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' - CITY OF 1 AMOND BAR
PARTMENTOFC( NUNITY&DEVELOPMENT SERVICES
- - 21810 Copley Drive, Diamond Bar, CA 91765 PRESS
,,, �� (909) 839-7020 Fax (909) 861-3117 Budding Inspection Hotline (909) 839-7027 FIRMLY
'�°' BUILDING PERMIT APPLICATION www.cityofdismondbarcom building@dinmondbares gov
JOB SITE ADDRESS IY /Q C^/ „' L Tra 1
APN LOT TRACT
OWNER A rn, Z
ADDRESS
CITY p6YYlOhIR ZI Ljle(2 TEL% %
APPLICANT
CONTRACTOR
ADDRESS I I �% '� CN21511v_14 ':°ALL—
CITY ZIP ' &iEL
ARCH/ENG/
DESIGNER
ADDRESS
CITY ZIP TEL
OMM-BUILDER DECLARATION
I hereby ammh under penalty of penury that I am exempt Mom the Contactors State Ucensa law for Me aesmks)
Indicated beow by MM chackmark(s) I have placed netl te the applicable wrote) ISecOon 70314 Busrnea ad
Prolessas Cade AM better owed, tlMl ra#area a pvmt W c mh t. alien, Npova. denMlWr, er raver, any
ebw:bpe, pdonte Norfmi8npa, sN0 ra#artl the&Mficahl Terthape WBIBaupWMbmmd aMdhomeb
set pinse ottato Ida al at■Conbxts's State lkesa Itw(CKWW B) Callwit: ng wiM Swum
of olasimh 3 of the Omand Pmbm Code] w that he or she Is exempt ham ImM11e¢ and tee call for
Me alleged exemption Any vdlaWn of Section 70315 by any applicant bra Want subject the applicant so a end penalty
of not mare teen Ave hundred Mines (5500)
U I, a owner of the property, or my employees won wages as then mle canpen4elbn, will do U all of or U Porbom
of the work and ice anrbee is M telmded or offered for ale (Swum 7044 Blw was, and Rotessbo Cade The
GtennbenaYB'Stete License taw d® not apply to an Omar of poperty who trough employees w personal start, bonds
or improved tee property provided Mat MM midaws me is are not Interded or offered for ale It hone er, ice Wilding or
Improvement Is wig within one year of comclatbn, ice owner Builder win have ice When of proving that It was not belt
or Improved for the cunxna of add)
U I, a aw'ner of the property, art exclusively wntractng with licensed Contractors to cmoV W the project (Section
70" Business and Praaa9ora Gotle The Convactore' Sale Licam paw does not apply to an owner of pars" Who
winds or Incomes Mention, and who cmtrabM ice projects With a licensed Cordell phA9ad W the Cortec 'Stet
License Low)
U I art exempt firm Ircenape under me Camectere Site license law for the Iallomng mussan(a)
By my spreare below l actrmdedge Mal except fa my personal miderxe in whph l must have resided for a l®done
year Ili W mmpMw of the Mprwernerhte covered by cols pamt I aarm Nga ly sap a structure that I have win m an
bu M II It has M been constructed In en eatray by Review mldnicto I understand that a copy of ice
applicable law, Section 7044 of MM Buldnew and Rol®Ions Code Is arWlable uponImmst when cols eppllath is
automated or at to fdlowl Web site hSAMaw legimo ca gov/calaw html
UCENSED CONTRACTOR'S DECLARATION
I hereby afflrm under pemlty of perjury the I am lkemol under provisions of Chapter g (canmerring with Seem 7DDe)
of Crown 3 of ere Business and Prelmdbn9 Code and my liwse Is In hill lace aim affect
LICENSE CLASS UC NO
DATE CONTRACTOR
WORKER'S COMPENSATION BECLARAnON
I HEREBY AFFIRM UNDER PENALTY OF PERNR( ONE OF THE FOLLOWING DECLARATIONS
I have end ova museum a feNAab of Coma W Seim trtaae la Wave a CamperseWn, as prMded by
Section 3700 a to dabs Coda for ere palo'mahre of ice wok for wnkh Mlle paint is Issued
I have and will maintain Wpdwrs CaeperraMon Insurance as required by Section 3700 of Me InMur Cade, for
teperformunco of the wok for which this permit la Issued My Wonder's Cumpersztdnlmurence Canerend
Polity Number are
CARRIER
POLICY NUMBER
(M SECTION s® NOT BE COMPLETED FTIE POW B FOR ONE HUNDRED D IRINS(MON OR LESS)
become
Maim led pMonmarmdNowak on Lewis
eNa Iarm11a I And Imall n 41 would
ouHarty to ths, orein
berme OMPtesioWMN9on 3700atlon lawsade I all
Mon efth rstt etmdbermeenbpttetlhe Worker's
famper®iM pmAUaw of Section 3700aled labor Cade IehM PodMiN taMty, witllDow prevNdts
DATE APPLIfNn
WARNING Fatere W socum Worki Compasatbn corsage is ertawha, and "I ermfen an employer to onbdrel
penaMlen and civil finds up W one andred tawsend Owns (3100 Tao) In WIW to MM cost of the mnpemabn
damages at provided for In section 3708 of the law code Internal end attorney d tees
CONSTRUCTION LENDING AGENCY
I therapy alllrm under mat, of perjury the Mare Is a Corabhndon Lending Agency for ere performance of to work for
Which the yerMl is lssad(SEC 3097, Civ C)
LENDERS NAME
LENDER S ADDRESS
I cartty, Nat I have read this appliaben and axe Nat ice above IawmaMon Is correct I agree to comply wish all city end
county ordinances and state laws relating to Wilding mnslrmtlbn and hereby authorize representatives of this County so
enter upon the above mentioned prmaty for laspecim purposes
PEIOWREE NAME (PRINT)
SIGNATURE OF PERMPTTEE DATE
APPLICATION DATE Q-LlftT P/C# PQ
ISSUE DATE PERMIT#
TYPE CONST OCC GROUP
Scope of Work 94MA1..J1s.)(a 1.4ALLS.
�e1�11fF„ni.1S
# DWEL UNITS # STORIES
As-+�
# BEDROOMS
DESCRIPTION
SO FT
FACTOR PSF
ADJ AREANALUATION
SFR/ADD/REM
Garege/Carpon
Ow
P.M./Deck
w
LL
Paol/Spa
Z
Randof
9
Commemlel
m
NN,,
W
C>
ValY ffa r
Adi Area
OUANTITV
DESCRIPTION
FEE
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CONSTRUCTION
PLAN REVIEW
ELECTRIC
PLUMBING
MECHANICAL
INSPECTION FEE
ISSUANCE
SMIP
ENERGY P/C
ENERGY PERMIT
RETENTION FEE
PRE -ACT FEE 9 % •,�
BASF
PLOT PLAN
ZONING CLEARANCE
TOTAL FEES • 6
COMMENTS
P/C PAID BY
RECEIPT M PAID BY
VALIDATION
VALIDATION
WHITE— Deperbnat Copy YELLOW — Finance Copy, PINK — Assessor Copy