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�. __1� GITY OF DIAMOND'BAI� � DEPARTA�IENT OP COMMUI�ITY&DEVELOPMENT SERVICES _ . � 21660 E.Copley Drive Suite 19I1 (909)860-3195 Fax(909)861-3117 PR�$$ 9�'��" I BUII.DING PERIVIITAPPLICATiON . --- FIRMLY � JOBSITE 9 � p APPLICATION ��.� PERMI7 /C o i . , ¢ ADDRESS t��� ����f(.. �� DATE NUMBER�� # 'Q' APN LOT_�'�L TRACT� Q " OCC T , �l� ISSUE TYPE� GROUP 'S_ DATE CONST. p OWNER LF'`' '�'- ZONING SETBACKS � APP LCANT 6' ZIP���.ro,_L�TEL�C�- Z� REART k RW . o CITY �" TEL. S I D E/S I Q E S T R E E T R W ❑ � CONTRACTOR C.�ioC��L , _ _ SIDE ❑ Q ADDRESS ... ,ryµLt IrL'» �, ROPOSED USE S�IL N � CITY � ' ZIP TEL. P , . oARCH/ENG! P� � �z.;� � � , UNITS STORI ',. � DESIGNER �S ���V"4'/V� NO.DWEL. �� ti., . NO. o� ADpR SS ES y�„�_BERRO4MS � CITY ZIP TEL. , . 10 � � DESCRIPTION SQ.F`7.'�� EACTOR PSF ADJ.AREANALUA7 — (�WNER•BUILDER DKELARATION �� � N Q SFFVADD/REM [j. I HENEBV AFFlRM UN�EA�ENALTY OF PEHJLIRY THAT 1 AM IXEMPT FROM 7HE CANTPACTORS L6 - . GHfdgC/CdfpOf[ - � � n � ' � W CEN9EUWFORTHEfOLLOWIN¢RE.4SON(SEG7a37.5BUSINESSANDPROFESSIONSCO�E:ANYqNOR (n � C7 . COUNNWHICMREIXAflESAPE ITTOWNSTRUCT.ALTER�iMPROVE,OEMOLISH,ORREPAIRANYSTPUC- � ,�.W i.w � Patio/Deck '°` i i �� 7URE,PRIOR TO ITS BSUANCE,�AL50'�REQUIRES 7HE APpLICANT FOR SU6H PEFMIT TO FILE A SIGNE� �W t� ' � w�� .STATEMENT iHAT HE OR SHE I�LICENSE�PUFSl1ANT TO THE PROVISIONS OF THE CANiRACTOflS LI� '�� ' :; +�4 y, ' ' ' , Z "�� TION.ANYYKK,ATIONOFSE�CT0�3HE SEX MPTTHEREF OMANDTH BASISFORTHEALLEGE�E%EMP- Z POOVSpfl 'k �.a��� ry h �� � q 4h . � ' 7�1.SBYANYAPPIiCANTFORAPERMITSU&lECTSTHEAPPLICANTTO � pe�Roof p ''A'CINL PENALTY OF NOT MORE FIVE HUNDRED DOLLARS(s5oo).j: . � , � � ❑I,ASOYVNEROFTHEPRO ERTY,OHMYEMPLOYEESWITHWAGESASTHEIRSOLEfAMPENSATION, C� CammeIC101 ' u `�'���� � � � . .� N7l.L DO THE WORK M10 THE.S�CTURE IS NOT INTEN�ED OR OFFEREO FOR SALE(SEC.7o4a,B11S6 . J '� � NE53 AND PflOFE9310NS CODE THE CONTRACTORS LICENSE UW DOES NOTAPPLY TO AN OWNER OF ,= ee�/��fi. �,, i' �i . '. PFpPERTYYYF109UILD50RIMPRDVESh1EREON,ANDWHO00ES5UCHWORKHIM5ELFOqNERSELFOq {d�4�'�T' •'. u ���., ., 'Q THRq1GHHISORHERONMEAIR�LOVEES,PROVIDEDTHAT$UCHIMPRO�EMENTSAPENOTINTENDE�OR 'm " ' I �,Q OFFEREDFORSN.E�F,HOWEVE�THEBURAINGOiiIMPROVEMENTI550LDWRHINONEYEAROFCOMGLE y� ��70 COMSTRUCf 7H PRO.IECT(�EC.�7UM,BU51 ESSEAND P�FESSIONS CODECTH DID NOT BU�LfJ OR � �' ��" '.�;,, , Z �TION,THE:OWNER�BUILOER WIl4HAVE THE BIIH�EN 6F PHOVING THAT HE OA SH .. . , , ;= I,�IMPROVEFORTHEPURPDSEO�SAIE�. _ � � . SFD CONTflAGTORS ' � I e coNrRperoas u. Valuation ADJ,AREA ' �W '.CENSEIAWDOESNOTAPPLYT ANONTEROFAPROPEFfiIYWHOBUILDSORIMPROVESTHEftEON,AND� ', � �� ���WHOCONTRACTSFONSUCHPR�IJECTSWITHACONTRACTOR[SjUCENSEDPURSUANT707HECONTRAG QUANTITY DESCRIPTION � �� � � . ��� FEE � , TORSIJCENSELAW.). . ,' . . . .O i .�... I . . ' Q . _. . _ . . . DIAME7(FAIPTUNDERS64,`. B.&PC FOFTHISREASON U .� � ' � F I ' _ ��. OATE '� OWNER � V ' � � Z.�, �, .. -. W , � LICE SED CONTRACTORS DECLAAATION W ' ��, �HEREBVAFfIRMUNOERPENALTVOFpERJURYTHATIAM4ICEN5EDUNOERPROVISIONSOFCHAP7ER � �''� '� � . , ��� B(COMMENG9NGWITHSECTION79D0)OFDIVISION30FTHEBUSINESSANDPROFESSIONSCODE,AN� .Z ' MY LICENSE IS IN FULL FORCE AIVO EFFECL m .. .�d LICENSEC � II � LIC.NO. � .'���..�..��� - �� . . fwp- � � DATE � � CONTRACTOR 7 1� � � "OJ-' . W � � WORI�ERS'COMPENSATfON DECLARATION � ���'T"�' ����IHEHEBYAFPIRMUNDERPENRL�YOFpERJUFYONEOFTHEFOLLOWINGDECLARpTIDNS � V � ��-� � �� ` � � � � Z � L�� _IHAVEhNOWILLMAINT NACERTIFICA7EDFCONSENTTOSELNNSUqEFORWOHKERS' 2 . Z COhPENSAT1aV,ASPF�VIDED'BVSECTIONa7o00FTHELABOftCODE,FORTHEPERFORMANCE U � OFTHEINORKFORNMI HTHISPERMITISISSUED. � W I HAVE AN�W�LL MAINTA N WORKERS'COMPENSATIDN INSURANCE.AS REOLIIRED BY SECTIDN ��[yyy � '~S� ��37000FTHELABpORflCA E,FORTHEPERFORMANCEOFTHEWORKFORWHICHTHISPEP.MITIS ��� � CAFiRiER � �;,r��, /lNSATIONINSURANCECARRIERANDPOLICYNUMBERARE: CONSTRUCTION A ISSUED.MY WO FAS' MPE j � �'%��f�� � PLAN REVIEW � z POLICY NUM86R C�,L��..� ��i ELECTRIC ��'�'� 4 �(� � (fHS5ECT10NN�NOTBEO�i.pLETEDOFhEPERMRLSFi�RO1JEHUI.OREDOdl.ARS[bY00JORLESSJ. PLUMBING I�V o� W . q Z I CERTIFY THAT IN THE P RFOqMANCE OF THE WOPK FOR WHICH THIS PERMI7IS ISSUED,1 MECHANICAt L��j��D �� (,'3 SHALL NOT EMPLOY AN pERSON IN ANY MANNEfl SO AS TO BECOME SUBJEC?i0 THE � WOHKERS'COMPENSAT L4WS OF CAUFOPAIIA,ANO AGREE THAT IF I SHOULD BECOME INSPECTION FEE 5UBJECTTOTNE WORK RS'COMPENSATION PROVISIONS OF SEC N oo OF iHE LABOR � - � j CA ,I SHALL FORTHWIh'H COMPLY WITH THO6E RO IONS �^ ISSUANCE g�L� '�� � SMIP �`i't��-- pl DATE: � PPLICANT: � . �, WANNING:FAILURETa SECl1RE'. RKERS'COMPENSATION COVERAGE IS UNLAWF AND SHALLBE ENERGY P/C �• , Il. �r+� � SU&IECTAN�EMPLOYEFTOCRI�INALRENAlT1E5ANDCIVILFINE6UPTOONEHUNDREDiHOUSAND , j�{,��� 4-i` ENERGY PERMIT OOLLAPS(f1W.000),INM�ITI �TOTHECOSiOFCAMPENSATIDN,DAMAGESASPflOYDEDFORIN �� � ��. � SECTION37oBOFTHF.II+BOR D61N7EREST,ANDATTORNEY'SFEES. ' RETENTIONFEE: �I�� I p�.,��, C����NSTRUCTIONLENDINGAGENCY - PRE-ALTFEE: I .¢ ��,IHEREBYAFFlRMUNDERPENAL�OFhERJUflY?HATTHEREISACON57AUC710NLENOINGAGENCV ' ' Z' FOflTHEPERFOFlMANGEOFTH WORKFORWH/lC/H�THISPERMITISISSUED(SEC.308],CN.CJ. , �L�� ..LENDER'SNAME�_.. _�//'�l . . . . W F-'. LENOER'SADDRESS �I � � � � T07AL FEES ''2..°2.(�� c.�� °2-(�{�I r�,� ' � . ICERTIF'lTHATIHAVEREAOTH APPLYCA710NANDSTATE77'IATTHEABOVEINFOfiMATKKJISCqRflECT. ;� IAGREETOCOMPLYWITHALLC�YlWDCOUNTYORDINANGESANDSTATELAWSqELATINGTOBUILDMG ���, � CONSTRUCTION,ANDHEHEBVAIrTNOqIZEREPRESENTATIVESOFTHlSCOUNTYTOEMERUPONTHE .,. . '� .. ' - � ABOVE-MENTIONEO P PER I CTION PURPOSES. 2!, � �� COMMENTS -� � � � �.i . . . . . . . _ PERMI EENAME(PRI � �������c,��n ����i. '� �j SIGNATUREOFPER1AITfEE I, D TE ' . RECPT.NO. PAID BY �. �� VALIDATION��� �~"� � � � � � " � °�WHITE—DepartmeM Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENRO�File Copy,GREEN—Applicant's Copyl - - ���� �s� ���;���� , . �w �� ������ ������� ' � � . �.. ��' ��� � � � $ m � � � � � ..�_}; , � k � A ' .� � . � ��`����.:�i€���,7��- -�---�- 'h c����.�__ � � �`}-����:�',l�g��� i � a � ^ � .yA ' �. ., . , , �--[' .. . . -..... . . . �.�"'� �e��. _..........r... f�..e ..., �. .�.�....-�.-�--_.._.... __. � ( �i-�rr�area a:���-.�a���a �w�. � . � i � i}i'��1,.:�,�-=���� �?�s��' � '1 .., ;..___.__�m.. s�` _�,_._.. o..__...W..._._.�._.w....... € ... '"7 ��i'awFd��.$�� ?"�,.�1�n."a��,6�� ✓/ � � �� �' . . ��.;E€���r�a 5�..._.,.%,.�..i�i�''�`.,�����„c'��__-__. � - .._. 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