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-- v�� CITY OF DIAMOND BAR �;%J
DEPARTMENT OF COMMUNITY&DEVELOP�IENAT SBRVICES � G,,;
� 2166()E.Coploy Drive Suite 14(1 �,��;�� � �,� �(� ESiS
(9d9)8bt7-3195 Fa�{404}861-311? � (�
�'�^'� BUII.DING PERMTT APPLICATION � �1\ FIRM�Y
� AD R�ESS ���/�. C, �Gt�G�� 1`�ISr� ����G� DATEICATION _._ �� � NU BER {'�3 I� #��(...,j ���'�t,..
� ISSUE �{ TYPE OCC
APN LOT TRAC7��2����__. DATE ,,�I- � 1 CONST. GROUP
p OWNER tJ �
p A44RESS���,. ' '� . .} ZOMNG SETBACKS
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CdNTRACTOR�� �,�. ��4E �
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Q CITY _ ZIP TEL. PROPOSED USE
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ARCWENGi
DESIGNER .�� .���� NO.DWEL. NC7. NO.
� � UNITS_ STOR1fS BEDROOMS
ADpRESS �,,�f,�
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tn „c,f_ .���y �,�� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION
p� f"��"��� OWNER-BUILDEFt 4ECUIRATIC}N SFR/ADDtAEM ��7 3 F
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t HEREBY A4FlFW UNDER PENAt.TY�PE(WRY THAT t AM EXEMPT FHQM THE CONTRAGTORS U- l.
� CEN$EUWFOHTHEFOILOWMGREASON(SEC.�031.5BUSINESSANDPROFESSION5COPE:ANVCITYUR � GaragefGarpott � �
COUNTVriMIpiRE1]UIHESAPERMITTOCONSTRUCT,u7ER,IMPROVE,DEMOLISH.ORREPAIRANYSTRUC- W P24i0/DBCk
TURE.PRIOR T6 RS i55UANCE,AlSO FiEWliREs THE APPIiCANT F4R S47CH PfRMiT Tp filE A SIGNED �
STATEMENT TMAT HE OR SHE IS IIC�NSED PURSUANT TO THE PROVISION5 OF TNE CONTRAGTORS ll�
� GENSE UW{CHAPTER P{COMMENCINO WI7N SEGTIDN TlqO)OF DIYISION 3 4f 7H6 BUSMESSAND PRO• LL' PoaUSpa
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� A GYiI P@I,LL7Y QF N67 MORE THAN FIVE HUNDRED 00l.URS{i5oo}.J:
� p�A50NMEROF7HEPRQPERTV,ORMVEMPLOVEESWiTHWAGESA57HEiR50LEGOMPENSA7K7N, C} COfTIfilBtCial _`
vALL C70 iHE WOIiK,ANU 7HE S7RUCTURF IS NOT MTENDED OR OFFERED FOR 5ALE(SEG�On�,BUSI- J
� NE53 NiD VflCCtF[SSKNiS CODE TFtE CXiNTRACTORS LICENSE UlW 60ES NOT APPI.Y IO AN OWNEft OF �
PFqpEHTY YJFIO BUILDS OR IMPROV6S THEPEON,AND WI�10 DOFS SUCH WORK HIMSELF OR HERSELF OR
� TNqOt1WiHI50RNEROWNEMPIAVEES,RROVIpEDTHATSUCNIMPR4VEMFNTSAqENOTINTENDEDOR m
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Z TION,THE OWNER�BUIIDER WILL H�VE THE BUflpEN OF PROVING THAT H�pR SNE Olp NOT BUILD OP
.� MEPRUVEFORTMEPURfb5Eqf5ALE)_
�,y,� ❑LASOWNEROfTNEPRpPER7V,AMEXGLUSiVELYCONTMCTiNGWiTHtiCc'NSEDCONTRACTORS
� TO f'xINSTqUCT 7HE PpQ1ECT(SEC,TON.9USINESS AND PPqFE5510N5 Cq�E:THE CONTqAGTORS LI- V81Ufl�i0t1 �� ADJ.AREA
� CEN$E IAW OOES tl�T APPLY TQ AN(}WNER OF APAOPERTY WMl BUll.DS OR IMPHOYES T41ER£Ok.AND �'�"'--
WFqCONTRACT5FOP5UCHPFOJECTSWITHACONTMCTOR(5)LiCENSE�PURSUANTTOTHECONTRAC pUANTITY DESCHIPTION fE�
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0 ❑I AM E%EMP7 UMOER BEC._„�, ....8.8 P,C.FOp THIS REASpN Q _
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� DATE OKTJER
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� LICENSEU GONTRAGTORS DECLARATION �
�C 1 NEflEBV AFFIHM UNDER PENQTY pF PERIIJRV THAT IAM LICENSED UNDER PROVISIONS OF GHpPTEN Z f'� },�
� ➢{GOMMENCINQ WITH SECTKiN'!oW)OF pIVlSbN 3 oF THE BUSMESS AND pROFES510N5 COpE,AND YJ +M1
X MY liCEt1SE IS M FUtI FQRCE AND FECT. m N .
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� WORKERS'COMPENSATION pECIAFATION � �,. ,� L�^�
� I HERE9Y AFFIRM UNDER VENALTY OF PER,IURV ONE O�'THE FOLLOWING QECLAqATIONS; z "�+ l `���
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� ' 1 MAVE AND WI�C MA�NTAIN A CERTYFICATE OF GQNSE�R TO SELFINSURE F6R WORKERS' _ �
' CpMPENSATION,AS PpONOED BY SF.CTION 3�W OFTHE UBqR CODE,FpR THE PERFpqMANCE � ` � . �'�`
� �$'i}iE MIAAK F4R XMICH TNiS GEf#M�T�S ISSUFD.
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QW �l i NAYEANO M9LlMA�NTNN WORKEflS'GOMPENSATION INSURANCE.AS REQUIRED 0Y SECTION ///���y� (�yyp��, /�,/`
3]00 Of THE LABOFi CODE.FOR THE PEfl WHMANCE OFTHE WOflK tOR WH1CH TN�S PERAHTiS ��' Z� ��lf*` y�
� Iu3UfD,MY W�p/g�t RS'COMP�flSA"fIQN INSURANCE CAR HAND POLIGY NUMBER9�. CONSTfaUCTiON � �� �
jcnpNER._L,_ � 'G � �L •_±',L_.�._.—.f�_..�_ PLANREVIEW 1
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z 1 CERTIFY hIAT W THE PERFORMANCE Of THE WORK FOR WHICH T'HIS P�RMIT I$ISSUED,I MECHANICAL _____ 1.�_ ,,..__,���,�„_��_,_
�r} SNALL NpT EMPtOY ANY P£R56N IN,tM'MN%dER SQ AS TO flEC.(?ME SU&IEGT i0 THE �
� W17RKER5'COMPENSATIONI.AWSpFCA1.IFORNIA,ANDAGiiEFTHA71fI5HOULpBECQME �NSPECTIONFEE ,_._
= SU&lEG7T0 TNE WOFKEftS'COMPENSnTION PROVISIONS OF S[CTION 370o OF 7HE L4BOR �i i f'1 �\�"� �
C06F,I SHAtL FONTNWiTH C�MP�Y WiTH TH6 E PROVi5iON5. (SSUANGE J J
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� DATE:e�=�.f A�flt.lGANT: _'�-l�-t�L-1_---" SMIP ����..�7� l.� (�.
J WARNINQ:F/ULURE TO SEC4flE WOAKERS'COMpENSATION CAVERAGE IS UNLAWFUL,AND SHALL BE ENERGY P/C ^. �r
� SUBJECT Ni EMPCOYEKt TO CPoMINAL P£MAtFiES AND CSYiI FlNES UP T6 t?P1E H17F&7fiED THOUSpNO �
�- pN ENERC�Y PERMtT ��r ( ��
OOI,AAFiS(T1oo,[qo),IMADDI710NTOTHEC05T4FCOMFENSATION,OAb1AGESASPROVi�EDFORIN ��� -- - �
SSECT#DN 3T�8 OF 7HEl.ABOft L'ODE,INT{REST,Ak0 ATTORNEV'S FEES. RETENTION FEE: __,,,_,,,,, l t}
OCONSTRUCTION LENDING AGENCY PRE-ALT FEE: ,,,,,_,,,,,, }) .����J f�
� I HEREBY AFFIRM UNCIER VENALTY OF PEPJURY THAT TNERE IS A CONSTRUCTION LENpING AGENCY /�/�-�-•;^-��-�--y/-y,'�--��-�--
� FqFiTME PERWRMANCE OFTHE WORN FOR ICN TNIS PERA.l�1T/IS�'IS ED(SEC.3097,CIV.C�). �� 1 � 1 f. I , y\1l..' �^
_____i�`- ���"'�d�-""� '4l 7 �—,.� �_
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� LENDEFYS NAME �
F_- LENDER'SADDHESS.,,�__�,
� ICEHTIFYTHAT'IHAVEREADTHISAPPLICATIONANOSTATETMATTHEABOVEMFORMA710NISCORRECT. TO�A�F[�EJ ,� �i�' C^, �
W I At3ftEE 70 GOMVIY WITH Ai.l CITY AND CAUNTY ORDINANC6S ANO STAT�UWS REUTING Tp BUILpING � �
�' CC7NSTAUCTION,ANOttEREBYAUTtiORiZEREPRESENTATNES�FTNISCIXJNTY70ENTERUWNTHE
Z A�fJVE�MENTK3NED PROPERTV FOP INSpECTIQN URPOSES.
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
C_Lfs3I CS
OI
ADDRESS
APN LOT TRACT'77
OWNER v S
ADDRESS IjEVIV 11 157WC
CITY/ZIP f_'TELC��
APPLICANT TEL.
CONTRACTOR C'/f'n r
ADDRESS
CITY ZIP-TEL.
ARCH/ENG/
r r+
DESIGNER [/
ADDRESS
CITY ZI TE
I-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 REOUIRESA 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 Y(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 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
9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND
MY LICENSE IS IN FULL FORCE AND FECT.
LICENSE CLASS .. LIC. N0. .-z7
SS/���10-101 CONTRACTOR-z2
DATE 2��J
'1
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'
COMPENSATION,AS PROVIDED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE
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 TH E WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WO RS'COMPBNSA71gN INSURANCE CAR RAND POLICY NUMBER I E'.
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CARRIER
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DOLL
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y(fFAS BECKON NEJ NOT B OF THE PERMIT IS FOR ONE HUNDRE
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 THO E 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(5100,000),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 ICH THIS PERMIT IS IS ED(SEC. 3087,CIV.C.).
LENDER'S NAME�'vr
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 URPOSES.
D PERMITTE NAME(PRINT)
r
SIG RE OF PERMI DATE
APPLICATION PERMIT P/C�
DATE NUMBER 1 I J # �J
ISSUE 1 i TYPE OCC
DATE I � + 1 CONST
GROUP
ZONING SETBACKS
FRONT RW^
REAR^
SIDE/SIDE STREET RW^
SIDE^
PROPOSED USE
N0. DWEL N0. N0,
UNITS STORIES BEDROOMS
DESCRIPTION SQ. FT. FACTOR PSF ADJ.AREANALUATION
SFR/ADD/REM _E7 Jr
Garage/Carport 1.
w Patio/Deck
LL Pool/Spa
Z Re-Root
0 Commercial
Valuation ADJ.AREA
QUANTITY DESCRIPTION FEE
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RETENTION FEE:
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PRE-ALT FEE:
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TOTAL FEES tl L°.'j
COMMENTS
RECPT. N0. PAID BY VALIDATION
WHITE-Department Copy,YELLOW-Finance Copy, PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy