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CITY OF DIAMOND BAR COMMUNITY DEVELOPMENT DEPARTMENT 21660 E.Copley Drive Suitc 190 PR ESS � (909)860�3195 Fax(909)861-3117 �'^�'� BUILDING PERMIT APPLICATION FI R M LY � JOBSfTE '] C� / APPLICATION `./ L� PERMITI Q� I P/C o ADDRESS - ! � / C`P�✓�-�� DATE 9 - �^I ` �� NUMBEF� J • $ ISSUE TYPE OCC APN� T TRA T DATE CONST. GROUP p OWNER G—Z o ADDRESS ✓ �I� ZONING SETBACKS W C�7y TEL FRONT RW ❑ � APPLICANT /G��q G� /m� REAR O � �� � �_ TEL SIDE/SIDE STREET RW O CONTRACTOR �--�-�—Q SIDE ❑ � ADDRESS I � -. �.L �J �4- _ PROPOSED USE CI7Y • ZIP 7 EL o ARCH/ENG/ � DESIGNER NO.DWEL NO. NO. ADDHESS UNRS STORIES BEDROOMS � CI7Y ZIP TEL. � DESCRIPTION SQ.Ff. FACTOR PSF ADJ.AREANALUATION � � OWNER-B�ILDER DECLARATION SFRlADD/REM O Q 1 HEREBY AFFIRM UNOER DENAITY OF VERAIRY 7}IAi 1 AM EXE4PT FROM THE CANTMCiORS U• GB�eqB/'W IpOR W CENSEUWFORTHEFOLLOWiNORE/I50N(SfG7o]t.SBU5NE55MDVROFES5101�LSCODE:ANYUTYOR (n U CpUMYWHp1REOURE5A0ERMITTOCONSTRUCT,ALTER,M7i1OVE,DEMOlJSN.ORREFURANYSTRUC• W P8110/DBGI( Z 7URE VRqR TO ITS ISSUM/CE,ALSO HEGUIRES THE MPLM•ANT FOR SUCH FEIWIT TO FlLE A SICNED W � SU7EMENT TU7 NE OR SNE R LICENSED RIRSUNJT TO THE iROVISION3 OF THE CONTMCTORS LF � CENSE UW(CHMTER Y(CdJYENGNO YATM SECTION Taool�DiY�SION l OF TNE Bu5ME55 AND PRO- u" P��PO FESSIONS COOF)Ofi TUT ME OR SHE IS EXEI�PT iHEREFROFI AND THE 81�515 FOq TME ALLEOED E%EMP• TiON.Iw�ViOLATiO'IOFSECTON7mt.6BYANVAPiLIWlTFORAPEPoAiTSUB.lECTSTHEMPIICANTTO Z Re-Raof � A CN0.PENALT'OF N0T YORE TM�N FNE HUN�NE�OOlLA0.5(fSco�J: 0 OL��IEROFTHEPROPEN7Y,ONIAYEMOIOYEE5IMTHWAGESASTHEIRSOIECOMPEN5AT10N, � COTrt10lCi81 Z WILL DO iHE WORK.AND THE STRUCTURE IS NOT WTENDED OR OFFERED FOR&LLE(SEC.701t.BU51- J NE55 NIO PRDFESSIONS CODE:THE CONTIUCTOi15 UCENSE UW DOES NOTAPPLY TO/N OMMER OF . � iROPENiYM�OBU6DSOfiWPROYESiHEREON.ANONMODOE55UCHWORKNIMSELFORHER4ELFOR m Q THROUQHHISORMEROWNEYPLOYEES,PROVIDEDTHATSUCM�MPROVEYEHTSMENOTMENOEDOfi � pOiFEREDFORSALEIF.HOWEVER7ME8ULDNGORMPR0VE4EMI550lDMATMWONEYEJIROFCOMRE- � Z TION.TME ON'NER-BUILDER NnLL FIAVE TNE BURDEN OF GROY7J0 THAT HE OR SNE DD NOT BUIID OR = WPHOVEFORTNEPURPOSEOFSALfF O l�3 C'A^�ER OF TME PROFEHTY,MI E%CU15NE�V CONTMCTNO NRTH UCENSED CONTRACTORS Q TO CONSTRUCT 7ME GROJEGT(SEC.70M,BUSINE55 NA PROFESSIONS CODE THE CONTMCTORS LI� VBIUeIlO11 AW.AREA W CENSEUWDOE9NOTAYPL7TOIWOWNEflOFAPROVERTYN'MOWLDSORMPilOYE9T1ERE0N.AN0 f NRqCO1RMCT5FORSUCHOROUECiSVATMACONTMCTOR�S)L�CENSEDW�YSUAMTOTMECONiMG Q�J/�N DESCRIPTION � � FEE � TORSUCENSELAW.�. t / 0 O IAN E7(FUPTUNDER SEC. B.t FG iORTN13 NEASON � G`� � �^ 3 ¢ LL' DATE ONMER V . . Z W � �ICENSED CONTRACTORS DECLAHATION W � IHEREBYAiFIRYUNOERPENALTVOFPE0.NRYT1UTI�MLICENSEDUNDfRVROVIS�ONSOFCHAPTER V. p. �(ODUMENGNO WIT11 SECTION TOao)OF DMSIDN 1 OF THE BUSME35 AND PROFEBSIONS CODG.IJA Z X YY UGENSE IS N FUIL FOfiCE AND EFFECT. m � UCENSE/C�U55 ���U L1C.NO. /�/� � � V DATE '7��-�I� � CONTMCTOFi,�._ • n- W �n � WOHKERS'COMPENSATION DECLARATION ��.y� � � IHEREBVALFlRMUNDERPENAL7YDFPEiWRYONEOFTXEiOLLDWWODECLAMTqNS: �' ' � Z a O _I NAVE AND W4L MAMTMN�CFRTIFlGTE OF CONSEM TO SELFaNSUR[FOR WORKERS' S L CdADEN5AT10N.A5DROVIDEDBYSEGT10N77000FiHELA60fiCODE,FORTNEVERiOfiMANGE U Q OFTHEWORKiORNMIdiTwSiERM1T18ISSUED. W � � W _IHAYEMAVYILLI.WMANWORttERS'COMPENSA7qNW5URANCE,A5RE0UREDBYSECfpN Q 77000FTHELABOfICODE,FORiHEPERFORMANCEOFTHEWOfUf WRN1fiO17NiSVERMRIS ISSUEAWriORxERS'COUPENSATK)NWSUiUNLECARRIERAND00lICYNUYBENME: CONSTRUCTION � �q�ER PUW REVIEW. � POLICVNUUBER ELECTR � � � (IllSsfcm+lE�NoieemX'tEIEDOFMVEw.fisPoROrEHK��ED00ttuisR�ao�aiLESS? PLUMBING Z I CERTIFY THAT W iME GERFORAIANCE OF THE NURK FORwHKH TNIS 0ER4iT 6155UED,1 MECHANICAL (,�} SMALLNOTEMPLOYANYiER50NN�N'lMANNERSOASTOBECOMESUBJECTTOTHE . . N WORKERS'COUPENSATIONUw50FGLLIFORMIANDAGREETMA ISt�OULOBECOME INSPECTIONFEE SUBJECTTOTHEWORKERS'CO►1PENSATIDNFHOViS�ONSOFSE 770oOFTMEIABOR � � ' cno¢,i s�uu coaruvnn�coua�r win�n+osE raowsar�s. iSSVANC pDATF:9",. �/47APPLMrWT. �' �� SMIP � W ENERGY P!C � WAiWtNG:iNLURE TO SEQIRE WORKERS'OOMOENSATION COVERACE�5 Ut1AWFlR.ANO SWLLL BE 6UBJECTANEMPIOYERTOCRIMiWLLVENALTIESAN�CMLFNESl1VTOONEHUNDREDT1qU5AND ENERGYPERMIT DOLLMS(f 100.0001.r1 ADDITION TO TME COST OF COMPENS1lTqN,DAYAGES AS CROVIOEO FOR N � SECTiON]TOeOfTMEUBOHCODE.MEREST,/JOATTORNEY'SFEES. RETENIIONFEE: -- — � CONSTRUC710N LENO�N�AGENCY PRE-ALT FEE: � INEREBYAFFWGUNOERPENKT/OFPEiiIURViHATTMEAEI5A00NSTRUCTIONLFNDPlOAGfNCY � dZ FORTHEPENiON.UNCEOFiNEVYON<FORwHIG1iH�5PERMITI5155UED�5EC.70o7,CN.G�. 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