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_ _�,�,� CITY OF DIAMOND BA1,2 ��� /
DEPARTMENT OF CpMMUrTITY&DEVELOPMENT SERVICES
21b60 B.Copley Ihive Suite 190
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o� JOBSITE �J�`' � �t, APFIlCATIO � � PERMIT � '�'`�� PIC��,. �
ADDRESS ,d [v`� � t- DATE,_ NUMSER��"�� #
iSSUE TYPE QCC
� aPN��PUL��ES acT�T'Z��,��} _ DATE CONST. �,ROUP _
p OWNER
LL ADDRE55 1804 VON I{1�RM .N S'PF 2a(; ZC/N�NG SETBACKS
� C1TY ��U��I� ZIPQ 1�1 7 TEL Cl d�q_�7 q 7,�t� REART RW ❑
APPLICANT TEL. $14FJSiDE STREET RW ❑
� CONTRACTOR ��,ME 5��� i °
g ADDflESS pRpPOSED USE
CiTY 21P TEL.
� ARCN7EM1iG1 �/�,q p�,� / - -
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ADDRESS � �� n_.�_�r�r�c�+�p����� ��+.�.,..�.� UNITS STORIfS BEDROOMS
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� DESCRIPTION S4.FT. FACTOR PSF ADJ.AREAfVA�UATtON
� QWNER-BUILDER DECIARATION SFRlADDlREM +��/�r , tJ �
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[� kl1EpE8Y AFFI!'�f UNDEA PENALTY OF PERri1RY THAT I AM E%EMPT FROM TIiE CONTRACTORS LI- � Garage/CarpoA �j+ �-• � � �"t.
� CENSELAWfOR'fHEFG4LOWINOREASGN(SEC.703/.SBVSINESSANOPqOFESStONSCOpE:ANYCiTYOfl
GOUNf'IWHIGNREQUIRESAPERMtTTOCONSTRUCT.ALTEii.7MPRQYE,DEMOLISH,ORREPNRANYSTl4UG W patiol0eck .
W TtiqE,PRK�R T4 iT$�uSUAkCE,AtSq REOUIRES THE APPUCANT FOH SUCH PERMIT TO FILE A SIGNE�
.g $TATEMENT THA7 HE OR SHE IS UCEN3ED PURSUANT TO tHE PPOVISIONS qF THE CONTRACTORS L6 .
� CENSE LAW(puP7ER D ICOt�MENCING WITH SECTtoN�006)pF DtV{S�ON 9 OF THE 9USINESS ANp PAo� u' PCiOUSpa
FESSIONS 006E)OR THJR HE OR SHE IS fXEMP7 THEREFRAM AND TNE BA515 FOR THE ALLEGED E%EMP- (�
TfON.ANYV#OLAi�ONOFSEGTtON70Jt.5B'fANYAPRl1CANTFOliAPERMITSUBJECTSTHEAP7LIGPNTTO z Re-Roof
r AClVII PENALTY OF N07 MORE TNAN FIVE HUNDRED DOLLARS(S5oo�.)�
� ❑I,ASOWNEROF7HEPHOPERTV,ONMYEMPLOYEESWiTHWAGESASTNEiASOIECOMPENSATK7N, C�I Commerciai
VAtt,DO TNE WCSpK,AN6 T}iE STRUCTUftE IS NQT INTENDED oR OF�ERE6 f(7R SALE(SEC.7GAd,B1751- J
HESS NiD Pfi�ES51ONS/X�E:TNE CONTRACTORS UCENSE UW OOES NOT APOLY TO AN OWNER OF
� PAOPERTYW{108VKDSORIMPROVESTHEREON,ANDWH9DOESSUCHWORKH�MSELF6AHERSELFOR �
� THROl1GFiH180RHEROWFI6MPLOYEES,FRONOEDTNATSUCHiMPROYEMENTSAflENOT#VTENDEDOR m
L�1 O�EREDFOi9SALE,�F,tiOWEVERT}168UflDW�f}RMIPROVEMENTISSOLDWITHINONEYFAROFCAMPLE- �
� TqN,TH�QWNER�9UIlDER Y!!U.NAYE TME BUHOFN OF CROVING 7HAT HE OR SHE DID NOT BUILD OR
� IMPMIVE fOR THE PUHPOSE OF SN..E;.
(7 i.AS OWNEROf THE PR6PERTY,hM E%CtU51VfI.Y f�77ftACTiNQ WITH tiCENSE{7IX}NTMCTORS
� TO CONSTRUCT TFfE pRWEC7{SEC.?04a.BUSWESS AND PRJFESSIOMS CODE:?HE CQNTMCTORS LI- V311182ipT1 �,..��, �" ADJ.AREA_,�,_
W CENSELAWCIOESNOTAP'PIYTOANOWNEROFAPROPEflTYWHOBUILDSORIMPRGVESTHEREON,ANb — "
� WFIOCONTRAC7SFORSUCHPRQIECT6WITHAGONTFACTOF(S)UCENSEOPURSUANTT0T4+EC9MRAG QUANTITY DESCR{P710N FEE
� 'TOfiSWCENSEI.l.W.�. .
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C]IAM EXEAIPT UNDEH SEC.i_.�_�_._—_�„_B.6 P.C.FOR THiS AEASON Q �
� _'__ CL ��1�/1 "'�C,�j
DATE OWNER_,_..._,—.� W �. l�
� LICENSED CONTRACTOAS DECLARA710N � ' � y �
OG I HEf7EBV AFFIRM UNbER PENQTY OF PERJURY TNPT I AM I�CENSED UNDER pRbViSiON56F CHAPTER �
YfCUMMENpN(iNl�THSEC7#N77oW�,6fD4Vi5iQYSOKTHEBUSINESSANOPROCE45K?NSCADE.ANO a � �.J
X MY UCENSE is IN RRl FOaCE ANo EfFECT � , ` ,.'` ,� : " ..
�7 <�`
� IICENSE CUSS_�__, LIC.NC,�,7_�(},�., � � �� ,}
� DATE_�,yz-A,�_.1.q._—„q�=�,_ CONTRRCT4R �- .7 v~ - -�,.
LL�.0 7 JV \l�,�` �
� WOflKERS'C4MPENSATION DECIARATION � � '�--
� i HEqEBYAFFIFiM UM!7Efl PL"NALTY OF VE0.IURV ONE l7F THE FQLLOWING DECLARATIONS:
� ��/�i ,Q ,. i V�_ �
� !:2.J�f HAVE ANp MAII MAINTM1�N A GERTtFiCATE tS�C6NSENTTQ SEIF-INSURE FOR WOftKEftS' = M. • 1 �
f�r CdA9ENSAtION.AS PRdV@FP BY 9EGTiON.3toa GF THE tAeUR CODF.FGR TNE PERFOpMANCE �J F�~�
� OF THEwOP%�OR WHICH TkNS PEpMIT IS ISSUEO. � ,y� �- ��
Ly I
� 1 HAVEl1ND WILL MAWTAIN WORKERS'COMPENSATIfJN M5l}RiNG'E,AS qEOv!RE06Y SECitON
� � 37C0 Of TFiE I.AE10R CODE,FOR THE 9[RFOflMANf;£OF TNE WOflK Wft WtQGH TNIS PEflM1T iS �i�'--4'�`�
�SSi.iE6.idY WORKERE'COMPENSATIQtd IN5UMNCE CARHIER AN�POLlCY NUM9ERAAE: CONSTRUCT�ON _ „�,,,_,� �
> �„�R�EA_„PgC.IEI!' EMPLf�YEE INS.-__CD Q�.nNaeviEw ___.
zaa.�cvNUMgE�_��nT n�n� � o^�n c,vn____�_g.p_�_ ELECTRIC _,.� ;�. , .���� �- �'- �
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� I CFRTIiY TNAT IN 7NE PERFOflMRNGE Of TNE iH�RK FaR WHICH THIS PERMI7IS ISSUEO,I MECHANICAL �_,,,_,_,�,�`y� __ � + ���V @ [
(;i SHPLI+aPT 6MpL4YANY PERSON IN ANV MANNEP So AS 709ECOME SUBJECT TO THE `1
(fj WORNEqS'COAAPEWSATICNJ LAWS OF CAI.IFQPNIA,AND AGREE THAT IF I SHCIU�D BfCOME INSPECTION FEE ` _ _, _ J
� SU&IECT TO iHe WDRKERS'CQMPENSATION PFOVtSfpHS�SECTI4N aloopf TNE LA90H 1 /
� GOC,Fj i SHAtt FORi4iWiTH npµptY WITH THOSE PROVI5k7NS. �SSUANC� _�__._.`.__i, !�� ! /
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� ENERGYP/C �..���+,._.__ (a�
� WMNING iMLURE70 SECupE WORKERS'C6MFENSRTroN CAY£RAGE 15 UNLAWFUI.,AND SHALL BE - ^�-' 7�.-r
LL St1Ei,�C1ANEMPIOYERTOCRIMlNALPENALTIESPNOCIVIIFWESUpTOOMEMUNDFEDTHOUSAN� ENERCYPERMIT ,.^--_---!-�� f
DOlURS(f10o.000l.IN ADDITION TO THE COSTOF COMPENSA71ON,DAMAQeS pS PR4V�pE0 i'{JR M
� SECTION 3�od oF TNE LABOR CODE,w�ERESt AND AT iORNEYS PEES. RETENTION FEE: . � ` �� '���`� ip
� CONSTRUCT}ONIENDWGAGENCY PRE-ALTFEE: ___ ,,,�, _
� IHEflEBYAFFIflM UNDEF GENALTV OF PEFJURV THAT 1�NEqE IS ACONSTRUCTION LENDWGAGENCY � -
FORTHE PEflFQflMMICE pF TNF WORK F6R WHICH THiS PERMiT 4S iSSVED{SEC.309�,C!V G.}. (` , —{} '�;�
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� IENUER'SNAME_„_._�.u-L„(yyL_��pTIT�TF.f , _`�' '"��
N LEN6ERSApQftESS �'
� 1 GEpTtFY THAT 1 HAVE REpD THIS AFPLICATION AN[7 57NTE THAT THE ABOVE iNFORMATION 45 CORRECT. TQTFIL FGES ,�i *•/�•� ����
� IAGREETOCAMP4YN7THAl.LCiTVPNDCOUtJTYORDINANGESANDSTATEiAWSfiEUTiNG;q$UI�.pING W
� GSNiSTRUCTi4N,AN6 NEREBY AUTHOHIZE REPflESENTATIYES OF THIS CWNTY 70 ENTER L1PpN THE
� ABOV�2AENTIONECI PROPERTY FOR INSPECTION 7URPOSES. COMMENTS
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CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21660 E.Copley Drive Suite 190
y�� < < i-
(909)860-3195 Fax(909)861-3117 E75-1
BUILDING PERMIT APPLICATION
e
JOBSITE
ADDRESS 3
APN LOT 2 TRACT--
OWNER P UL MES
ADDRESS 18 0 4 VON KARMEN STE_200
CITY IRVINE ZIP 94ti1'�TEL.9 49 79 7 4
APPLICANT TEL.
CONTRACTOR SAME
ADDRESS
CITY ZIP TEL.
ARCWENG//
&ft/
$4-
t-C
DESIGNER
t
ADDRESS 155 N.TUSTIN AVE. STE. 64
CITY ZIP TEL SANTA ANA
OWNER-BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE LAW 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 ANY STRUC.
TURE,PRIOR TO ITS ISSSUANCE,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 Y(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSIONS CODE)OR THAT HE OR SHE 15 EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TION.ANY VIOLATION OF SECTION 7031.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS(8500).):
^ I,AS OWNER OF THE PROPERTY,OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC. 7044. 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-
TKON,THE OWNER-BUILDER WIU. 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 CONTRACTlNG WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC. 7041, BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI-
CENSE LAW DOES NOT APPLY TO AN OWNER OF APROPERTY WHO 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&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
Y(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND
MY LICENSE IS IN FULL FORCE AND EFFECT
LICENSE CLASS A LIC. N0. 517593
DATE.L p .__CONTRACTOR
WORKERS'COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'
4
,T'COMPENSATION,AS PROVIDED BY 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 PACTFTC EMPLOYEE INS CO
POLICY NUMBER T.711 T]T it'0 0 1 1 0 7 A JXP
(THIS SECTION NEW)NOT BE CEVP,ETED OF THE PERMIT IS FOR ONE HUNDRED DOLLARS($100)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 SO AS TO BECOME SUBJECT TO THE
WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME
SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR
CODF I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS.
}
PULTE HOMES
-29-0 S
WICANT: -
DATE:
WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS(5100,000),IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3708 OF THE LABOR CODE,INTEREST,AND ATTORNEYS FEES.
CONSTRUCTlON LENDING AGENCY
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THEWORK
FFOR WHICH THIS PERMIT IS ISSUED(SEC. 3097,CIV.C.).
N
Q_�
P11TTF.11
LENDER'S NAME
LENDER'S ADDRESS
1 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 INSPECTION PURPOSES.
PERMITTEE NAME(PRINT)
I
DATE
SIGNATURE OF ITTEE I
APPLICATIO OO PERMIT PIC61r
DATE NUMBER
ISSUE TYPE OCC
DATE CONST. GROUP
ZONING SETBACKS
FRONT RW ^
REAR ^
SIDE/SIDE STREET RW ^
SIDE ^
PROPOSED USE
N0. DWEL. N0. N0.
UNITS STORIES BEDROOMS
DESCRIPTION SQ. FT. FACTOR PSF ADJ.AREA/VALUATION
SFR/ADD/REM (J DL"0
U) Garage/Carport
W Patio/Deck
LL Pool/Spa
0
Re-Roof
Z
Q Commercial
m
Valuation .. t ADJ.AREA
QUANTITY DESCRIPTION FEE
J
2
LU
w I +Q
Z
vj
U r
_ 1�
1
CONSTRUCTION_ _ [y y c, ! ry
PLAN REVIEW
ELECTRIC
PLUMBING
MECHANICAL 'jL_,_
INSPECTION FEE
ISSUANCE
SMIP
ENERGY P/C
ENERGY PERMIT I J i
• I/t'
RETENTION FEE: 1�
]--T5
PRE-ALT FEE:
A-w-A
TOTAL FEES � 'i • �J�)
COMMENTS
y e
RECPT N0. PAID BY VALIDATION
WHITE-Department Copy,YELLOW-Finance Copy,PINK-Assessor Copy,GOLDENROD--File Copy,GREEN-Applicant's Copy