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_�� CTTY OF DIAMOND BAR
DEPARTMENT OF COMM[JNITY&DEVELOPMENT SERVICES
�,,;;; 2I825 E.Copley Drive PRESS
(909)860-3195 Fax(909)861-3117
,�`""'" BiJILDING PERMTT APPLICATION FIR Y
� JOBSITE ,,/ h`�,�. APPLICATION - �� n "-' PERMIT � _P/C
o ADDRESS "T I L� PY�!'► ��n�h DATE �I �'� NUMBER
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p I HEREBY AFFlRM VNUER PENALTY OF PERJUqY T}iAi I AM EXEMGT FROM THE CONTR4CTOR5 U- G8f0gB/CBfpOR
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, � CENSE LAW(CHACTER Y�COMMENpNd WITH SECTION]o00j OF OIVISION 30P THE BUSINE55 FND PRO- � POOUSpfl
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Q TNROUOM HIS OR HEfl OWN EMPIOYEES,VROVIDED THAT SUCH IMPHOVEMENTS ARE NOT INTEN�ED OR m
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� LIC:ENSED CON7RACTORS DEGLARATION w
� I F7EREBV RFFIRM UNDER PEiJALTY OF VERJURV TMAT I PM LICENSED UNbER PROVISIONS OF CHAPTER �
p. 9(COMMENCIN(7 WITH SECTION 7000�Of DIYISION 30F THE BUSINESS AND PROFESSIONS CODE,AND Z
X MY LICENSE IS IN FULL FORCEAND EFFEC7.
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� IICENBEClASS `�LIC.NO. ��� �
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~ DATE � '� '�' CONTRACTOR�L�� •✓- � �� a
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� WORKERS'COMPENSATION DECLARATION Q
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� I HEREBY AFFIRM UNDER PEIJALTV OF PERIUfiY ONE OFTHE FOLLOWING DECLMATIONS:
N Q
� _I NI.VE AND WILL MAINTAIN ACERTIFICATE OF CONSENT TO SELF�INSURE FOfl WOFKERS' _
COMPENSA710N,A5 PROVIDED BV SECTION 3�o00F THE LABOR COOE,FOR TME PENfORMMlCE W
OFTME WOFK FOR NMICH THIS PERM�T IS ISSUED. �
�
� _I HRVE ANO WILL MAIWTAIN WORKERS'CAMPENSATION INSUqANCE,AS HEOUIFED BY SEGTION n
QQ 37ooOF THE LA90R�.bD[,FOR THE PERFOPIMNCE OF THE WONK FON WHICH THIS PERMIT IS � /�� . I r„�,
ISSUED.MY WORKERS'COMqENS ION INSURAN RRIER�Jyo POIICY NUMBER ARE: CONSTRUCTION {,�,
� GARRIER ��/ ��'� �'`'"���1 PLAN REVIEW
Z POIICYNUMBER_ �4 � ELECTRIC
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p (naSSEctin+r��r+�7eEoc�mocn+EaEwwi�sFoaonE�x��oounas(itmloa�essl. PLUMBING
ZI CERTIFV TH/T IN THE PERFORMANGE OF THE WOHK FOR WHICH THIS PERMIT IS ISSUE�,I MEGHANICAL
�J SHAIL NOT EMPLOV nNY PERSON M ANY MANNER 50 AS TO BECAME SUBJECT TO THE
Uj WORKERS'GOMPEN5�AT10NUW50FCALIFORNIA,ANDAGREETHATIFISHOUL�BEfXJME INSPECTIONFEE
? SU&IECT TO THE WORKERS'COMPENSATION PROVISIONS OF SFCTION 3l0o OF THE LA,OR �
CADE.I SHALL FORTNWIiH CAMPLY WITH THOSE PROVISIONS. ISSIIANCE
� ���j�j���G�� � �
p DATE:_���__�'APPIICANT: l +i"'�� ��� ' SMIP ' �,
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J WARNING:FAILVREYO SECURE NroHKEflS'COMPENSATION CAVERAGE IS UNUWFUL D SH L BE ENERGY P/C _
LL SU&IEGTANEMPIOVERTOCR�MINAtPENALIIESANDC�VILFINESUPTOONEHUN6RE�TF10U5AN0 ENERGYPERMIT
OOLLARS(5700,000�.IN ADDITION TO THE COST OF COMPENSATION,OAMAGES AS VROVIDED FOR IN
� SECTqN 3708 OF THE LABOR CODE.INTEREST.AND ATTORNEV'S FEES. HETENTION FEE: I �^
d �CONSTRUCTION LENDING AGENCY PRE-ALT FEE:
� IYIEREBYAFFIRMUNDERPENALTVOFPERJURYTHAT7HEREISACONSTRUCTIONLEN�INGAGENCY
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� LENDEp'S NAME —
1_ LENDER'SADDRE55 _
W I CERTIFY THAT I HAVE READ l"MIS APPUCATIONAND STATE THAT THE ABOVE INFORMATION IS CORRECT. TOTAL FE ES � ., � �
� 1 AGFEE TO COMP�v WITH ALL CITV ANO COUNTY OR�INANCES AND STATE LAWS RELATWG TO BUIDING
� GDNSTNUCTION,AND HEREB\'AUTMORiZE RE�REScNTATIVES OF THIS COUNTV TO ENTER UPON THE
z ABOVE-MENTIONED PROPERlV FOR INSPECTION PURPOSES. COMMENTS
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m PERMITTEE NAME(PRINT) ,L j`
(n ��'� (J/// /L)L���
� SIGNATURE OF P AITTEE 1. TE ��
_ � RECPI NO. PAID BY VALIDATION
~ WHITE—De anmeni Co YELLOW—Finance
p py, Copy,PiNK—Assessa Copy.GOLDENROD�ile Copy,GREEN—Applicant's Copy
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CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21825 E.Copley Drive
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
PRESS
FIRMALY
;n
I (I
AD DRESS
T
pp h
APN LOT TRACT
OWNER
ADDRESS
CITY ZIP TEL.
APPLICANT TEL.
CONTRACTOR Z1
ADDRESS aV&zlo
CITY ilklelldifr-ZIP TEL.
ARCH/ENG/
DESIGNER
ADDRESS
CITY ZIP TEL.
OWNER-BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE LAW FOR THE FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE:ANY CITY OR
COUNTY WHICH REQUIRES A PERMITTO CONSTRUCT,ALTER,IMPROVE, DEMOLISH,OR REPAIR ANY STRUC-
TURE,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 THEREFROM 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).):
^ 1,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 YEAROF 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 CONSTRUCT THE PROJECT(SEC. 7044, BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI-
CENSE LAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAC-
TORS LICENSE LAW.).
^ I AM EXEMPT UNDER SEC. B. &P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER 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
3
LICENSE CLASS
/LIC. N0.
DATE_y'L CONTRACTOR•J'C
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 37000F 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 .ENS ION INSURAN AR POLICY NUMBER ARE
CARRIER
(_J%
��
POLICY NUMBER_/V 1-4;6
(THIS SECTION NEED NOT BE CDAIRETED OF THE PERMIT IS FOR ONE HUIDREDDOLIARS($lOD)OR LESS).
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE
WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME
SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTlON 3700 OF THE LA OR
CODE,I SHALL COMPLY WITH THOSE PROVISIONS.
DATE:_/c?/ 1 APPLICANT:T+.A J-
WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL, D SH LL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3708 OF THE LABOR CODE. INTEREST,AND ATTORNEY'S FEES.
CONSTRUCTlON LENDING AGENCY
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION 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 HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
1 AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES.
T hI° ryes.
PERMITTEE NAME(PRINT)
J
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SIGNATURE OF P ITTEE/."4'TE
APPLICATION �', �f
PERMIT Kd L_P/C
IQ �
NE -4
DATE
ISSUE n
TYPE
G h� �I 150C
DATE ONST. GROUP
ZONING SETBACKS
FRONT RW ^
REAR ^
SIDE/SIDE STREET RW ^
SIDE ^
PROPOSED USE�tpr't 7/
t/.Y S t'-
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N0. DWEL. 0. N0.
UNITS STORIES BEDROOMS
DESCRIPTION SQ. FT. FACTOR PSF ADJ.AREANALUATION
SFR/ADD/REM
Garage/Carport
W Patio/Deck
LL Pool/Spa
0
Re-Root 9,4
Z
Commercial
m
Valuation dam' ADJ.AREA
QUANTITY DESCRIPTION FEE
U
U
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0
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0
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PLAN REVIEW
ELECTRIC
PLUMBING
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INSPECTION FEE
ISSUANCE
SMIP L
ENERGY P/C
ENERGY PERMIT
RETENTION FEE: (�^
PRE-ALT FEE:
TOTAL FEES i L
COMMENTS
fA is -7-1
RECPT. N0. PAID BY VALIDATION
PC,
WHITE-Department Copy,YELLOW-Finance Copy,IN Assessor Copy,GOLDENROD-File Copy. GREEN-Applicant's Copy