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� _�� CITY OF DIAMOND B:4R /°� �,� DEPARTMENT OF COMMUNITY&DEVELOPMENT SBRVICES �° _ � 21660 E.Copley Drive Suite 190 (909)860-3195 Fax(909)861-3117 PRESS ��\ BUiLDING PERMiT APPLICATION __ FIRMLY 9Ny.' o ADDRESS 17�5 �I�'l-L�-- �� APPLICATION ������{ NUMBEF�� #/C DATE a ro p OWNER �IAt+� TRAC�T ��• f�f�' D�UE �, IYP.E ,,' OCC .- APN � LOT • �S TE CONST. GROUP ¢ - " ADDRESS �� ZONING SETBACKS " � � � FRONT F, , , 'RW O CITY Y�r ZIP� TEL REAR :' ,, ❑ APPL�CANT r� i -TEL. SIDE/SIDESTREET RW CJ � CONTRACTOR �� �CC��- SIDE ' � ; ❑_�, Q ADDRESS � PROPOSED USE ��� y'-l�. ; , �y�` i � o ARCWENG/ , ZIP TEL. R, , { ,;; � o CIT`! ' z DESIGNER ��J�°�� ���'Z�'I'L1 NO. NO.DWEL. NO. ,.,,.. �.T � CI"IY S " IP TEL�� DESCRIPTION SQ.,�T." ">�FACT�R�kSF ADJ. OMS w ' UNITS STORIES BEDRO y AREANALUATION, �, OWNER-BUILDER DF_CLARATION SFR/ADD/REM ��;� �� '' O „0 I HEREBY AFFIRM UNDER VENALTV OF PERIURV THAT I AM E%EMPT FROM THE CONiRACTORS LI- _� Garage/Carport- "�",� 'W� �CENSE LAW f-0ftTHE FOLLOWINb�REASON($EC.)oa1.5 BUSINESS AN�PROFESSIONS CODE:ANV CITVOR � . ,G.1 COUNIYWHICHflEIX11HE5APERMITTOCONSTliUCT,ALTER,IMPflOYE,DEMOLI9H2ORHEPAIRANY9TRUC- .'I ''0 � ';W��NRE,PRIOP TO ITS ISSUANCE;IAL50 REQUIRES THE APPLIGANT FOR SUCH PERMIT TO FILE A SIGNED � �� W P2[IO/DBCIC ;, � .STATEMENT 7HAT HE OR SHE IS LICENSED PURSUANT TO7HE PflOVISIONS OF THE CONTRAC70R5 LI- ����A1CIVI��OFN�TMORE�NCINONATHSECTION700aJOFDiVISION90FTHEBUSINESSANOPRO- �' PoOVSPe �w -''dt k; ; ' � CENSE LAW(CHAPTER e(COMM . . SHE IS EXEMPT 7WEREFqOM MIDTHE 6A515 FOR THEALLEGE�E%EMP- 7031.66YANYAPPLICANTFORAPERMITSU&IECTSTHEAPPLICANTTO.. Z- R0-ROOE H�N FIVE'HUNORED DOLLARS(650D�.)'. ' � �,� ❑�,ASOWNEROFTHEPRObERiY,OftMYEMPLOYEESWITHWA6ESASTHEIRSOLECOMPENSATIDN,� fl COff1IfIBfC12I ��� `.' " .,WILL 00 THE YVORK M7�THE S�TRUCTURE IS NOT INTEN�E�Oft OFFEHED FAR SALE(SEC.7044,BU51-, . _.I NESS AND PROFESSIONS CO�E�THE CCNTRACTORS LICENSE UW DOES NOTAPPLY TO AN OWNER OF ��, � ��` J ' '� PROPEN7YWIiOBt11LD50RIMPpOVESTHEREON.ANDWHODOESSUCHWORKHIMSELFORHERSELFOR = �? "� �` 4 � ���' �� �THRd10HHISORHEPOWNEMf�LLUVEES,PROVI�EDTHATSUCH�IMPROVEMENTSARE�NaTINTENDEDOfi m � �� .,� � OFFEREOFOASPLE�F,FpWEVEn,iHEBUILDWGORIMPROVEMENTISSOLDWITHIN6NEYEAROPCOMPLE , w ' � �'�TION,THE OWNER-BUIIDER WIIL HAVE THE BURDEN 6F PROVING THA7 HE OH SHE DID NOT BUILD OR .:W .IMPROYE�-0RTHEPURPOSEO��EJ. - .'�' .. . � ... A. . . . . , , ,�. ❑4�OWNEROFTHEPR PERIY,AMEXCLUSIVELYCbMRFC71NGW11HLIGEN5E000NTRACTORS � �� .� TO CONSTRUCT THE PROJECT EC.7044,BUSINESS IWD PflOFE5510N5 COOE:THE CONTRAGTOflS LI- V2IU0210f1 �ADJ.ARE� � '�.,W CENSELIIWDOESNOThPPLYTpANOWNEROFAPHOPEFiiYWHOBU1LD50RIMPROVEShIEREON,AND - � ,, � �WFIOCONTRACTSFOR�ICHPRWEC7SWITHACONTRACTOR(5)LICENSEDPURSUANTTOTHECANTPAG� QUANTITY � DESCRIPTION FEE �,, TCRSLICENSELAW.�. ', . '.� . . � . , . .. � � ❑I AM EICEMPT UNDER 9EQ. B.&P.C.FOR THIS REASON � �,� U � � ����� i � � :�,� �_��� � �. � � DATE I' OWNER '�'� � . � � LICE�ISED CONTRACTORS DECLARATION w � .1 HEREBY/�FPIRM UN�ER PEN ��OF'PERJURV THAT IAM LICENSEO UN�ER PROVISIONS OF CHAPTER '� ���� � �� , )C MYLICENSEISINFULLFORCE��,pFDIVISION30FTHE8U51NE55AN�PROFES510N5CODE,AND � � �' ,� .0.. D EFPECT. m � �.9(CDMMENQN(i WITH SECTION � � LICENSE C . � . . UC.NO. �.�+���'� �- , ,�� . �xqp,',�C'33,T A'a'��� ��~' DATE .� �I. . . . CONTRACTOR . 8�. d, gq��^g7}�T d�1c1 , Lf�'b8� y^p� , .. W '�� 0.7RF.+LJd1'id..F�'Li�'��.��`5�'��`C.:eL 4'r � �� WORKERS'COMPENSA710NDECLARATION a . . . � . ���� 'IHEREBVAFFIRMUNDERPENA4TYOF'�.PEHJl1RVONEOFTHEFOLLOWINGDECLARATIONS: U "" ' ' � ""' ' " ' � � � i Z Q '� _IHAVEANDWILL�MAMTAINAGERTIFICATEOFCONSENTTOSELF-INSUFEFORWORKERS' _ '�� CDMPENSATION;ASPA�VIOE�BYSECTION37ooDFTHELA80RCODE.FORTHEPEAFORMANCE W �� OF THE WORK FOR WHII H THIS PEflMIT IS ISSUED. � W"� RKERS'COMPENSATION INSURPNCE,AS REOUIRED BV SECTION � -� ' ' — I HAVEAND WILL MAIN�W RTHE PERWRMANCE OFTHE WORK FOR WHICH THIS PERMITIS �� �^� ��� j ISSUED.MY W KERS' �NSATION INSURANCE CARRIERAN�FOLICV NUAABEHAHE CONSTRUCTION _ �j��r � �.a� cnRAERHE�' EMv � PLAPIREVIEW �� l7 t g 1 . .. .. . . . .. - . Z., roucvNUMSEa�������U�_� ELECTRIC ��'�'��p� �� `� �,�V i ��� .Q (IHss[c?�avNE�Mo7�EooMRET�oFniEaewxi�SFoaot�EHunARE000uaas(E�ao)oRLEss). PLUMBING i .,W^ ... . ' . p�/� �*{ �. 1 CERTIFY h1AT IN THE pERFQipMANCE OF THE WORK FOR WHICHTHIS PERMIT IS ISSUE�,I MECHANICAL `„O"IB Y 1J ,(�}' SHALLNOTEMPLOYANYPEp50NINANYMANNEHSOASTOBECOMESUBJECTT07HE . '�� WOflKERS'COMPENS A}ION IAWS OF CALIFORNIA,AND AGPEE THAT IF I SHOULD BECOME INSPECTION FEE SU&IECTTO THE WOR I{ERS COMPENSATION PROVISIONS OFSECiION 37 a OF THE LAeop - � � � S°L , ~ CA�E I HALLFORiH�ITHCOMPLYWITHTHOSEPR VI510 . �SSUANCE �y d _�� � SMIP 'R l� 'p��, DATE: � IAPPLICANT. , � . � WAPNING:FAILURETOSECUR WORKEFiS'CDMPENSATIONCOVERAGEISUNLAWFUI,ANDSHALLBE ENERGYP/C �.,���SUBJECTAN�EMPLOYERTOC�INAL�PENALTIESAN�CIVILFINESUPTOONEHUNDREOTHOUSANO ENERGYPEAMIT �� r � � DOLLARS(5700,0OO�.INAD�IT1 TOTHECOSTOFCOMPENSATION,DAMAGESASPFOVIDE�FORIN /+y �J�'�SECTION5To8 OF'fHE LABOR DE,INTEREST,AND FTTORNEY'S FEES. ' FIETENTION FEE: �� ��C�'� - ��'11$',;� . . . . . ����d.� �INSTRUCTION LENDING AGENCY pqE-ALT FEE: � ,�'�', IHEREBYAFFIRMUN�ERPENALNOFPERJVRYTHAT7HEREISqCONSTRUCTIONLENDINGAGENCV ' FORTHE PERFOHMANCE OF il{E WORK FOR WHICH THIS PERMIT IS ISSUEO(SEC.309],GV.C.). ._ �'�I�' I, . ., ' � � �.' LENDER'S NAME F�— ".. IEN�ER'SADDRESS i � EES t�7 a�� '�-'Q3�a f@ �'�����' i H TIH T111SAPPLI TIONAN�STATETHATTHEABWEINFORMATIONISCORRECT. TOTAL F ICEflTFYT A AVEREAD � � �,�i'�. IAGHEETOGa.APLVWITHALL�IT'N!1DCAUNTVORDINANCESANDSTATEL4WSRELATINGTOBUILDINO . - � ' .. . �-CONSTRUCTION,ANDHEREBYbU7HORIZE�REPflESENTATIVESQPTHISCOUNTVTOEMEFlUPoNTHE . . ' � - , ��,�ill' ABOVE-MEN7fONED PFOPERTII FOR I SRECTION PURPOSES. COMMENTS �� �'� `P��-r�►�.�a� ,�- 1f�✓�' m�'�.� PEHMITT NAM PRI . .. �; i°L �C'l�'I � .., .-� r I�'`' ��'�. 816 AEOF PERMITTE � I ' DATE fJ� ..,, ,,,._:, � . RECPT.NO. PAID BY ��VALIDATION� ",��'' �. 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