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CITY OF DIAMOND BAR �------�
DEPARTMBNT OF COMMUNITY&DEVELOPMENT SERVICES
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21b60 E.Copley Ckive Suite 296
(909)86U-3195 F�(909}861-3117 PRESS
�'��'�� BUILDING PERMIT APPLICATION ,�j FIRMLY
"�� AUDRIESS �I L fi�.! V I�y T ,G APPLICA710N ."� �'1_��� PERMIT (_���/C �^+� `� ��
� DATE �..� ! NUMBER ti 1
� APN LOT TRACT �-, �SSUE TVPE OCC
��f�— DATE GONST._ GROUP
p OWNER PGt
p ADpRESS � �i'']_,� C�/C►A/ / �/ I.�i�yZ"�__�7" ZONING SETBACKS
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APPISCANT " 7EL._ REAR � -
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� '�'S�� NO.DWEL. NO. NO�
DESIGNER L/�
� ADDRESS ��iS .t/t�L�/J���" C�t!T _�l"�. " UNITS STORtES BEDROQMS
� CITY ,,4/ . [,xs_, ZIP� TEL.
� �ESCRIPTION SQ.FT. F CTOR PSF ADJ.AREANALUATION
p� OWNER-BUILGER DECLARATION SFRIAL}DhIEA+.
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Gj 1 MEflEBY AFFIRM UNDER PFNALIY OF PERIURY THAT I AM EXEMPT FpqM THE CUNTRACTORS ll. � GaragelCarport ���-�-'-. .__...`.._.-. ' �...
{i7 CEhSEUWWRTMEfOILOMfRiGrREAfioN(5Ec.?oai.58USiNESSAi�DPflOFESSiOt7SCODE:ANYCiTYO{i ��
� COUNTYWHICHREWIRESAPEFMRTqCON57RUCT,ALTER,IMPqOVE,bEMOLISH,ORREPAIRANVSTRUC- W Pry�l 6CK '„ 4� �
TUf$.PR16H 70 ITS ISSUANCE,ALSG PEQUIRES THE APPUCNI�FOfl SUCN PERMIT TO Fl�E R 5MaNE0 �
� STATEMENT THAT HE OR SHE 5 LICENSED PURSUANi FO TNE PROV�SIONS OF THE WNTRACTORS U� �
� CENBE LAW(CHAPTEH Y(COMMENCINO W17H SECTpN 7M0)OF OIVISION 3 bF THE OUSINE55 AN�PFO- u' PooUSpa
F£SSKK1S WDE)OR FHAT ME 6R SHE IS E%EMPT TNEAEFpOMqMD TNE BASiS FOp THf Ak..i.EflED EXEMP- (� �
TION.ANVVIULhTKKJOFSECT14N7a3t.SBVANVAPPUCANTFORAPERMITSUBJECTSTHE'APPLICANT70 Z Ra�Roo1
� A pVIL PBJALTY OF NOT MORE THAN FNE NUNDRED Dp.VA5(x5o0).J: �
� OtA50'NNEROFTHEPROPfRTY,OftMYEMFt,OYEESWtTtiWA66SASTNEifl50lEfiAMPENSATidN, �p�rymBICIeI
WILl00 THE WOflK,ANp TME STRUGTURE IS NOT MTEN�ED Ofi OF�EHED FOR SAIE(SEC.�0<4,8U51- _J r j �!
� Y�ROP�WN08UII.DSOR MPRaVEST7IETNEON,MlO'VhiODpESSUCtiWORKHiMSELFOPHE SEIFOR � .JJr LX �^�J � �
� THRCIUGH HIS OR HER OWN EMPLDY�ES,PROVIDED THAT'SUCM IMPquVEMENTS ARE NOT INTENDED dR � �^ � ,
«� #FEREDfQRSAL,EiF.ikiWEVEi17HH8U1LDiMGQRiMPFK7YEMENTiSSOIDWiTHC�IONEYEAROifAMP1.ff- { � n
HCI
Z TIDN,7NE QWNER.Bl1iLpEP WILL HAVE THE BURpEN OF PROVING TNAT HE OR SHE DIO NOT BUItD OP
= IMPqpVEFl7H1HEPURPO5E6FSALE).
�,y� OI.A&�KTtER6FTHEPFIOPERTY,AMEXCLt)StVE�YCDNTRAGflpIGyJi�i1{LiCENSEDC�h'�PACTOftS
[= TO C%INSTRUCT THE PRC7JECT(SEC.7041,BUSINE5S AND VROFESSII?NS C'J�E THE CONTfiACTORS LI� V81U8t1tlf7 �,__,._ ADJ.AREA I
LLJ GEN3E UW OOES t/OiApPLY TOAN OWNER OFAPROP6RTv WNO BUNAS qR IMPROVES TH[flEON.AND —'" ' —
� YrtiDCONTRAC75FONStXX�tPRO,tECT5V11TNACtNVTRACTORi.SjUCENSEDPURSUANT767'NEIXJNTAAG pUANT1TY DESCRtATF4N
Y TORS LICENSE UW.). FEE
Q ❑I AM EXEMPT UNbEfl SEC._„ _ 8.8 P.C.FOR SH'S REASON Q ��� r� ` - +���
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Z OATE QWNER__�. ,r�, U � l .
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� �ICENSEp CONTRACTORS OFCLARATION w � „� - -
� IHEREBYAfFlflMUNDEflFENAtTYpfGERJVRYTHATiAMt3CGN5G�UNO[ftqFOViSIOtJ5OFCHAPTER �
� Y(IX7MMENCINO WITH SECTNNI]oW)OF DIVISION a OF 7HE BU`iiNE3$AND PROFESSIONG CODE,AN� Z
tl) ���£t15E 151N NLL FORGE AND EFFECT. m i.„ ,
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0 �10ENSE CtA55 �lC.NO._,_���J'_� �xt�� __ � ' /
U OATE� ,�._'__ CONTRACTOR Pil[....�.,.,__ �/ /V„/"Y� n � Z'�" �`� .' �-�
� �x� WOCtKERS'COMPENSATIUN DECLARA?'ION ���� Q d- �✓4 A
A�t" ,� r:S� �l. ,
� t HEREBYf AFFIRM UNDEH PENALTV OF PER}URY ONE OF THE FOLLOWING OECtANATh7N5: �
U' /� (` Q 1/` ,$^ t
� �f�j(�tHAVEAN6WitlMAiNTA!NACfATiFtCAiEOFCONSENTT4SElF.IN5UflEFOflVJOflKENS' f' �
� �0'�ClA1pEN5ATION,AS FROVIDEp 9V aECTI?N 91000F TNEUBpR CODE FOR THE PERFOqMANGF C� � � � '�_J
wOFTMEVK?PXl�OftWPiIt:HTHt59EflM17L$ISSVED. � . �....
� � __I NAVEAND W!l.4 MAMTIJN WORKERS':AAiPEN9ATION INSURANCE,AS REQUIREp PV S�CTION , �, � �� /�
�4 3Tti0 0F TNE IABQR CC1pE,FLkft TH$VEFi�'LtRA#ANGE OF THE YPG'ftK FOft NR3tCH TH�S PEYiMIT fS �`"V�( �,t„_{ti� � ��'�yJ�
ISS4IED.MYWQRKER5'COMPENSATiONWSURANCF.CARRiEHANDFtiJCVNUMBF.PSRE� CONSTRUCTION J �"1 � �,j
� CARRIER !"'�+"�'L.!fi 1 C (J � �,�_C.(J Pt.AN FEV#EW
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� In4ssEt N�F�NareEm� DOFniEat:RM1ttl�FoaontEMirApEo[7C%iaas(bim�oa�Ess). PLUM6ING _ _ ._L.,�� ._ ��,_1�r �
W
Z �CEflTIfYTMNT INTHE PERFqRMANCE OF THE WORK FOR WHICH THIS P�pMIT IS ISSUFO,I MECHANICAL a� � �j rV1_
SHALLNO(EMP�,OYANYPERSONU'1ANYMPNNEASOASTOD[COMESUqJEGTTp7HE
(� WfSRKEpS'COMPENSAiIONGW50FG,LLiF6RMA,ANDAGREETHATi�I5NOi1tDBECQME (NSPECTIONFEE �
__.�_ `
� SUBJECT TO THe M/Ofii([RS'COMPENSA(ION PROVISIpNS OF SEGTION J7DOOF THE LA90R — � � �- `
� GOOE.i SNAtt f(IRTHW�7H CQ4APLY W47H THOSyE�PRPVISIUNS. �r ISSUANCE _ J
� Dn7E: I�"'� � �D /"G!4- J SMIP � __._���--�� C..
p APFlL.ICANT: � �/�`7�7J f��."_ { �
J WIIRNING;FAILURE TO SEGUHE WOHKERS'COMPENSA71qN CAVERA{iE IS UNUWFIA,ANO SHALL BE ENERQY P/C _ f• li• , �/
{i SUBJECTMlEMPIQYERT6CRiM4NAl.PENALTIESANDCfYIlfiNESUPTOONEHUNDREDTHOUSAND ENERGYPEFIRAIT �y���"� y �
DOlLARS(5100.600),iN AOD�TItNI TO SHE COST OF CpMPENSAf'ION,DAMAGES AS PqOVipED FpR iN
J SECTbN 37oe OFTNE LABOfi CODE,INTEREST,ANDAT7l7RNEV'S FEES. .\ i-`i�
� FETEN710N FEE: ___ �+� � �
Q CONSTRUCTION�ENDING AGENCY PRE-ALT FEE: ,,, i__ _ _
� �HEREBYAFRRM UNDER PENAL7V OF PERJURY TNATTHEfiE�S A CONSTRUCTION IENOIFtG AGE4CV
FOR THE PERFORMANCE OF THE WORK F�F WMICH TiIS PERMIT 15I55UEp(SEC.3a&],CIV C.�,
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LENDER'S NAME
!'-� LENDER'SAODRESS�.
� ICEPTIFYTMA7IHAVEflEAD1HI5APPLIGATiONANpSTATETHATTHEA00YfiMfORMATK7Nt5C6flFiECT. T�IA�FEES ����� �
W I ARflEE TO CAMpLV WITH ALI.CIiY ANO CQUNTv qRDINANGES AND S7AiE LAWS ftELATING Ta 6UILDING � �
d.
� {:OPiSTRUCTiON,JWG HERESY AUTHOflizE AEPRESENTATiYES qF TNIS GOUNTY TO ENTER VPON THE
Z ABOVE-MENI'IONEp PROPERTV FOfl INSPEC710N PURPpSES. COMMENTS
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� RECPT.NO. 1_.._—..PAID BY _VAUDATION l. t ,
WHITE--Department Copy,YElL4W—Finance Gopy,PWK—Assessa Copy.GOI.pENROD—FiieCopy,GREEN—AppiicanYs 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 PERMIT APPLICATION
PRESS
FIRMLY
JOBSITE
ADDRESS V,(5 T C
APN LOT 647 TRACT
OWNER PLI
ADDRESS P 75'7 73 0 CI/4AJ\/lo,Sf�C7'
CITY bid BA-P_ZIP 1-L 5EL. �id9 ��j kl 'S!
APPLICANT TEL.
CONTRACTOR Pu 1-T£ in"-4f 0 P
ADDRESS//,iii V,/ ledmg .5.
CITY� i 2/„y f ZIP AIC TEL. 9S/g ' 17-
�14QG
ARCFUENG/
DESIGNER/(f7?Y E I)J� IT�
ADDRESS L� u P7 7 CA1 I I'L'
CITY ZIP TEL.
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 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($500).):
^ 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 OFA PROPERTY WHO BUILDS OR IMPROVES THEREON.AND
WHO CONTRACTS FOR SUCH PROJECTS WITH ACONTRACTOR(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
MY LICENSE IS IN FULL FORCE AND EFFECT.
LICENSE CLASS LIC. N0.
DATE CONTRACTOR�(�L7 LI�YI
x•WORKERS'COMPENSATION DECLARATION C
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'
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 WORKERSCOMPENSATION 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 r-M LU
POLICY NUMBER
S
OR LESS
F THE PERMIT IS FOR ONE MOPARED D(X
LA375
$lOD
�
RNE
�
)
)•
RE C
Y DO
(THIS NE ED 1437
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
COD
E.I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS.
I
DATE: . - UDAPPLICANT: AaL-I f ITIJCYO L
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($100,000),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 THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC. 3097. CIV C.).
LENDER'S NAME NDAI.-I'twLTf 1-tom CO
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
FOR INSPECTION PURPOSES.
ABOVE-MENTIONED PROPERTY
/
/ �-4e-/�-ti/L1.5
PERMITTEE NAME(INT)
3 !a 64-,
0 SIGN/F PERMITT DATE
APPLICATION /C 6
L
DATE J .
1 #
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- E ACTOR PSF ADJ.AREANALUATION
SFR/ADD/REM 41AVM 'I t,Q L4_j 1.t4 ILA, 1)�)
Garage/Carport
w Pati eck L
LL PooVSpa
0
Z Re-Root
Commercial
Si_ 2(0 1
M
Valuation ADJ.AREA
QUANTITY DESCRIPTION FEE
J
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lg,- J
U.J - '•�
0
'f- •
LU
Z
Q �
2 no
LU
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CONSTRUCTION i 1.
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1
PLAN REVIEW
ELECTRIC L
PLUMBING I
MECHANICAL
INSPECTION FEE
ISSUANCE
SMIP
7�; . 99J
ENERGY P/C
ENERGY PERMIT
RETENTION FEE:
PRE-ALT FEE:
TOTAL FEES 3,113
COMMENTS
RECPT. N0. PAID BY VALIDATION
WHITE-Department Copy,YELLOW-Finance Copy,PINK-Assessor Copy,GOLDENROD--File Copy,GREEN-Applicant's Copy