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:� CITY OF DIAMOND BAht ' � �-- " DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES � 21560 E.Copley Drive Suite 190 �„ (909}8G0-3195 Fax(909)861-3117 PRESS BUILDINGPERMIT APPLICATION -__ 11��e� FIRMLY '�" JOBSITE ' � q ..- APPLICATION PERMIT P/C A ADDRESS � ��� t ���� Y�tl����'�T DATE NUMBER_���� $ ISSUE TYPE OCC � APN LOT TRACT DATE CONST. GROUP p OWNER �'��1:� ����'1��a �� p ADDRESS � I �S I� �..b��"` �U��,��,' ZONING SEfBACKS � CITY �1 �W��II'ii b�i�f?LIP TEI. RE�ART RW 0 APPtiCANT TEL SIDEJSIDE STREET RW U � CONTRACTOR ,�.��` � � SIDE ❑ � ADDRESS p PROPOSED USE CITY ZIP TEL.'7��,f�J i i 'S� o ARCHlENG/ W DESIGNER NO.DWEL. NO. NO. a ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � � DESCRIPTION SQ.Ff. FACTOR PSF ADJ.AREANALUATION O_ OWNER-BUILDER DECLARATION SFRlADDJREM - � � �-p I MEREBY HFFIqM UNDER PENALtt OF PE0.IUHV THAT 1 AM EXEMPT PROM THE CANTRACTORS l6 :� Garage/Carport -��W. CENSEUWFOflTl1EFOLLOWINOREASON(SEC.7031.58USINESSAN�PROFESSIONSCODE:ANYCITYOR _ U� CWNTVWHICHREdlINE3APERMfTTOC�ISTRUCT,AI.TER,IMPROVE,DEMOLISH.ORREPAIRANYSTRUG � W pytio/Deck : NRE,PRIOR TO RS ISSUANCE,ALSO REQUIHES THE APPUCANT FOR SUCH PERMIT TO FIL6 A SiGNED � �.� STATEMENT iHAT HE OR 3HE 13 LJCENSED PURSUAN7 TO iHE PROVISION9 OF THE CONTRIICTOH9 LI• W ,,�.- CENSELAW(CHAPTER9(COMMENCINOWI7HSECTpN70U0)OFDIVISION30FTHEBUSMESSANDPRO• ' V' POOVSpa FESSKKJSCOD�OPiHATHEOFiSHEISEXEMPTTHEREFROMANDTHEBA515FOR7HEALL.EGEDEXEMP• . (� TION,ANYVKKATIONOPSECTION70.t7.58YANYAPPLICMlTFOHAPERMITSU&IECTSTHEAPPLICANTTO �.�Z Re-Haof �� ACIVILPENQTVOFNOTMORETHANFNEMUN�REDDOLURS(S`�D).): .� �I,ASOWNEROFTHEPROPERTY,ORMVEMVLOYEESWITHWAGESASiHE1RSOLECOIAPENSATbN, �� �, COmroerGiel -� . . WILL DO iHE WORK,AND iHE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC.70M,BI1S1• -.J � NESS AN�PROFESSIIXJS CWE:iME CONTPAGTORS LICENSE LAW�DES NOT FPPLY 70 AN OWNEq OF . `� PROPERTVWViOBUILD80fl�MPROVESTHEREON,ANDVYHODDE55UCHWOfiKHIMSELFORHERSELFOR = "�� TMAOUOIIHISORHEROWNEMPLOYEES,PROVIDEDTHAT6UCNIMPROVEMENTSAFENOTINTEN�EDOP m - - �W�. OfFERWfOR5ALEIFHOWEVER7HE8UIL01NGOqIMPROVEMENTi550LDW�THINONEYEAflOFCOMPIE- -'��:'� �'�TION,THE OWNER$111L0ER WILL HAVE THE BURDEN OF PHOVIN(i THAT NE OH 5HE DID NOT BUILD OR -IMPROVE FOR THE PUNPOSE OF SALE�. ❑I,AS OMMER OF T1E PflOPERTY,RM EXClU51VELY CONTMCTING WITH UCENSED CONTMCTORS _�' TO COlISTRUCT THE PROJECT(SEG 70{4.BUSINE9S AND PROFESSIONS WDE:THE CON7qACTORS LI• V81U8ti0n ADJ.AREA �- -W- CENSEUWOOESNOTMPIVTOANONAVEFOfAPROPERNWHOBUiLDSOHIMPROVESTHEREON,AND ' �-� WHOCONTflACT&WRSUCHPROJECTSWITHAGONfRACTOR(S)LICENSEDPUFiSUANTTOTHECONTRAG pUANTITY DESCRIPTION FEE � o-- TOfl3110ENSELAWJ. 1� q /� ,� ❑I Mt EXEMPT UNDER S�C. B.&P.C.FOR THIS REASON ��� Q .YJ IL L' '� LL ; F C1 L • OATE __OWNER . V .. . �.� �.Z. . . W . � ��,. UCENSED CONTRACTORS DECIARATION � W � � - IHERE9YAFFlP�IUNOEHPENPLTYOFPEFUURVTHATIMI�ICENSEDUNDERPROVISpNSOFCHAPTER- 1,� :,�' a(COIAMENCiNON7THSECTiON7000)OFDIVISKKJ30FTHE6USINESSANDPROFESSIONSCADE,AND ; z �,_X; MY LICENSE IS IN FULL WRCEANO EFPECT. LLJ , �t� ` m �,0" LI'�NSE CtAS �T �^' LIC.NO. � (� . . `-U:` 6ATE � CONTRACTOR�. W. -�_�:, WORKERS'COMPENSATION DECLARAT{ON a t � �-1s:� �,'+ ��.��� ^ U � �;-_ IHERWYAFFIRMUNOEflPENALTYOF�Efi1l1RYONEOFTMEFOLLOWINQDECIARATIONS: Z } Q �_ _IHAVEANDYJILIMAINYAINACEIiTIFICATEOFCON9ENTTOSELF-INSUREFOflWOPKERS' _ -��' � COMPENSA7ION,ASPROVIOEUBYSECTION37000FTHELABQHCODE.FORTHEPEFFORMANCE �U � OFTHEWORKFORWNICHTHISPERMITISIS3UED. � Di -�W� _I HAVEAND WILI MAIMA�N WORKERS'COMPENSATION INSURANCE.A5 RE�UIRED BY SECTION Q��. 3700 OF THE U180R COOE.FORTTIE PEflFOHMANCE OF THE WOFK F-0N WHICH THIS PERMIT IS -0�� ISSUED.MY WORKERS'COMPENSATION INSURANCE CARFIER AND POLICY NUMBER ARE: CONSTRUCTION �J:. ;'j'; cpRRiEp PLAN REVIEW ��O:- pOLICYNUMBER ELECTRIC 0 �-: .�: (1}pSSECTICNrJEE�NorgENMp.EfEooFitEpEaMt�waavEtp.NORmDOLtARS(S1ao1�lESS} PLUMBING J _,t1.1,, Z; �1 CERTIFVTHAT INTHE PERFORMANCE OF 7HE WORK POR WHICH THIS PEFMIT IS ISSUED,I MECHANICAL���` � � - -;-(f- ' -SMALLNOTEMPIOYANVVERSONINANYMRNNER50ASTOBECAMESUBJECTTOTHE - - "�° WORKEflS'COMPENSATIONLAWSOFCALIFORNIA,ANDAGAEETHATIFISHOULDBECOME INSPECTIONFEE - SUBJECTTO THE WbRKEflS'COMPENSA7roN PROVI510N50F SEGTION 37ao OF'HE LABOR !1 �,,s_� cooE, sHnu o �ni con+v�v win+ osE P owsioras. ISSUANCE � �° �t. � ' SMIP 'p�; DATE:- APPLICANT: A W� � ENERGY P/C ..�_ WARNIN6: AIWRETOSECUREWORKERS'CAMPENSATION VERAGEISUNL4WFUL,AN�SHALLBE yt, y� � SU&IECTANEMPLOYEFTOCRIMINALPENALTIESANDCIVILFINESUPTooNEH11N�RE�THouSAND �ENERGYPERMIT �� B' 7d DOLLARS(5100.000).IN AODITION TO THE C09T OF COMPENSATION,DAMAGES AS PROYIDED FOft IN - ;.J�: SECTIONs7o80FTHELABOHCODE.INTEfiEST,ANDATTORNEV'SPEES. RETENTIONFEE: �;; -��a��� CONSTRUCTION LENDING AGENCY PHE-ALT FEE: 'O; .--�; (HEREBYAFFIflMUNDERPENALTYOFPERJURYTHATTHEREISACON57RUCTIONLENDINGAGENCY FOPTHE PERFORMANCE OFTHE WORK FOR WHICH iHIS PERMIT IS ISSUE�(SEC.3oe7,CIV.C.). Z W i����, LENDER'SNM1E � - '-F��. LENDER'SAODPESS �' . �;W�-: ICERTIFYTHATIHAVEREADTHI9APPlJCATIONAN�STATETHATTHEABOVEINFORMATIONISCORRECT. TOTAL FEES -, ��' IAGREETOCOMPLYN7THALLCRYAN�CWN7VOPDINPNCESANDSTPTELAWSREIATINGTOBUILDING CONSTHUCTION,AND HEREBV AUTHORIZE REPRESENTATIVES OF THIS COUNiY TO ENTER UPON THE . � �Z:; ABOVE•MENTIONE�PROPERTY FOH INSPECTION PURPOSES. COMMENTS - - , ���; �..<< �,nt�� 1�1r� ' ,�_.— ��_� PEflMITTEENFME(Pfll e �� - � L � p J � y SIONANHE PER E DA7 .�_,Z < RECPT.NO. PAID BY VAUDA7ION ~ WHITE--0epartment Copy,YELLOW—Finance Co PINK—Assessor Copy,GOLDENROD—�ile Co GREEN— PY. 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