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, . ��/�G� _ �N CITY OF DIAMOND BAI� �/3v /U� � � '---�"'�— DEPARTi�4ENT OF COMMUNITY&DEVELOPMENT 5ERVICES � � 21660 E.Copley Drive Suite 190 �,�;�� (909)860-3195 Fax(909)851-3117 �%��' PRESS ��M�'�� BUII.DING PERMTT APPLYCATION —_ FIRMLY _ APPLICATION } PER � JOBSITE ���"�/'� ��� ��i DATE � 1� �� NU BER �� � �/C o ADDRESS I�� $ ISSUE � � ��.� TYPE OCC APN LOT TRACT DATE '' CONST. GROUP p OWNER G� �. p ADDRESS U � ZONING SETBACKS "'� CITY ZIP C� TEL. "(��� FRONT RW ❑ � APPLICANT TEL. REAR ❑ � ^ � SIDE/SIQE STREET RW ❑ � CONTRACTOR SIDE ❑ � CDDRESS ZIP TEL. � L PROPOSED USE o ARCH/ENG/ ��,, DESIGNER NO.DWEL. NO. NO. � ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANA�UATION Q OWNER-BUILDER DECLARATION SFR/AD�/REM O I HEREBV AFFlRM UNDER PENALTV OF PERJURY iHAT I AM EXEMPT FROM THE CONiRACTORS U- G8ffl90/C8l�OfI W CENSELAWPoqTHEFOLLOWINOREASON(SEC.1a77.6BUSINESSAN�VROFESSIONSCODEANVCI7VOR (n U COUNTVWHN%iREQUIRESAPERMITTOCONSTRUCT,ALTER,IMPROVE,�EMOL'EH,ORREPAIRANYSTRl/G W P8fi0/DeCk TUF1E,PRIOR TO ITS ISSUAHCE,ALSO REQUIRES THE APPUCM7T FOR SUCH PERMIT TO FILE A 3IGNED W S7ATEMENT TiAT HE OR 9HE IS LACENSED WRSUANT 70 THE PROYISIONS OF THE CONTFACTORS LI- W � CENSE LAW(GHAPTER e(COMMENCINO WI7M SECTION 7000)OF DIVISION 3 OF THE BUSINESS ANO PRO- u' POO�Spa FESSIONS CODE)Ofl TH0.7 HE OR SHE IS EXEMP7 7MEREFflOM AND TNE BF515 FOH THEALLEOED EXEMP- TION.MIYYIOLATIONOFSECTION70.11.SBYANYAPPLICANTFORAPERMITSU&IECTSTHEAPPLICANTTO Z qe_p�p} � A CML VENALTY OF N�T MORE THAN FNE HUNORED DOlL1RS(5500).): ❑I,ASOWNEROFTHEPHOPERTY.ORMYEMPIOYEESWITHWAGESASTNEIRSOLECOMPENSA710N, � Com010fClel � WILL DO THE WOqK,AND THE 5TRUCTURE IS NOT INTENDE�OR OFFERED FOR SALE(SEC.7ou.BU51- J � � NE35 AND PqOFE5S10NS CODE THE ODNTRACTORS LICENSE lAW�OES NOTAPPLv 70 AN OWNER oF = PNOPERTV Yh10 BUILOS O/i IMPROVES THEREON,AND WHO DOES SUCH WOPK HIMSEIF Oq HERSELF OFi � THHOUCiHHISORHEFlONMEMPLOYEES,PROVIOEDTHATSUCHIMPROVEMENTSMENOTINTENDEDOR m Q OFFEREDFORSALEIF,FpWEVERTMEBUIL�INQORiMPROVEMENTISSOIDWITHINONEYEAROFCAMPLE- Z TqN,THE OV'MER-&JILDER WILL HAVE THE BURDEN OF PROVIN(i THAT HE OR SHE DID NOT BUIID OR = IMPROYE FOR hiE PURPOSE OF SALt7. � ❑I,ASOWNEROFTHEPROPE(�V,AME%CIUSIYELYCANTqACTINGWITHLICENSEOCONTRACTORS TO CONSTRUCT THF PROJECT(SEC.7044,BUSINE55 AND PROFESSIONS CODE:THE COM'RACTORS LI- V81UetlOfl ADJ.AREA CENSE UW DOES NOTAPPIV TO AN OWNER OF A PROPERT'WHO BUIlDS 0R IMPROVES THEREON.AND � WFIOCONTMCTSFORSUCHPROJECTSWITHACONTRACTOR(S�LICENSEDPUFlSUANTTOTHECON7RAG QUANTITY DESCRIPTION FEE � TOHS LICENSE LAW.). ❑i AM EXEMPT UNDER S�C. B.fl P.C.FOF THIS REASON Q 3 � LL � Z �ATE ONT.ER � � LICENSED CONTRACTORS DEGLARATION W J � W I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER � (L 9(COMMENCINO WIiH SECTWN 70a0)Of DIVISION 30FTHE BU5INESS ANO PROFESSIONS CADE,AND z a � MY LfCENSE IS IN FULL FORCE AND EFFECT. ^� m � UCENSE CLASS �y UC.NO.�(��.�I �� � j �� V DATE !O " J"�� CONTRACTOR.�1 � a W � WORKERS'COMPENSATION DECLARATION a ,. � I HEqEBV AFFIRM UNDEF PENPLTV OF PEFUURY ONEOFTHE FOLLOWING DECLARATIONS: Z - � ^ " _ � _IHAVEANDWILLMAINTqiNACERTIflCATEOFCONSENTTOSELF�INSUREFORWORKERS' _ � COMPENSATION,AS PROVIUEU BY SECTION 37000F 7HE LABOR CODE,FOR THE PERFORMANCE W Q ObT1iE WORN FOR WHICH THIS PERMIT IS ISSUED. � � i/1 HAVE AND WILL MAINTAIN WORKEflS'COMPENSATION INSURANCE,AS FEQUIRED BY SECTION Q3700 OFTHE LABOR COpE,FOq THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS � ISSUED.MY WOFKERS'COMPE�NSATION'�INSURANC IER AND VOLI _NUMBEH ARE: CONSTRUCTION � CARRIER���1�_^�.� PLAN REVIEW � POUCYNUMBEH_1._.Lc�;,_c� � — ELECTRIC �� - /� 0 (iHISS[Cf10NNE�NOT8EOC7.7`LETEDOFTHEPEANTISFORONEHUWfiEDDq.IFRfi(5100)ORLESS� PLUMBING �//^r Z 1 CEHTIFYTHAT IN THE PERFOqMANCE OF THE WORI(FOR WHICH 7HI5 PERMIT IS ISSUEO,I MECHANICAL (,'} SHALL NOT EMPLOY ANV PERSON IN ANY MANNER 50 AS TO BECOME SUBJECT TO THE � WORKERS'COMPENSATIONL4WSOFCALIFORNI0.,ANDAGREE7HATIFISFIOULDBECOME INSPECTIONFEE S SU&IECT TO T VJORKERS'COMP TION PROVISIONS OF SECTION 3700 OF THE LA60F COOE I SH ORTHWITHCOMPL WI SE PROVISIONS- ISSUANCE � � /� ,/�' SMIP �r`r , � �nnn p DA�4' L``� APPLICANT. Q � WARNIN6:FAILURETO SECUNE WORKERS'COMPENSATION COVERAGE IS UNUIWFUL,AND SHALL BE ENERGY P/C��TL�`� ��3A� �y, SU&IECTANEMPLOVERTOqiIMINALPENALTIESANDCIVILFINESUPTOONEHUNOREDTHOUSAND ENERGYPE .hiNlfl' ^ � DOLLARS(StoO.oao),INAODITIONTOTHECOSTOFCOMPENSATION,DAMAGESASPROVIDEDFORIN �7�,p�G A.N�SAFETY SECTION37aeOFTHEL480RCODE,INTEREST,ANDATTORNE`!'SFEES. FETENTION QCONSTRUCTION LENDING AGENCY PRE-ALT FEE: � �HEREBYAFFIRMUNDERPENALTYOFPERJUfiYTW1TTHEREISACANSTRUCTIONLENDINGAGENCY f-0R THE PERFORMANCE OF7HE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.3a97,CIV.CJ. . Z W � LENDER'S NAME 1— LEN�ERSADDRESS � ICERTIFYTHATIHAYEREADTHISMPLICATIONANDSTATETHATTHEABOYEINFORMATIONISCORRECT. TOTAL FEES � � IAGREETOCAMPLYWITHALICtiYANDCOUNTVOADI ANCESANDSTATEU1WSqEU71NO70BU1lDING � CONSTRUCTION.AND HEREBY AUTffORIZE REPRESEN TNES OF THIS CDUNTY TO ENTER UPON THE ��` A90VE-MENTIONE�PP�PERTV FOR I PECT�ON PIJR SES. COMMENTS 0 J � m PERM P NT) ¢ �!'1MI UJ \ �— ./ � SKiNATUHE PERMITiEE DI1T � �� RECPT.NO. PAID BY � VALIDATION WHITE—Department Copy,YELLOW—Financa Copy,PINK—Assessor Copy,GOLDENROD--File Copy,GREEN—ApplfcanYs Copy .. .. ....,�� . ,.:':,�� ...�-n,� �.r.:P: �' ..- ����.�.� ..,, . �Ai�.:._.�. ..... :. .... .. . . .:..R.� . 4 . .. ..' .'r..r '..,_'�, . -.n`r;�... 7, -'.!:, '�-.,:=.n. . ..�:-..o�,': � ' "�'. � R� � � ��� - . .� . . . . . . w. _ �:�.... �Sr •. ,. . ._. , _ �W� � � �� '. .... , . �: . ,. .. . _ .s �.' �• ... � '_. B� _ y _ . .� �: � . N- � ; „�,� � � � �� - � b � � d 4 � y a ��.�, ..a-�a. � , :.� �� ��:. �+�.�, ::,;. ., - a._ � .�,rim rx � Y :.�.`:. . �>�� .,,... .. a �,y�.� '_�, .�:e. _ ��� ��-� .... � �,'�� '`�. .� � . � ' i _ 1 ,1 „� ���4.9P"r.,����'J� '�. . r' .. -v. 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