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_ __��_ CITY�F DIAMOND BAI� �,f DEPARTMENT OF COMMUNITY 8�DEVELOPMENT SERVICES _ � . 21660 E.Copley Drive Suite 190 (909)860-3195 Fax{909)8613117 PRE'$$ ��'9N° ' BUII,DING:PERMITAPPLICATION FIRMLY oa ADDRIESS j DATEICATION � f� ,r� NUMB R #/C �- ��"�-� �����~ L�z� -�--->�� � � � issuE ,�^` r� � TVPe occ : TRACT � v D�TE ''J' � /� ��T") _CONST. GROUP APN LOT t p OWNER 3" �L�4 � ADDR S ' ' G i�f ZONING SETBACKS g APPLICANT � ZII? ,�a TEL. � , " ' FRONT RW � 0 Z CiTY '� i TEL REAR ,] Z � SIDE/SIQE STREET RW [7 � CONTRAC�OR �. � 'G'� ` ' SIDE i� , � ADDR S ' PROPOSED USE � %�-� "�" �G'l CITY ZIP � TEL." �� � ARCH/ENG7 W DESIGNER_ - -- NO.DWEL. NO. NO. � ADDRESS UNITS STORIES BE�ROOMS 'CITY ZIP TEL. � DESCRIPTEON SQ.Fl: FACTOR PSF ADJ.AREANALUATION � .� � .. .' . .... 4yJNER-BUItDESiDECCARATItDN SFR/ADDlREPA � . � � . .. . �. . �, �0 I HEflEBY AFFIRM UNDER P�NALTY OF PERJURY THAT I AAS EXEMPT FROM THE CONTRAC70R5 LI- G0f296/CefPOf! ,W CENSELAWFORTF:EFOI.LON'INGREASON(SEC.7o3i.58USWESSANDPROFES510N5CADE:ANYCITYOR (n , Z .COIiMYWHICHflEQU1RE5APERA�IT1'OCONSTRUGT.AI,7Eft�MPflOVE,DEMOLISH,ORREPAlP.fiNYSTRUG W Patio/Deck- 'TURE,PRpR TO ITS ISSUANCE,!�50 REQUIRES THE APPUCAN7 FOR SUCH PERMIT TO FILE A SIGNED W' �.STATEMENT THAT FIE OR SHE IS LICEN$E�PUflSUANi YO 7HE PROVISIONS OF THE CONTRACTOflS LI- W �;�.:CEN9E UW(CHAPTEft d{COA9ME(JCINO'WITH SECTfON 7000]OF DIVISIOk 30F TNE BUSINESS AND PRO- �' POOUSP3 ' FESSIONS�E)Op THAT HE OA SHE IS EXEMPT THEREFROWt ANp THE SASiS FOF THEALLEGED E%EMP- i ��'�,;TION.IvNYYIOLATIONOFSECTION'�7097.5BYAPIYAPPLICANTFORAPERMITSU&IECTShIEAPPUCANTTO � Re-Roof � � �„�,�.AC!VILPENALTYOFNOTPAOFETHANFNEHl1N�REDDOLLAR5�S5C0)-k ' , . � ❑I,p50WNEROF7HEPROPERYY,aRMYEMPLOYEESWITHl1AGESASTHEIRSDLECOR9PENSATION, 0 CO.TmBYCial � ' '�� �. I WILL 00 THE WC1RK,ANU THE 5?PUGTURE IS NOT IN7ENDE�OR OFFERED FOH SALE(SEC.7oM,BUSI- J -� � ' ��NESS AN�PROFESSIONS CODE:7HE CONTPAGTOR5 LICENSE UW�OES NOT APPLY TO AN ONfNER OF ' � � � '��,Iq DpOV6RiVNhbBUILD50RIMPqG�VESTHERL'{N,ANDMMODOESSUCHWORKHIF,iSELFOAHERSELFOR � ��''"iHFlOUGHHISOHHEHOWNEMPL�,OYIFES,PROVI�EDiHATSUCHIMPROVEMFIJTSARENO7INTENDEDOR 'm . . . W'�„I:�OFF6iEDWHSAtE.IF,HOWEVER,ITMEBU0.DINGORIMPROVEIAENTISSDIDWITHINONEVEP.ROPCOMFLE- ' �.':�7IDN,THE OWNER�BUILOER WILL�iHAYc TNE BUPDEN OF PROYIN(3 THAT HE OF SHE DID NOT BUiLD OR IMPROVE FOq7HE PURPOSE OFSALE�. � " ❑I.ASOWtdEROF7NEPFOPiEHTY,&RAFXGLUSIVELYCONTRACT{NGWITHLICENSEOCAfVTRAGTORS �I TO CONSTRUCY THE PRQIEC'f'(SEC.7094,9USINESS A,ND PROFESSIONS CADE:7HE fAN7RqCTORS LI- � VBIUdf107i ALJ.AREA CENSEL4WOOESIV6TP.PPIYTOANOWNEfl9FAPHOPERTYWH09UtLU54R:MPROVESTHEREON.AN� . ,� ',WFiOCONTHACTSFOR5S1CHPpOJECTSWITHACONipRCTOR(SILICENSEDPURSUANiTOTHEC6kTRAG �(jANTITY DESGRiPTION FEE � � TORSLIGENS'cLAWJ. �, ,,� ' . �, �. . . . . ^ ❑i AM EXEMPT UNDER S�C., @.&P.C.FOR THIS AEASIXJ Q S j U � i ,� �I����DATE. � OWNER U . i zl ' � � ��� � �LlCFJ�!�I ED GONTRACTORS DECIARATIOP7 W . �. � � �1 HEREBYAFFIR0.1 UNUER REWALTY OF PERJU6iY THA8IAAA LICENSEb tINOER PROV{SqNS OFCHAPTER � ' � ( }��j � ��9(COMMENCINOWIFHSECTlON700ojOFtlIVISiON90�TNEBUSINESSANDPAOFE5510NSCADE,AN� Z - � {' �. � �p `°'°" '�>AY LICENSE IS IN FULL FORCE AND EFFECT. m Y ° L( i w� �_ �' r7a � LICFTEECLA , .. LIC.NC3._�n��.���/ � -.� � . .� �'�'l� `,G.'� � 'DATE �� COPtiRACTOR�.� �� n- ��:..�,; . . '�� WORKER9'C9MPcN5ATV0�'DECl..d+RA7fON � � �� I HEREBV AFFIRM UNOER PENALiV OF PERJURV O.WE QFTHE f-0LLQWING DECL4RA710tJS: U Z �' '��IHAVEANDWIIIMhiNTN�ACERTIFICATEOF:A,USENTTOSELF-IN3UREFORWORKERS' � - . . COh1PEHSA710N.AS PRO DED BV SECTIQN 3700 GFYHE LABOH CODE.FOR THE PERFORMAMCE �U OFTME WORK FOF WHIC�THlS PERMIT IS ISSUEO. , � 9.LI� . I . .. . �1 NAVEAWD{A'ILL MAINYAIPJ WOfiKERS'COF9pENSATION INSURANCE,AS REQUIR6C BV SECTION Q 37C0(]FTHE Ld90R WDE�FOR�THE PEPFORMANGE OF THE WORK FOR WHICH TMI'a PERMIT IS 193UED.NY WOR S'CC�MFEN A710N INSURANCE CARRIER RND fOLICY NUMBER ARE: CONS I RUCTION '4, ' CAftRIER ' �� ��` PL.AN R'cVIEW ��; aoucv NUMeeq�ti, d��tJ�� - ELECTRIC 6 �s�'' � (t}iIS5EC'IIONN�N07BEI�IFDOFhEPEF�AN1'iSiORCNEHUf�itEDD01.LAA3($SCa�ORLESSy, PL11M81NG �J ��a� W� ICEHTiFVTHATIPIYHEPEAF6RF`FpNCEQFTrlE{A'ORKFORWHICHTHfSPERM1T15lSSUED.1 MECHANICAL ' ��� 2, (°$�'. SHALL NOT EMPLOY ANY f�EFSON IN ANY MANNER SO AS TO B'cCOME SUBJECT TO THE . - ��' �WORKERS'CdAAPENSATIO�ILAW$OFCALIFORYIA,AfdDA3REETHATIFISHOULDBECOME . IPVSPECTIONFEE Sl19JECTTO THE WORKEF�9'COMPENSATCJN PROVISIONS OF SECTION 37ooOFTHE LABOfi p CA�E,ISHRLLPoRiHW17u,CpMpLYWITH'fHOSEPROVIS!ONS. ISSUANCE =� �+�R`—a���'3. -- I r � p �DATE:- AFiPCICANT: SMIP _ � ;e � � _,�y�C��. ta.l.. . ENERGY P/C ��a�'.' .-�'4 -��'.�M J. WARNING FAILUftE TO SEW RE W�RKEflS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL@E "SU&IECTANEMPLOVERTOCRIlAIMQALPENALTIESANOqVILFINESUP700NENUNDRE�TFiOUSANO �; � , •� '-4�' ����'�.00LLARS(ilaa,006�.INAD0ITIONYLO7HECOSTOFCOMPENSATION,OAMAGE5A5PflWIDE�FORIN E�cRGYPERMIT �. � :.l -`;�4' P' � 'SECTIDN37080F7HELABORCODk,INTEREST,AN�ATPORNEY'SrEES. � RETENTION FEE: y�"� �`•�c4� 1��.Y' � � �. . -�°Z.T r.,'�,�a...�� � ��� COhjIS7RUC710N LENDING AGENCY pRE-ALT FEE: =";"' ���1 HEREBY AGFIFlM�NOER PENALNI OF P�FLRJRY THATTHERE IS A CONSTRUCTION LENDING AGENCY - FOR THE P'cRFOflMANCE OF THE 4ytNiK FOR WHICH THIS PERMI7 IS ISSUW(SEC.308�,CIV.C.�. . . Z' i �.:'�..LENDER'S NAME . � . . . F--�,..,LENDER'S ADDRESS ' � �,�'�ICERTIFVTHATIHAVEREADTHIS�PPLICATIONANDSTAiETHATTHEABOVEINFORMATIONISCORFECT. TOTAL FEES ��."ZS's�✓��-� � � � �,IAGREETOCOMPLYYVIiNALIq IANDCOUNTYORDINANCESANDSTATELAWSF£L.4TINGTOBUILDING � � � '�.COIVSTRUCTION,AN9 HERE6YAUTHORIZE REPRESENTATNES OF THIS COUNTYTO E11TEN UPON THE � ' � ABOVEMENTIONEb PROPERTY FOb INSF,'ECTION PURPOSES. ; p p/��� � COMMENTS - � ��' L'f' �✓".�I��-�u'��.1r5.��1' I't _ _ m '',PERMI AME{ NT) - '- . . � -��"/`�/� �y�.�� SIGNATUREOFP:R4R '. ATE '� _� �. '� RECPT.NO. 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