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CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES U„r"
21660 E.Copley Drive Suite 190 PRESSw
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909)860-3195 Fax(909)861-3117
BUII.DING PERMIT APPLICATION
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APPLICATIQN , PERMIT i\ P/C
o ADDRESS ` ' E /ti'5 ' 'DATE NUMBER V #
c ISSUE TYPE OCC
APN l0T TRACT DATE CONST.GROUP
p OWNER 9.v1CNC i4 r/fv il
ADDRESS ' / c S +2- K.-ZS ZONING SETBACKS
CITY +' ZIP 7 S EL.ol-'l Z FRONT RW
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DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION
OOWNER-BUILDER DECLAFiATION Fq/qDDlREM
0 1 HERE6Y AFFlRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRqCTORS LI- Garage/Carport
W CENSEUWfORTHEFOLLOWINOREA50N(SEC.7D37.58USINESSIWDPRqFES510NSCQ E:ANVC1iYOR
V COUNTlWHICHREWIRESAPEFMtTTOWNSTRUCT,ALTER,IMPROVE,DEMOUSH,ORREPAiRANY57RUC- W pelio/D6CkWTURE,PRIOR TO ITS ISSUANCE,ALSO PE UIRES THE APPLICANT FOfi SUCH PERMIT TO FILE A SIGNED WSTATEMENTTHATHEORSHEISLICENSEDPURSUANTTOTHEPROYISIONSOFTHECONTRACTORSll-
CENSE LAW(CHAPTER 9(COMMENCINO WITH SECTION 7000)OF DIVISION a OF THE Bl1SW ESS AND PRO- POOVSpB
FESSqNS COOE OR THAT HE OR SHE IS EXEMPT THEREFROM AND 7HE BASIS FOH 7HE ALLEGE E%EMP-
TION.ANYVIOUTIONOFSECTION7031.6BVqNYAPPLICANTFORAPERMITSUBJECTSTHEAPPLICANTTO z Re-FootACMLPENALT'OF NOT MORE THAN FIVE HUNDRED DOLLARS(5500).):
I,ASOWNEHOFTHEPflOPERTY.ORMYEMPLAYEESWITHWA6ESASTHEIR50LECOMPENSATION, G COIIIRIBlCIflI
WILL 00 THE WORK,AND THE STRUC7URE IS NOT INiEN ED OR OFFEREO FOR SALE(SEC.7044,BU51- J
NESS M1D PROFESSIONS COOE:THE COMRACTORS LICENSE LAW OES NOT APPIY To AN OWNER OF
7HOPERTYYIHOBUILDSORIMPROVES7HEREON.AN WHODOESSUCHWORKHIMSELFORHERSELFOq =
THROUGHNISORHERONMEMPLOYEES,PROVIDEDTHATSUCHIMPROVEMEMSARENOTINTENDEDOR m
QOFFEREOFORSALEIF,HOWEVERTNEBUILOINOORIMPFOVEMENTISSOLDWffHINONEYEAROFCAMPLE-
Z TION,7HE OWNER-BUILDER WILL HAVE THE BUPDEN OF PROVIN6 THAT HE OR SHE DID NOT BUILD ORIMPROVEFORTHEPURPOSEOFSAI.
I,A6 ONMER OF THE PROPEiiTY,AM ERCLUSIVELV CONTRACTINQ WITH UCENSED CONTRACTORSQTOCONSTRUCTTHEPROJECT(SEC.70N,BUSINESSAND PROFESSIONS CO E:THE CONTRACTORS LI-VeI11821p17 ADJ.AREA
W CENSELAWDOESNOTAPPLY70ANOWNEAOFAPROPEflNWHOBWLDSORIMPROVE6THEREON,AND
WNOCONTR GTSFORSUCHPROJECTSWITHACONTMG70R(5)UCENSEDPURSUANT70THECONTMF QUANTITY DESCRIPTION FEE
Y 70RS LICENSE uw.).
g I AM EXFJ.4PT UNDER SEC. B.&PC.FOR THIS PEASON Q
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u' DATE OWNER U
LICENSED CONTRACTORS DECLARATION w
IHEREBYAFFIRMUNDERPENALTY9FPERJURYTHATIAMLICENSEDUN ERPROVISIONSUFCHAPTER
p e GUMMENCINOWRH5ECT10N7000)OF IYISION30FTHEBUSINESSAN PROFESSIONSCOOE,AND Z
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UCENSE CLASS M LIC.NO. ,!
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WdRKERS'COMPENSATION DECLARATION Q
I NEREBV AFFlRM UNDEfl PENALTY OF PERJURY ONE OF THE FolIOWING OECLARA71oNS: U
ZQ
L7 IHAVEANDWILLMAINTA NACERTIFICATEOFCONSENTTOfiEIF-INSUflEFORWOFKERS' 2
COMPENSATWN,AS PROVIDED 8V SECTION 370o OF THF.LABOR CODc,FOR 7HE PERFORM4NCE WOFTHEWORKFORWHlCMTMISPEPMRISIS5UE0.
QW I HAVE AND WILL MAINYAIN WORI RS'CAMPENSATION INSURANCE,AS RE UIRED BY SECTION
Q 3 0o OFTHE LA60R OOOE.FOR 1NE PERFORAAANC.F OF THE'JJORK FOfl WHICH THIS PERMITIS
ISSUED.MV WORKERS'COMPENSAiION INSURANCE CARRIEF AND POIICV NUMBER APE: CONSTRUCTION
CARRIER Ka« - PLAN REVIEW
POLICYNUMBER L p ELECTRIC
fFBfiSECtIqNNE N0TBE0 MPLEfEDOF7HEPEFM5T6FOROME.F#FARE OOLLAFU(57oo ORLE55 PLUMBING C Qu
I CERTIFYTHAT INTHE PERFOFMANCE OFTHE WORK FOR WHICH THIS PERMIT IS ISSl1ED,I MECHANICAL
SHALL NOT EMCLOv ANY PERSON IN ANV MANNER SO AS TD BECOME SU6!ECTTO TNE
j WORKERS'COMPENSATIONLAWSOFCALIFORNIA,ANDAGflEETHATIFISHOULDBECOME INSPECTIONFEE
SU&lECT70 THE WORKERS'COMPENSATWN PAOViSIONS Of SECTION 3'1Co OF TFiE LABOR
CODE,ISHAL1 f-0RTHWITMCOMPLYWITHh10SE OVISIONS.
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ISSUANCE
SMIP
p DATE: 16-?{C7I APPLICANT:
J WAflNINO FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL.AND SHAL.L BE ENFRGY PIC
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AN CIVIL FlNES 11P TOONE HUNDRED THOUSAND ENERGY PERMIT
OOUARS(51 aD,000).IN ADo1710N 70 THE COST OF COMPENSATION,AMAOES AS PROVIDED FOR IN
SECTION37080FTHELABORCODE,INTEFEST,ANDATTORNEYSFEES. RETENTIONFEE:
d CONSTRUCTION LENDING AGENCY PRE-ALT FEE:
1 HEREBYAFFIRM UNOER PENALTY OF PERJUiiY THAT Th1ERE IS A CONSTRUCTION LENDING AGENCY
J"E Y J
FORTME VERFORMANCEOFTHE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.3097,CIV.C.).
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LENOER'3 NAME 1FY 77p7 b 7 C° , .y'"7
3A_ 'y —"L:' 2A
F= LENDER'S ADDHESS
w 1 AGREE TO COMPLV WTHAALL CITY PN 0UNTY ORDINM'CES ANO STA E LAWS REIATNG TO BUIRDI
TOTAL FE ES S
CONSTRVGTION,AN9MENEBYAUTHORIZEREPRESENTATNESOFTriISCOUNTVTOENTERUPONTHE
Z ABOVE-MEMIONED PROPERTV FOR INSPEGTION PURPOSES.COMMENTS
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SIGNATl1REOFPEFiMITTEE DAT
FiECPT.NO. PAID BY VAIIDATION
WHITE—Department Copy,YELLOW—Finance Copy,PWK—Assessor Copy,GOLDENHOD--File Copy,GREEN—Applicant'S Copy
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