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^ �� CITY OF DIAlVIOND BAR � I _�,::--.1 ' DEPARTMENT OF COMMiJrTITY&DEVELOPMENT SERVICES 4 21660 E.Copiey Drive Suite 190 ��� (909)860-3195 Fax_(909)861-3117 PRE$S 9�°'�' � SUILDING PERIVITT APPLICATION _—_ ' FIRMLY (� APPLICATION C.�..� p �'`� a� JOBSITE I��! �lq�lb���''" �,�i !?� DATE �~ ` � NUMB R� �'��'l� �/C ADDRESS � � ISSUE �, TYPE OCC r APN aT TRAC7 �� DATE � CONST. GRQUP � OWNER � �.. G:.'1 & C. " O � ADDRESS � '� � f. �i++i ING SETBACKS z CITY 5 ` c-d*�. ZIP �a Z,. �E K ZON FRONT RW ❑ p APP"LICAN"f TEL. � S DE/SIDE STREET RW O Z � CONTRAGTOR , f ^m-. ' SIDE _, C � CITY ESS q ,,F ZIP.���.-TE Y ` `T p� PROPOSEP USE C7 _, o ,ARCWENG/ ! _ ' � CTMR SSR ZIP TEL. UNITS STORIES BEDROOMS W NO.DWEL. NO. NO. r� ' O WNER-BUILDER DECLARATION � D WA D/REInON SQ.FT � FACTOR PSF .ADJ.AFjEANALUA� " � � T ION; I HEREBV AFFIRI!UNDEq PENALTV OF PERJLAitl THAT I AM EXEMPT FROM THE CON7RACTORS LI� G3f8J8/C2fPOfI W����CENSELAWFORiHEFOLLOWINGREA$ON(�C,1D3i.58U$INE59ANDPROFE9SIONSCODE:ANYCITYOR _�(n � � U COUNiYWF11CHRFQl11RESAPERMITTOCONSTRt1CT.ALTER,IMPROVE.DEMOLISH,ORHEPAIMANYSTFUG .W- PdtIC/DBCK ' Z�� 1URE,PRIOH TO ITS ISSUANCE,Ai:50�REQUIRES THE�APPUCANT FOR SUCH PERMIT TO fILE A SIGNED ' W' STATEMENT YHAT HE Oq SHE IS�,LICENSED PURSUANT TO THE PROVISIONS OF THE CONifIpCTORS U- W �,�,�CEPISE LAW(CHAPTER e(COMMENCING WITH SECTION 7000)OF DNISION 30F THE BUSINESSAN�PR0- ' � PODUSP2 ' � ,� FESSIONS CODE)OR THAT HE OR 3HElS EXEMPTTHEREFROM AN�THE BASIS FOR THE ALLEqED.E%€MP- '�TION.ANYVIOLATIONOFSECTION7031.5BYANVAPPLICANTFORAPERMITSU&IECTSTHEAPPLICANiTO Z RB-RaOf . . �^,.����� ' ' "A CIVIL PENALTY OF NOT MORE THAN KIVE HUNORED DOLU1q5(S�}.): ' ' ' ' 0, ❑I,ASOWNEROFTHEPROPERTI;ORMYEMPLOYEESWITHWAGESASTHEIRSOLECOMPEN$ATION, �� COrt11119fC18I � .� �,WILL 00 iHE WORK,AND THE S'fRUCNRE IS NOT IN7ENOED OR CFFERED fOR SALE(SEG 7oda,BUSI- J I �.�,NESSAN�PpOFES510NS CODE:�THE CONTRACTORS LICEIi'oE UW DOES NOTAPPLV TO AN OWNER OF = PflOPEflTYVMOBUILOSORIMPROYE57MEREON,ANDNAIODOESSUCHWORKHIMSELFOFHERSELFOfl � CC'� '�THROUGHHISORHEROWNEAIPLOYEES,PROVbEDTHATSUCHIb9PROVEMENTSARE'NOTINTENDEDOR � � " " " W� 'OFFEREDWH9ALEIF,HOWEVER,THEBUILDWGORIMPRDVEMEiJTI55DlDW17HiNONEYEAflOFCOMPLE- ' Z,' ;SION.THE OWNER-BUILDEF WILL HAV�`THE BURDEN 6F PROVING THA7 HE OR SH:�IO NOT BUILA OP . � ... ���,IMPROVEFORTHEPURPOSEOFSpLE): � �, �.�� ❑I,AS OWNEH OF THE PRObER7Y,AM E%CLUSNELY W NTRACTING WRH LICENSED CONTRAC'fOHS ' �� ��,,TO CONSTRUCTTHE FR0.1EC7($EC.7046,BUSMESS AND PROFESSIONS CO�E:THE CONiHACTOFS LI� VAIUBIIOfl ADJ.AREA � W 'CENSELAW�OESNOTAPPLYTQ�ANO�/NEROFAPROPERTYWHDBUILDSONIMPROVESTfiEREOM,ANO � �.�WHOCONTRACTSFORSUCHPROJECT$WITkACONTRACTOR�S)LIGENSEUPUflSUANTTOiHECOWTRAG (�UANTITY - � DESCRIPTION � � � � FEE�. �,, '�TORSLICENSELAW.). ... .. ��o�'�� OIAMEYEMPTt1NDERSEC. � 8.6P.0 FORTHIS�REASON �,� � � � �� I �', . � W', � �. � .DATE OWNER �V �� Z , �y O LfCEN5ED CONTRACTORS DECLARATION � ' � �-, �F--�. . ... . , . . . �W . ��� 1 HEREBYAFFIRM 11NDER PENALTY OP PERIURYTHAT IMA LICENSE�UNDER PROVISIONS OF CHAP7ER � ,q,�. `�� ,j...` p�'�. 9.�COMMENCINCiWIiHSECTION7000)OFDIVISION30FTHEBUSINESSANDPROFESSIONSCO�E,AND �,Z. ti� ��1 C'+°�. ���,(� �,� X� AIY LICENSE IS IN FULL FOPCE AND�EFFECT. �m � � � o�td.0 � LICENSE CLASS UC.NO. ������ �7�� �I,�� � J ' V��, ��DATE -"''� � � CONTRAGTOR '0. "-' � � � � � W � WOR!(ERS'COMPENSA?lON DECLARATION a , � vJ�, , � U . . � . �� !HERESYAFFIRM UNDEil PENALM OF PEFLURY ONEOFTHE FOLLQWING DECLARATIUNS: z �. _IHAVEAN�N/1LLMAINTAINRCEPifIFfCATEOFCANSENTTOSELF-INSUflEFORWORKERS' _ r COMPENSATION,ASPHOVI6E�BYSECTION37000FTHELABORCDDE.FORTHEPERFORMANCE ' 6� `� OFTHE WOFK FOR WHICH THIS PERMIT IS ISSUED. � - ' 'W'' �1 HAVE AN�J WILI PrtAINTAlN WOflNERS'CMAPENSATION INSURANCE,AS flEOUIRED BY SECTION Q� 370o OFTHE LP,BOR CO��,FOR THE PERFORMANCE 0f THE WOAK FOR WHICH THIS PEAMITIS Q.: ISSUED.M`(WORKEP�S'CpM SpTION INSURAN ARflIERAND POLICY NUMBER ARE: CONSTRUCTION � cARRiEH � 1`�5��' _ PLANREVIEW Z POLICYNUMBER � .� . ELECTRIC . Q' Q ���ssEcnauNEmrp7e6wku�rEooFrwE�warr�sroaon�HurmaEooa.uAs�5w)oq�Ess�. PLUMBING �, ^ Z� IGERTIFYTHATINTHEP�RFOFPdANCEOFTHEWORKFOflWHICHTNISPERMITISISSUED,I MECHANICAL (� SHPLL NOT EMPLOY ANY�ERSON IN ANY MANNER SO AS TO BECOME SU8JEC7 TO THE � WORKERS'COMPENSAT� NLAWSOFCALIFORNIl�ANOAGREETHATlFISHOULDBECOPAE INSPECTION FEE � � "1,� B �� SU9JECTTOTHEWQRKE 5'COMPENSATIONPROVISIONSOFSECilON37000FTHElA60F �- � `t CODE,I SHALL FORTHWI i H COMPLV WITH TH�E PHOVISIONS. ISSUANCE � � '1 ��� . O � �6' � �i� �� SMIP � 'Q pATE: PPLICANT: � . � WARHING FAILVpE TO SEGUiE � FIKERS'COMPENSATION CAVERAGE IS UNLAVJFUL,AN�SHALL BE ENERGY P/C " yy� SU&IECTAtiEMPLOYERTOCR17dNALPENALTIESANt)CIVILFlNESUPTOONEHUNDREDTHOUSAND ENERGYPERMIT � DOLLARS(E100.uoo),IN A��ITION�O THE COST OF COMPENSATION,DAMAGESAS PROVIOE�FOR IN � ��s - J� SECTEON 37oe OFTHE LA80R CO�E,INTEREST,AND ATTORNEI"S FEES. � RETENTION FEE: � . o CO STRUCTION LENDING AGENCY PRE-ALT FEE: � ���� ' ��� � � ' � IHER�YAFFIflMUN�ERPENAI, OFPERJURYTHATTHEPE{SACONSTRUCTfONLENDWGAOENCY � ' ' � FOR THE PERFORMANCE OF7HE�ORK W R WHICH TMIS Pc'RMIi IS ISSUED(SEC.309],CIV.C.). . � . 173 �G'� LENDER'S NAME � � ' � - ^�-+. 0— LENDER'SMDP.ESS . �,,, ++� �'�, ICERTIFYTHATIHAVEREADTHIS;APPLICATIONAN�STATEPHATTHEABOVEINFORMATIONISCARRECT. TO�AL FEES � � .-, ` ��'yf�. �� ��', IAGqEETOCAMPLYWITHALLCIT/AN�COUNNOfi01NANCE5AN057ATELAWSqELAT�NGTOBUILDING - . . '� ' ' '�„ .CANSTRUC710N,PNDHERE6VAUTHORIZEREPRESENiATIVESOFTHISCOUNTVTOENTERUPONTHE � . � .ABOVE-MENTIONEDPFiOPERTYFORINSPECTiONPURP03ES. CQMMENPS ' � ' � �, J � �� PERMIT�i (PRI � � �y � � COS �^�– 4� � . . . _ . �� SIGNATUR f P qM EE �ATE � 't�� �; � RECPT.N0. � PAID BY -�VALIDATIqN � - ~'`� � - � .1FFHITc—Department Copy,YELLOW—Finence Copy,PINK—Assessor Copy.GOLDENROD—File Copy,GREEN—ApalicanPs Copy , �:��� � � �� ��������� � ���� w� � � ���g. „ � � �'� a � � � : � � � � � ` ��t �d�.���� � �. ��� .: �� _. . �.. .., l. ��L�'�✓��R:9�f 9� ., � , � ������ .. ., � �^+� s�y �,jg� --�� . � p ^ �3�-qpq .....�,..... . �:...._...,.— �4' ��1����i�.���"€ .'-�.. __mm__.�W__W._�'"�' � ; �?'�?t�-"s t��"�t!'�i��� ..,' . � � � , .�.,..,... _._„� � .. € � . ..,��� _._`—_-_`_"--._...... �,-.._._.,�—:�......,....�g ��, p"s.,���,Yc..�.A�.a.Si `�0.+' . �E...... ��..�___.�. 6.r��.3k.. �� �r A .�4-r..__�..�.._ ..� .. ._.. 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