HomeMy WebLinkAbout18810 �_ CITY OF DIAMOND BAR
DEPARTME'�.TT OF COMMUNTIY 8c bEVELOPMENT SERVICES
I ,
, �� 21825 E.Copley Drive
(909)860-3195 Fax(909)861-3117 PRESS
' "%�� BUILDING PERMIT APPLICATION FIRMLY
¢ DDRIESS�� CL-E� lr1\Cs��. C�N�/O APPLICATION � �C`_�� PERMIT IQ�� PJ� ���� `
p DATE NUMBER � �
� ���- ISSUE l.. � TYPE OCC
APN • ?G < TRACT _ �% Z-% DATE, ��� CONST. GROUP
p OWNER '� ' �L --
� ADDRESS O� l��K GIC�(.'L�..'. ZONING SETBACKS
Z CITY ZZIP "'TEL. " %�_ FRONT RW ❑
� APPLICA T _�` TEL.�+-.���'""� REAR ��
z SIDE/SiDE STREET_ RW ❑
a CONTRACTOR � l l. �L SIDE ❑
� ADDRESS _ (s
� CITY ZIP TEL. PROPOSED USE —�+ �-
w ARCH/ENG/ ��/
z DES1GNEfl Y���� � NO.DWEL. NO. NO.
� ADDRESS 'Z�J� 7 � � hial'(� ' p ?
� cirv nb �_ ZIP � . �TFL.�17,_r_____� UNITS STORIES ` BEDROOMS til
�
u� DESCRIPTION SQ.FT. FACTOR PSF ApJ.AREANALUATION
� OWNER-BUILDER DECIARATION SFR/ADDlREM
O
p I HEREBY AFFIR61 UNDEN PENALTY OF PE0.1URY THAT I AM EXEMPT FFOM?HE CONTRACTOqS LI� G8fa9Q/C8f�70R
W CENSEUWFORTHEFOL�OWiNGqFASON(SEC.�o3�.50USMES5AN0yqOfE55�ON5CODE:nN�GITYOR (f�
U COUNTYNh11CHRE0UIRE5APERMI7TOCONSTRUCT,ALTER,IMP9CtVE,DEMOLISH,CRqEPAIRANYSTRUG
WTINiE,PRIOR TO ITS ISSUANCE,A�SO REQUIRES THE APPLIGAM FOR SUCH PERMIT TO FlLE A SIGNEO W P8t10/DBCk
STATEMENT THAT HE OR SN[IS UCENSEO PVRSUANT TO iw.E PROVISIONS OF THE�O�TAACTORS LI�
� CENSE LAW(CHAPTEfl 9(COMMENUNG WITM SEGTION]000)OF OIVISIGN 3(1F THE BUSINESSAND PRO. � PooUSpa
O FESSIONSCODE)ORTHATHEOflSHEISE%EMPTiHGREFROMANDTHEBA5ISPoFTHFALLEGEDEXEMV� (3.
V TION.ANYYIO,k110tiOFSEGilON7�31.56YANYAPP'�ICAN�FORAPERMiTSUBJ�CfSfHfAGP�ICAN7T0 Z Re-Root
� A GIVIL 7ENALTY OF NOT MORI=7HAN FIVE HUNDRED DOLLaRS(f5oo).):
� ❑I,ASOWNEROFTHEPF',OPERTY.ORMVEMV�O�EESWiTHWqGESAJiHEIRSOLECOMPENSATiON, 0 COfTIrt1CfC10I
Z WiLL DO THE WORK,FND TMF STRUCTUqE IS NOT IN'ENDED OH O`FERED FOH SALE�SEG ioea,eu�.i- J
N NE55 AND PROFESSIONS COGE:THE CONTFACTORS LICENSE UW DOES NO�APPiY i0 AN pWNER OF ?
PqOPERTV NM1IO BUfIOS OP IMPROVES THGREON,ANO WHO DOES S��CN WORK HIMSEIF OR NERSELF OR
CL THROUGHHISORHEFONMEAAPLOVEES,PROVIDEDTHAT<UCHIMPHOVEMENT$ARENOTINTENDE�OR m
Q OFFEREDFOqSALE.IF.MOWEVER,TNEBUILDINGORIMVNOVEMENTISSOIDWITHINONEVEAROfCOMVLE-
Z TIpN,THE OWNER�BUILOER WILL HAVE THE BURCEN OF PROVING'HAl HE OFi SHE DID NOT 6UILD OR
� IMPROVEFORTNEPUPPOSEUFS/LE).
w ❑I,ASOWNEROFTHEPfIOPEflTY,AMEXCLIISIVELYC(1NrRACTINGWITHLICENSEOCONTfiACTORS
� 'O CANSTRUGT THE PFO.iECT I�EC.70a1,BUSINE55 AN�PRUFESSIONS rODE:THE CONTqpCTORSII- VdlllBllOf1 ADJ.AREA
W cENSEUWDOESNOTAPPLVI'OANOWNF.ROFAPPO�ERTVWNOd'JII,�SORIMPROVESTHEREON,AN� —
� WHOCONTRACTSFORSUCMPROJECTSWRHACONTqACTOq(SILICEN;CDPURSUANTTOTH[CONTRAC� QUANTITY DESCRIPTION �E
TORS LICENSE LAW).
OL 1 AIA EXEAIPT VN�ER Sf.G_ 8.6 P.C.fORTH15 REASON Q K�F
� U
� �]{' � K
TE�l✓1 OWNE / F" _
I O _— w
F LIGENSED CONTRACT 5 DEC RA ION w
Q
Q I HEFEBV AFFIRM UNDER PENA TV OG PERJURV'HAT I AM LIGEN J DEF PROVi510NJCF CHAPTER �
d 9(COMMENCING WITM SECTIO�I 7000j OF DiVI510N 3 0F THE BU51NE55 qND PP.OFESSiONS CO�E,ANO z
`X MV LICENSE IS IN FULL FOPCE AND EFFECi. m
L�
� LICENSE CLASS LIC.NO. �
� J , i��� .i.�..s
U DA7E_.._ CON7RACTOR__ n.
W
� WORM:ERS'COMPENSATION DECLARATION ¢
� I HEREB�AFFlRM t1NOEA PENAITY OF PEFJURY ONE OF THE FOLLGWING DECLARAT10M15�. Z
Z _I MAVE AND WIIL MAINT/11N A CERTIFlCATE OF CONSEN7 TO SELF-INSURE FOR NqRKL75' ¢
2
� COMPENSATION.AS PROVIDF�BY SECTION 310o OF TNE LABOR CODE,FOR TNE PERFORMANCE C�
Q OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. �
w _IHAVEArvDW'LLMAINTf�INWOflKEFS'COMPENSATIONINSURANCE.ASRFOUIPEOBYSECTION ^
Q 3�0o OF THE LABOR CODE,FOR THE PERFORMANCE OKTH[WORK FOR WHICH THIS PEflMIT IS ��,l�
ISSUE�.MV N'ORNERS'COMPENSATION INSURANCE GARRIER AHD POLICV NUMBER APE: CONSTRUCTION J
J -
j CARRIER PLAN FEVIEW ' � G
Z aa.icv NUMeER__ ELECTqIC _ �
¢ y �
� (iHIS5EGT10NNEmNOTEtEWMP�EfEDOFTHEFERIMISFOFONEHU�DRED00LLA0.S�5too)ORLESS�. PLUMBING __
Z I CEfiTIFV THAT IN iHE PERFORMANCE OF THE Y WHICH TIIIS PEFMIT IS ISSUED.I MEGHANICAL �
C�S SHALLNPiEMP�_OVANVPERSON�NANYM �RSOAS OAECOMESIIBJEGiTOTHE �.y
[n WORKERS'lAMPENSATION UWS Of CA� RNIA, D R REETHAT IF i SMWI�flECOME �NS?ECTION FEE v
j SUBJECiTOT4EWORNI:RS'COMPENS ONP SI OFSECIION3]OOOFTHEUAOR �� �)
GOOE,I HA�L F RTHWIiH GOMPLV W M iH - N5. ISSUANCE L
� ' � �.
p DATE:�r����i_�APPLICANT SMIP _
J WARNING:FAIIIIRE OSECURF\VORKERS' P. TION E JNLAWFUL,AN BE ENERGYPIC /�` J'
� Sl1A.lECTAN EMPLOYERTO CRIN�.INAL PENA IES D CIYIL N 5 UP i00NE MUN�RED THOUSAND ENERGY PERMIT �/
DO�LARS(f t W a00}.IN n�0�T10!.TO THE CO �z COMy E�. A'fON.OAMACES AS PROVIDED FOF IN -
J SECTION 3)aB OF THE�ABOR GCDE,�NTEFEST,AND AT�O NEV'S FEES. RETENTION FEE:
,�
� CGNSTRUCTION L NDING AGENCY PRE-ALT FEE:
O
� I HFFE9V AFLIqAI UNDER PENALIY OF PERJURV TMAT?MERE�5 AGON�ThUGiION LENDING AGENCY _
FOR THE PENF.'JRAIANCE OFTHE WORK FOR WMICN THIS PERMIT IS 155UE�(SEC.309],GIV C.�.
Z
W
� LEN'JF9'S NAME _ — � T�
H lENOE�i'SADDRE55
w� TOTAL FEES '- � �—
I CERTIFY THAT i HAV qEAD TNIS APPLICATIONAND STATETMnT TME ABCYE 1NGOFMA?ION IS WRRECT
� ACREE TO COMGLV TH ALL CI1Y AN�COUNTY ORDINANCESANO S7hTE LAW$FEUTING TO PUILDING
� ONSTRUCTION,A EBV AITHOFiZE FEPRESENTAIIVES OF TIIIS COUNTY TO ENTER UPUN THE
Z VE�MENTICN- ERTY FJA INSPEGTqN VUqPOSE$.
Q . � '� �'� ��� COMMENTS__ _
J
� _ _ —
m PE MI E NAME(P NT (
� C ,
� SIGNAiII OF PERMI DATC
= NECP?.NO. _. PAID BY VALIDATION
~ WHITE—De anmeniCo YELLOW—FinanceC �
p py, opy,PINK—Assessor Copy.GOLDENR00.-Pile Copy,GREEN—ApplicaM's Copy
�� ,.�_�,
� �__ .� �� ,_ _
,
a �� „ � M
� � �,, �, _ ;.�� � � ,� �. ��-�� ' � � �
a� . Fn . .
ift... �... . .. e '�. r - . . . . .
, . , ._._ . ...� l....... .. . .. .... .. . ... ; .... . .. .�. _..
+�
,..: '. . � �[/�} . . -. .. ..... ._. . ... .:
� v� V3 �.!
� � - .
., � �� = � � ` '
� � °�� � _
1a-�°`� � '�
' �..,,.�...�-^,r' t b��°�� �_� _
� � ,�_ _
; 4� _�
, �,.�. � �
_� _ _ _
, s'' � _ _ _
41
.
. .,.�� �
� . ... .. . . . . ...._. . ........ . ... ... .. .. . ,f��..:, � .. .. .. . ...... ... ...
i . , . . . ,. .. . .. . _ .. .
. .. ........ . . . ..._ ..... .. ..._ . . _. .. –. . _ rg-'- V.wtgm�ae .. .'�ygry' c 9� ,f.'ii�� �� .._ ... .._.� _.. .__
.. 4 a tt3 .a �Y.... '
. ... .. .. . . .... . . ....... .. .,. g '.. . ..,.. ..... .__ .. . ;
F, ' £ t
...._ . . ,; ` � . ...,..... . . ... . ._. . ..._ . .. ... ... . . . .. _.,... ...._. ..._.�, , ..�..._._ ..�.. .__... .. ._.._.. . ....._ ...._�_.�,_ . ._.-�4
�
. .. .... .. .... . . ..... ... .. .. .. .. _.._. ._...... , ..._,.._. . ..... .. .... ..... �
� . .. . .. ..... .. . . . ....... .. . .. . .. . .... .... .... . . .... .. ...... ___ . ..__.... .� �..u_. ._" __ .._. _.._.i
� .. .. ........ ..... .......,.. .. ......_ _........_ ...._. ...... ... ...�
. . . .. .. . . .. .... ... . . . .. .. .. . . . . .. .. !
.rth �.. "___. . _ ..""_,� '
k� �....+�1 � �N ����°G �_ . .. ... . ..... .. ... . ... ..... .. ....... __. _ . .— ...... C
:� d F� 4 t � 7''
B �"�.. .}� . t`
'� �
��'J '�+� g !� {y��i �� .._ . ... .... ..... �
�i.-�a.` � � . . . . .. ... . . ... . . .. . . _ .. .. . ._. ... ._ _ .__.. __. .�
�
�..� .... . .._.. .._.. _._. . .._. . __.._. . ..... y
,,.
�;f
� ,
�, , . _
� � � �' ��'M � �� _ _ ,__ ',
�
�;
�
,
�,. ' __ _ _ .
� �
�� �,, �:•
��'� _ _ _ _ _ _ _
x ' ' '
, �r,� CITY t)F DIAMQND BAR ' ,
� ` 1 i , DF;PARTME�'T OF COtvIIviLJNI"fY�k DEVELOPMF,NT SERVICES
�y������� 21 S25 E.Copley IJrive
�+ {�os�Bso-��g�Fa�t�4>e6 i-3l�� PRESS
����� • BUILL?ING PERMIT APPLlCATiQN FIRMLY
o� JOBSI7E J ,�-yy�r � J� APPLICATION �_/��'7 PERMI7 /G"�/,� #�C��v �/J
ADDRESS_./��� ,�Y�C. ����� DATE�,�� f / a'� NUMBER�Q f�f r
� APN LOT TRACT _� �SSUE /D��r� ,{� �N�T OGC
DATE` / T�(� _ GROUP
p dWNER �
LL. - �
o ADpRESS �, ZC7NiNG SETBACKS
QCI7Y _.� ZIP TEL._ FRONT q�r i
o APPLtCANT � TEL REAR ,�
z ��—`� SIDEtSfQE STREET qyy
Q CONTRACTOR_� SIDE _ �—" ��-�
� ADDRESS � -
� C�'n' ZIP_ TEI. � PROPOSED USE �
0
�+-+ ARCHfENGI
z DESIGNER -
� ApDRESS � — -`- NO.DWEL. NO. NO.
� �i�`�' Z!P�____ TFL i UN#7'S ST{?RtES � _BEDROOMS�__
�
`n DESCRIPTt4N SQ.FT FACTOR PSF ADJ.AREANALUA710N
Q OWNER•BUILDER DECLARATION ....
O SFR/AODlREM �
Q I HERE3Y AFFlRM UNDEH PENALiY OF PERJURY'HAT�AM EXEMPT FROM THE CONTRAf:T(u�S�I� (y'g�y 8IC3f(]OIT
W CENSELAWFoqTHEFOILOWIIVGREASON�SEC.To3i.58USME55ANDFqCFE5510NSCO0E:ANVCIrvqa (� Q
ZC�UNTYWtIICHRf�UiRESAPEi�hiTTOGLSNSTRUCF,AtTER,1MUROVE.6EF�tI$M,CflF£PAiRANY>iRUC- �J,J (]ali0/DBCk
W TURE,PR10R TO�T5ISSUANCL,ALSO tiEfKl1PE5 THE APPLICANT GOR SUCH PERMIT Tq FILE A SIGNED w
� STATEMEN7 TNA7 HE OR SME IS LICENSEO PURSUAN7 TO TNE PROVISIONS OF TME CqNTRACTQSS ih -
� CENSE I.AW tGHAPTEfl 9{CpMMENCiNti WITFi S£CTlON iM0)�F 6MSqN 3 OF THE BV5ME55 ANU PRO- u" Pp0USp8
O FESSION$COOEIORTHATHEORSHEISE%EMPTTHFq�fROMANO74�EBA515FORTHEALLEGEDE%EMV� (�
U TqN,ANVVIOLAT'ION4FSECTlDN7031.58V4NYAGF'�fCAN;fORAPEHMITSU31ECi5�t1EAPP(,tGANTTO � Re-RQO(
� AGMtPEMALTY6�N6TMDPETNANFtt+ENU1rDREDDOLIAflS(fSW�)�, - ..
Q ❑I.ASOWNEROF7HEPROPERfYOqMYEMPlOY6F5WiTHWRGESASiHEIp50LECOMPF.NSATiON, (] V��m�(uFa?
Z `MLL�O THE WORK,AMD iHE iTHt1GTUflE 15 NQT IN«END[b GR QfFEft£6 FOH SALE!3EC.1o4t,d�Si- _,j
� NESS ANO PROGESSIQNS CODI::THE CONTRACTURS UCENSE LAW L70E5 NO'AVPiV TO AN 6WNEq OF �
PROPEFNNM09UIl�SORIMf'ROVESiHEHEON,AN�WHppOESSUCNWORKHIMSE�FQRHfftSEIfOR �
CL LHACIUGH N154fl HEfl OWN EMP�OYEES,PflOVtp£D TNAT PUCHlMPpDVF1AENT5 ARE N07 iNTENOED OA W
. 0 OFFEilEDFORSALE.IF,MOWEVEq,7NEBUII.�INGORIMPRqVEMENTiS50�OWITHiNqNEYERROFGOMPLE-
Z TION,THE qWNER-BUII,DER WII1 MAVE TNE BUFQEM OF PRpVING`.NAT HE OR ShiE OID N0-OUIID UR � ,
� �MAN4VEFt}RTtt�PURPOSEOrSdI..Ey. �,
�y,� CI,ASOWNEROFTNEPROPERT'.AMExC4V5NElYCON7qAGTINGWIiHLICENSEbCONTpACTOpS
� TO CANSiRUCT THE➢ROJEC7(SEC,lPN.dU51Nf5S RND PitqfE55tpN�C}6E:THF CONTRACTOq5l6 �'dli13ti01i AQJ.AREA
� CEFtSEUWO6E5NOThPPlVi0AN4WNEROFAPROP�RTYWNOd�IiD50FIMPROVESTHEREON,AND
� WHOCONTRACT5FOR5UCHPFOJEC75WITHAGONTRACTOR(.1110EhS'EDPURSUANTTOTHECONT9AG QUANTITY DESCRIPTION F�E
Y TOR5liCENSELAW)_
� ❑I AM EXEMPT UM1DER SF_i..`._. __ ..._._�.d PC_f4R TMI.S REASCN! Q
� U
LL DA'� _ .— OwNER __ �_..� � �
Z —' -- _.._....._ U . . . . .. .
� LICENSEQ CQNTRAGTORS OECiARAT}ON � ���
Q W
IS I HEFEBV AFFIRM UNDEfl?ENAL�Y dF PERJURY TNAT!pM LICENSEO iIN�EN PROVi510N5 0F CNAPTEA � ��� 2
(L 9 iCpMMENqNG WITH 5�CTlIXd TflCb}OF p4Vi5ION 30F?NE 81JS7NE5$AND AROFESSiONS CODE,AND Z
`X MY UGENSE IS R�FULL FCJFCE AWD EFFECT.
m
� L!CENSc r;�a,sc�____�_ LIC.NO._'"_ __—...__R. _.._ �
WQATE CONTRACTQR_... _ _ 4J.. f ..—
� WOHKF-RS'CQMPENSAFiON UEG�ARATI4N Q
� IHEFEBVAFFIqMUNDEflPENALIYOFPEPAURYUNEOFTNEfGi.IOWtNGCffGIAflATiONS'. U
� Z i
� 1 HAVE 4NU WIL4 MAINiA4V q CER7IFICATE UF CONSENT i0 SEI.F INSURE FpR WdflKFp5' a
� _
,� CAMPEN$ATX�N,AS PRO`11D¢p 0Y 5ECTi6M 3J66nF THE 1A00R C40F.FpR THE pERFOftMANCE U
OF THE WORK FGF WHICN TM$PERMIT IS ISSUED. � �
b
� _ i HAV=AND WIt1 MAINTn�N wORKEftS'COMPENSAi bN MSURANCE.AS HEQUIRED BV SECTION '—"
� �31tk1 OF THE LPH{7P COpE,FOP TIiE PERF(7RMANGE OF 7HE WORK fOR WNICH 7HIS PE9M1'I$
iSSJEt}.MYWORKFfi>GJMP[NSATIqNlN3URANCFGAARIEFRN6POLK:YNUMBfRARE�, CCiNSTRUCTION
J —.,
_,. _..._._.._�___
� cnpaiea _ __. ... PtAN REVtEW
� POIICYNUMBER � ELECTRIC �^� —�.��...^i..
� �� �..._�_. �.—..
'Q -- ._..._ .. ..
� (ii-N5SEC�C7NNEE[}NCT3Ea:MREiEOOF`h[vEW.ariSFfiFONEHlM1RmOq.LAPS�$i0p)ppLESS). PLUMBING
W "
� i CEftTiFY THAF tN THE PEriFOflMRNGE OF 7NE WCSflK F6R WHICti FHlS AEFt/1TlS ISSUEO,i MEC{"IANICAI,.
C.�} SHALL N07 EMPLOYANY VERSON IN ANY MANNEH SOAS TO BECOME SUHJECT fO TV1F � �' --
(,/) WOFlKEHS'COMpENSA710NLAWSOFCALIFQqNIA.ANOaGR�E7HAT:FISHUUlDBECOME (NS�ECTIONFEE
SU81EG7'�O THE WORKEf45'CCNaPENSATi6N FRCIV�S�ON$c��$�CTIpN J�oo OF TryE LABOP —.._v--'� .'—' ....-�—"—'.
� cooE,i sHnu FaR7Hwir��coMa�v wirH rHosE PFovis�oNs. ISSUANCE
� __.'_ ------
DATE�_ APPLICANT SMIP
� ,—....— _ `._._ .__ _ �__�_.___�__�_—'
'J WARN+NG:FAl�UREiOSECUREIWJRKER5COMPENSA7iQNG6VF.RAGEtSUNLAWFUL,AtVpSHAI.�OE ENE,RGYP/C
.� __. .. ..�._..�_.___.—....^__....__..__....._�_.._
� SUBJECT qN EMPLC1VEfl TO CRIMINAL PENAL7IES AND CI41L FINES UP 700NE MUNCIRED iNOUSAN� ENERC�Y PERMIT
�U�I.ARS{f 1QI1."v00),iN ADLIITION IQ THE COST OF f:OM�ENSAT:QN,6AMAGES RS PRpYtUE[)�OH iN -. .._.,. _,,,� ,,,,__ _,� _ __
� SECTIqN 3;680F TNE UB(SR COOE,iNTEFEST,ANp AiTOANE'/'S FEES.
W ._ RE"fENTION FEE: _� � ------,.--„-�--
� CONSTFiUGTiC}N t,ENDIFlG AGENCY pRE-ALT FEE ._,.�______
'_--�--..,_____.._--�---
� IHERk'BYAFFIqMIINDEFPENAL;YOfVEP.JI)RYTHACTHF.REISAGON;iTa�}CI'l�NLENDINtiAU'ENCY
Poq?HE PERFORMANCE CiF THE N+OF.K FCR WHICN TNIS AEARiiT iS iSSVf.D(SEG.Jtl6],GN G_). —"""'--"'—' ---------�--.—___„��_,,,__„v�
W
__��_._ _..�......_.._..�_,�._...._.�.._.__.__
� lEN6ER'S hRME_......__'_ __"__.._.�__..__,_ '"_�
__..___...�__.._—"".—____—___....._ �.__'_._....___.....
�— 6ENOEF'SAO(1aF5S
— —...
_ ...___.._—�m�_____�.___..._�—_"'_—
S T C
� I CEF7IFY TMAT I HAVE HEAD 7H15 APP�4CAT:ONANCI STATE iH4T Tt�EAAOVE;NfpRMAFiON tSCt;F�N`eCT 1 QTA��ECS
� �AGREE(O C4FAPtY WITN ACL CITYRNO COUNIYORp�NANCES AN�STA(E LAWS fiELATING i(]P.UILDING
� GONSTqIIC.fION,ANp HERE9V AUTIbHIZE R6RRESENTnTIVES OF'TN1S COUNTY i0 ENIEq LIPON"ME
Z A80VE-MENI'I�NEO PROPEATY fii4i IH4PECTION PUftPD6E'a.
� COMMENTS�._.----.. _-- ----_,.^�-- ---_
�
� ..— ----'--._--__--..._._-_._,�_,__---
._-`__.___._--.��....._.._.___.—._.._.___.�..'--.__------------`------- �
� PERMI"fTeE tiAMF(PRINTi
"aC __�. .�..__�.__._��..�_�.r— .
'__"_—"'_�_.....�.— _
t!? � �
_._— �
� SIC.NATIflEQI'PEGMITiEG.—_..r—..�_.�__._�—�_ D4TE —._.__'__.._ ._..__W—_�......__. —�._,.�_l.._ �'_
� HEGPT NQ PAID BY VALIDATION - -- �
. .— .�___...._—_...._—._...— ..
__.
WHITE—Department Copy,YE�t.QW—Finance Gupy,plNK—Assessor Capy.G6l.[]ENROD—��le Capv,GREEN—Appiicar�Cs Copy �i
�
1� f .
� P;, +. y,� �� .t� �� �'" �.
. . . ^+'�. �wWk
. pa k�k-'-.:t ' -' �' ) �r y � ..� ,n. ,. , , ,r,M.,r �. ., uz,�;-,,x�r�. .�'..S�e.�...-a
� , ,_ ' ,; y.°rt � $ a�
� ����
�
�,��� ��
r �
�
� _ . :Y k�
� y' t� p
f �"
y � .
�. . � � , .s<..
� - � �- , �« , � .�^.,s„�'er.^., .�. ' .. . . . ... ._. . .. _. _ .. �
� _ - --- _
i �.�.�� . � � . . .. .. . .. . . . . .� �. _ . . . _ ,
: ,� . . . . .._ . . ... . ._. . . .
//-�1�3 ��P; �+�' _
; - � _ _
. �/��3. �-(�, _ _ _
, _
,:.: � � �
;: � : ��:.�-�� �C:, . _
,
� �-,. : _
�%� :
� �
. � , — . --
� ,. < < _
___ _ .
� v x .� , ,�� ���� .
___ _ _
_ , � 3
__
� _ �
, W�.�� _ _
, ,�����.�� > > .. _ _
�
;. .
_ _
;
�� _ _
�;
. ;n � t _
�,, ,
. , A
. � : x' k.` . . . .
v':-2 "a . . . . . ... . .. .._. _.
Y
� . :; _.. ... �
' q
�.:
� � y
{��. rt r
: , x�
�.� �� � �G�" � . . ... .. .. ... ....... ..
�'r � f Y
� N*"'�' . . ._ � . .
� � � . ... .. . . . . ... . . ._ ..... .. . . ... . .. ..... . ..W.. �,�.�-..e, . . .. .. .. �
� !
5 r
; ' a: FI ac � _ _ �
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21825 E.Copley Drive
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
ADDRESS-{{_,/Z C 1-T C�
ADDRESS j (/ 1-uly� 1�
APN 1G (TRACT
OWNER
ADDRESS 0
ZZIP
CITY TEL.
60 .f z
Q
APPLICA T--ii�i"
TEL. $bl.'
CONTRACTOR
ADDRESS
CITY ZIP TEL.
ARCH/ENG/
DESIGNER WAYNE f
ADDRESS Z5-!q III L4 W
CITY ZIP TEL. ]rA
OWNER-BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI
CENSE LAW FOR THE FOLLOWING REASON (EEC. 7031.5 BUSINESS AND PROFESSIONS CODE:ANY CITY OR
COUNTY WHICH REQUIRESA PERMIT TO CONSTRUCT,ALTER,IMPROVE, DEMOLISH,OR REPAIR ANY STRUC-
TORE, 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 THFREFROM 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)):
C 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 CONSTRUCTTHE PROJECT(SEC. 7044. BUSINESS AND PROFESSIONS CODE.THE CONTRACTORS LI-
CENSE LAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO B'JII,DS 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. &P.C. FOR THIS REASON
1
TE
OWNE
LICENSED CONTRACT S DEC RA ION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICEN U DER 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
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
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
ISSUED. MY WORKERS'COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE
CARRIER
POLICY NUMBER
(THIS SECTION NEED NOT BE COMPLETED OF THE PERMIT IS FOR ONE HUNDRED DOLLARS($100)OR LESS).
I CERTIFY THAT IN THE PERFORMANCE OF
THE WHICH THIS PERMIT IS ISSUED.I
M
SHALL NOT EMPLOY ANY PERSON IN ANY R SO AS 0 BECOME SUBJECT TO THE
WORKERS:COMPENSATION LAWS OF CAL RNIA, D A REE THAT IF I SHOULD BECOME
SUBJECT TO THE WORKERS'COMPENS ON P SI OF SECTlON 3700 OF THE LABOR
CO E,I HALL F RTHWITH COMPLY W H TH N5.
DATE:APPLICAN T
WARNING: FAILURE 0 SECURE WORKERS' P TION E UNLAWFUL,AN IiAIL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENA IES D CIVIL N S UP TO ONE HUNDRED THOUSAND
DOLLARS($100,000). IN ADDITION TO THE CO F COM E ATION. DAMAGES AS PROVIDED FOR IN
SECTION 3708 OF THE LABOR CODE,INTEREST,AND A17 NEWS FEES.
CONSTRUCTlON LENDING AGENCY
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS ACONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC. 3097. CIV C.).
LENDER'S NAME
LENDER'S ADDRESS
I CERTIFY THAT I HAV READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT
AGREE TO COMPLY TH ALL CI1 Y AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
ONSTRUCTlON,A EBY ALTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
VE'MENTION ERTY FOR INSPECTION PURPOSES
PE MI E NAME(P NT,(
I
SIGNATU OF PERMI
DATE
c0
w
0
w
z
On
z
0
Z
N
LL
0
d
X
W
0
I
U
w
C/)
c
Z
W
J
Q
Z
Lu
w
Z
U
H=
0
w
J
LU
8-
0
EI
d
W
F--
Er
W
W
CL.
CD
Z
m
C/)
U)
tILtMIOSD BAR i
PRESS
FIRMLY
DATLICATION-(� PERMIT /C
DATE NUMBER 1 t1V 1 #
ISSUE TYPE OCC
DATE CONST. GROUP
ZONING SETBACKS
FRONT RW
REAR
F
F7
1
SIDE/SIDE STREET RW ^
SIDE
PROPOSED USE--�� i nns-
N0. DWEL. N0. NO
UNITS STORIES .
BEDROOMSt3
DESCRIPTION S0. FT. FACTOR PSF ADJ.AREA/VALUATION
SFR/ADD/REM
U) Garage/Carport
W Patio/Deck
LL Pool/Spa
0 Re-Roof
Commercial
Valuation ADJ.AREA
QUANTITY DESCRIPTION FEE
J
tM �
1
V
C.�
m tom.
EL
Q
U
z
0
w
CONSTRUCTION
PLAN REVIEW
ELECTRIC
PLUMBING
MECHANICAL
INSPECTION FEE
ISSUANCE
SMIP II
ENERGY P/C
i.V
ENERGY PERMIT
RETENTION FEE:
PRE-ALT FEE:
TOTAL FEES
COMMENTS
RECPT. N0. PAID BY VALIDATION
I.
WHITE-Department Copy,YELLOW-Finance Copy, PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy
CITY OF DIAMOND BAR
DEPARTME�'T OF COMMUNITY&bEVELOPMENT SERVICES
21825 E.Copley Ilrive
(909)860-3 t 95 Fax(909)86 t-31 I 7
BUILDING PERMIT APPLICATION
PRESS
FIRMLY
APPLICATION�,/��� ��� �IC/SiJ � �
DATE (/p�
NUMBER
ISSUE�(
p��
TYPE OCC
DATE
CONST.GROUP
(f
ZONING SETBACKS
FRONT RW i
REAR rI
SIDE/SIDE STREET RW_
SIDE -�
PROPOSED USE I
N0. DWEL. N0. N0.
UNITS STORIES BEDROOMS ,�_
DESCRIPTION S0. FT. FACTOR PSF ADJ.AREA/VALUATION
SFR/ADD/REM
� Garage/Carport
W Patio/Deck
W
� PooUSpa
Z Re-Roof
� Commercial
J
m
Valuation � ADJ.AREA
QUANTITY DESCRIPTION FEE
J
a
s' 7
H
U
w
J
W
Z
m
J �
a
J
Q
U
Z
Q
2
U
w
CONSTRUCTION �
PLAN REVIEW
ELECTRIC
PLUMBING_
MECHANICAL
INS?ECTlON FEE
ISSUANCE_,. __
SMIP !
ENERGY P/C ._ _-_ � _-_ _�_
ENERGY PERMIT
RETENTION FEE:
PRE-ALT FEE:
TOTAL FEES
COMMENTS --
–�'–– --—
RECPT. Np_pglp gy VALIDATION ----
WHITE-Department Copy. YELLOW-Finance Dopy, PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy
.0