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Home My WebLink About16756 ' � � CITY OF DIAM�I�I)BAR ��' �.-- y,.� :� DE�AR'TMENT OF COMMUNTfY&DEVELOFMENT SERVICES 21825�.Copley IIrive PRESS (909}�60-3195 Fax(909)861-3117 w '`%.cK�'' BUILDINGFERMITAPPLICATION FIRMLY � JOBSITE �` �� DATE CATION �a�� NUMBER � l�P� #/C oADDRESS, o ISSUE TYPE OCC °D APN L07 TRACT DATE CONST. GROUP p OWNER �_QY""lA ��`� �� ZONING SETBACKS o ADDRESS � `'�` FRONT RN1 � z CITY Au� , ZIP__ TEL. "' REAR n o APPLICANT ' ^� �� TEL. �� SIDEISIQE STREET RW ❑ - z SIDE � m CONTRACTOR � ADDRESS PROPOSED USE � � �� C�Ty ZIP TEL. � ARCH/ENG/ z DESIGNER NO.DWEL. NO. NO. d ADDRESS - UNITS STORIES BEDROOMS � CITY ZIP TEL._ � DESCRIPTION SQ.F7. FACTOR PSF ADJ.AREANALUATION ¢� OWNER-BUILDER DECLARATION SFR/ADD/REM O � Q I HERE6V AFFIRM UNDER P�NALTY OF PERJURY THAT 1 AM E:CEMPT FROM THE CONTRACTORS LI- Gdfd(J2/C2�POft W CENSELAWFORTHEFOLLOWINCjREA50N(SEC.7oat.5BU51NE5SAN�PROFE5310N5CODE:pNYGITYOR (/� . �. COUNTY`M�IICHRE�UIRESAPEflMIT7000NSTRUGT,ALTEfl,IMPfiOVE,DcMOLISH,ORREPAIRANYSTRUG W P8110/DOCI( w� NRE,PRIOR TO ITS ISSUANCE,A150 RECUTAES 7HE APPLICANT FOH SUCH PERMIT TO FILE A SiGNED w �. STATEMFNI THA7 HE oH SHE IS ILICENSEO PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI, �.' CENSE LAW(CHAPI'ER 9�CDMMENCING WITH SECiION 7000)OF DIVISION 3 OF THE BUSINESS PND PRO� � POOI/SP8 O FESSION5CODE)ORiHATHEOR';SHFISEXEMF7THEREFR�MANDTHEBASISFORTHcAL'.EGcDEXEMP- V� TION.ANVVIOL4TIONOFSECTION7o31�:5BVANYAPPLICANTFOFIAPERMITSUBJECTSTHEAPPLICANTTO Z Re-Root � r ACMLPENALTVOFNOTMORETNANFlVEHUNDREDDOLLARS(S50D)J: �, ❑I,ASOWNEflOFTHEPfiOPER7Y,ORMYEMPLOYEESWITH3NAGESASTHEIRSOLECOMFENSAiiDN, � Commercial Z� WILI D�THE WORK,FN�THE STRUGTURE IS NOT INTENDE�OR OFFEREO FOR SALE(SEC.7044,OUSI� �.I �; �NE55 AND PFOFE%IONS COOE:tHE CONTRACTORS 110ENSE LAW�OES NOT APPLV TO AN OWNER OF j . PROPEf1TYWHOBUILD50RIMPRbVESTHEREON.ANDWHO00E5SUCHWOPKHIMSELFORHEFiSELFOF m �". THROUGHHISORHEROWNEMPLOVEES,PROVIDE�THAiSIJCHIMPROVEMENTSARENOTINTENDEDOR . W' OFFERECFORS�E.I=,HOV.'EVER�,T4EBU'��L�WGCRIMPftaVcTSENTISSCLDV7ITHINONEYEAFOFCOMPLE ' �''� TION,hiE OWNER-BUILDER WILL�HAVE'.THE BURDEN OF PROVING THAT HE OR ShIE DID NOT EUILD OF � �"� IMPROVEFORTHEPURfOSEOF$ALE). ❑1,q5 OWNEH OF THE PPDPERTV;M.7 E%CLUSIVELY CONTRACTMG W ITF LICENSED CGNTRACiORS � � �TO CONSTRUCT THE PROJECT(SEC.�044,BUSINE55 ANO PFOFESSIONS CODE:THE CONTRACTORS LI- V8IU8110f1 � ^y� ADJ.AREA ' IlJ' �CENSELAWDOESNOTAPPLVTOqNOWNEROFAPROPEflTYWHOBUILDSORIMPROVESTHEREUN,AN� ��.. WHOCONTRACTSFORSUCHPRO�JECTSWITHACONTRACTOR(5)LICENSE�Pl1R5l1ANT70THECONTRAC- QUANTITY DESCRIPTIOSV ' FEE TORS LICENSE LAWJ. �, % Y J Q� ❑i AM EXEMPT UN�ER SEC; .8 P.C.FOR THIS REASON � � �y p+ � LL. OATE /'43 'G$� '� OVJNEfl U Z W � LICENSED�CONTRACTORS DECLARATION —� 4 W � � 1 HEREBYAFFIflM UNDER PENALT�OF PERJURY THA71 AM LICEIJSED UNDER PROVISIONS OF CHAPTEF �i p,.'' 9(COMMENCING'NRH SECTION oo)OF DIVISION 3 0F THE BUSINESS AND PROFESSIDNS GO�E,AN� Z 'X MY LICENSE IS M FUiL'rOHCE A EFFECT. m � � UCENSE CLASS LIC.NO. j � OATE '� � GONTRACTOR �- W I � WORKERS'COMPENSATION DECLARA710N ¢ � U � I HEflEBYAFFIRM UNDER PENALTN OF PER.IUqV ONE OF THE FOLLOWING DECLARATIONS: ZQ � _IHAVEANDWILLMAINTAINAL�RTIFICATEGFCONSENTTOSELF-INSUREFOFWDRKEFS' S Q COMPENSATION,A5PA0 IDED'�.BYSECTION37ooOFTHELABOFCO�E.FORTHEPERFORMANCE U OF THE WORK FOflNhIICH TNIS PERMIT IS ISSUED. � W pp�� IHAVEANOWILLMAIIiTA1NW09KER5'COMPENSATIONINSUFANCE,ASREc1UIRE�BYSECTION p ,� Q. 37oD OF 7HE LABOR CO�E,FDR THE PERFORlAANCE OF THE VIORK FOR W HICH THIS PERMIT IS ISSUED.MY WORKFAS'CbMPENSATION INSLIRANCE CARRIERAN�POLICv NIJMBERARE CONSTRUCTION � �� j cnqRiER PLAN REVIEW 0 POLICYNlJMOEA ELECTRIC Z ¢ ([HISSECTIONNEmNO"f9EOJMPLFfE00FhEPFAMRISFORONEHUNOFEDD�'lARSf5100)ORLESS} PLUMBING 0 Z I CERTIFY THAT IN THE P�RFORMANCE OF THE WOPK FOR WHICH THIS PE�iMiT IS ISSUED,I MECHANICAL (} SHALLNOTEMPLOVANVPERSQNINANYMANNERSDASTOBECOMESUBJECTTOTHE INSPEGTIONFEE c� vj WOflKEflS'COMPENSATIONLAWSOFCALIFORNIA,ANDAGFEETHATIFISNOU�DBECOME SUBJEGTTO THE WORKERS COMPENSATION PHOVISIONS OF SECTION 37000FTHE LABDR � OJDE,I SHALL FORTHWITH COM1IPLY WITHTHOSE PflOVI510N5. ISSUANCE ,,,,u,, � O I � SMIP {��"`�}' a � �A7E�. APPIIGANT: . E.....". • .' `..-�-• � w � � ENERGY P/C � J WARNING:FAILURETO SECURE V�ORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AN�SHALL BE �p 7,, � � SUOJECTAIJEMPLOYERTOCRIMPIALPENPLTIESANDCNILFINESUPTOONENUNDREDTHW3AND ENERGYPERMIT � —�y_��.. 3 DOLLARS(E700.00�),INADDITIONTOTHECOSTOFCOMPENSATION,�AMAGESASPROVIDEOFpRIN Sy �d � � SECTION 3]aB OF THE LAROR CODE,INIERESi ANDATTORNEY'S FEES. RETENTION FEE: �� COIVSTRUCTION LENDING AGENCY PRE-ALT FEE: ! ' � �� I HEREBYAFFIFM UNOER PENALi�'OF RERJURY THATTHERE I.S A CONSTFUC710N LENDING AGENCY �o LL_ ., _ '""'"-""�� — FOfl THE PERFOFMANCE DF THE INORIZ FOFi WHICH THIS PERMIT IS ISSUEO(SEC.309�,CIV.C.). Z __ —' LLl = LENDER'S NAME � F_— LENDER'SADPRESS r ``''�� "' � ICERiIFYTHATIHAVEREA�THIS;APPL�CATIONANDSTATETHATTHEABOVEINFORMATiONISCORRECT. TOIAL FEES � �� W � I AGREE 70 COMPLV WITH ALL CITn'.4Nq GUUNTV ORDINANCES AND STATE LAV✓S RELATING TO Ol11LDIN� � CDNSTRVCTION,ANDHEftEBVAU7HORREREPflESENTATIVESOFTHISCOUNTYTOENTERV?ONTHE " z�' ABOVE-MENTIONEO PROPER7V FOF IN$PECTION PURPOSES. . � . COMPdENTS - � � � — � w I r � m� PERMITTEENAME(PRINTJ - � �. � ¢ �� a t� �y� i � SIGNATl1REOFPERMITfEE I DA7E RECPT.�O. � �� PAID BY E �`A VALIDAI'ION _ ~ � �'WHITE—Depart ent Copy,YEILOW—Finance Copy,PINK—Assessor Copy,GOLDENROD—Flle Copy,GREEN—ApplicanYs Copy .. .. .... .. ... . ... .... . .... . . . r�".i:J.V :,.......n.r :�.u.�w�r 2 ��+J".` . - . - ..� ..4� � a�, 3�.�.s. ,.�. �. .. 4 . .. - W 4 m . , ..��a .... . ..._ . .e. 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