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CITY O�DIA.MOND BAR /J�._,.``°� '� ----���-- DEPAR'T�NT OF COMMiJNTi'Y&DEVELOPMENT SERVICES � � � 21825 E.Copley I?rive t (909)860-3195 Fax(909)861-3117 ES$ `'"y��'�' BUILDINGPEItMITAPFLICATION FIRMLY � JOBSITE ,�ry�4 p s� 1�,„�/'__,.'Y "1('�g�,�� �� DATEICATION �� NUMBER O�/C _,�,.o ADDRESSI� (. ( V1I {�1N r\��� � ISSUE TYPE OCC APN LOT TRACT DATE CONST. GROUP p OWNER _�..Q� '� � p ADD ESS��,,,,��,_,,, IN� tt`� ZONING SETBACKS oCITY� •l���� ZIP � 9 TEL.— - FRONT RW C APPLICANT TEL. REAR ❑ � SIDE(SIDE STREET RW ❑ z .._ m CONTRACTOR SIDE ❑ � ADDRESS '�+ � C1TY ZIP TEL. PROPOSED USE �i o ARCHIENG/ W DESIGNER NO.DWEL. NO. NO. � ADDRESS UNITS STORIES BEDROOMS � CITY 21P TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p�. OWNEfl-BUILDER DECLAFATION SFR/ADDlREM O i �"� p.� I HEqEBY AFFIRM UNDER PENALN OF PER.NRV THAT 1 AM EXEMPT FROM THE CONTRACTORS LI- Gefe92/C3fpOft ''i W:� CENSELAWFORTHEFOLLOWINGREASON(SEC.7031.59USINESSANDPROFESSIONSCOOE:ANVdiYOfl ((� I U, �COUNTYWHICHHEDUIHESAPERMITTOCONSTRUC7,ALTEfl,IMP�90VE,DEMOUSH,ORREPAIqANYSTRUC- W Patio/Deck ' W,. ��TURE,PRIOR TO ITS ISSIJANCE,ALEO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED W .STATEMENT THAT HE'OR SHE'IS LICENSEO PURSUANT TO 7HE PROYISIONS OF THE CONTFACTORS LI- �;�� �;CENSE LAW(CHAP7ER 9(COMMENCINO WITH SEC710N�OOoJ OF�IVISION 30F THE BUSINESS AND PPO- � PooUSpa � �,FESSIONS CODE�OR THAT HE pR SHE IS EXEMPT THEREFROFfi AND iHE BASIS FOR THEALLEGED EXEMP- �, '�TION.PNYVIOLFTIONOFSEGTION7031.SBYANVAPPLICANTFORAPERMITSUBJECTSTHEAPPLICANiTO Z Re-Roat �,�,�'�ACIVILPENALTYOFNOTMOR�THANFIVENUNORED�OLLARS(f5oo).�: 0� ❑I,ASOWNEROFTHEPflOPERTY.ORMYEMPLOYEESWITH:WAGESASTHEIR50LECOMPEN5AT10N. O Commercial - z� WILL�O THE WORK,AND THE STqUCTURE IS NOT INTENOED OR OFFERED FOR SALE(SEC.7044,BU51- J NESSAND PqOFE5510NS CODE:THE CONTRACTOPS LICENSE LAW�OES NOTAPPLY TO AN OWNEfl DF �''� �PqOPERTYWH69UIL�50RRAPROVESTHEREON,ANDLYHODOESSUCHWORKHIMSELFORFiERSE:FOR � �: 'THROUGHHISORHEROWNEMPLOYEES,PROVIDEDiHATSUCHIMPROVEMENTSAPENOTIMENDEOOR m ��. �OFFEREDFORSALEIF.HOWEVERTHEBl11LDMGOFIMPftOYEMENTISSOLDWIPHINONEYEAROFGOMPIE ��, ',�TION,7HE OWNER-BUILDEfl WILL HAVE THE BUFDEN OF pROVING THAT HE OR SHE DI�NOT Bl11LD DR �, '��,IMPROVEFORTHEPUFPOSEOF5ALE).� w�, ��, � OI,ASOWNEROFTHEPROPERTY,AMEXCLUSNELYCONTRAC7INGWITHLICENSEDCONTRACTORS � �� ,�'�,TO CANSTRUCT THE PROJECT(SEC.7a44,BUSINESS AND PROF SSIONS CO�E�.THE CONTRACTOHS LI- ' Ve1u8110f1 ADJ.AREA W. '�',CEN5ELAWOOESNOTAPPLYSDANOWNEROFAPROPEFiTY 6UIL�SORIMPROVESTHEREON,AND ��,�"�.WHOCONTRACTSFORSUCHP,ROJE 5 ITHA� N7RACTOR � ICENSE�PURSUPNT70THECONTqAC• QUANTITY DESCRIPTION FEE Y '�TORSiJCENSE y , � ❑I A���'y[� B.&PC.FOR iH15 flEA50U Q O V 'S' ¢ LL �A � U W �� � LICENSE�CONTRACTORS DECLARATION W �,'�1 HEFEBYAFPIRM UNDER PENALTY OF PERJURY THAi I AM LICENSED UNDEP PROVIS!ONS Of'CHAPTER � �"�.,9(COMMENCING WITH SECTION 7ooa)OF DIVISION 3 OFTHE el15ME55 AN�PRDFESSIONS CO�E,AN� Z `X �MY LIGENSE IS IN FULL FOflCEAND EFFECT. m � � � LICENSE CL45S � LIC.NO. ,� J U�,'��ATE � � � CONTFIACTOR �d � W , �. WORKERS'COMPENSATION DECLARATION —� ¢ �� 'IHEREBV0.FFIRAAUNDERPENALT'OFPEqJL1RYONEOFiHEFOLLOWING�ECLAAATIONS: � Cn Q �, _I HAVEANO WILL MAIN7AIN ACERTIFICATE OF CONSEN7 TO SELF-INSURE r'OR WORKERS' 2 � COMPENSATION,ASPROVI�E�BYSECTION3�aoOFTHELABORCODE,FORTHEPERFORMANCE U ¢ OFiHEWOFKFORWHICHTHISPERMfTISISSUED. � ��, 0.. W' �IHAVEA�OWILLMAINTAINWORKERS'COMPENSATIONINSIJRANCE.ASqEOVIREDBVSECTION ^ Q„ 37aoOFTHEIABORCOOE,FOR'fHEPERFORMANCEOFiHEWORKFORWHICHTHISPERMITIS �� �� ISSUE�.MY WORKERS'COMPEh$AiIIXJ INSURANCE CARFIER AN�POUCYNUMBERRRE: CONSTRUCTION �;/ j cnqaiEa PLAN REVIEW � POLICYNUMBER ELECTRIC Z Q W (f};ISSECTNNJNEmNOTBE�APLEfE�OFhIEPERMRISFORIX�IEHUI�l9EDWLLA{t5($100JOFLESS). PLUMBING �q'�'�,��, �� '^^'�^• _ z ICERTIFYTHAT��INiHEPERFORMANCEOFiHEWORKFOflWHICHTriISPERMIiI5155UED,l MECHANICALr ;,!_ ��� '�, (� SHALL NOT EMPLOY ANY PERSOtd IN ANY MANNER 50 AS TO BECOME SUBJECT TO7HE � � � WORKERS'COMPENSATIONLAWSOFCALIFORNIA.ANDAGPEETHAiIFISHOULDBECOMc INSPECTIONEEE ' = SUBJECTTOTIIEWORKERS'COMPENSATIONPROVISIONSOFSECTION37000FTHELABOR : � � ���`� /\� CODE,ISHALL�'FORTHWITHCOMPLYWITHTHOSEPFOVISIDNS. ISSUANCE ? �� � SMIP • �� p DATE: APP4ICANT. � �� WARNINGFAILURETOSECl1REWORKER$'GOMPENSATIONCOVERAGEISUNLAWRIL,ANDSHAILBE ENERGVP/C�y�_� �T. _ _ �j._ SUBJECTANEMPLOYERTDCfiIMINALPENALTIESANOCIVILfINESUPTOONEHUNDREDTHOUSAND ENERGYPEHIVIIT`"W ' � � - ��-' � �OLLARS(S1oD.000�,IN.ADDITION TO THE COST OF COMPENSATION.�AMAGES AS PFiOVIDEO FOR IN � � SECTION3lOeOFTHELABORCODE,WTEREST,ANDATTORNEY'SFEES RETENTIONFEE: � CONSTRUCTION LENDING AGENCY PRE-ALT FEE: O � IMERE6YAFFIflMUNDERPENALiYOFPERJURY7HATTHEREISACONSTqUCTIONLENDINGAGENCV FOR THE PERFORMANCE OF iHE WOPK iOR WHICH THIS PERMIT IS ISSUE�(SF.C.3091,CIV.G). � W __--' _ .-., �� LENDER'S NAME � _ ' h_^ LENDER'SADDHE55 � � TOTAL FEES � C��, � � ICERTIFYTHAYIHAVEREAD7HISAPOLICATIONANDSTATE7HAT7HEABOVEINFORAIATIONISCORRECT. W IAGqEETOCOMPLYWITHALLCITYANDGqUNTYORDINANCE5AN�5TATE�W5,9ELATINGT03UiLDING � CONSiRUCTIDN,ANOHEREBVAUTHOAIZEREPRESENTATIVESOFTHISCOUNTYTOENTERUPONTIiE ZABOVE-MENTIONED PFOPEFiTY FOR INSPECTION PURPOSES. 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