS ^ � CITY ZIP TEL. �j DESCRIPTION SQ.Fl: FACTOR PSF ADJ.AREANALUATION Q- OWNER-BUILAER DECLARATION SFWADDlREM O p i HERE9Y AfFlRM UNDER PENPLTY OF PERIURY THAT i AM EXEMPT FROM TME CONTRACTORS U� GHfBcJB/C8lPOfI W CENSEUWWRTHEFOLLOW�NGREASON(SEC.7031.58USINESSANDPPOFESSIONSCODE:ANYCITYOR (n . U COUNiYWHICMREQUIRESAPEflMITTOCONSTRUCT,AI.TER,IMPflOVE,DEMOLISH,ORREPAIRANYSTHUC- W PatiO/DeCk � TURE,PRIOR TO ITS ISSUANCE.ALSO REQ�IRES THE APPLICAN7 FOR SUCH PEflMIT TO FILE A SIONED W � STATEAIENT THAT HE Ofl SHE IS UCENSE�PUfiSUANT TO THE PROVISIONS OF THE CONTHACTORS LI- � CE1�E LAW(CHAPTER 9(COMMENCINO WITH SECTION 7W0)OF DIVISION 3 0F THE BUSINESS AND PflO� � �'�' PODVSPB FESSqNSCO�EjOHTHATHEORSHEISEXEMPTTHEREFROMAND7HEBA515FORTHEALLEGEDEXEMP• TION.ANYVWLAiIDNOFSECTiON7o31..•,BYANYAPPLIGINTFORAPERMITSU&IECTSTHEAPPLICANTTO Z Re-Roof � ACML PENALiV OF NOTMORE THAN FIVE Hl1N�flE0�OLLAHS(L5oo).�: - �� ❑I,ASOWNEROFTHEPROPERN,OflMVEMPLOYEESWIhIWApESASTHEIRSOLECOMPENSATION, � Com1118fCi21 ' VM�LL DO THE WOqK,ANp THE STRUCTURE tS NOT INTENDED OR OPFERF�FOR SA�E(SEC.704a.BU54 J NESSAND PROPESSIONS CODE:THE CONTPACTOflS LICENSE LAW OOES NOT APPLY TO AN OWNER OF � PROPER7VVhiOBUIIOSORIIApROVESTNEREON.ANOWHO00E5SUCHWORKHIM&ELFORHERSELGOR = ' CL TNROUOMNISIXiHEROWNEMPLOYEES,PROVIDEDTHATSUCHIMPiiOYEMENTSAHENOTINTENOEDOH m �Q ,OFFERFAFORSALEIF,HOWEVERTMEBWLDINGQRIIAPROU�MENTlSS(M.OWITHINONEYEAROFCOMPLE- Z TqN,7HE OWNER-BUILDER WILL MAVE THE BURDEN OF PPOYINO THAT HE OR SHE DID NOT BUIID Oq � IMPROVE FORTHE PUHPOSE OF SALE). W pI,ASOYMEROF7HEPROPERiY,NAEXCWSNEIYGONTRACTINGWITHLICEN5EDCOMRACTOflS [C TO CONSTRUCT TNE PROJECT(SEC.1041,BUSINESS rWD PROFESSIONS CODE:THE CANTRACTORS lb V8I118I1011 k ADJ.AREA -�W CENSEUWOOESNOTAPPLYTOANOWNEROfAPROPEPTYWHO8U14➢SORIMPflOYESTNEREON,AND � WFIOCONTMCTSfORSUCi1PRQIECTSWISHACONTMCTOR(SjUCEN5E0PUR5UANTTOTHECOMRAG -QUANTI . DESCRIPTION FEE � T00.5 LICENSE UW.). O O��IXE/APT UNDER SEC. B.d P.C.FOR THIS flEA50N � � � � DAlE OWNER � Z �j �� UCENSED CONTRACTORS DECLARATION � � W IHEREBYAFFIRMUNDERPENALTYOFPERJURVTHATIAMLICENSEDUN�fRPROVISIONSOFCHAP7ER � d 9�COMMENCINQWITHSEC7ION70v0)OFDIVISION30FTHEBUSINESSANOPftOFESSIONSCOOE,ANO � MY LICENSE IS IN FlJLL FORCE AN�EFFEC7. � / m '�y �,/� � p UCENSE LASS � UC.NO. /��y�!_'��,�,J� �(�� � �V DATE CONTRACTOR�AL>11�RI-FJ Y'YST��W �- t�� WORKERS'COMPENSATIpN DECI.ARATION Q - - � - � U N IHEREBYAFFiRAiUNDERPENALNOFPERJURYONEOFTHEFOLLOWiNGDECLARATIONS: � C/3 a G IHAVEANDWILLMAMiAINACERTIFICATEOFCONSENTTOSEIP-INSUFEFORWORKEqS'� ' 2 � ' - ' ' ' - � COAAPENSATION,ASPHOVIDEDBYSECTION37oo0fTHELA80PCWE;:F,ORTHEPERWPMANCE� W OF THE WORK FOR WHICH 7HIS PERMIT IS ISStJED. - �� � , . . ' � Q .,. W IHAVEAN�WILL�IA�NTNNWOflKERS'COMPENSATIONIN�URANCE,ASRE�UTAEDBVSECTION Q 37000FTNElA9�R COOE,FORTHE PERFORMANCE OF iHE WORK FOR WMICHTHIS PEflMIT IS - °r ISSUED.M7WOHKERS'COMPENSATKKJ�I7y��RANCECARqiEflANOPOLICVNUMeEftARE: CONSTRUCTION j CAFPoER__ O °" _ PLAN REVIEW -Z� POIiCYNUMBER � 2����.- ELECTRIC Q o (IHSSECfIONNE�NDTEEOxMLEfEDOFiF¢PERtNTISPoRQ`7EHlNDRE�00L1M5(579o)ORlESS� PIUMBING W .,. .Z f CERTIFY THAT IN THE AERFORMANCE OF THE WORK FOR WHICH7HIS PERMIT IS�SSI/ED,I MECHANICAL �� �� � �,(j:: SHALLNOTEMPLOYANYPER50NINANYMRNNEfiSOlSTOBECOMESUBJECTTO7HE ,,, - ��- WORKEfiS'COMPENSATIONIAWSOFCALIFORNIA,MIDAGREETH0.TIFISHOl1LOBECOMF INSPECTIONFEE S SU&IECTTOTiEINOHKER5COMPEN5A710NPROVI510NSOFSECTION37ooOF7HEl1BOR ISSUANCE _____. : CO�E,I SHALL FORTHWITH COMPLY WI1H THOSE PRO�IIS�QNS., :.�- re�-� \�(lr i .SMIP (.` �C � ; O � . p OATE��iLVAPPLIGANT. yt � . . . w ENERGY P/C -- .J. WARNING:FAIIURETOSEWREWDRKERSCOMPENSATIDNCAVEflAGEISUNLAWiULANDSHALLBE { -� .a, ��� SUBJECTAN EMPLOYER i0 CRIMINAL PENAL7iE5 AND CIVILFINES UP To oNE NUNDRED THOUSqN� ENERGY PERMIT -- � - - �� � � pp(,LApS(S1a0,0o0),INl�OITIONTOTHECOSTOFCOMPENSATION,OAMAGESFSPflOVI�EDFORIN j=j,� 4 �L.,, _ -`,,. ,J� SECTION 3708 OF THELABOR CODE,INTEflEST,AND ATTOflNEY'S FEES. RETENTION FEE: � CONSTRUCTION LENDING AGENCY PRE-ALT FEE: �:��. IHEflEBVAFFIRMUNDERPENALTYOFPE JUflYTHATTHEREISACONSYRUCTIONLENDWGAGENCY ' FORTHE PER4'ORMANCE OFTHE W RK F WHICH T IS PERMIT IS I55 ED SEC.3087,CIY.C.�. Z W. :� LENDER'SNAME — .. . -F_- LENDEfl'S AOORESS� - . t _�w ICEtii1FYTHATIHAVEREADTHISAPPLICATIONANDSTATETHATTHEA80YEINFOHMATiONISCARRECT. TOTAL FEES ���� �V d IAQFEE T�CAMPLY N7TH ALLCITYAN�COUNiY ORDINANCESAND STATE LAWS RELAT�NG TO BUILDING � CONSTRUCTION,AND HEREBV AUTHORI2E REPflESFNTATIVES OF iHIS COUNTV TO ENTERUPON TNE -Z� A60VE-MENTIONE�PROPEftNFORINSPEC�S-�� COMMENTS - 0 — — m PEPAIITTEE NAAIE(PRINT) �d � � C-�—�� ���� — ---- �y- SI6NATUREOFPERMITTEE �ATE ._. RECPT.N0. __PAID BY IDATION ~ WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—ApplicanYs Copy :. .� _.� _M�� r_ j - �,_�,.._.� �.�... .. . j �" � n � �"io-ict' f��7 � �"L�I� --f�.t`fs�f71E��,`� - � f!"t{b . � i , � , E � � '`� a .'�'� �... r f �7� � �7'"°"`j te e-`` ^.t : rr n"; i B s �-" i - E :°�i i' _ -t ��.� C, � .s . . -y� � _ �' - r1� CT�. j -i . p , ; : z `� � '� � r �- � �`�° �..���` € `-� `� ,�.. T,--4. 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