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_`,� _ CITY OF DIAMOND BAR +
DEPARTMENT OF COMMUNITY&DEVELOPMENT SEItVICES "
21660 E.CopTey Drive Sui te f 90
{9(?9)$b0-3195 Fax{909)$61-3117 PRESS
���^� BUILDING PERMTI'APPLICATIQN FtRMLY
o'� JOBSITE �}"Z"'�'C/1 C/°y-r�llni q���^�.��" APPUCATION �_-l�� ��B R__�� ,-,� �;�#!C f�� �r'1'�
ADDRESS or_,.Z I�3t„} t'ii. ��1 u v 3� DATE � i��I `J
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APN LOT T ACT QATE CdNST. GROUP
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� DESIGNER - Np.pWEt. NO. NQ_
ADDRESS (1N1TS STORlES BEDROQM5
a CITY IP TE
� DESCRIPTIpN SQ.FT. FAC70R PSF AdJ.AREANALUATfO
� OWNER-BUILDER DECLARATION SfRtADDlREM E? ` (
a
1 NEqE6Y AFFIRNI UNpEp PENALTY G1F PERlURY THAT I pM EXEMPT FRI�M THE CONTFACT4R5 L�- � 4 /
W CENSEUWFORTHEFOILOWMGREA50N(SEG.7o3750VSINESSANDP(iOFESSipNSCU6E-ANYCtTYOR GaragelCarport �-
� COUNTYWHICHpEQUiRESAPERihITT{7C6NSTRUCT,AIiER�MPfiOYE,DEMOCiSH,I�RREPAif{ANYSTRUG �{,j patfolpeck �� �..., � � 1 ��
tURE,PRpR TO tTS 13SUANC£,F1S0 HES]UIRES THE APPIlGANT FOR SUCH PERMIT TO FILE A 51GNEp
w STATEMENT MAT NE OR SHE IS LICENSED PURSUANT TO TNE PROV�SIONS OF THL CANTRACTpRS Li. W
� CENSE LAW(CrMPTER 9�COMMENCMp WiTH S6CTqN 7000j OF OMSIUN 3 OF 7HE HUSiNESS AND PRO. �'�' POOVSpd
FE5SIONSW6E]ORTHATHEOflSNEiSEXEM�TTNEqF.FFiDMANOTHE8ASf5FQRTHEALI.�GEDE%EMP� {�
7IDN.ANYVNkATKK1pFSEGTIUN7C31.50YANYAPPUCANTFORAPERMITSU&IECTSINEAPPLICANTTQ � Re-Roof
� ACIY14 VENALTY OF Nt�T MORE 7HAN FIVE HUNDRED�OLIARS iFsoO).):
� OI,ASONMEROFTNePROPERTY,ORMYEMPi.0YEE8Wi7HWAG£SASTNEIRSCSLECOMRENSAT70N, (� CpmmBtCi2i
Wltl DO TNE WOAK,AN6 THE STAUCTURE IS NUT INT£NpEp Oft OfFERED GOR SALE(SEC.7914,9U51- �
� t#55 Mi0 PROfE55lONS CODE:TNE CANTflAC70RS I.IGENSE UW DOES NOT nPP1..V TO AN OWNER OF � '
PPOPEATV NRN)BV ILpS OR IAIPROVES TNEREON,M!D Vh70 C10ES SVCH WORK MMSELF OR HERSELF Ofl
� THROU(iH HI3 pFl HER ONTI EMFLDYEES,PRQVI(SED 7NAT SUCN IMPROYENENTS AflE N4T INT�NDEp OR �
� OFfEREDFORSN.E.fF,HtWJEVER,iME9U1lOHi60RIMPROYEMENTlS50lpW4THWONEYEAfiOFCOMPLE�
� TqN.THE G7WNER-@UR9ER WILL MAVE TNE BUqOF.N pF PROVING THAT HE OH SHE DID NOT BUILp OR
= IMPRpVE FOH TME PUflPOSE OF SALE).
�,y� C]I.ASOWN'cROFTXEPROPERTY,AMEXCIUSiVEtYCAN7MCT1NOWiTNiICEtiSEDCCSiTRACTOfl$
� TO COF15TAt7C7 FNE PftW£CT(SEC.T4ta,�USINESS PND PROF[SSIpNS fADE:THE CONTRAGTORS LI� V21U0110n 1 A�J.AREA
W C6NSELAwDOESNOTAPPIYTOANOVMEROFAPROP[qTVWNo9u1LD50RIMPROVESTHEREON,AND ���
i WFIOCONTMCTSF6HSUpiPR0.1ECS'SW1iNhCONTRACTOR(S7liCEN5E6FURSUANTTOTFtECbflTHAG (�UANT{TY DESCRIPTIUN FEE
� X/RS UCENSE LAW).
Q C 1 AM EXEMPT VNOER SEG__„_�___„_�B,b P,C FOR THIS REASDN U Y • �J �;���
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LL' �u� ..__.� awnEn..� —. � U / L I
�4 UCENSED CONTRACTORS DECIARATiON w �_ � '�
J •ify
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I MEFlEBV AFFIRY UN[?Ep PENAI,TV OF PER.IURY THAT"I AM IiCENSED UNDER PRQ�n5i0YS OF CHAPTER �
q Y(G�lAMENCINGWITHSECTION70W}OF6IVt5iON30FTMEBUStNESSRNOPROFE5St(7NSCOQE,AND Z �
X MY LICENSE 4..`MJ FUI�F17fiCE sWD EfFECT. � � .i��1,+�
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� L�CENSE _�____._„ LIC.NO. � , 3 �
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� � • WORIt�RS'CC7M£'[NS0.TIONDECLARATION • 4 � �.i C � � t;-`�
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y tHERE AfFlRMUNUEFlPENALTYOF7ERJ�RVONEOF'HEFOLLOWINGDEC4ARAnONS�. Z !I� . �1
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� '�HAVEANOW�LI.MI.INIAMACERTiFiCATE�FCCMISENTTOSEiF-MSUREFQRYMURKEftS' _ /1 /� y ����
��� P£NSATiON,AS PROVI6ED BY SEc:TipN 3�6f50K THE I.AeOR[;CDF,FOR THE PERFORMANCE W G'` j
Q _ Qfl FHE WOpK f4q Y[P{�CH TN65 PERMIT IS ISSUED. � D � �.
� I HAVE AND WILI,MAIN7NN WOAKERS'COMP�NS0.TION INSURANC,E,AS q'cQUIFED BY SEGTION � �,
4� 3700 OF TNE LABOR CW£,fOR iH'c PFflRJRM1iANCE Of THE WORK FOfl WM�CH TH15 PERMVT IS ` / �� (� �'�
i5SUE6.A(Y K HS'CC}MPEtwS KiN IN^ AANCE A41ftIER AND POUCY NIAMBER RE GONSTRUCTION �,"J��,'��_ � ,��.�� ✓
�j c�awEN_�., .� PIAN REVIEW �-..—.._
p aJ Y�u 9ER ELECTR�G � + � �J�l\
� �Tn�SFCnwNEHS E�octt+FaEFUNiuFOFlot�Ettir�otbtinr+sRimyoA�Essi PIUMBING �--�j', �r- �._ �]'l� , }.�
w i CER7IFY THhT IN THE PFRFORMANGE OF niE WG�RK fOH WH1CH THl5 PERMIT IS ISSUEO,i MECHANICAL `�(��� � � .�� ,"}� � ��
Z & .,.�..1t.—..���.__. , ..�. y
(� SHAIt NOT E61P14Y ANY FERSON IN ANY MANNFR SO AS TO BECOME Sl19JECT 70 THE
((� WbfiKEiiS'COMPENSATION LAWS OF CALIFURNIP,AND AGREE TNAT�i i SNOIRD BECAME S�SPECTIOIU FEE _,. ---^^^---���^---, �
� SU&IECT TO THE WORNERS'WMPENSA7iON PROVt5K9N$QF SECTtON 370o QF THE LAEpR —� ��
O CqD@,i StihtL F4RTHW�THCfIMPi.y Wl�SE_PROVIy�QNS I`JSUANCE A C�� �-�
p flATE:__.__ APPLICRNT: l���t, ��,� _ 5MIP �a�� ... L � 4'
� WARNINQ:FARUftETOSEf.UREWOflKERS'COMPENSATtONG4VEflAGEtSUNtAWF11t_AND:71iALLBE ENERGYP/C � ,,,� __ ���
� SUBJECT tli EMPLi7Y�R TO CAIMINAt PENALTfES AN�CIVIL FINEB UP TC7 ONE NVNDREn THOUSANO �NERGY PERMIT tT--!C��"% Q_�`
OOLI.ARS Sf��.+�},IN A[7DITION TOTNE COST OF COMPENSATION,DAMAGE5 AS PROVIOEO fqR IN
� SECTIUfi 3�OB OF lliE 1A60f4 CODE,MTEREST.AND AITORNEY'S FEES. � ^� ^��
RETENTION FEE' J eJ. �J`�
� GONSTFii1GTtON�ENQWG AGENCY PRE-ALT FEE: �_ .� .
� I NEREBV AFFIpM UNpEH VFNALTY OF PERJURV TNAT THEPE IS A CONSTRUC"frON LENOMG AGENCY ----�1 j-�{����r--��\��� ..
W FOF THE PEflFOaMFNCE OF TNE W4RK F WHICN THIS PERMiT IS iSSUED iSEG ala9].GV.C.). �� ` �
� LENDEA'S NA6iE_�� _�•�,���1� p . � .
IEN�RSADDNE55
� 1 GER7IFY TNAT I HAVE qF.AD THIS APPLICATION ANO STATE THAT THE A00VE IhFOftAIATpN IS CPRRECT. TOTAt��E�J �(�� � �
� 1 AGFEE TO CAMG{.Y WITVI All 4'IN ANO COl1NTV OflOMANGES AND STRTE LAWS REIATMiG TO BU�DING
� C.ONSTAUCT70N,N3�H£AEBYAll7t10PiZEftEPRE5Et1TAT1YE54FTHlSCOUN7YTOEN7ERUPONTNE
� A$OYEMENT10NE0 PROVERTY F6R INSPECTION pUflPOSES,
Q COMMENTS _ _
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� PEPM�TT/EEJ'(�IAME(PRM!'f}
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CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
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21660 E.Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117
BUILDING PERMTT APPLICATION
PRESS
FIRMLY
ADDRESS O1�/;�(,J I�J
APN LOT TRACT
OWNER L
ADDRESS V
CITY��ZIP TEL.
APPLICANT TEL.
CONTRACT
ADDRESS
CITY ZIP TEL.
ARCH/ENG/
DESIGNER
ADDRESS r
CITY IP TE
OWNER-BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE UW FOR THE FOLLOWING REASON(SECJ037 5 BUSINESSAND PROFESSIONS CODE:ANV CITY OR
OOUffTY WHK71 REOUW ESA PERMIT TO CONSTRUCT,ALTER IMPROVE. DEMOLISH,OR REPAIR ANY STRUG
1VRE, 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 Uw(CHAPTER 9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSgNS COTJE)ORTHAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FORTHE ALLEGED EXEMP-
TK)N.ANY VIOLATION OF SECTION 7031.5 BV ANV APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DWURS(5500).):
^ 1,AS OWNER OFTHE PROPERTY,OR MY EMPLOYEES WITH WAGES AS THEI R SOLE COMPENSATION,
WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC. 7041,BUSI-
NESS AND PROFESSIONS CODE:THE CONTRACTORS LICENSE UW 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, HOW EVER,THE BUILDING OR IMPROVEMENT LS BOLD WITHIN ONE YEAR OF COMPLE-
TION,THE OWNER-BUII9ER WILL HAVE THE BURDEN OF PROVING THAT HE OH SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
^I,AS OWNER OF THE PROPERTY,AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC. 7044, BUSINESS AND PROFESSIONS CODE THE CONTRACTORS LI-
CENSE UW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND
WHO CONTMCTS FOR SUCH PROJECTS WITH A CONTRACTOR(S)LICENSED PURSUANTTO THE CONTMG
TORS ucENSE uw.).
^I AM E%EMPT UNDER SEC. B.6 P.C. FOR TNIS REASON
DATE OWNER-,
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT'I AM LICENSED UNDER PROVISIONS OF CHAPTER
0(COMMENC8K1 WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND
MY LK:ENSE IS IN FULL FORCE AND EFFECT.
LICENSE C_LIC. N0.
CONTRACTOR
DA
(((Csii WORKERS'COMPENSATION DECLARATION
1 HERE AFFIRM UNDER PENALTY OF PERJURY ONE OF'HE FOLLOWING DECORATIONS:
I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'
PENSATK)N,AS PROVIDED eV SECTION 3700 OF THE LABOR CCDF, FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
I HAVE AND WILL MAINTAIN WOR7CERS'COM PENSATK7N INSURANCE,AS REWIRED BY SECTION
3700 OF THE LIBOR CODE,F0.9 THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY KEHS'WMPENS ION IN'RANf.E ARRIER AND POLICY NUMBER RE:
CARRIEN_.
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1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOH WHICH THIS PERMIT IS ISSUED,I
SHALL NOT EMPLOY ANV PERSON IN ANV AIANNF.R SO AS TO BECOME SUBJECT TO THE
WORKERS'COIAPENSATK)N OWS OF CALIFORNIA,AND AGREE THAT IF 1 SHWLD BECOME
SUBJECT TO THE WORKERS'COMPENSATON PROVISIONS OF SECTK)N 3700 OF THE LABOR
CODE,I SHAII FORTHWDH COMPLY WI OSE PROVI S\�/��
T
APPLICANT
�a ��
DA
E: ^
a_�f A./{s-�
i WARNING FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNOWFUL AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLORS(f700,000),IN ADDITION TO THE COST OF COMPENSATK)N,DAMAGES AS PROVIDED FOR IN
I SECTION 3708 OF IRE LABOR CODE,INTEREST AND ATTORNEY'S FEES.
CONSTRUCTION LENDING AGENCY
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
' FOR THE PERFORMANCE OF THE WORK F WHICH THIS PERMIT IS ISS3097,CIV C. ).
�p
LENDER'S NAME
LENDER'S ADDRESS
I 1 CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATKNJ IS CORRECT.
1 AGREE TO COMPLY WITFI ALL CITY ANO COUNTY ORDINANCES AND STATE UWS REUTING TO BUILDING
�CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OFTHIS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR INSPECTK)N PURPOSES.
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7 PERMITTE
111AME(PRINT)
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�SIGN E PERMITTEE DPTE
4
APPLICATION_/�
(PERMIT�)•"1 �
f�P/Cf�I
DATE
NUMBER ELI�I"# ��
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 S0. FT. FACTOR PSF ADJ.AREANALUATIO
SFRIADD/REM
Garage/Carport 3 � �_
LLI Patio/Deck � �/ „ �C
W -
� PooUSpa
Z Re-Roof
� Commercial
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Valuation 1 ADJ.ARFJ1
QUANTITY DESCRIPTION FEE
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ELECTRIC
PLUMBING
MECHANICAL J •�
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INSPECTION FEE
ISSUANCE I ��, �-
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ENERGY P/C�„��
ENERGY PERMIT•
RETENTION FEE: 7��,7�-�
PRE-ALT FEE:
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TOTAL FEES�� ��,
COMMENTS
RECPT. N0. PAID BY VALIDATION �-(-
WHITE--Department Copy,YELLOW-Finance Copy,PINK-Assessor Copy,GOLDENROD--File Copy,GREEN-Applicant's Copy
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