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Home My WebLink About17108 `'��.�,�,(� ��P..� c.--Z� G� c�+� �-� , CITY OF DIAMOND BAR � - 1�''`` .� I7EPARTTviENT OF COMML7NTI'Y&DEVELUPMENT SERVICES 21$25 E.Copiey Chive "` PRESS (409)860-3195 Fax(9Q9)861-3117 ��b� BUILDING PERMIT APPLICAT'ION FIRMLY o DDRIESS ��v V It.L OG1�'1...+RP�""� �R�� DATEICATION - � d` �� NUMBER � � � V�#/C OI�i � � � ISSUE TYPE OCC APN LOT TRACT __ DATE � CONST._ GROUP p OWNER _ LL AddRESS ZONIFi� SETBACKS � ClTY ZIP TEL. FRONT RW ❑� �.Qj APPLICANT _ TEL. S DElSIDE STREET RW Ci! z � CONTRACTOR R L� I G. �,,,,,_,^ SIDE �] p CI�TY��V !�! lE,�_ Z�P�Z��—�O� PROPOSED USE �.. w ARCH/ENG/ -p z DESIGNER C?�1x+�1 +'�'Qt�,�i�CSSOG. W N0.DWEL. NQ. NO. � ADDRESS�� Z'—��L�.. � (JNITS STQRIES SEDROOMS � CtTY ZI TEL71�-Z.�� cn dESCRIPTIdN S4.FT. FAGTOR PSF ADJ.AREANALUATIdN � OWNER-BUILOER DECLAWATIpN SFFVADQ(REM O I HERGDY AFFIRM UN�EN PENFLTY OF PEWJRV THAT I AM E%EMPT FROM THE CONTRACTqRS LI� G2f8J8/C.BfppH W CENSELAWFORTHEiOLLOWINGREASON(SEC.7tl31.5@USINESSANDPflOFESSIONSCO(?E:ANYCITYOR (f} K.} GWNTYVMIGHftEQUiftESAPERMiTTOCONSTRUCT.ALTER.IMPROVE,DEM�I.iSH,ORREFA�RANYSTRVG W Pdf10/DBCk W TURE,PRIOR TO ITS ISSUANCE,ALSq REOUIRES TME ApPLICANT FOp SUCH PERMIT TO FILEA 916NED W .� STATEMENS THAT HE OR Sl1E IS LICENSE�PUFlSUANT TO'HE PROVIS�.ONS OF 7ME CONTRACTORS 41� � .� CENSE lAW(CttApTER 9 jiXSMMENGiNG WfTN SECT�6N t0oo}OF OfViSiON 3 QF iHE BUS'NESS FND FRO� POOIISPB FESSIONS CODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND iHE BASIS FOF THE ALLEGED E%EMP• p T14N.ANYVK1lATiONOFSECT{ON70.41.58YANYAPP�ICANTfOftRPEAMlTSV&lECTSTHfiAPPUCRNFTO Z Ae-Roaf ACIVIL GENAI.TV OF NOT MOR[THAN fIVE HUNORED DOLLARS(1500�.�: � Z~ ❑I,ASOWNEIiOFTHFPROPERTY,OFMYEMPLOYEESWITHWAGESASTNEIqSO�ECOMPENSATION, Q Wlll Q6 hCE WOftK,AND THE STRUCfURE�S N47 iNTENQEQ QR 4FFcRE6 Fqft SALE{SEC.�od4,eUSi� J C6RlmetCldi � NESS AND PROFESSIONS COOE:THE CONTRACTORS LICENSE LAW D4ES NOT APPLV To AN aWNER OF � PROPERTY WHO 9UIL�5 dli IMPFOVES THEpEON,AND WH�DO65 SL1C.H WORK HIMSELF OR HERSELF OR C.L THRpUC,tiHiSORHER�WNEMGIOYEES,PRtJY76EbTHA7SUGFiiMPROVEFAENTSARENOTitJTENDEDpR m QOFFEflEDFOR5AI.E.IF,HCIWEVER.THE6UILDINGORINPROVEMENTI55bLDW'�THINONEYEAROFC4MPLE� y� TION,FHE OWNEfl�BUILpER WILL NAVE THE AUPD�N pF PROVING THAT HE Ofl SNE QIO NOL BUILD pR � #dPRC7VE FLiRTHE PIIRPO5E OF SALE). �y,� f11.ASOWNEROFTNEpqppERTY,AMEXCWSNELYCONTPACTMGWITNLICENSEDS:ONTqACTOFS " (r TO CONSTRUCT TF4E ARPlECT(SEC.?Osa,0US?NESS ANfJ PR9�ESSItJNS GOUE:THE fXJNTRACTQftS l;� Vd(U8ti0ti ADJ.AREA ttl CENSEUWDOESNoiqPPLYTOANOWNEROFAPFOPERII'wHo6uIL�SORIMPR4VE5THEREON,AND � NM1IOCAN7PAC7SFOR5UCHPROJECTSwIT4iACON7RACTOR{S}LICENSEDPURSUAN7TOTHECON7RAC- QURNTITY DESGRIPTlQN FEE TOR9llCENSE V,W.)- � � -� 3 l., —,x-- � U�AM E%EAIRT UNDER SEC._..._......_ 8.8 P.C,FOR THIS PEA54M Q � _ U LL � DATE OWNER� . � � � . W �'—� tICEN5ED CON7RAGTOR5 DECIARATI4N W 4 � I HERE9Y AFFIRM UNDER PENPITY Of PERJUHY THAT I AM LICENSED UNDER PAOVISIONS OF CHAPTER � (L e{CONM.1EnCiNG W7TH SEC(KKi laoo)OF D:YiSiON 3 OF TNE BUSINESS AND PROFESSIOnS C�Oe,ANO Z W MV UGENSE IS IN FULL fORCE AND EFFECT [p � �pA '�T • �Tn! S�.- � LICENSE CIJtSS�'� LIC.NO._,_,L[��,_�„!�"" _ j ' Q �� 'Ty� t . � �1 f Kr ' W onrE_4'T—�.�,—G�-- coNTrucTo�f��_ifa&c N �' a (y c_L. � WORKEFiS'CQMPENSATIQN DECLARATI4N ¢ '� � � � IMEREBYAFFIPMUNDERPF:NALTYOFpER�U�tYONF�FTNEFOLL�WINGDECLARATIONS: Z � _I HAVE AND WILL AAAINTAIN A CERTIFICAT[OF CON3ENi TO SELi-INSURE FOR WOHKERS' a � _ tYJMPENSATi�N,A5 Pft4ViDED 8Y SECTION 3I�a UF THE tABDR C�JDE,FQA TNE PERFORMANCF C} � OF TME WQRK FOR WHICH THIS PEFMIT IS ISSUEb, � 0 W �,I HAVE AND Witl MAIMAIN WORKER5 COMPENSAT�ON MSURANCE,A5 REOViRED BV SECTION /�) Q 31o00F THE LABOR CODE,FORTHE PERFpRMANCE OFTHE WORK FOR WHiCH�HIS PERMR IS _�_. � __ ISSUED.MY WflRKERS'COMPENSAT7QM INSURANL"E GAHAIEft AND POIICY NUMBERARE C4NSTRUGTIQN J � CARRIER_� _ PLANREVIEW ._�� aoucvHOMseR_ . �— ELECTRIG _._._. _. � 4 a (iHISSEc7�NwEEnNo7aEaYJit'tErEooF7H"eaEFB.lrziSwnoN=_NuwREooauas;8�oo)oRLEss). PLUMBING _. . _ W i CEt3TiFY TNAT IN THE PERFLtRMANGE OF TNE WQFK FpR WHICH FMIS PEftMii IS ISSUE6,i MEC�..FIANICAL Z � ` ��CTTOTHE CODE,I SH LL FOR7 WITH COMPLV TH 10 R IS N ULO BFCOME �NSPECTION FEE ,--�� _ SHALL NOT EMPLOY ANY PERSON I�ANY MANNE � �_ � pFTHElA60R . .. � � t � y�� ISSUANCE , __ ,J...,l \l�J WOflKERS'GOMPENSA IQN LAW50� SU&lEGT TU THE W{7ftKEft5 CURiPEN ATI O NS F E t 3]ab � SU&1ECTANEMPL4YER10CRIMINALPENALTIESANbqVILFlNESUPTtJONEHUND��,—i OOLLAR�SAOo oIXl T N ADDIT ON TO TNE COST OF COMPENSA ON.DAMA ES AS Pq (� ��x DATE _ APPLIC � SMIP " O — � �.nND sttu�_sE ENERGY PtC �,��.� `) `i r r+t � RE�TH{k1SAND � ��T�� ` � �, OVfDEDFOP,IN ENERGVPERMIT �—�`�,f J SECTK7N37�B�THEtA80RCODE.INTEftEST.ANDATTORNEY'$KEES. RETENTIONFEE: __---�I\�,(A 1 .. � � CQNSTRUCTIQN I.ENDING AGENCY PRE�AIT FEE ,,,_,,,. .__ _ � I HERE6V AFFIRM UNDER PENALTY OF PERJUflV THAT THEPE IS A CONSTRUCTbN�EN�INf,AGENCY FOft FME PERFoftMANCE 4FTNE WbRK F6R WHICH 7Ht5 PERMI'IS ISSUEO iSEG 5a4T,Civ C.). "�—"' � —� --"' � W - � 4ENDEft'S NAME „_ . .,......_. F_ IENDER'SAOORESS____...._.. ' I � I CERTIFY THAT I HAVE REAQ TNIS APP41CAiIQN ANO STA'E 7HAT THE ABOVE IN�ORMATION IS CORRECT. TQTAL i�E�J "�� I 7� � i AGREE TO GQMPtY W7TH ACl CtTY AN6 COGNTY 4RDMANCES AN6 STATE IAWS REtATINC.TO B�It.PIN6 �t� � � GONSTNUCTION,ANOHEREBVAUTHORIZEREPRESEYTATIVESOGTHISCOUNTYTOENTERUPONTHE Z AeovE�MENTICJNE6 PROPERTY FORINSPEC'ION PUNPOSFS. �(}(�l,MENTS � � LlV �/ � _...... -. ... . ...—.. ` m PEFMITTEE N ME fPR � 4 _ � ��_ � $IGNATURE �ATt � = RECPT PKJ. PAIQ BY VAUDATiON ~ WHITE—Department Copy,YELLOW—Finance Copy.PINK—Assessor Copy.GOLDENROD—File Copy,GREEN—Applicanl's opy 8 � � � � s' 9 � '� �� 4 �i��. . �`�� 6� �� . , . - . . . . 9'�^+a�'�:��W'-��., � �i �!-.�.�t.�.si�s$a� ,�. � /-��-r� �.`/� �.G � : , r�_ _ �� ; . �� ,.�, � . n��. �,-a� .� ..� � � . �,_ � !—� i S. ,. ��.� xY� Sr - ,v� , .► i �� - � �� `�$�H .. . ..r . .. a -"" �. � . . .. . . .. + , , , I t/I �� " � 1 V 4�1J��Y.l.'� L.��1�C.i.• S��...,� ��„4 v..._...Y�. . . ... •.` .. . .. . . . . .. . . .... �r ��s�� S �1.�'� C�-,3��-� " � �(� . . � ,�"- �� _ �2-3-�� -�3�� r,s �c�� ,�� '��c�C�� ,c/ �':�3-�� t � � � � : w _ a �� , �� "�� t�� _� � � i� g�h i�e��.0 � _ . -. ... ... .. .. - — .�: ry�'.j ' � �'�;��r��`��e�3��q��j"�` ... ..... . . ... . . .. . _. .. ._. ._ _. . ._. _.. — -�- ... ,�p� a � t�r .�� .. __ . .. . -- . �.:. -° _�. , , ' ,a.'y i � ��; � � - .._... .. ..... .. ... .. .. . ... .. . » 5 �. . .. .. _.. ._ , � . . .. . . . .. _. � n 3 � • � x4 �"c��-�� . -�, a�M �'r��a T� . . . . . ... ... . ... . .. ... . .. .. . ... . _ . . ..-. _ . . . . - , g � .. �. . : :� _ .. . . �. � ' � � w `� _ . _. . .. _.... . . .._ .. _ _.. .. ,. � , , �, j � �'n . . .� ��. ... .. . � .:.i"�' . '°'�" � x'�� . ._. .. . ... . ..... . . ... . . .... .. . ... . _. _. .. ... ..... ... �R� �(� �Z� �Z�� k CITY OF DIAMOND BAR DEPARTMENT OF COMMLJNI'I'Y&DEVELOPMENT SERVICES 21825 E.Copley Drive (909)860-3195 Fax(909)861-3117 BUILDING PERMIT APPLICATION JOBSITE .I,s �^' $ D Q^' T 1 �G� 21 ADDRESS L�G APN LOT TRACT OWNER ADDRESS CITY ZIP TEL. APPLICANT,TEL. CONTRACTOR Q L G ADDR SS CITY 1�1�ZIP TEL. �0' ARCWENG/ / I�I �SSOG• DESIGNER ADDRESS CITY S�q-� ��ZI TEL/-Z. � OWNER-BUILDER DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI- CENSELAW FOR THE FOLLOWING REASON(SEC. 7031.5 BUSINESS AND PROFESSIONS CODE:ANY CITY OR COUNTY WHICH REQUIRES A PERMIT TO CONSTRUCT,ALTER,IMPROVE, DEMOLISH.OR REPAIR ANV STRUC- TURE,PRIOR TO ITS ISSUANCE,ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI- CENSE LAW(CHAPTER 9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO FESSIONS CODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP� TION.ANV VIOLATK)N OF SECTION 7031.5 BV ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS(EE00).)� ^I,AS OWNER OF THE PROPERTY,OR MV EMPLOYEES W ITH WAGES AS THEIR SOLE COMPENSATION, WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC. '1044, BUSI- NESS AND PROFESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF PROPERTY WHO BUILDS OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR OFFERED FOR SALE. IF, HOWEVER,THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF COMPLE- TION,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALE). ^ 1,AS OWNER OF THE PROPERTY AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT(SEC. 7044, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LI- CENSE UW DOES NOT APPLY TO AN OWNER OF A PROPERTY W HO BUILDS OR IMPROVES THEREON,AND WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAC- TORS LICENSE LAW.). ^I AM EXEMPT UNDER SEC. B. 8 P.C. FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER 9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND MV LICENSE IS IN FULL FORCE AND EFFECT. G//X'� ! - LICENSE CLASS�� LIC. N0. � [�U� 10 DATE'e/�I Z'�G�CONTRACTOR��I EGG WORKERS'COMPENSATION DECLARATION I HEREBY AFFIRM UNDER PF:NALN OF PERJURY ONE OF THE FOLLOWING DECLARATIONS: I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TOSELF-INSURE FOR WORKERS' COMPENSATION.AS PROVIDED BV SECTION 3700 OF THE LABOR CODE,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. MY WORKERS'COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE: CARRIER_ POLICY NUMBER_ (THIS SECTION NEED NOT BE OOMPLEfED OF THE PERMIT IS FOR ONE HUNDRED DOLLARS(E100)OR LESS). I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN ANY MANNER 50 AS TO BECOME SUBJECT TO THE WORKERS'COMPENSATION LAWS OF CALIF NIA, EE HA�I SHOULD BECOME SUBJECT TO THE WORKERS'COMPEN ATI�0 ryS F EC� 37000E THE LABOR CODE,I SHALL FORT WITH COMPLY TH 0 R IS N q�� D T A E: APPLIC WARNING FAILURE TO SECURE WORKERS'COM ENSATION COVERAGE IS UNLAWFUL,AND SHALL BE SU&IECT AN EMPLOYER TO CRIM INAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS(E700,000),IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. CONSTRUCTION LENDING AGENCY I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS ACONSTRUCTION(ENDING AGENCY FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC. 3097,CIV C.). LENDER'S NAME LENDER'S ADDRESS, I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ABOVE-MENTIONED PROPERTY FOR INS EGTION PU R P OSE S �� J\ J C 0�7/K.JV PERMITTEE N ME(PR SIGNATURE DATE WHITE-Department Copy,YELLOW-Finance Copy, PIN PRESS FIRMLY �C�t�i-� h. 'i Z�� +�� -. -d -fir��l� I �(�