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:R_!� , CITY OF DIAMOND BAx � � DEPARTMENT OF CqMIvIUNITY&DEVELOPMENT SERVICES a � 21660 E.Copley Drive Suite 190 � PRESS �, (9Q9)8GU-3195 Fax(909)861-3117 r :y�° BUII.DING PERMI�'APPLICATION � F1RM � JOBSITE �Q� APPLICATION PERMIT � P/C � ADDRESS �� ��L�a'1�� �t i`U DATE I� ' MUMBER k c�° ISSUE TYPE OCC APN L T TRAC7 _ DkTE CONST. GROUP c,�^y OWNER 'a ZQNING SETBACKS ADDRESS.' f� � �, c r. W � , � _,� L °+ �°''d.�� FRONT RW � Z PPLICANT� � z1 REAR ❑ O �_ 8� — TE o �`f'���'�aTE�.. � "r rr SIQEISIDESTREET RW p � CONTRACTOR C� "�` ' SIDE ❑ I � ADDR SS '"i S.I �' : Ca " CITY 21P ���t TEL: � , �� PROPOSED USE QAACH/ENG/, , � DESlGNER NO.DWEL. NO. NQ. � ADDRESS UNITS S'fORIES BEDROOMS CITY ZtP TEL. cyr� � DESCRIPTION SQ.FF. FACTOR PSF ADJ:AREANALUATI ON ' � OWNF�i-BUfLDER DECLARATION SFR/ADDlREM O p' ' I,HERFBV AFFIRM UNOER PENALTY OF PER.:lURY THAT�!AM E%EMP7 KROhi THE CONiRACTORS Lb ' GdfdJB�C8C�012 � LiJ CENSELAWFORTHE�;FOLLDYdIN�fiE'A90N(SEC.7031.58USINESSANDPflOFESSIDNSCODE:qNYCITYOR , (/) C.��7 COUMYWy1CHREWkRESAPEP �TO,CONSTRUCT.A�TER,IMPROYE.DEMOtJSH.OHREPFIflANYSTRUG W PdtiO/DBCk W 'TURE:PFiIOR TO i7S ISSUANCE,, SO�REQUIRES THE TPPIICAN7 FOR SUCH PERAqT 70 FILE A SIGNED W . �.� STATEMENT iHA'f'HE OR SHE IS LICEPYSEb PUflSUANT TO hIE PHOYISIONS OF THE GIXJTRAGTORS Li� . � 'C�NSELAW(CHAPTERB(CYT4�tAENCIN!2WITHSEC71ON7000)OFDIVISION30F7HE8USINESSANDPPA• �' POOUSPB FESSqNSC09E�OliTHATNEO SHEISEXEMPTTHEflEfROMANDTP7E0A518FORTHEALLEGEDEXEMP� . �(� T'AN:ANVVIOIATY?NOFS'cC71O�17037;58YANVAPPLICANTFORAPFRMBTSU9JECT5THEAPPLICANTTO � RB-RODf F, ACIVIL pENALN OF NOT MORET�IqN FIVE HUN�RED DOLLARS(SSaOJ.): . � , , .�� � OI,ASOWFIEPOFTHEPflOPER7Y,qRMYEMPLOYEESWITHWAGESASTHEIRSOLECOMPENSATIDN, C� Commercial - N7LL DO'THE WbRK;M1D THE 5�6iUC7UHE IS�N071NT64DED OR OFFEREO FOR SALE(SEG 7044,.BU51-� J NESS�AND PflOFE551QN5 CW@:THE fANTRACTtl95�_lCENSE LAW DOES NOTPPPLY TO AN OWNER OF �� � PP�PEqTVWHO�B'JIlRSOAIMP OldE57'H�RFCN;ANDYhIODOE55UCHWORKHIh9SELFORHEHSE�FOR � � 'THROUGH Hi50R HERUIVN EMPLOYEC3,PROVIDEpTMAT SUCH IMPROVEMENTS ARE NC7 iltlTEk�ED OR m .� . LL1 OFfER�FORSALEIFHOWEVE �THE�U0.aNGOR1�9PROVEMENTI550LDWliHiNONEYERqOFCOMPIE � TION,THE�OWPJER-BU!LAER WILL HAVE,THE BUflD6N OF PROVING THAT HE Ofi Sk'c DIO N07 9UIL0 OR ' � IMPRS7VE�WRTM6PWRPOSE�JF�AI.E)� � ' �W '❑I,ASOWNEROFiHEPF7fJPERTY,AA7"EXCLUSSVELYCONTflACT1NGW15HLICENSH➢CONTRACTORS � , ' [][ TOCONSTryUGTTNEPR3JECT{iEC.'o�148U81NESSk�.Y�PROFESSION9CADE:THECOSdTRAGT05SU- � V81U2t�lOfi ACJJ.AREA � .Lll .CEIJSELAWDpESNOtRpPLYTOAN�OWNEAbFAFROPERTVWH08UILD50fi1MPROYE57NERF_oN,ANA �-- F �VffOCONTMCTSNR6UCHPR 'EC76WI7NACONTRACTOR(SJL�CENSEDPURSUANTTOTHECCNiRAC- QUF4!VTITY DESCRIPTION FEE � � . . Y 70RS LiCENSE LAW.1. � , � . �.. � ❑fAME%EMPTUNDERSEC�_ 9.&P.GFORTHISREASOM � � 6L. .. . . I.. ,� � - . I'_ c0 �A v , � .o�xe. � �ECEN Fo� QN � �- . : ��. 1NN . . .� . . ... ... TRAC7URS DECIARATIOM1! - � - ..�.` .. � ! ��i ' � , �Of PERJ,URY THAT I AFA LICENSED UNDEfl PftOVISIONS oF CHAPTER � -�'-" "'� : ' ,... ,� -�.„ , lHEq58YAFF�RMU1dpERAENAL �r - _ . p„ B(COA9INENCIldCiWiTHSCC710ld oW)OF6IVISION30F1}1EBU5lNESSANDPAOFESSIOkSCODE,AND � MY UCENSE IS IN FUL,,��I//��FOftCEA�a EFPEC7: �`„ � � �.q ��,����� � ru . 0 LICENSE CtASS ��2�t� '-+'� LIC.NO. _ � I�ill'' v aAr� n�'rz"r _. +'�:� car�r�acroR 9�{.�'�"i�3Y� �'b�t��'r. a w �� CGMPENSATIOPV DECLARATION � , . . � � Vr'OR�'.EPoS' � y IHEREBYAFFIRMUt�ERPENALI OFPSFJURYpNEOfTNEFOLLOWINGQECLARA710N5: V{ � Z� a �� __t#1pyEAN�'�,N'ILLM0.1N7A1 )1'�C�flTIF[GAT66FCCkVcENTTOSL3F-INSUREFOHWORKERS' S � � � � ' CCbAPEHSATIOF,AS P�O iD6q BY9EC7fON 37ooOF 7HE L490F GtlDE,FOR THE PERFORMANCE � � OF7�1E4YORKWRWtf�Qi'CpilaaEP,iRIT:515SUED. � d w �IHAlE�iBda"J�IliPAAINTAI MK1flKE[i5"COMPEN5l1"IOfJINs'Jq0.MC�A5REQl11REDBYSECTICN . � `�ENOOF it�1E�90R COU.,rpf�THE AERFORM.ANCE OF THE WORK FOR WHICH THIS PEPMIT IS � � �.ISSUEp.,Fi`5KK3 KERSd� NEP19RTflNINSU CECA9RIERANOPOLICYNUM9ERP,RE: CONSTFUCTION illlll� . � �� - ... .,,�¢, ,�cqA�iex�'�'',, � ', �''� PLAN REVIEN! � �¢� ���roucvau�e�H � ''�� � 6� ELECTRIC , . ¢ 198 �� ��NEH,71dOT lRkMFi.FiEnQFhiEP'ei�ATISFYSFQ'VEHUt�6CaLLA(',S s000a�ss. P�UMBING .(fFh ECfPNd 9., (S 1 1 �. il il _ � . �, .�, ,. � [� W IC�RTIF1'THRTIN7HEP RPOR�dANC�'OF7HEtl(QRKFORWNICHTHISPERMITISISSUED,1 � MECHANICAL �� '.+ !� ��I�PB f,�� SNALLMO'(EMPtQYANYP�R50NilIi�ANYlu1ANNERg{7AST00ECOMESUBJEC�TOTHE 8`° 4 ,WORKERS��OMPENBAfl i W''UWS,,uF CALIFDFNIA ANDAGREE TNATIF ISHOULD BECOME . � iNSPECTION FEE �'�'�� . �SU&dECtN YHE YdOFiKE�F��$��GbMP�ENSATION PPOVISIONSOF SECTION 370o OF THE LABUR C� ��y{}�"�p 8�A���j� �J ISSI➢At� �v �+.��aPs awar . CODE.ISH�II.FOFiTHV�l1�F�60MpLYiWITHTNOSEPpOVI510N5. !" , .. � , �„� .. ¢ . d .. ..��,�. py . . ( ��� s�neP �}II� .�1�D S �' . ° �."" �PPLCRNF.' �✓tl� � � DATE;�� !. . � } i„ illll�l..'�, iW . �,��L� . �" -J WARNlNG�FA16Jp�ITQ SECUp@ RI�RSI�qMPENSATION COVENAGE IS UNL4WFUL,AND SHALL BE ENERGY P/C LL SU&IECTAN EMpt,�LL1Y�ER TO CRiM M1�AL pENA�LTIE5.4ND CIVIIFiNES UP TOONE HUNDREbTHOUBAND ENERGY PER170T III��I � DOLLpRS(;7ap00qj.'�INA�DITION QTHFCQ�STOFCOMPENSATON.DAMAGESASPROViDEDFOfl!N ' � .�_I SECTION3�/tlBtl�THELAAORC30bE;IN�TER�ST,.,ANDATTOftNEV'SFEES. � RETENTIONrEE= � � � � � � GONSTRU�TION LENDBNG AGENCY PRE-ALT FEE: ___ __ _ _ Q . . .,. :�. ii , ,-- ' ���� IHEREBYAFKIRM�(1kDERPENAL �OFPEF��IRYTHATTHEREISACONSTRUCTIONLENDiNGAGENCY .. FOH THE AERFORMANCE OFTHE�OPK FO�WHI6FI THIS PEflMIT IS ISSUEO(SEC.30AJ,CIV.C.]. , , W '.. , �, � „ . .. . �T LENOERSNAME' '� '� ' � - Z „� F- �,LENOEAS�DDR�55� � I ' ' � � ICERTIFVTHAT H VEREAOTHI APFLCR ICSN �OSTATETHATTHEABOVEINFORMRTMJNfSCORRECT. TOTAL FEES � w I a � I , �r ( 'i AG � � 'COlAP V WITH Al1 CIN�AN�COLNTV�RDINANCES AND STA7E L4WS REIATIAIG TO BUILDING � .. �� . . R�EN L y"1 . . �COM$TqU4T10NpryDHEREBYA � RZE�Ef'PESEN7ATIVESOFTMISCOUNNTOENTERUPONTHE - - - . . � A� NT� "�P OP TY. RIN PE� ���NPl1RPO5E5. ' ' BOVB•M �ED ER .F . E �CF� ., R $ Z, i��. , , . CO MENTS � M . � I�.�,, p', . . . . — � 7 ���a.� J��� , � I� IIII II � �� EE h' itPiilM- III +!9.� �:�':I Q I'I�III I' ..C/� � I I li�:� I � � I�I 5 �. R E DATE � '+ - '� ��� - RECPT.NO. ` � PAI�BY ` VALIDATION F=-- — � JJHITE—Dapartment Copg YEILOW—Finance Copy,PINK—Assessor Copy,GOLDENROD—�Pile Copy,GREEN—ApplicanPs Copy � iiIIIIIIiIi Ill�l�,i�ii�'i �' . _ . ��� � � � � � u,.a t . %��'. e; �J�,� ua�6,'> �#?+u.., �+., _'�=?i' . .. -�. � . . . . r`s x��-s :.� �, ...�-� � 4.�: �, � �k.. .,,i'y. . � � ' , , ;� . .. . . 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