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__,,�.�,\ CITY OF DIAMOND BAR
� DEPAR'i'MENT OF COMMLTNITY&DEVELOPMENT SERVICES
a 21664 E.{:opTey Drive Suite 144
(904)660-3195 Fax(409)861-3117 PRESS
'4*"� BUILDING PERMTi'APPLICATION � $ ; FIRMLY
� JOBStTE ` _, � APPLICA710N 1^�q { 1 PERMIT ff P!C
o ADDRESS �y<~ �`�c.i fi:�N 1.1 S-T"� DATE d- i -� i NUMBER_�G I�} i #
� ISSUE Typ� ��
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p OWNER j(�'� ������.,,, ���
p ADDRESS �,,�i-i,�� i,r)ff�����yfty►k� ZONING SETBACKS
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� DESIGNER!'�� Cr�u iS �}' ' i 1 t. NO.DWEL. NO. �yp.
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'� pESCR�PTION SQ.Ft PACTOR PSF ADJ.AREANALUATI4N
p� OWNER-BUILDER DECLARATION SFRtAAOtREM
Q i MEREBY AF61RM UNDER PENAI,.7Y OF PERI4.IRY THAT I AM E%EMPT FROM THE CONTRACTOqSII- �afdge/GBfpOf!
1,11 CEN5EUWFOqTHEFq,LOWINORFMSON{SEC.7tl'lt.s9USMESSANDFROfES5pN5t:�06:ANYGTfOR {f)
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STATEMEN7 THAi HE Of?SFtE IS LlCENSEP PUFiSUAMT TU Li1E PHOVISIONS OF TFiE CdNTRACTOFiS U.
T �NSE UW jCHApTER i�COMMENCING WI7N SECi10N 7D00)OF DIVISION 3 fJF THE BI151NES5 AND PRb� u' POOVSP&
g FESSIONSCODE�ORTHATMEORSXEISEXEMPTTHEREFROMMlOTHEBASISFORTHEALLEGEOEXEMP- �
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� AaVIL PENAL7Y 4F NOT MORE TNAN FNE HUNDRED DOLLARS(t5oo).�;
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WN1.DO TFIE WORK,JrhlD TFiE STRUCTUf�iS NpT IMENDED OR 4FF£RED FOR SALE(SEC.�M4,BUSI- � ....
� NESS AND PROFESSION3 CODE�THE('-0NTRACTOflS LICENSE LAW DQES NOT APp�V TO AN OWNER OF �
PROPEqTY YVF10 9UILDS OR IMPR04£S THEFlEON,M1D Wf�lO00ES SVCHN4ftK kEMSEIF OR HEHSEIF OR
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� OFFERmFORSN.EIF,FNaiHEVERTMEBU1lDINGORIMPFOVEMENTI550lDWITHINONEVEAROF(:OMPLE-
Z TION,7HE QWNEN$lN[AER WILL HAVE THE @tiRbEN OF PRQVING M�IT ME QR SHE Qi6 t�T BUtiD pp
� IMPq4VE WR 7HE PURPQSE OF SAIEy.
L7 4 AS OWNEROF THE PfltlPERTY,AM EXCLUSIVELY COMMCTWG WRH LICENSED CDNTflACTOR9
('�� TO CQNSTAUGT THE FqPi�CT(SEC.tpH,BUSlME55 ANQ PApFESSN�75 W6E:THE CONiMCTORS li- V2llle[IO11 ADJ.AREA
� CENSEUWDOESNO7MPLYT4MIOWNEROF�PROPERTVWNOBUIIASORIMPRqVESTMERffqN,Aryp --
WlIOCONTRACTSFORSUi:HPRQ.IECTSWITHACbNTRRCTOR(S)LICEN6EDPURSUANTIOTNECtktTPAC- QUANTITY DESCRIPTION
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� �IAM EXEMPT UNbER SEO. 8.d P.0 FbFi Tt{t5 REASQN Q
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� OATE � OWNEfi ~
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(� i{COAVAEHCMp}y�THgECTqN7oa0)pFD1ViSiON30FTNEeU51NESSANOPPOFESSiIXJSCODE,ANO z
��L MY LICENSE IS IN FULL FOFCEAND EFFECi m
� LICENSE CL,ASS.,__� LIC.NO. S� .J_ �
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� W{)RKERS'CflMPEN6ATI4N DECLARATI6F! Q —�-
� 1 HEREBY AFPoRM UN�ER PE:NAITY OF PERIURY OME CF T7i'e FdItOWIt�Ki DECLARAi IRNS: v
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L' .�INAVEANCIWILLMAINTAINACEFiTIFICATEOFCqNSENTTOSELF-INSUREFOpWORKEftS' _
;� CIJMPENSATWN,AS PAbylpED BY SECTtON 3�0o OF 7iiE tABpR CODE.PoR THE PERGDHMRNCE U
� OF THE W4RK FOR 1NHICH THIS PEPMIT IS ISSUED. �
� _iHAVEANDWiLLMAtMAMWOflKER5'COMPENSATIONINSURANCE,qSREOl11RED0V5ECTION ���
� 37oq l7F THE U1BOH COOE,FOfl THE P�RFORMPNCE QF THE WpRK Fbp WHICH THIS PGRMIT IS
4S$t,iED.MYw,.,/epx EI{$' PENSAT(�O^N;iNS(7flANCECARPoEAANdPOIiCYNUMBEftARE: CONSTRUCTION
} CARRIEK_!�_�C.�/' L`�_,p_�,�_���__ pLqNREViEW � ~
� POLICv NUMBER_�� u�i ELECTRIC _,,, ��
� (naswEcrior�HEa>rroraEo�nw��[7�nE�aMITSFaaoNE1-Ax�nF'iEooal.aas�Siro�op�Ess} PLUMBING _�.. � � . � .i
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� �CERT7FY MA&�tTH£PERFORMANCE 6FTNE WCNtK FOR WHICN iHiS PEAMiT IS iSSUEO,� MECHANICAL
SHAI.L NDT EMPLOV ANV PERSOhI IN ANV AIANNEp SO AS TO BECOME 9UBJEC7 TO TME
{/a WbiUCEHS'COMPEN:iATIDNUWSOFCAL7F4qN1A,AMQAGREETHAT�fiShqULOBEGOME IN$PEGTIONFEE
� St1B.7ECTTOTHEWC67iCER5'C�?MPEN5ATIONPRPVISpN50F5EGTION3�00pF7MEU180R '� � ��i�
CADE,I SHALL FOR7IIWITH COMPLV WITH TNOSE PqOV1510NS. ISSUANCE
� thz_-_�,r� - _
`p DATE: J�Di�-^C I�' _ qpPLiGANT: _�4_�'��� PY)(� SMIP
� WAflNNiG:FA%,ttRE TOSECUIiE WOflKERS'CQGiPENSATION CAVERAGE IS UNLAWFVL,AND SHIILL ENERGY PJC _�,�_. �
�'y SUB.IECT AN EMPLOYER i0 C:RIMINAL p6NALTIES AND CNIL FlNE5 UP TO ONE h1UNOREU TH4USAN� ENEftGY PERMIT `
� CKILURS{;t W,�Oo),IN Mp1710N TO TNE COST#COMPENSATION,DAMAGE5 AS PR4V76ED F�t IN
SECTION3�UeOFTHEUBORWDE,INTEFEST,ANDATTORNEY'SFEES. RETENTICJNFEE:
QCONSTRUCTIQN l.ENDWG AGENCY ppE-ALT FEE: ��
� IMEAEBYAFFIftMUNDERPEM.ALTYOFpEfUUR`�THATTHEREISACONSTRVGTIqNlEN01NGA�ENCY
FOR iHE PERFpRAiANCE OF:'HE WORN FOR WH�CH THIS PERMIT IS i55UE0(SEC.3097,CIV,CJ. —
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� ICERTIFYTHATIHAVEREADI'WSAPPf.1GA71aNAkDSTATETHAtTMEA84VEUifORMATKKI�SCOflftECT. � `�` \
� i AGREE TD t;qMVIY WITH Alt Ct7Y AND CDUNTY ORDINANCES AND S7ATE UWS flELA71NG TO BUIL�ING L t ��
� I:ONSTRUCTIbN.AND HEREB\'AUTHORIZE REi'qESENTATIVES OF TMIS GYJVNTV 70 ENTER Uf"ON TNE
Z A80VE�MEMIONED PROPE0.7Y FOR INSPEGTION?UfiRO5E5.
� COMMENTS
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� RECPT.NO._ PAIO BY '' .J- _
WHITE-Department Coqy,YEi.l.OW--Fi�arwe VALIDATION
Copy,PINK-Assessot C�py,GOI.DENROQ-Fiie Capy,GREEN-RpplicarN's Copy
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CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21660 E.Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117
BUILDING PERMTT APPLICATION
T
�.a..A�S�c.
PRESS
FIRMLY
JOBSITE
ADDRESS_-Jr.,3 E' �j �^ ��-�U u t:� N'l.�t S�T�S
APN LOT�)•' �'t)TRACT S2Z It7?
OWNER� �
ADDRESS�,f�L�UI (ir)i'1 �If(-lr:�(1
CITY�Y y�jl�-ZIP 1 n ZTEL.9��[,- )���'�'ll'/I1
APPLICANT�7AMYLEATEL. �iG17�(7
CONTRACTOR_y L���I'
ADDRESS J
CITY J [�t�1{�_ZIP_L�TEL I t{ �/�/�i')-� �(
ARCH/ENG/A/� 1L�
DESIGNER 1"��fh ��:rS rt}'�t:7( .
ADDRESS i�S'-i •�'�'�n
CITY-��i�ZIP y�7o,�TEL.°'��j--S�S7�"T?
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 REWIRESAPERMR TO CONSTRUCT,ALTER. IMPROVE,DEMDLISH,OR REPAIRANVSTRUC-
TURE. PRIOR TO ITS ISSUANCE,ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS UCENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI-
CENSE LAW(CHAPTER Y(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSgNSCODE)ORTHAI" HE ORSHE ISEXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TIDN.ANY VKKATgN OF SECTION 7031.5 BV ANV APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT 70
A CIVIL PENALTY OF NOT MORE THAN FNE HUNDRED DOLLARS(5500).):
^ 1.AS OWNER OF THE PROPERTY,OR MV EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION.
WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC. 704/, BUSI-
NESS AND PFK)FESSKNIS 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
7HROOOH HIS OR HER OWN EMPLOYEES,PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE IF. HOWEVER THE BUILDING OR IMPROVEMENT IS SOLD W ITHIN ONE YEAR OF COMPLE-
TKX�1,THE OWNER$UILDER WILL HAVE THE BURDEN OF PROVING THAT ME OR SME DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
^ I,AS OWNER OF THE PROPERTY,AM EXCLUSIVELY CONTRACTlNG Wmi LICENSED CONTRACTORS
TO CONSTRUCT THE PRO.IECT(SEC. 70N. BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI-
CENSE L.I1W DOES NOT APPLY 70 AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND
WMOCONTRACTS FOR SU('.H PROJECTS WITH A CONTRACTOR(S) LICENSED PURSUANT TO THE CONTRAG
TORS UCENSE LAW).
^ I AM EXEMPT UNDER SEC. B.t P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
9(COMMENCWG WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND
MY LICENSE IS IN FULL FORCE
AND EFFECT.
A
S
LICENSE CLASS�J.� LIC. N0.
DATE/-CJ LI-�d I CONTRACTOR IN t/7�,�It•'LC CO rp
WORKERS'COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'
COMPENSATKOJ,AS PROVIDED BY SECTION 3700 OF THE LABOR CODE,FOq THE PERFORMANCE
OF THE WORK FOR 1NHICH THIS PERMIT IS ISSUED.
_I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BV SECTION
3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY
KE
RS'CO PENSATK7N INSURANCE CARRIER AND POLICY NUMBER
ARE:
W
/
t
/
CARRIER! L�,1 ��� �rpQ���E'� �n�, L(,7,
POLICY NUMBER_�T�,W C1 1 fC'I
(f}ELSSECTION NEED NOT BE OOMR.EIFD OF THE PERMff S FOR ONE HUFDRED DOIlAfiS(S70D)(IR LESS}
I CERTIFY THAT IN TFIE 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'COMPENSATKOJ LAWS OF CALIFORNIA,AND AGREE THAT IF i SHOULD BECOME
SUBJECT TO THE WORKERS'COMPENSATION PROVISKNS OF SECTlON 3700 OF THE LABOR
CODE,I SHALL FORTHWITH COMPLY WITH��TIHIOSE PROVISKKJS.
DATE: � 'D t"JC�_APPLICANT: �L"�� 1 I tl" ��,��
WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL BE
SUEUECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS(5100,000),IN ADDITION 70 THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3708 OF THE LABOR CODE,INTEREST AND ATTORNEY'S FEES.
CONSTRUCTlON LENDING AGENCY
I HEREBY AFFIRM UNDER PEkALN OF PERJURY THAT THERE IS A CONSTRUCTION LENDWG AGENCY
FOR THE PERFORM
ANC
E OF'� HE WORK FOR WHICH THIS PERMIT IS ISSUED(SE
. 3097,CI V.C.).
C
/
��
LENDER'S NAME iV L rU�_f IQy� �'�' �; MP. C�+'I�Q�
LENDER'S ADDRESS
I CERTIFY THAT I HAVE READ PHIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
I AGREE TO COMPLY WITH ALL CITI'AND COUNTY ORDINANCES AND STATE UWS RELATING TO BUILDING
CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OFTHIS COUNTY 70 ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR INSPECTK)N PURPOSES.
PERMITTEE NAME(PRINT)
SIGNATURE OF PERMITTEE DATE
WHITE-Department Copy,YELLOW-finance Copy,PINK-Assessor Copy,GOLDENROD--File Copy,GREEN-Applicant's Copy
A--41 9