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CI'I'1'OF DIAMOND BAR ----�--- DEPA.RTMENT OF COMIvIUNTTY&DEVELOFMENT SER'VICES I ..n.w 2ISB5 E.Copley Drive _, . ... , n (909)860-3195 Fax(909)861-3117 PRESS ��-•�y BUILDING PERMIT APPLICATION FIRMLY o DDRESS �����f`",����` DATEICATION �� � � NUMBER� ���D4'' #/��� � ISSUE f� � i'l� TYPE OCC .- APN OT ' TRACT DATE L•S� �� CONST. GROUP p OWNER � -/�i��� - - ADDR S !'� �I �` - ZONING SETBACKS Z CITY ZIP TEL. FRONT RW ❑ g APPLICANT�'JII��d�iras�aAV' TEL�`j'������ REAR ❑ Z -T SIDE/SIDE STREET RW ❑ ¢ CONTRACTOR � SIDE ❑ ADDRESS' � ��`- `� PROPOSED USE f � CITY ZIP , ' � TEL. � o, ,,ARCWENG/ ' . w DESIGNER NO.DWEL. NO. NO. � 'ADDRESS � UNITS STORIES BEDROOMS ' � CITY ZIP TEL. , � ��� DESCRIPTION SQ.FT. FACTOR PSF A�J.ARENVALUATION . p� OYIJNER-BUILDER DECLAFATION SFR/ADD/REM O I HEREBY AFFIfiM UNDER PE�JALN OF PERJURY THAT I AM EXEMPT FflOM THE CONTflACTOR3 LI- � Garage/Carport ' .W�'���CENSEtAWFORTHEFOLLOWINGf1EA50N(SEC.7C31.5BUSINESSANDPROFESSIONSCODE:ANYCITYOF � ��U �I,��,COUNNWHICHREQLIIRESAPERM�TTOCONSIRUCT,ALTER,IMPROVE,DEMOLISH,ORREPAIRANYS7RUC- W Pgtio/DeCk Z� "TURE.PRIOR TO ITS ISSUANCE.A SO REOUIRES THE APPLICANT FOR SUCH PERMIi TO FILE A SIGN� W �J ' I��STATEMENT THAT HE OR 5HE IS V'ICENSED PUPSl1ANi TO THE PflOVI51DNS OF THE CONTRACTORS LI- ' ��'�,'��i,,CENSE LAW(CHAPTER 9(COMMEI�CING WITH SECTION 7000'�OF DIVISION 3 OF THE BUSINE55 ANO PRO- V' POOVSPe ���'.�FE6SIONSCOD�ORTHATHEOR HEISE%EMPT7HEREFROMAN�THEBASISFORTHEALLEG�EXEMP- (� ',�'O.�''',,"�,�TION.ANYVIOI:ATIONOFSECTION�031.5BYANYAPPUCANTFORAPERMITSU2JECTSTHEAPPLICANT'IU z Re-Roof '.'�A CIVIL PENALTV OF NOT MOFE THAN FNE HUNDRED DOLL4fl5(SSoo�.): �'�0 �'�, ❑I,ASOWNEROFTHEPFOPffRTY,ORMYEMP�O!'EESWITHYVlGESFSTHEIRSOLECOMPENSATION, � Commercial -- ,Z;��',:WILL DO THE WORK,AND�THE STfjUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEQ 7044,6USI- J � '�.NESS AN�PROFESSIONS�CO�E:7}IE CANTRACTORS LICENSE LAW DOES NOTAPPLV TO AN OWNER OF ''�.'��.PROPERTVWHOBUILDSOR�IMPROVESTHEREON,AN�WHODOESSl1CHWORKHIMSELFORHERSELFOF � ���; 'I'':iHROUGHHI$OFHEROWN,EMPLbVEES,PROVIDEDTHATSUCHIMPROVEMENiSARENOTINTENDEDOR m . 'Q, ''�,OFFERE�FORSALEIF,HOWEVER,�HEBUIIDINGORIMPROVEMENTIS50IDW!THINONEYEAROFCOMPLE- _ �'iION,THE OWNER-BUILDER WILL AVE iHE BUftDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR 'j IMPftOVE FOR THE PU�4POSE OF LE�. ❑I.AS OWNER OF THE PflOP�RTV,AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS '0j���.'. ��TO CANSTRUCT THE PROJECT(SEC.7044,BUSINESS AN�PROFESSIONS CO�E:7HE CONTRACTORS LI- V81U8tion a ADJ.AREA �'_�,' I,CENSELAWDOESNOTAPPLVTO�,7yNOWNEROFAPROPERTYWHOBUIL�SOaIMPROVESTHEREON,AND ,,F;� '�WHOCONiRACTSFORSUCHPRO.{ECTSWITHACONTRAC70R(S)LICENSE�PURSUANTTOTHECONTRAC- QUANTITY DESCRIPTION FEE Y., ��Toqs UCEN5E IAW.). � �p�c�� ��'' ' ❑IAM�XB�APT UNDER SEC.�I� B.&P.C.FORTHIS flEASON Q � �'�+°'�'°! ��bsSS�� � �', ' �'' o� � `9,�C�.C,l'E�Ls i�� LL' 'DATE I OWNER � U .���� �. LICENSED CONTRACTOFS DECLARATION W � ��I HEREBY AFFIRM 11N�ER'PENALT OF PERJURY THAT I AM UCENSEO UN�ER PROVISIONS OF CHAPTER � ,,py�,, ;,9(COMMENqNG WITH SECTION 7 00)OF DIVISION 30F THE BUSINESS AN�PROFESSIONS CODE,AND Z �, ��,,MY LICENSE IS IN FULL FORCEAN EFFECT, �y � j m �Q�I �'LICENSE CLASS�+ ��ry� IJC.NO. � 6!��/ � '�V. DATE�[� ��!!" CONTRACTOR 9 a W' I �` � WORKE�RS'COMPENSATION DECLARATION /��(`1.(� I �/7 �f� U ��;' '�,I HEREBY FFIRM l/NDER PENALT�'I OF PERJURVONEOFTHE FOLLOWING DECLARATIONS:,/ � Z ,Z� �_�EANOWILLMAINTAI�ACERTIFICATEOFCONSEMi05ELF-INSUREFORWORKERS' 2 � � CAMPENSATION,AS PRO I�ED 8Y SECTION 37ou OFTHE LABOR COD�FOF THE PERFORMANCE W Q ,�OFTHE WOFiK FOR WHIC THIS PERMIT IS ISSUED. � W ' �� I HAVE AN�WILL MAINTAI WORKERS'COMPENSATION INSUflANCE,AS REQUIFED BY SECTION - ► -g g Q' � 3700 OF THE LABOR COD�y.FOR THE PERFORMANCE OFTHE WORK FOR WHICH THIS PERMIT IS j �'qg ISSUEb.MV S'CmMPENS IONINSURANCECAflRIERAN�POLICVNUMBERARE: CONSTRUCTION ��°�)� �4 �v� J: . j. �, caAaieR � -� '� � � �� '��'h.� i 1 PLAN REVIEW _ -� 0 POLICYNUMBER�j�� � � � �J ELECTFIC � � (iHISSECI'IOPINEmNOTB�IOJMPLEfE�OF1HEPFRMffISWRONEHl1NDREDO�LLARS�51 ORLESS). PWMBING D LLl L .w� �Z�' I CERTIFYTHAT IN THE PEnFOflMANCE OFTHE WORK FOR WHICH THIS PERMIT IS ISSUED,I MECHANICAL (,�'' SHALLNOTEMPLOYANYrOEPSONINANY1dANNER50A5TOBECOMESUBJECTTOTHE �/y WORKERS'COMPENSATIyN LAWS OF CAUFOflNIA,AND AGREE T IF I SHOULO BECOME INSPECTION FEE SUBJECT TO T E W6RKERS'COMPENSATION PRO ON OF SECT N 370o OF THE LABOR "� � COOE SHAL FORTHWITHCOMPLYWITHTHOS� f �ioNs. 15SUANCE � 3 � L - C - , , . � . �� DATE: ���� ArPLICANT: "I��! � SMIP W ' WARNING;FAILURETOSECUREWOflKE(iS'COMPENSATIONCOVERAGEISUNL4WFUL.ANDSHALLBE ENERGYP/C ' �y', SUBJECTANEMPLOVERTOCRIMI�JALPENALTIESAN�CIVILFINESL1Pi00NEHl1NDREDTHOLI�AN� �� . DOLLARS(51oo.00O),INAbDITIONI OTHECOSTOFCOMPENSATIDN,DAMAGESASPROVIDE�FORIN ENERGYPERMIT � SECTION3]OBOFTHELABOFCOYE,MTEftEST,ANDATTORNEY'SfEES. 1 RETENTION FEE: d . , CO STRUCTIONLENDINGAGENCY PR LTFEE: h �.3�. � ���„�l I (�lo �----... '� IHEREBVAFFIRMUNOERPENALT�OFAERJURYTHATTHEREISACONSTRUCTIONLENDINGAGENCV � �, FOR THE PERFORMANCE OF TI{E OFK FOR WHICH THlS PERMIT IS ISSUED(SEC.309],CIV.C.). �,`��- . Z., UJ''', �,'�, LENDER'S NAME � � F-�'�, LENDER'SAD�RE55 � ��"i ICEflTIFYTFIATIHqyEREADTHI5,APPLICATIONANOSTATETHqTTHEABOVEINFORMAiIONISCOftRECT, TOT/"1L FEES 1 ��,��'�, IAGREETOCOMPLYWIiHALLCIYIYANOCOUNTVORDINANCESANDSTATEL4WSFELATINGTOBVIL0ING .� ��. CONSTRUCTION,AN�HEREBYA 7HOR EREPRESENTATIVESOFTHISGOUNTYTOENiEflUPOIvTHE � � Q���i ABOVE-MENTIONEO PR ERTYF�IR INS cnoN PURPosEs. COM�NT { - � � � ,� - , �,,,,�,.� ��� PERMI7TEE NAM ) �' - .�-^"""`.'"..--`� ��� i } �---� S..✓ � SIGNATURED . I DAT _� � RECPT.NO. 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