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CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21810 Copley Drive, Diamond Bar, CA 91763 PRESS
(909) 839-7020 Fax: (909) 861-3117 Building Inspection Hotline (909) 839-7027 FIRMLY
BUILDING PERMIT APPLICATION Www•cityofiliamondbar.com building@diamondbarca.gov
JOB SITE ADDRESS
APN LOT TRACT
OWNER - AAKfL114N eRE%l EC7A?E LLL'-_
ADDRE Y cy /j LY ]�
CITU IF, gi'}1f TEL.
APPLICA_ TEL.
CONTRACTOR rT
ADDRESS.
CITY LOA ZIP *Z TEL. �Z-'
ARCHIENGf
DESIGNER A b f AQ -1 tyej s
ADDRESS
CITY ZIP TEL
OWNER -BUILDER DECLARATION
I hereby afford under penalty m perjury, met I em exempt from the Contractor's State License Law far toe reamnh)
indicated below by toe checkmarkls). I have placed next to Me applicable Harris) IBeeNon 70315, Bmbeu and
PrOINSIMS Code: Any city o county mat mqukea a permat m cerebra 1, door, heprove, dere ltsq or repair, wry
structure, prior to IN issuance, else roquires to applicant for mm permit to file a signed statement that he m she
Is licensed pursuant to Me provisions of the Contr9elor's State License Lew (Chapter 9) Commencing wife Section
7000 of Division 3 of me Business and Prolessione Code] or that he or she d exempt from licensure and the basis for
the alleged exemption. Any Wolohan V Section 7031.5 by any applicant fora permit subjects fee appllcam to a cowl penalty
of not more than ileo hundred dollars 1$500).
UI, as owner of the property, or my employees with wages as their sole tempora len, will do U all of or U PO"IOM
of the work, and the structure Is not Intended or altered for sale (Seco m 7044, Business and Professions Coag: The
Comtectos' We License law does malapply to an fawner a1 property who, lMq+gM1 empbyees' o pertonal tow. bells
or Improves the property, provided that the improvements are not mounted or offered Io sale. If however, Me building m
Improvement Is sold within one year of completion, the Owner -guiltier will have the Medan of proving mai A wee not bum
m Impnwedso Me pumosem sab.1.
U I, as owner of the property, am exclusively contracting with licensed Conerectom to construct the project (Section
7044, Business and Rolessions Cotlm: The Conbactom' Siete Lksnae Law ticoa nm apply td an oxnmV prapedy Who
Wilds or Improves thereon, and who contracts for the projects with a llcensetl Conimctor pursuant to The Conhactas' SM1e
i License Low.).
U 1 em exempt from Rcenaua now ma Codmmots State License law iothe maewing reasaMa):
Oats:_ Sign'.
By my a%fl mm below l ackmontal that except fa my paerarel seWnca In witch) m an have resided to m hast me
S year prior to completion V me Improvements formed by this rea lil cannot legally sell a structure that i have built M en
owner Duprer, 0 It has nm been constructed In M entirety by Mensed cm Main. I understand that a copy V the
j applicable law, Small 7044 V the Business and PrVesslons Cade Is available upon request when this appIcaUm Is
> submitted u at Me falowing Web rifts: hgpf. ..leginfo.ce.govfcalaw.html.
j LICENSED CONTRACTOR'S DECLARATION
I hereby affirm under penalty of perjury that l am licensed under provisions V Chapter (mmmmcing with Sectlm 7000)
a V Divle w 3 of the Business and Professions Code, and my Ilnense Is in full fares and effect.
a
7 LICENSE CLASS: LIC NO.: `f O •s 7-3
-
a
� EKP.OATE. CANIRACTOa,
j WORKER'S COMPENSATION DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE Of THE FOLLOWING DECLARATIONS;
o _ I have and AIR maintain 8 Certificate V Cmsem to Self -Insure fa Worker's Compen raHm, as provided by
Section 37DO V the Lebo Code, fa the performance V the wore for which this permit Is leaned.
I have and Mil maintain Worker's Combination Insurance, as required by Seci on 3700V the Labs Code, To
i
the performance of the work for which this permit a Issued. My Worker's Compensation Insumnm Carver and
POICy Number or
� CAflflIER � ✓ L'
c, POLICY NUMBER
3
THIS SECTION NEED NOT BE COMPLETED IF TIE PERMNG FOR ONE HUNDRED DOLLARS $100 OR LESS).
j I certify that in the performance V the work for which MN parted is Issued, l shall not areal any perm M ally master m m to
became subject to MB Worker's CTflWmMn Laws V California And agree test B I mwm become Sol BI to the WVWs
Compensationoneslms of Section 3700 of the Labor Code, I scall form comply with Mme pmdslms.
OATE: APPLICANT:
r WARNING: Failure M secure Worker's Compensation coverage 18 unlawful, and shall object an employer to Criminal
5 penalties and civil Mee up to one hundred thousand pa0ers ($100,000), In eadmm to the cost V the compensation,
j damages as provided for In settlor 3700 of the tabu code, Interest, and e0aney'eleee.
L CONSTRUCTION LENDING AGENCY
0 1 hereby affirm under penalty V pool that Mem Is a Cerebra loo Lending Agency for the performance V the well fu
Mich this penult Is Issued (Sec. 3097, Co. Q.
LENDERS NAME:
LENDER'S ADDRESS:
fortify That I have read this application and state that the abate Imunetlon Is Coleco. I agree to comply wit all dty 01d
county oalnamceaeM slate laws reeongta hulWing commrudlw,entl Araby euNiMxe repmmmebvesV RaecamNb
5 enter upon the above memlmed property fa W
Inspection Noses.
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= PERMITTEE NPMI[/ IN7)�7s
2 .�(-1 l� Her+—} I �. r' c--•l,J /�
SIGNATURE OF PERMITTEE
APPLICATION DATE: %V
ISSUEDATE:IZ/1'�PERMITS:
TYPE CONST.
P/CA P", I—
QqI(ki— O-a�__ 1___
OCC GROUP:
Scope of Work CL6R$^n %77£ E
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)t• L. UNITS N STORIES
1V o- /NV' j1eEhf L$�S
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to L'
N BEDROOMS
DESCRIPTION SO. FT. FACTOR PSF
ADJ. AREANALUATION
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Adj. Arae:
QUANTITY I DESCRIPTION FEE
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CONSTRUCTION:
PLAN REVIEW: %%xP
ELECTRIC:
Zq 1. Z0
PLUMBING:
11RAD
MECHANICAL
INSPECTION FEE:
ISSUANCE:
SMTP:
�1 ai3q
14
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ENERGY P/C:
ENERGY PERMIT:
RETENTION FEE:
2.00
PRE -ALT FEE:
BASF:
I •OO
PLOT PLAN:
ZONING CLEARANCE:
TOTAL FEES ��a./1
COMMENTS: v_
Q'J12•�/'ll
P/C: I) PAID BV:,If-PQ I
RECEIPT As PAID BV:
VAUDATION:
7 VALIDATION: