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��` _ CITY OF DIAMO1dD BAR DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES 21660 E.Copley Drive Suite 190 � w (909)860-3195 Fax(909)861-3117 RESS �'9�° BUILDING PERMTI'APPLICATTON ,� FIRMLY � JOBSITE �i��� --'�-„���' �t��� APPLICATION ��J �I G�PERMIT � �P/C o ADDRESS � F� DATE `-` � NUMBER •� ' # $ ISSUE TYPE OCC APN LOT TRACT DATE _CONST. GROUP p OWNER �'n'►�s "'r�.� +2 o ADDRESS ZONING SETBACKS � CITY - ZI _�.`3�'�_ � 'L �ty .' ' � FRONT _ RW � � APPLICANT s TE . '"�1�14��Z�i.�' REAR ❑ � � SIDE/SIDE STREET RW O CONTRACTOR t�`r1� _" SIDE ❑ p� ADD�SS "'s S' � CITY [�,:�M� ZIP � 3� TE . 'r' - 'x� PROPOSED USE 0 ARCH/ENG/ z DESIGNER_ � ADDRESS UNITS EL STORIES BEDROOMS � CITY ZIP TEL. � cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREtWALUATION Q OWNER-BUILDER DECLARATION 0 SFFt`ADD/REM � I HEREBY AFFIRM UNOER PEN/LLTY OF PERJURY iHAT I AM EXEMPT FROM THE CONTqACTORS LI- G8f8gB/CdfPOft W CENSEUWFORTHEFOLIOWINGREA50N(SEC.7031.58USINESSANDPROFESSIONSCODE:ANYCITYOq (n V COUNTYNM1UCHREOUIRESAPERMRTOCONSTRUCT,ALTER,IMPROVE,DEMOUSH.ORREPAIHANYSTRt1C- W Pgt10/DBCk W 7I1RE,PRqR TO ITS ISSUANCE,A�50 HEQIIIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED W STATEMENT THAT HE OR SHE IS LICENSEO PURSUANT TO THE PROVISIONS OF THE CONTRACTORS U- � CENSE LAW(diAPTER e(COMMENCING WITH SECTION 7a0o)OF DIVISION 3 OF THE BUSINESS AN�PRO- V' POOI/SP8 FES9WNSCODE)ORTHpTHEORSHEISEXEMPTTNEREFNOMANDTHEBA515FOHhIEALLEGEDEXEMP- (� TION.ANVVIOLATIDNOFSECTION7o31.5BVANYAPPLICANTFORAPERMITSUBJECTSTHEAPPLICANTTD Z Re-Root � RCMLPENALTYOFNOTMORETHANFlVEMUNDREO�OWRS(5500).): Q ❑I,ASOWNEqOFTHEPROPERTV.ORMYEMPLOYEESWITHWAGESAS7HEIRSOLECOMPENSA710N. L� Commercial � L WILL DO THE WORK,M�THE STRl1CTURE IS NO7IMENDEO OR OFFEFiED FOR SALE(SEC.704a,BUSI- J � NESS ANO PROFESSIONS CODE:THE CANTRACTORS LICENSE L4W OOES NOT AVPLY TO AN OWNER OF � PROPERTY YVFIO BUILDS OR IMPROVES THEREON,AND NMO DOES SUCH WOFK HIMSELF OR HERSELF OR � TNROUQH HSOR HEF oWN EMPLOYEES,GROVIDED 7FiHT SUCH IMPROVEMENTSARE NOi INTENDE�Oq m 0 OFFENEDFORSALEIF,HOWEYEFL7HEBULDINGONIMPROVEMEN7ISSOLDWITHINONEYEpROFCAMPLE Z TION.THE OWNER-BUIL�ER V/ILL HAYE THE BURDEN OF PROVING THAT HE OH SHE OID NOT BUILD OR � IMPI�VE FORTHE PURPOSE OF SALE). I w ❑I,ASOWNEROFTHEPROPER'TY.0.NEXCLUSIV:IVCANTRACTNGWRNLICENSEDCOMTRACTORS � � TO CONSTRUCT THE PRQIECT(SEC.70td,BUSINESS ANO PROFESSIDNS CADE:THE CONTRACTORS LI- VflILlALiOfI ADJ.AREA W CENSELAWDOESNOTRPPLVTOANONMEROFAPROPERTVWNOBUILOSORIMPROVESTHEREON,AND — � Nh1000NTMCTSFORSUCSiPROJECTSWfTHACONTMCTOR�S)UCENSEDPJRSJANTTOTNECONTRAC- QUANTITY �ESCRIPTION FEE TORS LICENSE LAW.). o �I AM E%EMPT UNDER SEC.. B.B P.Q FOR THIS REASON Q I I �Y� "��7 a p 1� �� 3 �r � � � DATE OWNER__ � 0 --i W � LICENSED CONTRACTORS DECLARATION W � I HEREBYAFFlRAI 11N�ER PENAITY OF PERJURY THAT 1 AM LICENSED UtJDER PROVISIONS OF CHAPTER � � 0(COMMENCINO`NITH SECTKKd 7o00)OF DIVISION 3 OFTHF.BUSIhESS AND PROFESSIONS CO�E.AND Z ��� MY UCENSE IS M FULL FORCEHND EKFECT. m � LICENSE CLCq,��S,��y�..� LIC.NO, � • j ~ DATE [ _l��� _ CONTRACTCR J W � 1M1�OFiKERS'COMr ENSATiON DECL TICY ,� �j� � ¢ � I MEREBY 0.FFIRM UN�ER PENALTY OF GERJUFY ONE OF THE FOLLOWING DECLAflATIONS: ' �� Z � I HMEAND WILL MAINTAIN.0 CERTIF�CATE OF CANSENT TO SELF-INSUPE FOfl VlORKEFS' _ — COMPENSATpN,AS PROVIDED BV SEC i ION 370o OF'NE LABOR CODE,FOR?HE PERFOqMANCE `U OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. � � W ,�I HAVE AND WILL qAINTAIN WOAKERS'CpdPENSATION INSURAhCE,AS REQUIqED BY SECTION Q 37000FTHE LA60F CODE,FOR THE PERFORMANCE OF hIE WOFK FOR WHIC4THI5 PERMR IS ISSUED.MY WOR'ER5 COMP€kSATIC�INSURANCE CARRI'cA ANC PO'JCY N:IMBER ARE: , � CONSTRUCTION jCARRIER_ 0 . ��_� PLAN REVIEW �_ ` ZPOLiCYNUMBER �_ '� ' � ; ELECTRIC � � � � �. — � (fH55EC17CNNE�NO76EWt.�LE'fEDOFTHEPEPoATSFU'70NEF�N�DRED�OLLPAS!S10%OfiLESS� PLUMBIiJG _ ' �� I � tCEiiTIFYTHqTIN7NEPERFORMANCEOF7HEWORY,FORWHICHTHISPEaMITi51SSUE�,1 MECHANiCAL ��� .� Ff SHALLNO7EMPLOYpNYPERSONINANYMANNERSOA5T06ECOMESUBJECTTOTHE j��../�� `' 0 � WORNERS'COMPENSATbNLAWSOFCA!IFORNIA,ANDAGREETMA7IFISNOU�DBECOME INSPECTIONFEE _ , / �� S SU6IECT TO THE WORKERS'COMPENSAT N PRONSIONS OF SECTION 37o00F?HE LA60F — Li�/ CODE�SHAI.�FORTNWITNCAMPLYWITH OSEPqOVI510N&� ISSUANCE i � DATE: * ��.A!R APPLICMIT: ��"^_ 1 SMIP _ J WARNING:FAWRE TO SECIIRE WORKERS'COMaEN ?IC COVERAGE IS UNLAWFl1L,AN--D�SHALL6E ENERGY P/C ��+ � �y SU&IECTRNEMPLOVERTOCRIMINA�PENALTIESAN� IVIL INESUPTOONEHUNDREDTHOUSAND � '„ DOLLARS(51a0.UW}IN ADDITION TO THE COSTOF CO EN ATION,DAMAGES AS PROVI�ED FOR IN ENERGY PERMIT __T`� i � SECTION37o0OFTHELABOHCODE.INTFAEST,ANDATT rsFees. RETENTIONFEE: _ J & OCONSTRUCTION LENDING AGENCY PRE-ALT FEE: _ � t HERE9V AFFIRM UNDER PENALTY OF PERJURV THAT THERE IS ACONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.309T,CIV,C.) Z W — � LENDEfl'S NAME 1— LENOER'SADDRESS_ ___ _ � TOTAL FEES ' � IGERTIFYTMATIHAVEREADTHISAPPUCqTIONAND5TA7ETHATTHEA60VEINFORMATIONISCOFifiECT. dW 1 AGREE'•O COMPLY WRH ALL CITYAND CAUNTY ORDIVPNCESAND STATE LAWS REIATING TO BUILDING • � C04STRUCTION.AND 1�REBY AUTHORIZE REPRESEN7A7IYES OF THIS COUNTY TO ENTER UPON7HE Z ABOVE-MENTIONEO 7ROPERTY F0�21NSPECTION PURPOSES. 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