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_!� CITY OF DIAMOND BAbt
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES MAY O 9 ?003
21660 E.Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117 PRESS
������ BUILDING PERMIT APPLICATION FIRMLY
� JOBSITE -2� � /��Q APPLICATION / PERMIT �r P/C
o ADDRESS L. ' """ DATE I �I NUMBER I � #
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ISSUE NPE OCC
N LOT TRACT DATE CONST. GROUP
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a ADDRESS UNITS STORIES BEDROOMS
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Q OWNEFi-BUILDER DECLARATION SFR/ADD/REM
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I p 1 HEREBV AFFlRM UHDEH PENAL7Y OF PERNRV THAT I AM E%EMPT FROM 7HE CON7RAC70RS LI- Gefe96/CflfpOR
� CENSELAWFOHTHEFOLLOWINOREISON(SEC.70.71.58USINESSANDPROFESSIONSCODE:PNVCITYOH (n
COUNTYNMIp1RE0UIRE5APERMRTOCONSTRUCT,ALTER,IMPHOVE,DEMOLISH,ORREPAIRANVSTRUC- W P81i0/DBCk
w TURE,VRIOR TO ITS ISSUANCE,ALSO RE�UIRES THE APPLICANT FOR SUCN PERMIT TO FILE A SIGNED W
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI-
� CENSE UW(CHAVTER o(COMMENCINO WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO- � POOUSp2
FESSpNS CODEJ OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEOED EXEMP-
TION.ANY VIOLATION OF SECTION 7037.5 BYANV APPLICANT FORA PERMIT SU&IECTS THE APPLICANT TO Z Re-Roof
� ACML PENAL7Y OF NOT MORE THAN FNE HUNORED DOLURS(t5oo).�:
� ❑I,ASONMEROFTHEPROPER�Y,ORMVEMPLOYEESWITHWAGESASTHEIRSOLECOMPENSATION, � COrt1rtIBfC181 �
WILL DO iHE WORK,AND THE STRUCTURE IS NOT IN7ENDED OR OFFERED FOR SALE(SEC.70H,BU51- J
NESS AND PHOFESSIONS CODE:THE CONTRAC70R5 LICEHSE UW DOES NOT APPI.Y TO AN OWNER OF
� PROVERTYWFiOBUIIDSORIMPROVES7HEHEON.ANDWHODOESSUCHWORKHIMSELFORHERSELFOR �
Q THROU(U1 HIS Op HER ONM EMPLOVEES.VROVIDED TNAT SUCH IMPROVEMENTS ARE NOT INTENDED OR m
Q ,OFFEREDFORSALEIF,HOWEVERTMEBUILDINGORIMPROVEMENTISSOIDWITHINONEYEAROFCOMPLE-
Z 'TION,THE OWNER�UILDER VALL HAVE 7HE BUHDEN OF PROVIN�THAT HE OR SHE DID NOT BUILD OR
� IMPROVE FOR TME PUPPOSE OF SALE).
w ❑I,AS OVMER OF THE PROPEHfY,AM E%ClU51VELY CANTRACTING WITH LICENSED COHTRACTOR3
� TO CONSTRUCT hIE PRQIECT(SEC.7oM,BUSINESS AND PROFESSIOHS CODE:THE CONTRACTORS LI- V81U0f1Of1 ADJ.AREA
W CENSELAWDOESNOTMPLYTOANOWNEROFAPROPERTYN'HOBUILDSORIMPROVESTHEREON,AND
MhqCONTRACT5FOR5Uq1PRQIECTSWI7HACONT CfOR(5)LIC SEDPURSUANTTOhIECONTMG pUANTITY DESCRIPTION FEE .
TORS LICENSE UW.J.
� ❑I AM EXEMPT UNDER SEC. F �P.C.FOR THIS REASON Q �
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DATE WNER V
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�Q LICENSED CONTRACTOAS DECLARATION W
2 1 HEHEBV AFFIRM UNDER PENALN OF PERIURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER � .
� Y(COMMENCINO Wlhi SECTION 7000)OF DIVISION J OF THE BUSINESS AND PROFESSIONS CADE,M1D Z
�� MY LICENSE IS IN FULL FORCE AND EFFECT. m
0 LICENSE CLASS LIC.NO. j
� J
V DATE CONTRACTOR �-
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� WORKERS'COMPENSATION DECLARATION � �
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� I HEREBY AFFIRM UNDER PENALTV OF PERIURY ONE OF THE FOLLOWING DECI.AMTIONS: � A/ �l
Cn Q •V
� _I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS' 2 �
COMPENSATION,AS PROVIOED BV SECTION 3700 OF THE UBOR CADE,FOH THE PERFORMANCE U A � � e
Q OF THE WORK FOR WHICH 7HI5 VERMIT IS ISSUED. � f'�'�Tw c I�Q
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� _I MAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSU{UNCE,AS REQUIRED BY SECTION ��O�`
QO 37o00F THE LABOR CODE,FOR hiE 7ERFOFMANCE OF THE WORK FOR WHICH 7HI5 PERMIT IS AJ�T 1�/�
ISSUED.MV WORKERS'COMPENSATION INSURMICE CARRIER AND POLICY NUMBFR AfiE: CONSTRUCTION "•J� 'L�11
� CAFR�ER PLAN REVIEW �AI.'h�
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� POLICV NUMBER ELECTFiIC �
0 (RiIS6E(.•TKJNNE�NOTBEOOMPLEfmOFTHEPERMTiSFORONEF0.X�DREDOq1AR5(t100)ORlESS} PLUMBING � �
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Z I CERTIFY TNAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I MECHANICAL
�J SHALL NOT EMPLOV M!Y VEHSON IN ANV MANNER SO AS TO BECOME SU&IEC770 THE
� WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SNOULD BECOME INSPECTION FEE
S SU&IECT TO THE WORKERS'COMPENSA710N VROVISIONS OF SECTION 370o OF THE LABOR �(J
CA�E,I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS. ISSUANCE
� SMIP
p DATE: APPLICANT. .
� ENERGY P/C
J WARNING:FAILUHE TO SECURE WORKEHS'ODMPENSATION COVEfiAGE IS UNUWFUL,AND SHALL BE
� SUBJECT AN EMPLOYER TO CRIMINAL PENPLTIES AND CIVIL fINES UP TOONE HUNDRED THOUSAND ENERGY PERMIT
DOLURS(i1o0.oDo).IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN
J SECTION 3708 OF 7HE L1BOR CODE,INTEREST,AND ATTORNEY'S FEES. RETENTION FEE:
�
d CONSTAUCTION LENDING AGENCY PRE-ALT FEE:
� I HEREBV AFFIRM UNDER PENALTV OF PERIURV 7HAT 7HERE IS A CONS7RUC710N IENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.9007,CIV.C.).
Z
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� LENDER'S NAME
1— LENDER'SADDRESS
ERTIFV THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. TOTAL FE ES
w I AGHEE TO CAMPLV N77H ALL CITY AND COUNTY ORDINANCES AN�STATE LAWS RELA7ING 70 BUILDING
� � STRUCTION,AN�HEREBY AUTHOfiIZE REPRESEN7A71VES OF THIS COUNTY TO ENTER UPON THE � �
Z -,VE-MEMIONED PHOPER7V FO 9NSPECTION VUR70SE5. COMMENTS �
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m CERMITTEE NAME(PFI
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� SIONATURE OF PERM 7TEE DATE
= RECPT.NO. PAID BY VAL�DATION
~ WHITE—Department Copy,YELLOW—Finence Copy,PINK—Assessor Copy,GOLDENROD--File Copy,GREEN—ApplicanYs Copy
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