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` �� CITY OF DIAMOND BAR \_l,/
DBPARTMENT OF COMMUNITY 8c DEVELOPMENT SERVICES
21660 E.Copley Drive Suite 190
(909)860-3195 Fa�c(909)861-3117 PRESS
"�^�'�W BUII,DING PERMIT APPLICATION �� FIRMLY
o DDRESS ����55 �RN�D� Y I�JTA C� APPLICATION �..�,� j NUMB R � � �`/C ��"��L
DATE
� ISSUE TYPE OCC
APN LOT TRACT DATE CONST. GROUP
p OWNER L
LL ADDR S ZONING SETBACKS
� CITY ZIP TEL. ' REART RW ❑
APPLICANT TEL. SIDE/SIDE STREET RW ❑
� CONTRACTO L SIDE ❑
q� ADDRES PROPOSED USE _
� CITY ZIP TEL.
w ARCHlENG/
� DESIGNER NO.DWEL. NO. NO.
� ADDRES � UNITS STORIES BEDROOMS
� CITY IP TEL.
u�
� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION
Q OWNER-BUILDER DECLARATION SFR/ADD/REM '� . � �(�U
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� 1 HEREBY AFFIRM UNDER PEN�LTY OF PERRIRY THAT I AM EXEMIPT FROM THE CONTRACTORS LI- GOfa JB/C3fpDff � �' � l
W CENSEUWFORTHEFOLLOWINGREASON(SEC.]031.58USMESSANnPROFESSIONSCA�E:ANVCITYDR (� /�
� COUNTYMhi1CHREIXIIHESAPERMITTOCONSTqUCT,ALTER,IMPROVE,�EMOLISH,ORREPAIRANVSTHUC- W pati BCK 1 ' L �� �!) ^
w NRE,PRIOR TO ITS ISSUANCE,AL50 ftEOUIRES THE APPLICANT FOR SUCH PERMIT TO FIIE A SIGNED w �
STATEMENT THAT HE OR SHE 13 UCENSE�PURSUANT TO THE PROVISIONS OF THE COMRACTORS LI- �
� CENSE UW(GiUPTER Y(GOMMENCINO WIT1 SECTION 70D0)OF DIVISION J OF THE BUSINE55 AND Pfl0- � PooV pa
FESSIONSCODE)OflTHATHEORSHEISE%EMPTTHEPEFROMAN�THEBASISFORTHEALLEGEDEXEMP- �
TqN.NlYYKKATqN OF SECTION 7031.5 6YANY MPLICANT FOR A PERMIT SU&lEGTS TME FPPLICANT T0 Z RQ-ROO�
� A CIVIL FENALTY OF NOT MORE THAN FNE HUNORED DOILAfiS(5500).):
� ❑I.ASOWNEROF7HEPROPER7YORMVEMPLOYEESWITHWAGESASTHEIRSOLECAMPENSATION, � COmmercial
MALL DO THE WOi1K,AN�THE STRl1CTURE IS NOi INTENDED OR OFFEFED FOP SAL.E(SEC.)0�6.&151- J
� NESS AND PROFESSIONS ODD@ TME CONTRACTORS LICENSE UW DOES NOT AVPLY TO AN OWNER OF � 1�\ ' J
GROPERTV W/IO BUILDS OR IMPROVES TIEREON,ANO VRiO DOF.S SUCH WORN NIMSELF OR HERSELF OR '�J
WTHROVOM HIS OR HER OWN EMPLDVEES.PflOVIDED THATSUCM IMPROVEMENTS ARE NOT INTEN�ED OR m - ' I ,
Q OFfEREDFORSKE1F,410WEVERTMEBUILDMGORIMPiIOVEMENTI550lDWITHINONEVEAROFCAMPLE- � � ��,
Z TqN,TME OWNER-BUILDEFl WILL HAVE THE BUNDEN OF PflOVING 7HAT HE OR SHE DID NOT BUILD OR
� IMPROVE FOR 7lVE PURPOSE OF SALE).
❑I,AS ONMEF OF TNE PROPEHTY.M1 E%CLUSIVELY CONTRACI'ING WITH UCENSEU CONTHRGTORS
� TO CONSTRUCT THE PRQIECT(SEC.7od1,BUSMESS AND 7ROfE5SIONS CODE:THF CONTRACTORS iJ� ValUalion ��! ADJ.AREA
W CENSE UW DOES NOTAPPLV TO AN OWNER OFA 7ROPERTY WHO BUILDS Ofi IMPROVES THEREON,AND
� W}qCOMRACTSFORSUCHPROJECTSWITH�CONTRACTORIS)LICENSEDGlIRSUANTTOTHECAMRAG QUANTITY DESCRIPTION FEE
TORS UCENSF UW.).
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^ ❑I AM EXEMPT UNOER SEC. B.L P.C.FOR THIS REASON Q � � r
� [[ / J,� 7 �.L' N \.
Z DATE OWNER U ��
�4 LICENSED CONTRACTpRS DEGLARATION W ��� ' � ��`��.
CL I HEREBV AFFlRAI UNDER PENALTY OF PE0.1l1RV THAT I AM LICENSED UN[1ER PROVISInNF OF CHAPTER �.
s Y(COAAMENCIN(iWITHSECTiON10a0)OFpIY1SKKJ30FTHE8VSINESSAN�PROFESS10N5WDE,AN� z
X MV LICENSE IS W fUll PoRGE AND EFFECT. m
� LICENSE CUSS LIC.N0. � /' � f'1 � �
~ �ATE ^�_ CONI'RACTOA __��� d S l
U /1 1�)j
w �..�-
d� � WORKERS'COMFFNSA.TION DECLARATION Q � . ., _�\ L I�
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� I HEREBV AFFIRM UNDER PENALTY OF PERRIRV ONF_OF THE FOLIOWIHG DCCLARATIONS: Z �� ' '
O I MME AND WILL MAINT.41N A CEPTIFICATE OF CANSENTTO SELF-INSURE FOR WOfl%ER5 = �/'v ' I�l.•�
L 9ENSATION,AS DROVIDED BV SECTION 3�00 OF THE LABOR CODE.FOR THE PERFORMANCE U J'J
� OF iHE WORK FOq NMICH THIS PEAMIT IS ISSUED. � � J� ; '
Q 4'
W _I HAVEANU WILLMAINTAIN WORKERS'CAMVENSATION INSURANCE,AS REQUIRED BY SECTION `}
Q 3'700 OF TNE LABOR CODE,FOF THE PERFORMANCE OF THE WORK FOR WHICH THIS PEFlMIT IS y �
ISSUEO.MV KER'COMPENSAiION NS�UR) CARRIERANOP LI('�y,p�U 8 A CONSTRUCTION � lI_I_ . __ __ ���U;� �,J
� CARPIER ��• �� -�+ - � PLAN REVIEW
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Z ICFRTIFYTHATINTHEPEflfORMANCEOFTHEWORKFORWHICHTHISFEFMITI51SSllED.l MECHANIGAL V: _�_�_J 1� _l.J___ �
(J SHALL NOT EMPLOV ANY 7EfiSON IN ANY MANNER Sb AS TO BECOME Sl1BJECT TO THE
y WORKERS'COMPENSAiIONUWSOfCALIFORNIA,ANDAGFEETHATIFISHOULDBECAME INSPECT�ONFEE _
SUBJECT TO THE M/ORNFRS'ibMPENSATION PkUVI510N5 OF SECTION 3)00 UF THE 1.480R � �
� CADE,i SHALL FORTHWITH COMPLV WlTijj[IOS�E�PROVISniONS. ISSUANCE (' ( '
p DATE7 zz��APPLICANT: ���A L I T_ 1 il J�� SMIP �f, �__,7_ ,�, /)
J WARNING:FAIIURE TO SECURE MIORKERS'CAMPENSATION COVERAGE IS UNLAWFUL,PND SHALL BE ENERGY P/C , ��� (
�y SUBJECTANEMPLOVERTOCRIMINAIPENALTIESANDCIVILFMESUPTOONEHUNDR[OTHOl15AND ENERGYPERMIT _ ��
DOLURS(f10D.000),IN ADDI110N TO THE COSTOF COMPENSATKKJ,DAMAGES AS PROVIDED FOR IN ---��--��` �-�-1-----
J SEGTION3/oeOFTHELABORCODE,INTEREST,ANDATTORNEY'SFEES. RETENTIONFEE: �1��\�
Q
a CONSiRUCTIDN LENDING AGENCV PRE-ALT FEE:
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� I HERE9V AFFIRM 11N0ER PENALTV OF PERJVR`/THAT THENE IS ACONSTRUCTION LENDING AGENCY
2 FOR THE PERFOf1MANCE OF THE WOR jF0$W�CH THIS PERMI��SS�(SEc.30B),CIV.C.)._� 1
� '1!/1(�,{^ / uLl�. �' �:�L
LENDER'S NAME V\J�v( l �r
i_ LENDER'SADDRE55
� ICERTIFYTHATIHAVEREADTHISAP�LICATIONAN�STATETHATTHEABOVEINFORMATIONISCORRECT. TOTAL FEES � V�`� /�
� I AGPEE TO COMPLV WITN ALL CI7V AND COUNTY ORDINANCES ANO STATE UWS iiELATING TO BVILDING ��
� CIXJSTRUCTION,AND HEREBY AUTHORI2E REPRESENTA7NES OF TFIIS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED FROPFRTY FOq INSPECTION PURPOSES.
Q �� _ ^ COMMENTS
� �
� I(/l' 7 --
QPERMITTEE AME(PRINT)
cn �-L�c „�'—�--� '�(
N SIGNAT OF PERMITTEE DATE /� �l
= RECPT.NO. - tJ PAID BY VALIDATION
~ WHITE—Department Copy,YELLOW—Finence Copy,PWK—Assessor Copy,GOLDENROD�ile Copy,GREEN—Applicanfs 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 755 Ch[NO n)Vl 5M CT
APN LOT LA 0,11
TRACT
OWNER L
ADDR S
CITY ZIP TEL.qrP
APPLICANT TEL.
CONTRALTO IL Qw_0_n12
ADDRES
CITY ZIP TEL.
ARCH/ENG/
DESIGNER
ADDRES
CITY IP TEL.
OWNER-BUILDER DECLARATION
1 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).):
^ 1,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 NOTAPPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS WITHACONTRACTOR(S)LICENSED PURSUANTTOTHE CONTRAC-
TORS LICENSE LAW.).
^ 1 AM EXEMPT UNDER SEC. B. 5 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 30F THE BUSINESS AND PROFESSIONS CODE,AND
MY LICENSE IS IN FULL FORCE AND EFFECT.
-7 15q
LICENSE CLASS LIC. N0.
DATE-�CONTRACTOR L: -t#w
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'
PENSATION,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
MPENSATION IN SUR CARRIER A P I
ISSUED. MY KER
;CARRIE
R
B10Cf I IXMPLETED OF THE PERMIT D FOR ONE HJ DRED 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
CODE,I SHALL FORTHWITH COMPLY WI OSE PROVISIONS.
L�
DATE: ZZ/APPLICANT: (LT 9 1 �I IM
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 CO W CH THISS IS ISSUED
5 unq((SSEC. 3097,CIV. C.).
LENDER'S NAME Wf U E'I PLIL
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 PPURPO
SES..
Q
PERM
TTEAME(PRINT)
4
SIGNAT OF PERMITTEE DATE
APPLICATION
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PERMIT
0
DATE
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N
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ISSUE TYPE OCC
DATE CONST.GROUP
ZONING SETBACKS
FRONT RW^
REAR^
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PROPOSED USE
N0. DWEL. N0. N0.
UNITS STORIES BEDROOMS
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Valuation ADJ.AREA
QUANTITY DESCRIPTION FEE
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ENERGY PERMIT-�"'1 da0 I
RETENTION FEE:
PRE-ALT FEE:
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TOTAL FEES
COMMENTS
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PAID BY 7
RECPT N0.
VALIDATION
WHITE-Department Copy,YELLOW-Finance Copy, PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy
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