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CITY OF DIAMOND BAR �
COMMUNITY DEVELOPMENT DEPARTMENT
� :,,.,� . 21660 E.Copley DrivcSuite 190 PRES+S
; (909)860-3195 Fax(909)R61-3117
� �'A^'� RUILDING PERMIT APPLICATION FIRMLY
j Y JOBSITE �����I� � ��., APPLICATION ��;7 -�'+ NUMB R��Q'��#/C
� o ADDRESS DATE_
;' � , ISSUE 7YPE OCC
APN LOT TRACT_ DATE_ _CONST. GROUP
' � OWNER
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APPLICANT _ ta� c�.<'�hc'` TEL.---- REAR CJ_._
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� Z DESIGNER — NO.DWEL. NO. NO.
a ADDRESS UNITS STORIES BEDROOMS
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; � DESCRIPTIQN SQ.FT. FACTOR PSF ADJ.AREANALUATION
� p� ONRJER-BI;ILDER DECLARATION SFR/ADD/REM
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0� I HEflEBV AFFIRM UNDEN PENALTV OF PERJURY THAT I AM F.XElAPT FROM THE CANTHACTOqS ll- G8f0gB/C81POfI
l W. CENSELAWFOFTHEFOLI.OWINGREASON(SFG'/o31.58USINE5SAN�PROFE5510N5CADE:ANYCITYOR (n
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� W TUNE,PRIOH TO ITS ISSl1ANCE.AL50 REQUINES THE APPLICANT FOR SUGH PEFiMIT TO FILE A 51GNE0 W
�� STATEMENT THAY HE OR SHE IS LICENSE�PURSUANT TO THE PROV1310N5 OF THE CONTRACTORS I.L
q O� CENSE LAW(CHAPTEH 9(CDIIJMENCINC WI7H SECTION 7C00)Of UIVISION 7 OF THE 9USINE55 ANO PRO- LL' P��VSpB
FE5910NSCODE)OR THAT HE OR SHE IS EXEMPT THEfl[FROM AN�THE BA515 FOR 1'HEALLEGF.D EXEMP� (�
� U TION.ANVVIOLA710NOFSFCTION7o31.5BVANYAPPLICANTFORAPERMITSU&IECTSTHEAPDLICANTTO Z Re-Roof
ACIVIL PENALTY OF NOT MOHE THAN FIVE NUNDRED DOLLAflS(i500).):
' Z ❑I,ASOWNEROFTHEPROPERTV,ORAIYEMOLOYF.LSWITHWAGESASTHF.IRSDLECOMPENSAT'AN, � � COfPIffI0fC18I
�� WIIL DD THE WORK,PND THE STRUCT�RE IS NOT INTENOED OR OFFERED FOF SALE(SEC.7046,BUSI- . J
NESS AND PHOFESSIONS CADE:THE CANTRACTORS LIC[NSE L4W DOES NOT APPLY TO AN OWNER OF
' � PROPERTYWHOBUILOSORIMPflOVESTMEREON,ANDN770U0ES5UCNWOPKHIMSELFORHERSELFOq m
S ��, THROUGHHISORHEROWNEMPLOYEES,OHOVIOEDTHATSUCHIMVqOVEMENTSARENOTINTENDE00q
7 W' OFFEREDFORSALE.IF,HOWEVEF.iMEBUIL�INGO'rIIMPROVEMENTI550�.DWITHINONEYEAROFCOMPLE
4 ��' TION,7H[OWNER BUIL�ER WILL NAVE THE 9URDEN OF PHOVINC.THAT HE OP SHE DID NOT BUILO Oq
� = IAIPROY[FORTHEPURPOSEOFSALE).
� ,W; ❑I,ASOWNEROFTHEPflOPERN,AME%CLUSIVELVCONTfiACTINO,WITHLICENSEDCONTRACTORS - ---_
�,. TO CONSTfYUCT THE PRQIECT(SEC.7044,BUSINE55 qN0 PflOFESSIONS CODE:THE CANTMCTORS Lb V811J81i0Y1 _ ADJ.AREA
�W, CENSELAWOOESNOTAPPLYTOANOWNfROFAPFOPEftTVWHOBUIIOSORIMPROVESTHEREON,AND
'�� WHOCONTRACTSFORSUCHVROJECTSWITHACONTflACTOR(S�LICENSEDPURSUANTTOTHECIXYTRAG QUANTITY DESCRIPTION FEE
� TOfl3 UCENSE LAWJ.
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� �� ('I IAM IXEMPi UNDER SEC.._. _.______..__ B.&P.C.FOq iHIS flEASON
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� DATE OWNER__._„_
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; �' LICENSED CONTRACTORS DECLARATION
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�: I NEREBV AFFIRM UNOER P[NALTY OF PERJURY 7Hf.1'I AM LICENSEO UNOER PFiOVI51ONS OF CHAPTEfl i^ � � ..�J. Q
'd`.� 9{COMMENCING WITH SECTION 7000)Of OIVISION 30F THE BUSINESS AND VFOFESSIONS CADE.AND ,� z - K-`�`L '��...J
X� 1AY LICEVSE i5 IN FULL FORCE AND EFFEC. � /� ,� J � m �� i ��
O� L."'_ ::3�' LS-`��-�Ci��r�� " � s�...
�; UCENSE CLASS ____._LIG.NO._._._ �;__ _ -j- �. �
V��. DATE__ ____ CONTRACTOR "�'�JC1t�.� �C�=1h.� y d�
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. � ��; WORKERS'COMPENSATION DECLARATIDN /���
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�-' I HEAFBY AFFIRM UNDER PENALTV OF DERJURY ONE OFhIF FOLLOWING DECLARATIONS:
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i d,, __I NAVE AND WILL MAINIAIN A CEf1TIFlCATE OF CONSENT TO SEIF-INSURE FOP WOHKERE'
� Q COMPENSATION,ASPROVIOEDDYSECTION37000FTHE�ARUqCOOE,FORTHEPEHFORMANCE _ _
�// OF THE WOflI(FOR WHIGH 7HI5 PEM11T IS ISSUE�.
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-{� I HAVE AND WILL MAINTAIN WORNERS'(:OMPENSATION INSURANCE,AS RE�l11RED BY SECTION
� Q / 9700 OF THE LABOR CODE.FOq THE PERFORMANCE OF THE WORK FOR WHICH THIS PEFiM1T IS —_—i--
�', ISSUED.MY WORKERS' MPENSATION INSURANCE CARRIE AND POLICV NUM6ERARE: CONSTRUCTION
! j: �t2-� �bt v q _„_ PLAN REVIEW
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':! � POLICVNUM�E���a._-�• � �' �..._. '� ' ELECTRIC __�_ ,'. j.
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� 0 (IHISSLCTANkE�NOTBEQN.1Rt7EDaFTHEPEWNfISFORONEHUPUiEDDOt1?RS(Eiao)ORLESS} PLUMBING ._ __.
W I CERTIFY THAT IN THE PERFONMANCf OF THE WORK FOR WHICH THIS PERMIT IS ISSIIfC),I MECHANICAL
: j ...C7.. SHALLNOTEMPI.OYANVPERSONINANYMANNERSOAST06ECOMESUBJCCTTOTHE -- � --
d � WORNERS'COMPENSATIONIAWSOFCALIFORNIA,ANDAGREETHATIFISHIXILDOECOME INSPECTIONFEE
� SU&IECT TO TNE WOFKEftS'fAMVFNSPTION PROVISIONS OF SECTION 1/0o OF THE LABOR � -r
~ CODE, SHALI�ORTHWITH COMPLV WITHTFIOSE ISSUANCE i� �
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� + O: /,J�` SMIP ��: ---
� p �ATE:_.. � .__ APPLICANT: _.(_ ..� �._ .'.. -.---__-___ '
• W� � ENERGY P/C
WARNING:FAp.UFE TO SECURE WOHKEPS'COMPENSATION CAVEHA6E IS UNLA L.AN�SHALL 6E
' �R �r SU&IEGTANEMPLOVEqTOCRIMINRLPENALTIESANDCIVILFINESUPTOONE N�REDTHOUSAND ENERGYPERMIT '�"'� e '�' � k '
DOLLARS(5100,0001.�N ADDITION TO THE COST OF CAMPENSATION.DAMA .AS PROVIDEO FOR IN Xt- -�-
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� � J� SECTION37080F7HELA90RCA�E,INTERFST,FNDATTORNEYSFEES, RETENTIONFEE:
� � ' _— _—" _—
�; CONSTRUCTION LENDING,B.GENCY PRE-ALT FEE:
�' 1 MEREBY PFFIPM UNDEfl PENALTY UF PERJURV iHAT TNERE IS ACONSTRUCTION LENDING AGFNCV
FOR TNF.OERFORMPNCE OF THE WORK FOR WH�CH THIS PEFMIT IS ISSUED(SEC.309�,CN.CJ.
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LENUER'SNAME�__,_ _._..__ _._.-_
�: IENDER'SAD�flE55_„_ ___ ..__—.._..
�� ICERTIFYTHATIHAVEPEADTHISAPPLICATIONANDSTATETNATTHEA60VEINFORMATIONISCORRECT. TOTA�FEES �'
��' I AGREE TO CAMPLY WITii RLL CIiV FND COUNTY OROINANCESAND STATE LAWS fiF.IATING TO 9UILOING
CANSTRUCTION,AND HEREBY AUTHOPIZE REPFESENTATIVES OF THIS COUNTV TO ENTEF UPON THE
ABOVE-MENTIIXJED PHOPERTY FOR INSPECTION PURVOSES.
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� ~' WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—AppllcanPs Copy
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