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� � � ��� - - CITY OF DIAMOND BAR �F 1�— DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES 21660 E.Copley Drive Suite 190 (909)860-3195 Faac(909)861-3117 _ PRE`SS '^�"��� BUII.DING PERMIT APPLICATION FIRMLY � _ ; : � o ADDRESS I 1�� ��.��► J� C�l��- APPLICATION� �(� NUMB R � � � #/C DATE l � � ISSUE (,� j'd!� TYPE OCC APN LOT� TRACT DATE v CONST. GROUP Z p OWNER �t9(C� ; n ADDRESS ��-C `-�v"d;� � ZONING SETBACKS Z CITY �'" ZIP �'i�"� TEL. � � ��' l=� FRONT RW ❑_ g APPUCANT �Y� �,t.Cs�. TEL. �i REAR ❑ SIDE/SIDE STREET RW O � � CONTRACTOR ��� �'�-� � A SIOE ❑ ADORESS � '�'�` n-" � CITY l,k.�U i��. ZIP EL `�.�v g PROPOSED USE o ARCHlENG/ � DESIGNEFI NO.DWEL. NO. NO. a ADDRE5S � � UNITS STORIES BEOROOMS � CITY ZIP TEL. � u� DESCRIPTION SQ.PT. FACTOR PSF ADJ.AREANACUATION _� OWNER-BUILDER DECLARATION SFRlADD/REM 3 � .� I HEflEBY AFFlRM UNDEfl PENPLTV OF PERJUqY THAT 1 AM EXEMPT FflOM THE CANTFACTORS LI• G8f898/C8f(70tt W- CENSEUW�ATV±Ef•OILOWINQRE0.50N�5EC.7037.58USINE55ANOPROFESSIONSCODE:ANVCINOR -- (n -� _.z_: COUNTYWHICHREWIRESAPERMITTOCONSTRl1CT,ALTER,IMPROVE,DEMOlI51i3ORREPAIRANY5Tfll1C• - W poll0/DBCK � .W TURF,PRIOR TO ITS ISSUAACE.AL50 REWIRES THE APPLICANT FOR SUCH PEHMIT TO FILE A SIGNEO : w �_ STATFMEPfT TMAT XE OR SHE IS LICENSE�PUi15UAN�TO THE PflOVI510N5 OF THE CONTflACTOHS L6 CENSE LAW(CHAPTER 9(COMMENCW�WITH SECTION 7000�OF DIVISION 30F THE BUSINESS AND PRO- LL' Pool/Spa FESSIONS COD�OFiTHRT HE OR SHE IS EXEMPT 7HEREFROM AND THE BASIS FOP THE ALLEOEO E7(EMP� TION.ANYVpUTI0NOF5ECTION7031.5BYANYAPPUCRNTFOflAPERNITSU&lECTSTNEAPPLICANTTO - Z- RB-ROOf -F A CIVIL PENALTY OF NOT IAORE THAN FIVE HUNDRED DOLLAHS(SSOD).): �I.ASOWNEROFTHEPftOPER7Y.ORMYEMPLOYEE3WiTHWAGESASlHEIRSOLECOMPENSATON, _ COII1R18fC10I ' --�� WILL DO THE WORIL ANO 7HE STRUCTURE IS NOT IN7ENDEOOR OFFERED POR SALE(SEC.7oaa,BUSb -.�J - NESS iIND DRQFE$SIONS COpE�TNE CANTRACTOpS LICENSE UW OOES NOT APPLY TO AN OWNER OF -�� PROPEpTYWFpBU1LD30RIMPROVESTHEFiC-0N.ANDYlNODOESSUCIiWOFKHIMSELFORHEflSEIFOR -_ � -��- THROUGHHISORHEqOWNEMPLOYEES,PROVIDEDTHATSUCHIMPFOVEMEMSARENOTINTENOEDOR -m ` W- OFFEREOfOflSALEIF,HOWEVER�NEBUIIDINGORiMPROVEMENiISSGLDWRHINONEVEAROFCOMPIE- f --z� -TION.THE OWNER�IIILDEH N'ILL HAVE THE BURDEN OF PROVING 7HAT HE OH SHE DID NOT BUIID OR � IMPROYEFORTHEPURPOSFOFSALE�. -W ❑I,ASOWNEROFTHEPHOPEflTY,AME%CLUSIYELYCONTflACTINGWITiLiC�NSEDCOMflACTOfl3 _-�.� TO WNSTRUCT THE DRQIECT(SEC.70u,9USINESS AND PROFESSIONS CODE THE CANTRACTOflS LI V8IUH110n ADJ.AREA :W_ CEN.SELAWDOESNOTAPPIYTOANOWNENOFAPROPEftTYW1iOBUIlD50RIMPftOVESTHEREON.AND � YNIOCONTMCiSFORSUCHPR0.IECTSN7THACONTRACTOR(S�LICENSEDPURSUMITTOTHECONTFAG (�UANTITY DESCRIPTION fEE � -� . TORSl10ENSEUW.} sa /7� -�_��� O 1 AM EYEMPT UNOER SEC. B-8 P.C.FOR THIS iiEASON ' Q � �O 6d � ii P.Cn'.�� �l iti p V- 3 V • r ¢ �_ � r�t.� ,� �t�_ . � -_Z. DATE OWNER � � W � � �. LICENSED CONTRACTORS DECLARATION W s:i _ IHER�BYAFFIRMUNDERPENAITYOFPERIURYTh1ATIAMUCENSEDUNOERPROVISIONSOFGHAPTER __� � + -:�_ 9(COMMENCINGWIiNSECTION7o00)Of�IVISION30FTHEBU5I.UESSANDPAOFESSIOYSCA�E./J:D ., z -� ��-_ MY LICENSE IS IN FULL FORCE ANO EFFECL - ry �/ m �_0; LICENSEGLASS �-�`�C�`�' UC.NO,_�� � r�-� ! � J �V.. DATE , +�`-� - �'�_GONTNACTOR �'� � 4 II W. . ;"{ -d�_ WORKERS'COMPENSATION DECLARATION ��'� --i �`�. y�� � $r��,j�,��;� �. i ��N_ l HEflEBY AFFIRM UNDER P@NAL7V OF PERJURY ONE OF THE FOILOWINO DECLARATIO -'`'� - j i r�.�, �'j�� �• � 7 _-:� �0-- __IFUVEANDWILLMAINTAINACERTIFICATEOFCbNSENTTOSELFINSURE�_ffFCR - d _4�, y � ��- �'�_ COAIPENSATKKJ.ASPROVIDEDBYSEC710N37oUOFR1ELABOqCOD�NTHE/�R OF AN•, ���+�`� �`u d� � . Of THE WOFK FOR WI{��µTHIS PEFM!T IS ISSUEO. � 4: _! _INAYEAN�WILLMqIMAINWORKEHS'GOMPENSATIONINSURANC ASHE�NHEDBYSE .� -.Q_ 37000f1HEUBORWDE.FOR7HEPERFORMANCECFTHEWOR FORWNICHT,Nn9-PER ISSUED.MY WORKERS'COMP�NSATION INSUNANCECARRIEfiAND t1MBEFl RRE: - CONSTflUCTiON � Q. t _�, CMRIER PLAN REVIEW __I _:Z�_ pouCVNUMeER ELECTRIC __ � a m - -..0_ .�rwssccnaar�mnarsEaonw.�rFooFnie�RMruroacxvEfxx�naeooatn�is(siro)oa�Ess? PLUMBING �W ICERTIFYTHATINTHEPERWRMANCEOFTHEWORKFORWHICHTHISPEHM�TISISSIJED,I MECHANICAL ��.�,-�"?� �' J z- -_� --:�CJ- �SHALLHOTEMPLOV�ANYPERSONINANYMANNERSOASTOBECAMESUBJECTTCTHE -:'�� WONKERS'(pMPENSAT�ON LAWS OF CALIFORNIA,AND AGflEE THAT IF I SHOUID BECAME �NSPECTION FEE SU&IECTTO THE WOFll(ERS'COMPENSATbN PROVISIDNS OF SECTION 37000FTHE LABOR __� -,-S: CODE.ISHALLFOqTHWITHGpMPLYWITIb7HO5EPPOV1510N5. �SSUANCE c � 0 4� 7p� ,. �p q`�: DA7E:R�� APPIICANT: ��:��.i�"L ��-�" �SMIP y '�� .WAPNING:FAILUflETOSECUREWORNERS'GOMPENSATIONCOVEHAGEISUNIAWFUL,AND9HALlBE ENERGYP/C �� � T_����34��� �i _ _ -.J._ � p�T� . _ �� SU&IECTANEMPLOYERTOCRUAINA�PENALTIESANDCIVILFINESUPTOONEHUNDREDTHOUSAND - -ENERGYPERMIT YS-�'f,�il P��` - .- �. DOlLAR5�E10U.000),INADOITIONTOTHECOSTOFCOMPENSATION,DAMpGESASPROVIDEDFORIN �����gx _ ¢:_ SECTION3'loeOFTHELABORCODE,INTEREST,ANDATTORNEY'SFEES. RETENTIONFEE: -` p-- CONSTRUCTIONLEN�INGAGENCY PRE-ALTFEE: 0- _ - �. I HEREBYAFFIflM UNUER PENALTY OF PERJURV THAT7HENE ISACONSTRUCTION LENDWG AGENCY - FOF THE PERFORMANCE OF7}IE WOqN FOk WNICH iH15 PERMIT I5ISSUE�(SEC,3087.CIV.G.�. . : Z . W -�-- -�-�-- . _ � LENOERSNAME - - Ns LENOERSA��flE55 - W ICEi1TIFYTMATIHAVEREADTHISAPPLICATIONANDSTATElHATTHEA00VEINFORMATIONISCARRECT. TOTAL FEES ��� , _ �y IAGREETOWMPIYWITHALLCITYANDCOUNTVOH0INANCESANDSTATELAWSRELATINGTOBUIL0ING - WNSTPUCTION,ANDHEREBYAUT}iORIZEFEPqESENTATIVESOFTHISCAUNTY70ENTERUPONTHE . ZABOVE-MENTIONED PROPEflTY FOR INSPECTION PUfiPOSES.� - o �����h��g ���i COMMENTS .,�Cd� 1� � m PEHMITfEEN (PFl�Nn - - - a � _' � - - y SIGNATUREOFP E D TE - = RECPT,NO. - PAID 8Y VqLIDATION ~ WHITE--Department Copy,YELLOW—�inance Copy,PINK—Assessor Copy.GOLDENROD—File Copy,GREEN—Applicani's Copy � � _, ��_��"� ,�' €- f ��__ E �f € ,� �-� ��€���t��,"�� � � f � � tY,_ � _ � ��4 I ,� "7€ r� � i ��J"I > i � ... 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