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CITY OF DIAblOND BAR ' COM!�tUNITY DEVELOPMENT DEPARTb1ENT � �.,.� 21660 E.Copley Drive Suite 190 PRESS (909)860-3195 Fax(909)SGI-3117 �'""' BUILDING PER'�tiTAFPLICATION FIRMLY y .1���TE L/ � ,r * APPUCATION � �Q PERMIT O � �/C o ADDRESS �7� N_ PL�q%INA l�� , DATE_� � NUMBER � ISSUE TYPE OCC APN LOT TRACT DATE CONST. GROUP p OWNE�M � AM /S Q ADDRESS 5S/�_L�CA�/Vjd , ZONING SETBACKS � CITY �1 ZIP TEL.�`�' fRONT RW O APPLICANT /�,.fA F 6.•Fi✓�.�d.�POTEL. REAR ❑ � SIDE/SIDE STREET RW p � CONTRACTOR � SIDE p � ADDRESS � ' , PROPOSED USE o CITY P/dF.Ptil�E ZIP '�. �TEL. e ow AFCFVENG/ iz DESIGNER NO.DWEL. NO. NO. a ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � DESCRIPTION S�.FT. FACTOR PSF ADJ.AREANALUATION Q ONMER•BL'ILDCFi DECLARATION SFR/ADDlREM O � 1 MEACBYAFFIRM Uh�ER PENILTV OF PCR1l:RY 7HAT 1AM EXE�PT�pOAI TM[�pf;TMC,`iOfiS LI- G82Q9ICl�p011 W CENSEUWfORiNCFOLLOWNGREll50N(SEG70715&15�CSSANDPfiJFE55�ONSCAOCANTGTYOR (n U �,HTYN91Ip1f1Eq1�RC5AVER4ITTOCd:57fR1CT.ALTERM:FqVC.DC�/OLISSORfiE1+AIRANY5Ti1UC- W paiia'Deck � 7URE,iROH TO ITS ISSU4ICL A�50 f1E0UIRE5 THE IPPICANi FOfI S'JO�VEPY T i0 FI1E A SIGN[p W S7ATE4Cti:MATIiE M S++C�`+UCCM1SC�PV�'+VMIi 70 TNE FlWYS�CwS CF TME COhTMCT0�5 LF � CFNSE UW(Cw�PTEp o(Cd1�ENCUO NnTM SECTqa 7�oal OF dVIS�ON]OF iME BUSiM[SS AND VNO V' PODLSpI FESSqr:SCOOElON7n�7MEOR5��EI5Ex"eM�TTNCRCfROUIN�iNEBA5�5iOqTHCALLEGE7EXEwo• (7 TIp:M:YVIOLATqNOFSCCilON701150YANYAFP:ICAhTFORAVCiYAI'SVBJCCTS7wEA7PIGlvTTO Z Re-Rool r ACN.LV[NALiTOFNOTMOqETNA.4iNEMl:1.9REDDOLUR5�f5�0�) � Ol�4SOM"1EROfiHEFFiOi'CI7TV,OI7YYEMPLOYEESWITMN'AGES�SMEiASOIECW.�PENSAiip11, � �mmerc,al N^LL DO THE YYOPo(.M:D THC STRUC7UflC IS NOT INTENCC�Oil OfFFR1.0 fOR StiE(5'eG.7D��,BUSI• J N NCSSANOPi10�E55Ww5C0�[:1NCCANiM..^TOM1SL�CN;'cUWDOCSNOTM'PLYTOANOwNEROf ? if1DPE HTY 1N0 W�DS OR NPf10VES iM[ii[pN.AI.01M10 DOCS SVCM INCRK Hi45eLF OR NE0.5ELF Oq 2 THROVGnN13qiNENOMNEM?LDYCCS.PROVI7CDiHAT5Ud1WPf1pV@MENTSMEHOTY.TEHDE�OfI m � Occ[NFOiOfiSALEIf.�qwEYE0.71+EPVtDMGdiuntq�4uEtiT155d=vnTwvd.CYEApOFCOM0.E- Z TqN.TXE OWhER BURDER w�LL 1UVE TNC B:J�DEN Of iROv'NG i1uT MC OR SM[DDlqT W1LD OR _ �APNOVEiOHri�EivAVOSEOPSALEI �y,� CL�SOw'.E�10FiNCViiOPE"tfY.M�E%�USMIYCONTMCTNGY�TNLICEYSCDCON7RACTORS Q 7000NSiRt1C7 TME PAOJECT ISEC.7:a�,8'JS:NL55 AN�PROFCSSIONS CME 7ME WNTRACTOAS U- V91UeliOfl ADJ.AREA W CCNSCU�4DOESNOTAiPLYTOAYdH+IEROFAVR07CN1YN?qBU1LD50fINPROVCSiNEREON.N1� � NeqCANTMCT5FOR4'JCNPH0.ICCTSM'•THACO�ITMCTORiS)L�CC45EDp'JRSUANTiOTMECpfTMG QUANTITY DES'�RIPTION FEE � TO0.5 LICEhSC LAW�. � O�M.�f%EunTUH�ERSCC. B LPC.FO�T�iSFE►SOr: Q 3 � � ¢ / ` �/�-� O DATE Owr:CN W f�i1�� �.7/ CC/V✓ (/ �4 LICENSEO CONTFiACTOfiS DECIAiUl710N W (� �H(REBYAFFIRMUNDERPC�ALTYO�FEIilUf1Y7HA�lAMLICEYSCDUN.^.[IIPRONSqI:SOFGUPfF� � (L Y(COW�EhCIN�WITHSEC7qN70m)OlOMSqN70(T1IEBUSINESSl4[1VROf[SSqN9CODCl1.�D Z K MY LKCNSE�i N ML fORCE AND EFiELT. LLI �J/'�I/L��� �D � UCENSE CUSS�.� -- 11C.NO._{�2 � �-- oarE 1-3/- /3�_� conrrucroa��� a LL ' � WORKERS'COMPENSATIONDECLARATION �!� � Q �j ,� ,. � � I � IXEREBY�FililAAlh'JERVCIiILLTYO�PE0.AIRYONCOF7HCiOlLDW:NCGECIAfUTIdHS. Z � �IHAVEANON"LIMANTA'HACC�T:fICAiEO(COhSCNT705ELFJAuURCi0i1NORRERS' _ C04vENSA7qN,ASPipwCC7BY5[C7:ON7foDOc7N[WIO�[OCC.FOnTNEPEPiORUU�CE W OF iHC WO�K fqt�tiMIG1 TN:S PC�IMIT C'i I^aSUCD � C W _IN�YE�NOW'LLlWN7ANWORKERS'COY�ENiATqNIHiUM4CEA5REWWE7Bv5[CTId: Q ]lU0 CF TME L/4FIIX1 COO[.f011 iHE iEH�ORMA4CC CF 1MC YlONI{F011 W1np1 iM15 VC�MfT IS GS:1C7.4YWON(ERS'CO4PE1:S�iqNINS �WKECARf1�CRIfOPOIICYM1VBcRMC. CONSTAUCTION J p,�� j unn�en_y>.y�� /�'� PLXJREVIEW /e 11 0 COIICYM.LAER �3�I �� aic � ?S l/ Z ¢ 0 �nas s�erou reo no:ee mu;�e�orne rcr�rr 6 wr+a��a���us a�ao;oa iE.s> Z ICERTIiYTHATHTHEPC�fOilMtivCCC�TNC�WRKF011YN�KJ�i�:SPERM:'ISISSUCD.1 ECHANIC ). .,,.(,�J SHILLLNOTF4I�LOYAWPERSONIHIWYY�NNERSOAiTOBCCOMESUNCCTiOTMC � YYOPI(Ef15'COMPCYSA�IDNL�'�OFC/�.:F00.ti:A.lU.D�G�fETMA'IFIS�qULOBiGdAC ECTIONFEE 5:161CCT i0 TNC MAORKCIIS'C04�E�:SAiON ifi0Ni10Ni OF SECi ION]T00 O:TME UIBOfi cooe,i s�u:i vonTHvnrn cornr�r wn�na•c P ISSUANCE � pDATE.J�I/3� A07LIUNT _`y�'-��w"'�^� SMIP � ENERGY P/C WAiW iNC FALURE TO SCCUHE WOfiNEliS'COuoENSAT�ON COVEMC[IS l;N;.A�.KUL.HD S�U:L 0E �y SURICCTWCMPLOYEFTO[IUYWA!VENALTIESMI�CN1i1NC5l1PTOOhEfIt,TDRC]TlIOUSAhD ENERGYPERMIT DOL{AfiS(i�7C.7aC1,IN INDRION 70 THE COSTOf fA4YEti+�TION.D�1/1A�:5 AS P110VDCD FOI11N J SECiqH7�0aOFTMELABIXiCODE,N7CfIE5T,ANDA7TpfWEY5FEE5. RETENT�ONFEE: � Q p"'�. COhSTRUCTION LCNDItiG AGENCY PRE-ALT FEE: O � IIICf1CBVAFFIf1Ml1M�E11PCNALTVO�PC0.1UiiVTWITTNEfiCISACONSTRUCTIONLFN�L4G113CNCY Fql iHC 7CRiCM/ANCE Of iH[WdiK FON WwGI TNIi PCRYIT li iswc��s�c.oaar.crv c�. 7 � ` - ' � LCN�ER9NAN[ F- lCN0ER5h7�FE55 � TOTAL FEES � I CCRTIFV iMAi l NAY[pEA�i11:5 APV�1G1TqN IJN STATE 711AT TNE ABOV(Y.FOM1ATqN IS COMCCT. W I AGREE TO COYVLV YAT.1 AlL GTY FhD CdNTY O�JIHIW CE5 A1A STATE lA'NS NCUTwC TO DU[CiNG � � CONSTRUCTION.�h9MCREBYAUiMOR12C11CVRe5CNTA7M50fT1115COVNiTTOENTERUPONTIIE S�. ABOVC wENTqNED PROPERTYFOR IH;PECTqN PUNPOSCS. COMMENTS a /� �- � �.�a� � PE iTTEE N ��P ' � � ..� _ //-9� � SG/N11NE 04 PENY�REE CATC Cn 1 � RECPT.h0. � � PAID BY VALIDA _ WHITE—Dparlmont Copy,Yf:LLOW—lm�nce Copy.PINK—A6te�sor Copy.GOLDENROD—Fik Capy,GREEN—Appkant'a Capy , . .. � . � , f. . .�. � . . ... t .... � . .T� . . . . . .,�. ..� . . . . �� .1, '� . , �.r• .. . . ,� • � •. . `. 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