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_e�„�,� CITY C?F DIAMC?NI7 BAR
DEPARTMENT OF COMMiJNITY&DEVELOPMENT SERVICES -�
21660 B.Capiey Drive Suite 190
(���o-3�4s r���os�a��-�i l� PRESS
u'��"�W BUILDING PERMTI'APPLICATIdN �`- FIRMLY
y JOBSITE APP�ICATION �_.��� �1TM PERMlT � P/C �p_("��
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o ADpRE5S I'a l/ �'j"�° ZONING 5ETBACKS
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� ARGHtENG! 717' _
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� S7A7EMENT THAT HE OR SHE IS LICENSEtl PuqSUANT TO THE PFOVISIONS OF 7HE CONTRACTORS Lh � _
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z TK1N,THE OWNER�NLDER WILL NAVE THE BUROEN OF PR(riING 7NAT HE OF SHE Dip NOT BUILD OR . �"�
� IMPROYE FOp TNE PUflPOSE OF SAI.E).
� ❑C ASOYM£R QF TttE PflOPEHTY,AM EXG".USN£tY G1�NTMC"@IG Wf7H liC£MSEO CbN7tiAGTORS __._...
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W CENSEUWOaESNOTMPIVTOANOWNEflOFAPROPERTYWH0l3U1lDSqRlMPROV65THEpEON,ANU -----
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DATE OwNER � F� � � x
� LIGENSEp GDNTRACTlJRS UECI.ARA710N W `y v• , �
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I HEREBYAFFIiiM UNpER PENALTY OF P£RJURY THAT tARi LIGENSED VND[R PPOVi51c�N3 oF CHAPTER �
� 9(CX)MMENCINCi WITH SECTION 7004)OF L7IVISICNJ 30F1'HE BUSMESS PNU PROFE�SK?NS CO�E,ANp Z.
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C,�S SHAL(,NQL ENPL4Y ANY PERSON M1ANY MMlNER 50 R5 TO BEGOME SUBd£CT 70 TNE
� WOflNEHS'Ct?MPENSATiONLAWSOFCALiFOHN1A,AkDAGREETHATiFiSHOu�DBECqME INSPECTIONFEE _ „ ^"'�
____ ' •
r 3U&I�CTTO THE WORKEI?5'COAIVENSA710N PpOViSIONSpF SEL�ION 3700GF 7HE LABOR �� ^
� C06E,ISNALtFORTHWiTHCOA?PLYWI7HTHp5EPROYiSIONS. ISSUANCE _ � `'\,�.. � �
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� WARNING:FAI�URE Tl1 SECURE WORKERS'COMPENSATION G'AVEHAGE 13 UNIAWFVL AN�SHALL BE �NERGY P/C ��,J i\..Y� � �
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� SU&7ECT AN EMP�6YER T4 CRI6it4At PENALTIES ANp CIYiI KINES UP T4 tiNE HUt�RED Tt16USAND �(.}ERGY PEFkMIT
DQILAqS(f1CO3poo).IN AODITKNJ TO TNE COST OF CnMPENSATION,DAMAQES AS PROVIDEU FOR IN
J SECTION3TOBiJFTHEL480RCO0E,INTF'.qEST,ANDATTORNEY'SFEES. —� ' I
�C RETENTION FEE� `7 . . ,��
OGONSTRUCTIpN LENDING AGENCY pRE-ALT FEE: �//yy ._
� I HERE9V AFFIRM UNpER PENAI.TV OF PERJURY THAT7HERE IS A CqNSTRUG710N LENDMG AGENCY ��#���� .—._
� FOF THE PERR]RMANCE OF THE WORK FOR ICH THIS P�RMIT IS ISSUkO(SEI.:.aoN7,GV.G.�. �
� LENDER'S NAME__��.i�_..�J�'u G-�T�L. �"/'Y�` GD�+ � � t i"
F""^ LENOER'SADDRE55
� I CERTIFY THAT 1 HAYE READ THIS APPLICNTIONAND$TATE TNAT TME ABOVE INKORMA7kJN IS CARRECT. TLlTA�F�ES �1 t��l����r}
Q I AGREE TO COMVLY WITH ALL CITY AND COUNTV OftpINANCES AND STATE lAW3 RELATING t0 BU0.DING Y �y
� CONSTRUCTKM',ANO NEAEBY AUTt16RtZE ftEPPESEN7ATIYES 4FTHIS CpUNTYTO ENTEfl VPQN TNE
ABOVE-AIENTIONEO PFOVERTY F6R INSPECTION PUqp65E5. COMMENTS
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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
APPLICATION PERMIT I�� p/C(�
1
1
DATE NUMBER)r
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. ACTOR PSF ADJ.AREANALUATIO
N
SFR/ADD/REM . _ ^^
'OL.I
U) Garage/Carport LID
w Patio/Deck Ld
LL Pool/Spa cl LIC
O ��
Z Re-Roof
Commercial
D Z Z(d�
°° fj�9t 3 I,�
I will Valuation DJ.AREA
QUANTITY DESCRIPTION FEE
Q 7 r.+7V
Ir 7
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ENERGY PERMIT
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RETENTION FEE:
PRE-ALT FEE:
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TOTAL FEES
COMMENTS
RECPT. N0. PAID BY t, 3 VALIDATION
JOBSITE
ADDRESS a-3•'7(cD L//,i-
APN LOT 84 TRACT J I�� 1
OWNER 19iJ L.P.t-#,r7£S
ADDRESS,9 0 fr LT°
CITY Di f/f'>'DALD FftR ZIP TEL
APPLICANT TEL.
CONTRACTOR u LTA
ADDRESS/KA'-
CITY. Ie/,AJt.ZIP 9,1?FEL. 9-46
ARCH/ENG/-]C/'7-._
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DESIGNER 1-715)VA-7- Ilf�-AI
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ADDRESS Z)OIL L.OrArTA2 j)
CITY A Jr Lc4e,02< ivy ZIP TEL
LDER
ECLARATION
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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
ACIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS($500).):
DI.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).
D 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 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.).
D I AM EXEMPT UNDER SEC. B. d 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.
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LICENSE CLASS_! I LIC. N0.I s/,3
DATE q '-•CI CONTRACTOR PL/L7-L_NOM£
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EX. p
WORKERS'COMPENSATION DECLARATION
AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
I
9
1 HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'
COMPENSATION,AS PROVIDED BY SECTION 3100 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
N INSURA
NCE CARRIER AND POLICY NUMBER ARE:
ISSUED. MY
WORKERS'COMPENSATI
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PDREDLEILARS
100
OR LESS
9HISSECTlION
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[.ETED 0
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 WITH THOSE PROVISIONS.
H,90/L-S
DATE: 4:2 APPLICANT. L 4 47-
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
ORR ICH THIS PERMIT IS ISSUED(SEC. 3097,CIV. C.). 1
WOORK F
1
LENDER'S NAME_Wl�, I�u T�t firms GD��°/
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.
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PERMITTEE NAM (PRINT)a�
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2 SI T RE OF PERMITPFE DATE
WHITE-Department Copy,YELLOW-Finance Copy, PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy