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CITY OF DIAMOND BAR ---�� - � DE3'ARTMENT OF COMIviUNITY&DEVELOPMENT SERVICES 2 L825 E.Coptey Drive .--�° (909)860-3195Fas{909)861-3117 ���,�C.Y^..:p-o-, PRESS '''%v�� BUILDINGI'EIZMITAPPLICATIO�F-9--=----� ---_---- FIRMLY � JOBSITE l,t � APPLICATION ..a PERMIT P/C o ADDRESS�`6–I.C� DATE �� NUMBER�� # o� ISSUE TYPE OCC APN LOT TRACT DATE CONST. GROUP p OWNER o ApDRESS ZONING SE�BACKS oCITY ZIP TEL._ REORT RW o o APPLICANT TEL. — SIDE/SIQE STREE7 RW ❑ z Q CONTRACTOR SIDE ❑ � ADDRESS � CITY ZIP TEL. PROPOSED USE o ARCH/ENG/ W DESIGNER_ NO.DWEL. NO. NO. � ADDRESS UNITS STORIES BEDROOMS � CITY Z6P TEL. ' r� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREA/VALUATION p� OWNER-BUILOER DECLARATION SFR(AD�lREM O I HEREBY AFFIRM UNOER PENALN OF PERJUPY iHAT I AM EXEMPT FROM THE CONTRACTOflS LI- GBfBJB/CflfPOfl W 'CENSELAWFORTHEFOLLOWINGREASIXJ(SEC.7o31.5BUSINESSANDPROFESSIDNSCODE:ANYCITVOR (n V COUNTYWHICHREQUIRESAPEflM1TTOCONSTRUCT,AL7EF,IMPROVE,DEMOLISH,ORREPAIRANYSTRUC- W p3110/DBCK w TUqE,PPIOp TO ITS ISSUANCE.ALSO RE�UIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED W STATEMQJT THAT HE OR SHE IS LICcUSE�PURSl1AN7 TO THE PROVISIONS OF TME CONTRACTORS LI- � .CENSE LAW(CHAPTER 9(COMMENCMG WITH SECTION 7000�OF DIVI510N 3 0F THE BU51NE55 AND FR0- � POOI/�79 �FESSIONS CODE)OR THATHE OR SFIE IS EXEMPT THEREFROM AND THE BASIS FOR iHE ALLEOED EXEMP- d �110N.ANYVIOLATIONOFSECTIDN7o31.56YANYAPPLICANTFOqAPERMITSUBJECTSTNEAPPLICANiTO z Re-Roof A CIVIL PENALTV OF NOT MORE THAN FNE HUNDREO�OLLARS(5500).): 0 ❑�,ASOWNEROFTHEPROPERTY,ORIAVEMPLOVEESWIiH.WAGESASTHEIRSOLECOMPENSATION, � Commercial -- Z .WILL 00 THE WORK,AND iHE SiRUCTURE IS NO7INTENOE�OR OFFERED FOR SHLE(SEC.�O4A,BUSI� NESS AND PROFESSIONS COOE:THE GONTRACTOflS UCENSE LAW DOES NOTAPPLYTO AN OWNER OF � PROPEHTYWHOBUILDSORIMPROVESTHEREON,AN�WHODDESSUCHWORKHIMSELFOPHERSELFOR = � THROUGHHISORHEROWNEMPLOYEES,PROVIOEDTHATSUCIiiMPaOVEMENTSARENOTINTENDEDOR m QOFFERE�FORSALEIF,HOWEVEF,iHEBUILDINGORIMPROVEMENTISSOLOWITHINONEYEAROFCOMPLE- � 'TION,iHE ONMER-BUILDER WILL HAVE iHE 6URDEN OF PROVING THA7 HE OR SHE DI�NOT BUIL�OR � �.IMPROVEFOqTHEPUFPO5EOF5ALE). W ❑I,ASOWNEROFTNEPHOPEHTV,AME%CLUSIYELYCONTFACTMGWITHLICENSmCONiRPCTOFS � '�TO CANSTRUCT THE PROJECT(SEC,7044.BU9INESS AND PROFESSIONS CODE:iHE CON'RACTORS LI� ValU2tion ADJ.AREA W CENSELAWOOESNOTAPPLYTOANOWNEROFAPROPERNWHOBUILDSORIMPFOVESTHEREON,ANO � .�WHOCONTRACiSFORSUCHPROJECTSWITHACONTRACTOR(S)LICENSEDPURSUANTiOTHECONTRAC- (]UANTIIY DESCRIPTION FEE � Y TORS LICENSE LAWJ. � ❑I AM EXEMPT UNDEF SEC. B.S P.C.FOF THIS REASON Q � —— U � � OATE OWNER U � LICENSED CONTRACTORS DECLARATION � ¢ � IHEREBVAFFIPMUN�ERPENALTVOFPEAJURYTHATIAMLICENSEDU4DEflPROVISIONSOFCHAPTER � p„ 9�CAMMENCINGWITHSECTION700o)OFDIVISION30FTHEBUSINESSANOPROF'cS510NSCO�E,AN� z ''�., Xw MY LICENSE IS IN FULL FORCEAN�EFFECT. m � LICENSE CLASS LIC.NO. j V pATE CONTRAC70R d W � WORKERS'COMPENSATlON DECLARATION Q � IHEREeYAFFIRMUN�ERPENFLTYOFPERJURYONEOFTHEFOLLOWMG�ECLARATIONS: Z Q � IHAVEANONALLMAINTAINACERTIFICA7EOFCONSENTTOSELF-INSUREFORWOflKERS' _ �COMPENSATION,ASPROVIDEDBYSECfION3�o00F7HE4A00RCODE.FORTHEPERFORMANCE U ¢ OFTHE WORK FOR WHICHTHIS PERMITIS ISSUED. � � w I HAVE AN�WILL MAINTAIN WORKERS'COMPENSATION INSUR4NCE,AS REQUIRED BY SECTION Q 3'IOOOFTHELABORCODE,FORTHEPERFORMANCEDFTHEWORKFORWHICHTHISPEflMIT15 ISSUECI.MV WOHKFAS'COMPENSATION INSURANCE CARRIER AND POLICY NUMBERAftE: CONSTRUCTION Q > CARwER PLAN REVIEW �� � zz0 POLICY NUMBER. ELECTRIC � Q (IFiISSEC110NNEmNOTBECO�IF'_ETEDOFP-IEPERMITISFORONEHU�REDDJLWiS(SI00)ORLESS} PLUMBING - �- _ -"'�' -�"'✓ Z I CERTIFY TNAT IN THE PEftFOR1AANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I MECHANICAL'�'.'- ' �' SHALLNOTEMPIOYANYPER50NINANYMANNERSOASiOBECOMESUBJECTiOTHE � {�� �, Uj WORKERS'COMPENSATONLAWSOFCALIFORNIA,ANDAGREETHAYIFISHOULDBECOME INSPECTIONFEE N° 6J _ = SUBJECiTOiHEWORKERS'COMPENSATIONPpOVISION5CF5ECTION3�000FTHELABOR — "' - ' � /� !jy CC�E,ISHALLFORTHWITHCOMPIYWITHTHOSEPROVISIONS. ISSUANCE '\ ` F � SMIP p DATE: APPLICAN7: �,��. , W ENERGY P/C � --_ .t _ � WARNINGFAIWRETOSECUREWORKERS'COMPENSATIONCOVEPAGEISUNLAWFUL.AN�SHALLBE .��"� � � �- � �y SIIBJECTANEMPLOYEflTDCFIMINALPENALTiESANDCIVILFINE5l1PTOONEHUNDREDTHOU5RN0 ENEiiGYPERMIT � � � OOLLARS(f100,000�,IN ADDITION TO THE GOST OF GOMPENSATION,DAMAGES AS PROVIDE�FOR IN — � SECTION 37�8 OFTHE LABOfl CODE,INTEflES7 ANDATTORNEI"S FEES. RETENTION FEE: a CONSTRUCTIONLENDINGAGENCY - PRE-ALTFEE: O � IHEflEBVAFFIRMUND'cRPENALNOFPERJURYTHA7iHEflE13ACONSTRUCTIONLEN0INGAOENCY � FOR THE PERFORMANCE OF THE WOW(FOR WHICH iH15 PERMIT IS ISSUEO(SEC.3oa],CIV.C.�, - — � —� Z W � LENOER'S NAME F— LENOER'SADDRE55 � � I CERTIFY iHAT I HAVE READ THIS APPLICATION AN�STATETHATTHEABOVE INFOflMATION IS CORRECT. TOTAL FE ES � IAGREETOCOMPLYWIiHALLCITVAN�COUNTYORD:NANCESANDSTATELAWSFELAiINGTOBUIL�ING � CONSTRUCiIDN,ANOHEREeVAUTHORIZEFEPftESENTATNE50FTHI5G0UNTYTOENTEFUPONTHE ZABOVEMENTIONEDPROPERiYFOflINSPECTIONPl1qPO5E5. COMMENTS 0 J � m PERMITTEENAME(PRINT) ' N . n .y�. _-a � � SIGNAiUREOFPERMITTEE DA7E _ � = RECPT.NO, � '' - PAIDBY'. `� VALIDATIO ~ WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GfiEEN—ApplicanPs Copy ?.� � . � , �' . ` � .t� . m._ ,i a= x � �� ; . ����� `� �� x � � �;� i� �� . ��"�i � -s S' � �. 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