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� � „ y' 1,� CITY OF DIAMOND BAB � DEPARTMENT OF COMMUNITY&bEVELOPMENT SERVICES � 21660 E.Copley Drive Suite 190 w BUIL,D 3195 Fax(909)861-3117 � � PRESS �"°�"� (�)8 ING PERMTT APPLICATION FIRMLY � JOBSITE r'� ���G �- r,�- APPLICATION �,,,a PERMIT A�� P/C �l , �u� o ADDRESS �� �`'�G DATE NUMBER # � � g ISSUE Y TYPE OCC APN �OT TRACT ,��-Ga"�J DATE { � CONST. GROUP °C OWNER 11A - O � ADDRESS S ZONING SETBACKS "' ' '` ""'� 0 W CITY ,`��i'N ZIP Z � TEL� e� FRONT RW ❑ � APPLICANT TEL. REAR ❑ � SIDE/SIDE STREET RW ❑ � CONTRACTOR SIDE p O CDDRESS ZIP � TEL. PROPpSED USE oARCFUENG/ _ � DESIGNER��1�- � � �-� NO.DWEL. NO. NO. ADDRESS �- UNITS STORIES BEDROOMS � CITY ZIP ^ TEL� u� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANA ATION O OWNER-BUILDERDECLARATION fa �.. �� SFR/ADD/REM �C I HEREBY AFFlRM UNDER PENAIN OF PEFUURY hIAT I M1 EXEMPT FROM THE CONTRACTORS LI- G8f8J8/C81'P011 C � CENSEIAWFORTHEFOILOWINOREASON(SECJo31.58USINESSAN�PpOFESSIONSCODE:ANYCITYOR (n - d � COUNTYMMICMREWIRESAPERMITTOCONSTRUCT,ALTER.IMPROVE,DEMOUSH,ORREPAIRANYSiRUG W P8t10/DBCk NRE,PRqR TO ITS ISSUANCE,ALSO REQUIRES 7NE APPLICqN7 FDft SUCH PERMI7 TO FILE A SIGNED W STATEMEN�7HA7 HE OP SHE IS LICENSED PUqSUANT TO THE PROVISIONS OF THE CON7RACTORS LI- � CENSE LAW(CHAVTEH 9�COMMENCINO WITH SECTION 7Doo)OF DIVISION 3 OF THE BUS�NE55 AND PRO- �'�' Pool/Spa - �. , FESSpNSWDE)ORTHATHEOHSHEISEXEMPTTHEREFROMANOTHEBASISFORTHEALLEOEDE%EMP- (� . V TION.ANVVIOI.ATIONOFSFCTION7031.6BYANVAPPLICANTFORAPERMI75U&IECTSTHEAPPLICANTTO Z Re-Rooi � ACMLPENALTYOFNOTMORETHANFIVEHUNOREDDaLLARS(fSoolJ: , . � ❑I.ASOWNEROFTHEPROPERTV,ORMVEMPLOYEESWITHWAGESASTNEIRSOIECOMPENSATION, � Commercial � � ��y �. - WIU.DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC.7044,BUSI- J � NESS NIO PROFESSIONS CODE:THE CONTRACTORS UCENSE UW�OE3 NOT APPLY TO AN OWNER OF = � � " - . PROPERTY WIiO BUMS OR IMPROVES THEREON,AND WHp CIOES SUCH WORK HIMSELF OR HERSELF OR Q 7HROUGHMISORHEROWNEMPLOVEES,PPOVIOEDTHATSUCHIMPROVEMENTSARENOTINTENOEOOR m ' QOFFEREOWRSALEIFHOWEVERT1iEBUIL0INGORIMPflOYEMENTI550LDWITHINONEYEAROFCAMPLE z �TION,7HE OWNEREUILDER WILL HAYE THE BUH�EN Of PFOVINO THAT HE OR SHE DIO NOT BUILD OR = IMPROVEFORTHEPUHPOSEOFSM,�. ❑I.AS OVMER Of THE PROPEFfTY,NA E5(CLUSIVFLV CONTflACTIN6 WIT4 LICENSEO CIXJTqACTOFis � TO CONSTRUCT THE PRO.IECT(SEC.7041,BUSINE55 AND PqOFESSIONS CODE:THE CANTRAC70RS U� VffIl18I1011 � ADJ.AREA W CENSEUWDOESNOTAPPLY70ANOWNEROFA?iMPERTYWHOBUILDSOHIAIPROVESTHEREON,AND � � WIiOCONTRACTS FOR SUCH PROJECT6 WITH A CONTRACTOR(5)LICENSED PURSUANTTO THE CONTi'1AC- roasuc�sEuw.). QUANTI7Y DESCRIPTION, .. ,,.�., .:_.�.,. FEE � ❑I M1 E%EMPT UNDER SEC. B.8 P.C.FOR THIS REASON � � � a y c� . LL � �' '1 ' OATE OWNER_ V Z - .. , � e^" :r_, . / � UCSNSED CONTRACTORS DFCLARATION W „ � J � f 1 HEREBV AFFIRM UNDEP PENALTV OF PERJURV THAT I AM LICENSED UNbER PROVISIONS OF CtIAPTER O,� � 9(CnMMENCINO WITH SECTION 7009)OF DIYISION 30F THE BUSINE33 AND PROFESSIDNS CODE.AND Z V MY LIGENSE ISlN FULI FORC/E�AND EFFECT. �---��^ � UCENSE CLASS�[� LIC.NO. ��� �� ! � � (/�°i�� ~ DAT� _ CONTRACTOR �.�tl y�_ d � �, � + W ,e_ � � ��TTrT �� � � VJORKERS'COMPENSATiON DECLARATION 4 � � � IHERE YAFFIRMUNDERPENALTYOFPERJURYOMEOFT4E�-0LLOWINGDECLAPA?IONS: z � � IH�VEANOWILLMAIN7AINACERTIFICA7EOfCONSENTTOSELF-INSUqEFORWORKERS' 2 '{' �, COMPENSATION,AS PROVIDED RV SEC710N 370o OF THE LABOF CODE,FORTHE PERFORMANCE U �F ti OFTNEWORKFORWNICHTHISPERMITISISSl1E0. � � :-��� � I HAVEANO WILL MAIMAIN WORNERS'COMPENSATION INSURANCE,AS REQ'JIRE�BY SECTION Q �37000F THE LABOR CODE,FOR PHE PERFORMANCE QFTHE WORK FOR WHICH THIS PERMIT IS —�� .� � � Q '4/j � ll ISSUED.MY W ER5 COMPENSRTION I�CE CARRIEF AND VOIICVJIf1M8ERARE: CONSTRUCTION �lL\C,�l.0 � •r•� r� ie•' � caaruEa ���'�G �� L-f4'>_ 4���Z3J• pLqN REVIEW � POLICV NUMBER�_I�y� L-- a'-+ � O I L''"7 LA- Z +{�'�—�r-G�-r-T-��-T,.� ELECTRIC ..� ¢ � '�+` 0 (IHlSSECTqNNE�NOTBE00A9PLEfIDOFiFIEPERAi1"ISFOFOI�EF0.I�DREDDOL.IAfiS(EIW LU 1 IN � .,no C. '�d•�f .� W n f 1 Z �CENTIFYTHATINTHEPERFORMANCEOFTHElVORKFORVJHICHTHISPERUITISISSU o,i MECHANICAL __�Ty��� -� (J SHALL NOT EMPIOV PNY PERSON IN ANV MANNEq SOAS TO BECOME SUBJECT TO THE � WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECA E �� ��IN�PE�I��EE � SU&IECT TO THE WORKEPS'CPMPEh'SAT�ON PflOVISIONS OF SECTION 3]0o OF THE LA OR '� . � SGODE,ISHAI.�FOft1HWITMCOMPLYWiTHTHOSEPROVI5pN5. ISSUANCE pDATE:���APPLICANT: _.._�jr^'��� ___ SMIP ( � � I V —� WARNINO:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SH �� T� J SUBJECTANEMPLOYERTOCPIMINAUPENALTIESANDqV',LFMESUPTOONEHUNDREDTHOUSANO a�/ ' � OOUARS(51ao,aoo�,IN ADDITION TOTHE CQST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN ENERGY PERMIT '���-��)�e y�1,-4�'�� � � SEGTION 3708 OF iHE LABOR COOE.INTEREST,AND ATTORNEY'S FEES. RETENTION FEE: ��,J+�/'O^� � OCONSTRUCTION LENDING AGENCY PRE-ALT FEE: � IHEREBVAFFIRMUNDERPENALNOFPERJURVTHATTHEREISACONSTRUCTIONLENDINGAGENCV 2 FORTHEPEflFOFiMANCEOFTHEWORKF �WHICHTHISPERMITSISSUED(SEC.3oD],CIV.C.). � . � LL' �A19���u'%?��, � � I.ENDER'S NAME L __— I--' LENDER5ADOHESS W� TOTAL FEES `��� �"j� � � I CEFTIFY THAT I HAVE fiEAO THIS APVUCATION AND STATE TH0.T7HE ABOVE INFORMATION IS CORRECT � I AGREE TO COMPLV WI1H ALL CITY AND CDUNTY ORDINANCES AND STATE IAWS RELATING TO 6UILAING � CONSTRUCTION,AND NEREBY AUTHORI2E REGRESENTATVES OFTHIS LbUNTV TO ENTER UPON THE z ABOVE�MENTIONEDPROPERTYFORINS ECTIONPVRPOSES. COMMENTS � .� .r _ m PERMITTEE NAME(PRI .�+� /J Q N../ s-�.1 CI') 'f''/' 6- � SIG REOFPERMI E OATE = RECPT.NO. 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