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CITY QF DIAMOND BAR ,`_ ,•.• .. `' �� A,
--��--- DEPARTMENfi pF COMMUNITY&DEVELOPMENT SBRVICES
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� 2165D E.Captey Drive Stute 190 >
(9�9)SbQ-3195 Fat(909)861-311'7 PRESS
����°'� BUILDIIVG PERMIT APPLICATION FIRMLY
p� JpBSITE APPLICATION�_'l_`�j PERMIT P!C Ct1
AQDRE5S ��7 f� �i4 t? 1 pATE � � NUMSEFi "��� #_�,�=�,1��
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c't�.Z� DATE CONST. GROUP
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DE5IGNER NO.DWEL. NO. ^ NO.
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� CITY�/f"/�• 'ff .ZIP EL. -
rn DESCRIPTION SQ.FL CTO PSF ADJ.AREANALUATION
� OWNER•BUILpER DECLARATIQN SFRIADDIREM . �?�
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Q I HEp&BV AFFIRM UNDER PENALTV OF PERJURY TMAT I MI E%EMPT FROM THE CONTRACTORS LI- G81'H48(CBtpOti � � {" � �
� CENSEUWFORT1iEFOi.LOWlNGREASON(SEG.703tbBU5INES5AN6FROFESS�7S{X70E:ANYClTYOfl {j)
COUN7YNMiCFi FlEWIRES A iERMITTO CONS7HUCT,ALiER,IMPROVE,�EMOLISH,OR NEPAIR ANY S7RUC- �
NRE.PRqP TO I75 ISSUANGE,AL50 REQUIRES THE APPUCANT FUF Sl1CN PERMIT TO FILE A 51GNED W Pa4io BCk ' / I„ .(„ � ���
� SFATEMENT 7HlQ ME OR SHE IS UCENSEO FURSU+INT TO 7NE PROVI3IONS oF ThE CONTPACTORS 4i�
CEN8E UW�CHM7ER 6(COMMENCINO WITH SECTION 7b00)OF DIVI$ION 3 4F THE BUSINE55 AND Pflp� u" POOVSpB
FESSIONS�DE)QRTHATHEORSHEISEXEMPTTHEREFROMAMDTHE9AStSFORTHEAl4EGE0EXEMP• (�
� TKJN.ANYViOLATKM70FSECTIQPt7A31.58YANYAPPIiCANTFORAPERMiTSUBJECTSTHEAPfi,IGAMfO Z Re-Roof
� ACIVtI PENALTY 4F NOT MOqE THAN FNE NUNDRED DOUARS(i5oo),); ��
� OI.ASOWNEROFTHEPR9PFflTY.ORL4YEMPtOYEESWITNWACiE5ASTNElRSD�ECAMPENSAT6�M. {,`pmttiHtCiel
WILL,p0 7HE M/Ot4K,;Wp THE STAUCTUAE�5 NOT IN7ENDEo 4lfi oFFEREO WR SALE ISEC.7041,BUSI� �
� NESS AND PROFE9SKKJ9 CODE:THE CANTPACTORS LICENSE LAW�OES NOT APPLV TO AN OWNER OF �
PflOPFATY Vh16 BUItAS CNi M/Pi�YES THERER't,AND VM060E5 SUCN WORK HtMSEIFOR HEf3SElF 4R
(� 7HROUGH HIS OR HEN dM/N EMPLOYEES,PROVIDED THA7 SUCH IMPRqVEMENTS AFE NOT INiENOED Op m
� OFFEREDFORSALEIF,NOWEVER711EBUILDINGOR�MPROVEMENTISSCKOWITHINONEYFAROFCf�MPt,6•
� FqN,TNE UVtMER$UIlAER WKL Ht�YE THE BUFi[FEN OF PROVING THAT HE OR SHE DID NOT 6UkD OR
IMVR4VE FOF iH8 PURPOSE OF SALE).
� ❑I,ASCIWNEAOFTHEP£1b7ERTY,AM6SC�U5IYELYCANTMC.T!NGWiTNLICEN5E0CqNifiqGTOftS
(L T6 CANSTRUCT TNE flR(7.IECT(SEC.7oN,9USiNESS AND PROFE5310N5 COGE:THE GONTRAC70A5 I.I- V2IUAtiOlt � ADJ.AREA
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� WHUCAMRACTSFONSUCHPROJECTSW17NAa."Ot�tTRRCTOR�$jlICEN3EDPUflSUAPlTT6THECONTfiAC� Q(JAIdT3TY 6ESCRIPTION FE�
TORS LICENSE UW.}. �` ,�.
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� GL i#1fRf8Y AfKWAS UNDER PEttAi.TY 6F AEfUURX THAT i t«�A UCENSED tNUER AROViSiONS Q�GHAPFEft � �
� V(CQMMENCING WITH SECTIpN�oop)OF�iVISiON 30F TNE BUSINE53 AND PRCIFESSIONS COOE,AND � i ��
�� MY LICENSE IS IN NLL FORCE AN�EFFECT iD �
� LICENSE CUl S ' � LIG.NO. �
on'rE___i1�����1��� con�Tflncror� G_ _— a � r
� ���" WORKEitS'COMPENSATK�N DECLARATION f f�J f
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� itiEREBY 'FIAMtiNDERFEttALTY�PERJCtRYONGOFTNEFOL�6W101C+0Et:lA41ATiOb75: Z �' p,
C� �43,��j��YEANOWIiLMAWTA1ttACERTIF{�ATEOfCONSLkTTOS'cif-IMSUREFORWGAKEHS' � ' y•
q �'t CAMPENSAiION,AS PFiOviDEp OV SECTION 37oopF iHE LAF3pN COD�,FON THE PERFURMANCE U� � �4
OF TNE WORK F6R WHICH THIS f'EHMI715 ISSUEb. W
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(y� I HAVEAND WILLMAINTAIN WURKEqS'CAMPENSATION INSUAANCE,AS RECUIHED 6YSECTION , -
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Q97000F TNE LA60R CORE,FGR SNF.�EAFORMANGE Of TFtE WORK WR WnsGht FNIS FEHMIT IS ' � t '} �
...,�_.! iSSUEO.MY WO,pHK[RS'COMPENSATION INSUpqAN�C_E CAPRIEH AND POLiCY�urneEiAcnae: CONSTRUCTION r„^� . ' I J-� � �
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,'Z I CEf7TiFY THAT iN THE PERFORMANCE OF THE YIORK FQfl WHICH 1 HIS PERMIT I51S5UEQ,l MECHANICAL _ `l�f=l.�.�) „ __^� �J y
f,� SHALL NOT EMPIOY ANY PERSON IN ANY MANNF.fl Sti AS TO BECOME SUBJECT TCl THE �'�)
�,J} W4RKER3'GOMPEnSA'AJN ihWS a�C%IFRRNlA,Af�AGREE THAT IF I SHOUt6 BEC6M£ iNSPEGTIL)N FEE i _,,. �,/
SUBJEGT 1'O THE WORKEHS'COMPENS4TIqN PRQVISIONS OF SECTIpN 3700 OF THF LA54R y
� GOpE,l HALL FOHI'HWffH COMP�Y WiTNTHOSE PROVIfiI�Ne. �SSUANGE _, , „____.,,,,,,_ � ry,J-.y�°�-�— ,j�
PAT6: I� /�G m�-5 �� ��', \
� APPUCAN7: _.�,(���T_� � SMIP _i f� -+��}-' .. ._....-�?�-�i--i-..s.�t- �
J WARNING FAILUP,E TO SECURE riORKERS'CDMPENSFTKIN COVERAGE IS UNLAWFUL.AN6 SHALL.BE EM1iERGY P�C ._ I�,j'� .'l_'��,
LL SUBJ@CTAN EMP.OVER TO CRIMINAL PENPLTIES ANO CNIL FINES UP TO ONE NUNpRED THOUSANO ENER�Y PEAM17 ��
LYSLL/�RS{itU0,000j,IN AnCNT10N TO iNE t;OST OF C'�MFENSATpN,DAMAGES AS pR�VlDEO FOft IN --��--�
� SECTIDN3)p80F7HELAHORCC/DE,INTEREST.ANbATTORNFV'SFEES. RETENTIONFEE: �^
� CONSTRUCTION LENp�NG AGENCY PpE-ALT FEE: _.__ �,,, _
CL !HEAEBYAFFIRM VN4ER PEHRtTY OF PEH,IURY T AT THERE I.S A CONSTRUCTION LENO�}�AGENCY '� 1 ,
d FOR THE PEFlFORMANGE OFTNE WOHK FOR W H THIS PERMIT IS ISSUED�SEC 309�.CIV C.�. -}-}- """—""'—"'—
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W I AGREE TO COMPLY WIiH ALL CITY ANO COUNTV ORD'NANCES AND STA'fE UWS RELATING 70 BUILOING a
� CONSTRUCTiON,AND MEFEf1Y AUTHOHIZE REPFESENTATIVES OF THIS COVNTY TO ENTERUPONTHE
� RBOV£-MEN7iopE0 P�PE4TY F4iilNSPECT'k�N PURPOSES. COMMENTS
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VIAM OXD ILL 1
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21660 E.Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
)37/0 C'
I
ESS o
ADDR
.4 D il/6777
APN LOT TRACT w�
OWNERLTf- 14d-- '1
ADDRESS a ITitl cT
CITY di r1MAl. 8142 ZIP/7 TEL. 909 yi/
APPLICANT TEL.
CONTRACTOR Pu c.r-
ADDRESS
CITY ZIP--TEL.I
Y
ARCH/ENG/T7 L�
DESIGNER
ADDRESS o
CITY .ZIP V,2C2620TEL.fV&j
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 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 EXEMPTTHEREFROM 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-
TION,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
^ I.AS OWNER OF THE PROPERTY,AM EXCLUSIVELY CONTRACTlNG WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC. 7044. BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI-
CENSE LAW DOES NOT APPLY TO AN OWNER OF A PROPERTY 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
0 (COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND
MY LICENSE IS IN FULL FORCE AND EFFECT
LICENSE CLA S LIC. N0.
DATE
CONTRACTOR L-
p
irX/-
WORKERS
COMPENSATION DECLARATION
I HEREBY),FFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'
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 UMBER ARE:
CJ e,
E
r9c i
CARRIER/
mffi
s
L
ce,
rY
POLICY NUMB
F00 r
D
S
P
�
iS
ECTlON NEED NOT BE 0
AWLEf ED OFfFE
ERMIT IS FOR ONE HUNDRED DOLLARS (8/00)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
CODE,I MALL FORT'HWI TH COMPLY WITH THOSE PROVISIONS.
DATE:APPLICANT.
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(8100,000),IN ADDITION TO 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 PENALTY OF PERJURY T AT THERE IS A CONSTRUCTION LENDING AGENCY
OF
TH
FOR THE PERFORMANCE
EW
OR
K FOR W H THIS PERMIT IS ISSUED ISEC. 3007,CIV.C.).
AAA rA
W
RK
LENDER'S NAME J �-_((,11LtL./ryJIW-6
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 INSPECTION PURPOSES.
41,/A/6S
PERMITTEE NAME(P9 T)4 �
SIG RE OF PERM ITTE DATE
r
DATE APPLICATION NPERMIT 0
UMBER C 01-06
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
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