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� � CITY OF DIAMOND BAR > "" DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES J� _ � , 21660 E.Copley Drive Suite 190 (909)860-3195 Fax(909)861-3117 PRE$$ �"�'� BUII.DING PERMTT APPLICATION FIRMLY N JOBSITE APPLICATION ��p � PERMIT /C o ADDRESS �� � �� � C'�. � DATE `— NUMBER # � ISSUE TYPE OCC APN LOT TRACT DATE CONST. GROUP S OWNER . � � o ADDR�SS ` ZONING SETBACKS Z CITY ' ' .1 ' �`L /IP��v JTEL. � C - FRONT RW ❑ � APPLICANT - . � � TEL.� � � , REAR ❑ � SIDElSIDE STREET RW ❑ CONTRACTOR -�J i� l�� SIDE ❑ ADDRESS Q- � CITY 1 �� ZIP � %TE �n• .:1 " PROPOSED USE oARCHlENGJ � DESIGNER NO.DWEL. NO. NO. ? C�ESS Z�P TEL. UNITS STaRIES BEDROOMS � u> DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATiON � OWNER-BUILDER DECLAflATION SFRlADDJREM O Q 1 HEREBY 11FfIM1 UIJ�ER PENALiY�PEFWM THA7 I MI E%EMM FiIOM THE CONfRACTOR3 U. G8f8yB/CidtpOA tL I�/SELAWFWiTHEFOILOIVMOREA90N�SEC.7Wt.58U31NE33ANOP1iOFE5510NSCODE:ANYq7YOR (� S2 Cd1MVMMICMREOUIRESAPERMRTOCONS1HUCf.N,TER�PAOVE.DEMOI��I.ORREPAIRANV57RUG W Z IUHE,PRIOR 7U fT9 198U1NCE,ALSO REOl11RES 7HE APPIICANT Wfi SUdi PERMIT TO FIIE A SIGNED Patio/Dedc u� $TATEMENT IYiAT NE OR BHE IS UCENSED PURSUANf TO THE PROVISIONS OF THE CONTMCTORS L4 W � CENSE UW(GUIPTER►(GOMMENCINO WfIH SECTION 7000)OF OMSION 9 OF hIE BUSINESS AND Piro- � POOVSpB iE64qN4 COO�OR TFNT HE OR SME IS EXFIAPT 7HEREFF101A AND iHE BA515 FOR THE ALLEOED E%EMP- iqN.N1YV10UiqNOF5ECT10N1o31.6BYNiYAPPIICANTFORAPERMITSUBJECT57HEAPPLICMfiTO Z qg-ROOf � ACIVILPENKT'OFNOTA10REiTWJFlVEHUNOREDDOIURS(65ao).): � ❑LASOWNEROFTliEPROVERT�'.ORMYEMPIOYEESN7THWAGE5A5THEBi50LECOMPEN5AT10N, � COttlllfefClBl - WILI DO 7fff WORI�HiD iHE 57AUCNRE IS NOT INTENDED OR OFFERED FOH SALE(SEQ IDM,BUSI� J N t�38 NA PNOFESSIONB OWE iHE WNTRAClORS LiCEN3E LAW DOES NOT APPLY TO AN OYMER OF � VPOPEfl7Y Y1FIDBURDS OR MPROVES TMEREON,M�IDVYMO 0�5 SUp1 WORN HINSELFORHEPSELFOR LL 7MRO1M3111N30R NER OYJN ENPLOYEES.PROVIDED iHAT SUdi MAPqOVEMENTS ARE NOT INTENDED OR m Q .OFFEAEUiOR9ALEIF�NOWEVER7HEBUILDIN60RNAPHOVEMBlf193qDWR1iMONEYEAROFCOMVLE- Z TION,THE ONMERAUILUER YVILL HAVE THE BUHDEN OF PROVING THAT ME OR SHE DID!OT BUILU OR = IMPipVEFOR1FiEPURPO5EOF8ALE�. �y OI.A40MNEROFT/IEOROPERT/,WE%CLUSNELYWMRACTtlJGW1iML10ENSEDCOHTN�ICTOR3 (r i0 CONSTRUCT TME YROJEGT(SEG JON,BUSINESS M!D PROFESSION3 CoOE THE WNTMCTOR3 LI- Value[�1 ADJ.AREA � CBiSEUWDOESNOTAPPLYTOANOWNEHOFAPHOPEHTVWf10BUtlD50RITIPRD4ESTHEREON,AND 1N1000NTRAGTSFORSUCNFROJECTSWI7HACONTRACTOR(SJLICENSEDPUNSUINfTOTHECONTRAG pUANTITY DESCRIPTION FEE � lORSIJCENSE UW.). � �I NA E7CEMPT UNDER SEG 8�8 P.C.FOR THIS REASON U _ Q u' DATE OMMER t j`"� U � W LJCENSEO CONTRACTORS DECIARATION W � 1lIEREBYAFFiW.Il1NDEAPENKTYOFPERJURYl1UT1ANLICENSmUNDERPRDVISKKJ30FCtU.PTER � s 0(CAANAENCRJOWI7NSECfION70m)OFDIVISION30FTHEBUSINESSINOPROFESSIONSCODE,�HD Z 4tJ ��ENSE�S W FUl FORCE AND EFFECi. /+ m 0 LICENSE SS l.._�C _LIC.NO. L �� � � VDATE � ._ CONTRACTOH . LL • � WORKERS'COMPEN5ATION DECLARATfON �,i3,� U �y �. � . + � 1/1EREBYA�IPoAWAERPENIILTYOFPERfilRYONEOFTHEiOLLOWINGOEQAMTIONS: t� Q � 11UVEAHDMNLLM�IMAMIACERfIFICATEOFCONSB�TTOSEiHNSUREWHWIXiKERS' _ ENSATpN,A3PROVIDEDBY5ECT10N37000FTMELABOHCOOE,FOflTHEPEPiORMANCE w OF THE WOFU(FOR WH�F/hilS PERMR IS I&SUED. � 1 MAVE AND WILL MiUHTAN N'ORKERS'COMPENSATION INSURANGE,AS REMIIRED BY SECTION � 37o00FiHElABOHCODE,P�RTHEPERFORMANCEOFiHEWORI(fOHWHiCHTHISPERMRIS � ISSUED.MYy.tlWCER3'COMP�,/1 ATbMI.r�Ir�RMI�EGRNIERANOPOLICYNUMBERAHE: CONSTRUCTION � awWEi1, i��� i�C I-'"�L � PLANREVIEW r_ Z �a�cYM»�aER 4 ' ,..2-� r w �� ELECTRIC ¢ 0 �ssEcnor��wreEaonv��IDOFn�v�.�r�scoaa��oauASM�)a+�ssl PlUMBING Z t CERTIFY TMAT IN THE PEfiPoRMANCE OF THE WORK PoR WHI�HIS PEHMR IS ISSUED.1 � r �J SHN.L NOT EMPLOY rN(PEHSON Nl M1Y MAMNER SOAS ECOME9l(AIECT TO TXE � WORKERS'COMPENSATIDNUWSOFCALIFORNIA,AND� EETHATIiiSHOULDBEWME INSPECTIONFEE S SUBJECTTOTHFWORKERS'COAIPENSATqNVROVISIONS SECTION3�OOOFTHEUBOF E i ywu�r-atrrrvnrn r wmi e enovisarvs. ISSUANCE V O DATE �� APPLICAM�' -'C-lC( � SMIP Y : � WAIWMO:FAIWRETOSEf.11FiEWORKEP3'COIJPEN6ATIONCO N'FL/�,/Wp51{ E ENENGYP/C �—y 8lBIECT AN EMPLOYEH 70 CRIM WFL PEWLLTIES MA CMt FINES UP TO�lE HUNDREO 7HOUS D ENERGY PERMIT A(i� � /_� '��[1�1 OOU.1�N9(f700.0�0).M 11DDff10N TO hiE CAST OF fAMPENSATION,DAMACES AS PROVIDED FDA IN ���5...�v ¢ SECTION 37D!OF TME LABOR COUE,MTEREST,ANO�TfOFiNEVS FEES. RETENTION FEE: d CANSTRUCTION LENDINGAGENCY pRE-ALTFEE CITY OF DYr*.is��J:'vD Fil�'-�� � INEREBYNFFIPoAUNUERPENPLTYOFPEPJURYTHATTHEREISACONSTRUGTIONLENDINGAGENCV BUII..DI\TG�:r?�;�i:Fv�y'T Z FOfiTHE PEFFORMANCE OFTHE WORK fOR WHICHTMiS DERMIT IS ISSLIED�SEC.3oB7,CIV.C.�. W � LEfJ�EH'S NAA� C LEN�E1f5A0DRE53 � I CEHTIFYTrUT�FiME REM TMIS MPLICATION AND 8TATE 7HAT THE ABOVE INFORMAiION IS CORRER. TOTAL FEES ` W IA6iiEETOCOMPLYN/1THALLCIIYIWDCOUNlYOROINANCESANDSTATEIAWSREUTINOTOBUKDING � WNSTRUCTION.AN�HEPEBYAUiF10flREREPRESENT^TIVESOFTHISCOUNTVTOENfERUPONiHE ' Z -MEMIONEO PHOPE FOR INSPECTqN PURipSES. COMMENTS \� 0 � m � NM1E( � �� -� .�,d�, � � � . N S16 �i i ERM E DAT ---G�`��� � RECPT.N0. 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