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��.;, . j - .. - � CITY OF DIAMOND BAR � C�MMUNITY DEVELOPIvIENT DEPARTMENT � ' ...„�.;� . 21660 E.Copley prive Suite]9D , ,,;:, ;;;:. ,i' �,.f-'� (909)860-3(95 Fax(909)861-311� - �S ���SS BUILDING PERMIT APPLiCATION , FIRMLY .. . .. , �li:"'f d I°'ir 4 ,:,,.�,. .. . ,... ... . y JOBSITE -Zl IZ 1 NO I�� �� , � : APPLICATIOf�J�3, ..7 PERNfiIT �� P/C t�3 o ADDRESS DATE �� � NUMBER # �� � � �� ISSUE TYpE OCC *- APN _ LOT �3 TRACT 3��I � DATE_ CONST. GROUP p OWNER ..�01�N �SPAR��t"� � ,. �` ADDRESS 9I ZONING SETBACKS z CITY ZIP TEL. 1 O o FRONT RW �❑ � APPLICANT _S'�A.��2.Y JA KSQ�J TEL. -�_�QIQj � REAR ❑ _ � , i :.. SIpE/SIDE STREET RW ❑ � ¢ � SIDE . ❑---- m CONTRACTOR ��'+�k�C � ¢ ADDRESS'Y�R k �a�;✓ ` c 0 CITY O.�Ji'.E.+"m"t�!`,iA ZIP���"`-+�TEL�����+��<���'� PROPOSED USE ' _ �w ARCH/ENG/ �^�� — z DESIGNER 1'�`��R�'C ��� NO.DWEL. NO. NO. � ADDRES5 '' UNITS STORIES BEDROOMS � crry �N6 � ZIP TEL �Q' � DESCRIPTION SQ.FT: FACTpR PSF ApJ.AREA�VALUATION � OWNER-6CILDER DECLARATION SFR/ADDIREM � O p I HERE9V AFFIRM UNDER PENA'�_TV OF FERJURY THAT I AM EXEMPT FROM THE CONTRACTORS L�,'- GBfdgP,IC3(�Ot� LLI CENSELAWFpRTHEFOLLOWINGREA50N(SEC.7037,SBUSINESSANDPROFESSIONSCODE�,ANVCITYOR (fj U COUN7YWHICHRE�UIRESAPEFMITTOCqNSTFUCi,ALTER,IMPRO'JE,DEMOLISH,ORFlEPAIRANYSTRUG W Patio/Deck Z TVRE,PR�OR TO I'S ISSU1iNCE,ALSO REQUIRES 7HE A�PLICANT rOR SUCH PERMITTO FILE A SIGNED � S?ATEMENT THAY HE OR'SHE IS LICENSEO PUFSUANT TO THE PROVISIONS OF THE COIV'fRACTOFiS�U� � �����- � � -� •�-�-�- - � OCENSE LAW(CHAPYEP 9(COMMENCING WITH S"cCT10N 70oaJ OF DIVISION30FTHE'6USINESS AND PRO- �'t' POOUSpfl �� 2 / . '� 1 j'� FESSIONS COOE�oR THAT HE OR SHE IS EXEMPT THEREFROM AN�THE BASIS fOfi TNEALLEGE`D'EXEMP- U TION.ANVVIOLATIONOfSECTION7�31.50YANYAPPLICANTkORA?ERMITSUBJECTSTHEAPPCICAN7T0 z Re-Roof ACIVILPENALTYOFNOTMOfiETHANFIVEHUNDFED00LLAF15($50bj.): -"� � ""-' " - o ❑I,ASONRJEfiOFTHEPROPER7V.ORMYEMPLOYEe54VITH'NAGESAS7HEIRSOLECOMYENSATION.� I� Commercial Z WILL DO THE W�RK,AND THE STRUCTUflL IS NOT INTEN6ED OR OFFEREO FOR SA'..E(SEC.7044.6U51- .J � NE55 ANO PROFESSIONS CODE:THE CONTRAC70RS UCENSE LAW DOES NOT APPLY TO AN nWNER 6F o /D ��� PFiOPERTYWNOBUILDSORiNPROVESTHEREON,ANDWHODOESSUqiWORKHIMSELFORHERSELFOR = �`X �S� p[ THROUGH HIS OR HER OWN EMPLOYEES,PFOVIDED THATSUCH IMPROVEMENTS ARE NOT INTEtJDeD OR m - � OFFEREDFORSALE.IF,HOWEVER,iHE8UIL01NGORIMPROVEMENTISSOLDVJITHINONEVEAqbF'COWIPL.E- � TION,THE OWNER-BUILDER WILL HAVE 7HE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR J IMPROVEFORTHFPl1RPOSFOFSALE). - �, � OI,ASOWNEROFTHEPPOPERTY,AMEXCLUSIVELYCONTRACTINGWITHLICCNSEDCONTRACTORS [[ TO CONS'RUCT THE PROJECT(SEC.7044,EUSINE55 AND PROFESSIONS COOE:THE CONTRACTORSLI-- V81Ud1iOt1 � ADJ.AFtEA LL! CENSELAWDOESNOTAPPI.�TpANOWNEROFAPROPERTYWHOBUILDSORIMPROVESTFIEREON,AND � WHOCONTRACTSFOFiSUCHPfiOJECTSINITHACON7RACTOH(S�LICENSEDPURSUANTTOTH�CONTRlC- QUANTITY DESCRIPTION FEE Y TORSLICENSELAW.). . � ❑I AM EXEMVT UNDER SEC. B.&P.C.FOR THIS REASON Q � � � � � U � �ATE OWNER � ^ �• •� iA p� � W W t (J � UCENSED CONTRACTORS DECLl+RATION ,. _ W ¢ � IHEREBYAFFIRMUN�ERPENALiYOFPERJURYTHHTIAMLICENSEDUNDERPFOVISION50FC11APTER � 9(COMMENCING WITH SECTION 700�)OF DIVISION 3 0F THE BUSINESSAND PROFESSIONS CODE.AND Z �-�''�/� X MY LICENSE IS IN FULI FOFCEANO'cFFEC'. � � LICENSE CLASS �^' �� LIC.NO. ��^a'� ��w�y,., � � U �ATE �"�"' �t'�J GONTRAGTOR��� ���• � a � f) v�... � WORKERS'COMPENSATION DEC� +�"w, q�'� Q� � IHEFiEHYAFFIPMl1N0ERPENALTYOFPER.Il1RVONEOFTHEFOLLOWINGDECLARATICNS: z �2±"� pjT� Q ` d I HAVE AND WILL MAIN-AIM1'A CERTIFICATE OF CONSENTTO SELF-INSURE FOF WOHKEFiS' _ Q COMPENSATION,ASPROVIDEDBVSECTION31oaOFTHELABORCADE,FORTHEPERFORMANGE � 0=THE WORN FOR WHICH THIS PERM��T IS ISSUED � � W IHAVEANDWILLMAIN'AINWORKERS'COMPENSATION�NSURANCE,ASREOUIREDBYSECTION � 370o OF iHE LA60R COOE,FOR THE PERFORMANCE OF THE WORK FOP INHICH TNIS PERMIT IS '' �-' . ".:, ���,�� _ ISSUE�.MY WORKERS'COMPENS ON INSURANCE CARRIER AND POLI�YNUMBERAREi-� CONSTRUCTION ' " �� �� j CARRIEF ����� ��°i"'r'� PLAN REVIEW 2� .�� � Poucv N��h!sEa �y'�._�Y'�j'��$ 44�r f' �,"'t��a^�F���G� ELECTRIC � 4 , Q (IIiISSECTK)NNEmNOTBECNAP�E'1'EDOFTHEPERMRISFOfiONEHUJDR�Dq.LAR6(�YW) RLESS� � PlUM81NG �}';"'�r,"�;; �. Z I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUEL`,' MECHANICAL � �'���� E ('3 SHAILNOTEMPLOYANVPERSONINANYMANNERSOASTOBECOMESUBJECTTOTHE '---�f,J'. ' - ' . � WORKEFS'COMPENSATION LAWS OF CALIFORNIA,AND AGFEETHAT IF I SHOUI�BECOME ' i INSPECTIDN FEE � = SUBJECT TO THE WORKERS'COMPEYSRTION PROVI IDNS OF SECTION 37a F T BOR CODE,I SHALL FORTHWITH COMPLV WITH THO VISIONS. � � ISSUANCE � p DATE: � �`� �`t � APPLICANT. � ��- - r' SMIP �� i J WARNINGFAILUftETOSECUREWOftKERS'COMPEIJSATIONCOVERAGEISUNLAWFUL,AND$H.41.LBE"- ENERGYP/C '� � LL SUB.fECTANEMGLOVERTOCRIMINALPENALTIESANDC:VIL'.INESUPTOONEHUNDREC7THOUSAN� ENERGYPERM(T OOLLARS(E1a0,o0o�,IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROYID[D FOR IN -- � SECTION37080FTHE�ABOPCO�E,MTEREST,ANOATTORNFV'SFF_E5. RETENTIONFEE: . ¢ - � CONSTRUCTIONLENDINGAGENCY PRE-ALTFEE: �7�Z�E��O �� - O — . CC I HEREBV AFFIRM UNDER P'eNAL7Y OF PERJURV THATTFIERE ISACO�S'IFUCTION LEN�ING AGENCV 7 FORTHE PERF-0RMANCE OFTHE WORK FOR WHIGH THIS PERMIT IS ISSUED(SEC.309],CIV.C.). ���' .� � � — W S LENDER'SNAME ' ' ' - zS . -.;.:,.. ..,..;...:��.,.: .. ... � LENOER'SAD�RE55 � �-� """"""��" � � ICER7IFYTHATIHAVEREADTHISAPPLICATIONANDSTA'"ETHATTHF.ABOVEINFORMA'IONISCARRECT. TOTAL FEES � w I AOREE TO COMPIY WITH ALL CITY AND COUNTV ORDINANCES AND STATE LAWS FiELATIIdG TO BUILDIN6�� " -' " " � CONSTRUCTION,AND HEREBVAUTHORIZE REPHESENTATNES OFTHIS COUNTYTO ENTER UPON TH'e � z nBOVE-MEP'TIONED PROPERTV FOR INSPECTION?VRPOSES. COMMENTS_ � �, r !+� C J.1 �� e�'��'� . , �':t.�. ', y ` . m PE'�&IF NAME(PRINT). 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