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. ._ ._ _ _ _' . . . __.... _ ._ . _ .. .. . -_ . / ; \ _ \ � �.,,� CITY OF DIAMOND BAA � /;� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES � � _ .. � 21660 E.Copley Drive Suite 190 � , (909)860-3I95 Pa�s(909)861-3117 PRE$S 9�� � BUILDING PERMIT APPLICATION FIRMLY y JOBSI7E *�, P � . _ ISSUE � �y, ,— �PERMIT . P/C �Y'.J P�� � � �� APPUCATION � � , o AODRESS ���t� ,����V�R���� �� pATE NUMBER� # � APN ��a�"� T TRACT �.�1��� DATE ONST. GROUP � OWNER ,l�'s��-'"+�� �Li"f P�.���,L �` ADDRESS �. C'��—� �,T ZONING SETBACKS w CITY - , � W ZIP� _ TEL. . � . REART RW O I � APPLICANT �����'���J TEL: �` — r SIDFJSI�E 3TREE7 RW ❑ � CONTRACTOR"°` ' � �,/ SIDE ❑ RDDRESS pRQPOSED USE ���� '��b�F�t�� ''�' . � ��r� � CI7Y ZIP TEL w ARCH/ENG/ — ,� DESIGNER NO.DWEL. NO. NO. �I a ADDRESS � CI3Y ZIP TE�. UNITS STORIES BEDROOMS. � DESCRIPTION SQ.FT. FACTOR FSF ADJ.AREANALUATION � �'p�� � OM/NER-8179LDERDECLARATION SFR/ADD/REM �� � � O �� Q ' I HEREBY AFFlRM UNOER PENAI.TY OF PERJUPV THAT I AM EXEMPT fRON iHE CONTRACTORS LI- G2f2J8/C8lPOft � � � ' .�LJ CENSEIAWWR4HEFOLLOWMGREASON{SEG7037.58USINESSANDPROFESSIONSCADEANYCINOR (� �J...COi/NTYWHICHflE0U1NE5APERtj11TTOiCONSTRUCT.AI,7ER.IMPAOYE,DEMOLISN.ORREPAIflANYSTRUG W Patio/D�ck � � TUflE,PRIOR TO ITS ISSUANCE,QSO REQUIRES THE APPLICANT FOR SUCH PERMITTO FILE A EIGNE� � . ___ �. STATE6�NT THAT HE OR SHE IS;LICENSED PURSUANT TO THE PROVi510NS OF 7HE CONiRACTORS L6 �- . , � _ � 'CENSE LkW(CNAPTER e(COMMENCING WITH SECTION]aaoJ OF OIVISIIXJ 3 OF THE BUSINESS RND PRO- U" POOUSpB�� °ESSIONSCODE�ORTHA7ME��OR�SHE15E%EMPTTHEREFROMAN�THEBA813FOFTHEALLEGEDEXEMP� (� '�TION.ANYVIWATIONOFSECTION7031.SBVANYAPPLICANTFORAPERMITSU&IECTSTHEAPPLICANTTO Z Re-Roof �' Ad�ENALTV OF NOT MORE TFIAN FIVE HUNDREtl UOLLARS(5500).): � I,A50WNEROFTE1EPpOPc'RTT;O{iMYEMPLOYEESWRHWAGESASTHEIRSOLECAMPENSATION. Q COff1f118fCIfli � � YVILI YHE WORK,Ml�7HE STF�iIJCTURE iS NOT INTENDEO OR OFFEREO FOR SALE(SEC.7044,9US7� J 'i �� N'eSS M!D PROF6SSIONS CODE:T'FiE CONTRACTOR$LICENSE LAW�OES NOT APPLY TO AN OWNEF OF �� �, 1 '.� � � '�, �� ��P�PEHPY4VH06111LDSORIMPROVESTMEHEON,APOWNO00F5511CHWONKHIMSELFORHERSELFOfl ��� �•'� LL� 'THHOUGHHISORHEROVMEMPLOYEES,PflpVIDEDlHATSUCHIMPROYEMENTSARENOTINTENDEDOR � , ,'�,,QI� .,OFFEREDFORSALEIFHOW-NEI�TN€BUIIDINGQRIMPROVEMENTIS80LDNJffH!NONEYEAROfCAMPIE� ��PI�J,THE OWPlER-BUILDEH WlLLI�{AVE'7HE BURDEN OF PROYBNG THAi HE Oq SHE DI�NOT BUI4D OR �,�� "IMPROVEFOF7MEPUHPOSEOF$JLLEJ.�'� �� �� . ��� � ��Ayg ❑P,q&OWNEROF7HEPROqEFTI;'AME%CLUSIYELYCONYAACTINGWRHIJCEMSEDCONYRACTORS - ��,��'.,' TO CONS7RUCT TkE PF'�7JECT(S�C.7tl4d BU INESS AND PP.OFESSfONS CODE:THE CON'fHACiORS LI- V&IJ�fiOl1 ` f1DJ.AREA .W�. ,CENSELAWOOESWOTAPPLYTOANOWNEROFAPROPERTYWk(SBUILQSOflIfNPROYESTHEFEOP�AN6 . �i :�.' S� �,RhC 3 CENS PURSUANTTO7HECON7PAG . CON RACT F6R5UCHPRWECT WITHACONT T�i LI E� . WI10 7 5 () C .�I �F"�� roRsucersevew.. � � � �U�TOTa° DESCRIPTION FEE � � Y .. � . � , . , '' ���� � ❑I M1 EXEMPT UNDE�9 S�G� .. � ......�w ... • �. '', .� . .II . . .. _'B.&P.C.FOflTHI$REA50PJ Q ,� � -._ ...... . .. .�. -�- ': . .,'-' U . �"g'. UATE ��-��OWNEfl U LIS o� LICEN�SED CON7P.ACTOR9 DECLAHATION � �- ` - �� " � .. 'i � IHEFE6YAFFIRMUNDERPENAI.7�'OF?�RJUFiYTHA7IAMLlCENSE�UNOERPROVISIONSOFCHAPTER � , �� — 0 P ESS 'S CO AN .. 9l�MMENCNK3WITHSEGTiON7Qa00FDlVISIbN30FTHE6USINE�SAN .RO� IOh CE. D o_ 1 D , Z � MY LiCENSE IS IN FULL F�RCEAN'�EFFE�. — � � , �{ .. ,, '�F`b . ,. � �, m �, iL .,. � v � � � . 7„ ;r �'' . . ��`. �, � LlC�NSE CL4SS____ ��_,_L1C.NO. � j , �"'�--� F- -1 ��. QA7E , COPJTRAb70R d � W saas F -1 �� WORICEFiS'CORRP_NSATlON DECLA6iATll'3M ,. . �' _ I ¢� �i �ma ', � IHEflEBYA€FIRMLAJ6ERPENALTNOPPEflJIJRYONEOFTHEFOLLOWPJODECLp,RATiONS: � ;��`�y 1_ � Z �'+'a U3 ' �.X �d^' �;.?d,ld"`m..iTq n.;w. O _M__.IHAVEANPWI9_LMAINTAI'ACERTiFICAT56FCANSENTTOS6!F-INSUREFORWORKERS' $ ����+p �,y�R ` ' M-,s'� ' � CAMPEoYSATlON,ASPROV�DE�BYSECTION370oOFTHELA90RCODE,Fl�RTNEAEAFORMANCE UW � t�� � � -"� OF T@JE WCRK FOR WHICH,7HIS PEfiMIT IS ISSUE�. � �. I e �, �IHAVEMIDWILLMAIN7AIN�iYVORKERS'G9MPENSATIONIIdSURANCe'.RSR'cQUIREDBY5EC710N 7 6� 37000FTHELABORCOOE,FORTHEPERFOR�RANCEOFTHEWORKFORWWCHiH15PEfll✓I715 � / ' � � � PSSUED.M:'WOFiKE9S°GOiMPEfi'£ATIOtd INSURANCE CARflIERANCJ POLICY NUMBEP,ARE: CONSTRUC?ION 1 L� tl � s ,���I, ', caacsosa � .----- PLAN REVIE'JY . _.�,- ----- � Pa:ICY�bU.�uBER_ I�� ELECTRIC ii Q � (fHSSEL'fk"�fiNEWIdOTBEESFAPLEfmOFTHEPERMdf�SFnRONEIiIN.DAED�C1.iAftS(5700)ORLESS�. PLUMCiING Z 1 CEFiTIFY THRT IN TNE PERFORhyANCE OF PHE WDRK FOR WHICH 7HIS PERMIT IS ISSUEO,I PAECHANICAL �' SHAILNOi EMPLOV ANY P�R3DlV INANY MANNEF SO AS TO BECOME SIJBJEC7 TO THE , ¢� WORKER£'GOtdPENSATIO LAW50�CALIrOfiNIA.ANDAGREETHATIFI5F10ULD8ECAME INSPEC710N FEE �� � SU8,1'cCTYOTHE4NORKER�'COFAPENSATIONPAOVI510NSOFSECilIXd37JOOF7HEU00R I$$UANCE � CAD'c,l SHALL FORTHWITFI COPoIPLY WIPH THOSE?RCVISIONS. , � � I � SMIP .� � . p DA7E: AHPLlCANT � ' ENERGY P/C ' d d r WARkING:FlU�URE TO 5EWftEW qI RKEf{5'COAVPEp'SATION LOVERAGE IS UNLAWFl1L,AND SHALL BE SUBJECT AN EMPLOVER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUN�RED THOUSAN� `+- P I �` � � DOLLAPS(flbo.000),IN0.7DITION7r THE'�COS70FCOMPENSATIIXJ,UAMAGESASPFiOV@EOFORiN y� ENERGY ERM T �_ SECTION3]aeOFTHEl.`90R�DE,IN7�RESiP7JDATTORNEY'SFEES. ' RETENTIONFEE: ____,__ ( . � I W 4 COl�STRUCTION LENDlNG AGENCY pRE-ALT FEE: O CC ' Y T 1 N CT LEN 'GAG NC I'' IHER�VAFFIpMUNDERPENALTVIOFPERJUR THAT HERE SRCA STpU ION DiN E Y � FOPiHEPERWNR9ANCEOFTHE'A`ORKFORWHICHTHISPCRMITISISSUEO(SEC.3�8],GIY.C,�. ' . '���j Z - '�� W �'i . �- �Ij, . � LEN�ER'S NAME : F- . LEN�JER'SAU�RE55 � �� N LLI . ICERTIFtlTHAiIHAVEREA�THIS PPLICpT1ONAN0STATETHATTMEABOVEMFOflMATI�N15CURfiEGT. TOTAL FEES TY � tl Y IN SA S7 W E TI OT UI D Oj .I AGFEE TO COMPLY WITii ALL CI AND�'A NT ORD ANCE ND ATE tA 5 ft LA N O B L INO , � I'� I R T T SOF IS NTV EN U T CANSTRUCTON,ANDhEP�YAU ORIZEREP ESEN A IVE TN COU TO TER PON HE � CS v � �l'� �. � A60VEMENTIONEO PROPERT,F Fi I SPECfION PIIRPOSES. ��Il ��6 �J` �� ' �� COMMENTS .p � ' ���. / / �� �� . . , � r — �/; F' �"�,d� � �N r�C � .P � N PRINT • II'. t ) � ��.- � / L � I � �', SIG UREOFPERMITTEE I DATE ' Z,.,,. �� - HECPT.NO._ � PAID BY VALIDATION i '� �.'' 6NNi7E—�epartment Copy,YELLOW—Finance Capy,PoNK—Assessor Copy,GOL EN D--File Copy,GRE N— plicanPs Copy . .. ._ . 7 � r,�� g �„€� 4 �.,. ° �,# . . . 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