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� ,�� CITY OF DIAMOND BAI� � � r � DEPARTMENT OF;COMMUNITY&DEVELOPMENT SERVICES � 21660 E.Copley Drive Suite 190 � Pf�ESS ,,w (909)860-3195 Fax(909)861-3117 '9�° . BUILDING.PERMIT APPLICATION -- FI,F�MLY a DDRIESS '� �°' � �" DATLICATION PERMIT ��� ►,//_ P/C o E NUMBER �.t`.�.r� # � ISSUE .- /�/� TYPE OCC APN `LOT' TRA pAT6 ���I-`"!% CONST. GROUP p ,OWNER , _ n, p ADD SS ' ZONING R ARTCKS RW O Z CI , ZI , TEL , -.' g APPLICANT T '� '- _ "'� SIDElSIDE STREET RW ❑ � CONTRACT ,,>. 3 � PROPOSED USE � � ❑ ADDR ' O o CITY' ZI TEL. W ARCWE G! ��`�_ a ADD GNER �z DESI NO:DWEL. NO. NO. RESS UNITS STORIES BEDROOMS � CITY ZIP TEL. DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION" �Q_ „Q�VNER-BUILDER DECLARA710N. � � � SFR/ADD/FlEM � � � � � ���� � -� �W ��CENSELAWFORiHEFOLLOWINdR .�,��. 0 I HEFiEBY AFFlHM UN�ER P�NALTV OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI- GdfBCJe/CBf�JOfI � - EASON(SEC.7037.SBUSINESSANDPROFE65bNSCOOEANYCINOfl (n , , , _ ... _ _Z,_,,,.COUNiYWHICHREWIRESAPER�y117TOCONSTRUCT,AL7ER',IMPHOVE,�EMOfJSH,ORREPAIRANYS7RUG �1J patio/Deck � W "TURE,PRIOR TO ITS ISSUANCE,RLSD REQUIflES 7HE APPLICANT FOR SUCH PERMIT TO FILEA SIGNED W . .� ,STATEMENT THAT HE OR SHE ISI�LICENSEU PURSUANT TO�,THE PROVISIONS OF THE CON7R�1C7",ORS LI• , , �. .CENSELAW�CNAPTEH9(COMMENCINGWITHSECTION70W)OPDIVISION30FTHEBUSINESSANDPH0. � � �'1' POOUSP2 FESSIONS�EjORTHATHEO�'SHEISEXEIAPTTHEREFROMANDTHEBASISFORTHEALLEGED�XEMP- (� V TION.ANVVIOUTIOHOFSECYION7031.6BVANYAPPLICANTFORAPEFMITSU&IECTSTHEAPPLICANTTO . Z Re-Roaf '�� 'AqYILPENALT'OFNOTMOflEi}IANRyEHUNDREDDOLURS(b500J.): ' " ,O ❑I,ASOWNEROFTHEPROPERN,ORMYEMPLOYEE9'�WITHWAQESASTHEIRSOLECAMPENSAT�ON, �� � COf11R1BfC18i � � ,Z .WILL DO THE WORK,AND THE 57RUCTURE IS NOT INTENDED.OR.OFFERED FOR SALE(SEC.7044;BU51- � J 'NE55 MD PROFESSIONS CODE:ITHE CANTRACTORS UCENSE UW OOEs NOT APPLV 7D AN DWNER oF �� � 7pOPERTYWHD8U1L0.50HiMP OVESi'HEREOpLANOWH000ESSUCHWOFKHIMSELPOFiHERSELFOR ��m �Q ',�h6tWGH HIS bR HEROWN EMP�OYEES,PROVID�THAT Sl1CH IMpROVEMENTSARE NOT INTENDED OR � � � - � � � �, �W ���OFFEREDWRSPLEIF,HOWEVER,IHEBNIDINGORIMPROVEb1ENTI550LDWITHINONEVEAROFCAMPLE- '�0 '���TION,THE OWNER-BUILOER WILL�HAVE THE eURDEN OP PROVWG 7HA7 HE OR SHE DID NOT BUILD OR � - � Z� IMPROVEFORTHEPURPOSEOF�SALE). - �� -' �� ��,AS ON7/EFOF THE PR�ERTY,AM EXClU51V0.YCANTRACTING WITFi LICENSED CAMR/1CTOP9 �� I��TO CONSTRUCT YHE PRQIECT(�C.70�4,9451NE55 AN�PflOFE5SIONS CODE:THE CONTRRG70R5 LI- V81UaUOf1 �� ADJ.AREA �' �W� I CENSELAWDOESNOTAPPLYTa ANONMEROFAPROPERNWHOBWLDSOHIMPROYESTHEREON,AND� �� . �'.� ��p.WHOCONTRACTSFORSUCHPROJECTSWITHACONTRACTOR(S)LICENSE�PURSUANT?OTHECONTRAP QUANTITY �DESCRIPTION � � ' FEE ' � TORS LICENSE LAW.). � � �, J . O ❑{AMEXEMPTUNDERSEd. B.&P.0.FOR7HIS�REASON Q � �h i's+l. ..�; Q � � �" �. � '' :' �.;' � DATE�. � .OWNER � � � � '. �� U , , � LICEt�SED CONTRACTORS DECLARATION � -- �'' I HEREBYAFFIRM UNDEfl PENALL�r"OF.PEAJURY THAT IAM LICENSED UN�ER PROVISIONS oF CHAPTER � . � ��i , �'�, � e(COMMENCINOWi7HSE P000)OFDNISION30FTHE0USINE39ANDPFiOFESSIONSCOOE,AN9 Z , ' MY UCENSE IS IN FULL A�JD EFFECi. � �� ��• �. 0 LICENS SS �y,�� LIC.NO. � �� .F"'��. DATE "'! ••- a•-C,�T . . � CONTRACTOR:� � ��•� a l 3' ���, WORKERS'COMPENSATION DECLARATION a �, U �, IHEREBYAFFWIAUNDEaPENAl�4VOFPEFUUAVONEOFTHEFOLLAWINGDECLARATIOIJS: Z Q ' � IHAYEANDWILLMAINTF�INACEflTIFICATEOFfAPSENTiOSELFINSUREFORWORKERS' 2 '� ��� COMPENSATION,ASPRdVIDEU9YSEC710N37ooOFTHEL190RCODE,FORTHEPERFORMANCE U � OF TFff WORK FOR WHI�H THIS PEPMIT IS ISSl1ED. � W . �,� ' I HAVE AN�WILL MAIPlr�IN WORKERS'COMPENSATION INSURANCE,AS REDUIRED BY 9ECTION ' Q 37000FTHE LABOR CO E,FORTHE PERFORA9ANCE OF THE WORK FOR WHICH THIS PERMIT IS . ISSUED.MYWOpKE ' ENSATIOMINSURANCE RANOPOLICYNUMB'eRARE: CONSTRUCTION 'Q. cneaien � i �y PLAN REVIEW ...-. . . . . . �� , ..� �..:-�:v. >'v �o"� c.� �' POLICV NUMBER . `� � - Q (IHISSECTIONNE�NOT�E�MRETEDOFiHEPERrNf�SFORONEHUrDRE�00U.Ni5lbiW)ORLESSJ. P MBING �g Z 1 CEFiTIFI°THAT IN THE PI�ERFORIAANCE OF THE WORK FOR WHICH iH15 PERM�T IS ISSUED,I MECHANICAL �� � �+k����•" � �} SHALL NOT EMPLOY AN�PEF$ON IN ANY MANNER SOAS TO BECOME SUBJECTTOTHE -�p �, �fj� WORKERS'COMPENSAIONLAWSOFCAIJFORNIqANDAGREE7HATIF13HOULOBECOME �N FEE x �y � �' �: SUBJECTTO THE YWFl ERS'COMPENSATION PflOVI510NS CF SECTION 37DOOF THE 1A80fl ����a� d� ��' ,�p�j _. CADE,ISHALLFORTHY�ITHCOh9PLVWlh1T OSEPROVISIDNS. ISSUANC �rs,��$��y."�4�''kt*' n�- 'sY ���YAF� _a ._ � Ip � .. . �r v . ��( �a`�' ��d;�:�?�, �p' OATE:��IAPPLICANT.Bq.�����-. �,�X.�' �,,, y, . �. � -� ENERGY P/C __ WARNINGFAILUqETOSECUH WORKEAS'COMPENSFTIONCDVERAGEISUNLAWrUL,AN�SHALLBE �y�� SU&fECTANEMPLOYERTOCR INALPENALTIESANOCIVII.FMESl1Pi00NEHUNOREDTHOUSAND ENERGYPERMIT � � DOLLARS(S7o0.o00�.INPD0171 TOTHECOSTOFCOMPENSAT!ON,�AMAGESASPROVIDEOFORM . �, SECTION37000F1NELABOR DE,INTEREST,ANDATTORNEV'SFEES. ' RETENTIONFEE: � �' C�ONSTRUCTION LENDING AGENCY PRE-ALT FEE: d' 'I �,�., IHEREBYAFFIRMUNDEFlPENn�TVOFPERJURYTHATTHEREISACONSTRUCTIONLENDINGAGENCV _ n� ' FORTHEPERF-0RMANCEOFTfiEWORKFORWHICHTHISPEfiMITISI55UED(SEC.3a9],CIV.C.). Z, LLI' �,�� LEN�ER'S NAME � ' ' F— LEN�ER'SADDRESS '. � �- �k �'.� ICERTIFVTHATIHAVEREf�THISAPPLICATIONANDSTATETHATTHEABOVEWFORMAT10NI5CORFECT. T�TAL FEES ' � - w I AGRE'c TO COMPLY WRH ALL¢ITY AND COl1NNORDINANCES AND STATE LAWS RHATNJG TO BUILDING '� � CONSTNUCTION,AND HEREBYAUTHORIZE REPRESENTATIVES OFTHIS COUNIYTO ENTER UPON THE . - '' � � ��',,' ABOVEMENTIONED PROPEflTY,FOR INSPECTION PURPOSES. COMMENTS -� �: 6 � � �1�,/'�����-f'�I � _ 1'��� m��� PERMI ENPMEIPRI � ,Cn�. . ��. . �. . . � SIG TUREOF� RMITTEE '� ATE ' ' � � � FECPT.NO. PAID BY �� ' - 'i VRLIDATION. '�Dn' � WHITE—De admen[Co -VELLOW--Finance Co �PINK—Assessor Co GOLDENROD—File Co GREEN— icanYs Co � �� P PY, PY, PY, PY, APP� PY . ��� � � ���� ����� ��� � `� " �p _� a � � � � � . � � � � � � � . : ,, . a�^..�"�'�t�-te�� � � i ; F�4�?��,1L'�'�3 �.;, 'T� "s, � , ;" ' "'"" B � �..''Yt�.A f'. "x`t"'�9`e#��I�ti"a���L, ..�. � _.._. .._ a__ ����F76'���.ti.,L�✓!R�'..3 ' . ... ,_. 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