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��� CITY OF DIAMOND BA� EXPIRED
DEPARTMENT OF COMMUNITY Bc DEVELOPMENT SERVICES
� 21b60 E.Copley tkive Suite 190 MAY 0 9 2003 pRESS
������ BUII.DIIVG PERMIT APPLICATION FIRMLY
� JOBSITE /"/� APPLICATIONJ �/�� PERMIT P/C
� RDDRESS�� C.G��„�C-�'� lYF�''`�I��'?�� ___t� tTCf � � �
�""� � � DATE NUMBER #
� IS5UE /',r IYPE OCG
APN LdT TRACT DATE ���� CONST. GROUP
�j QWNER � l� �U'L�"1�� ,�2� � ZONING SETBACKS
� ADpRESS ��—h-, FRONT RW (J
�" CI?Y �//.3"1t�Ni)/�L+r ZiP
� APPLICAtJT TEL. REAR ❑
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o CITY I"I�;%�/11i:�i,/i.L- ZIP`�s;+,(�_ TEL.
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� DESIGNER� NCI.DWEL. Np. NO.
ADDRESS UNITS STORIES BEDROOMS
� CITY ZIP TEL.
� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION
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� OWNER-BUILDER DECL4RATl4N SFRlAOOtREM
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p 1 MENEBY AiFIHM UNDEF PENAU'Y OF PERJURY THA7l MI EXEMPT FROM TNE CONTRACTORS U� GgfB(JBIC3lpQR
W CEFISEUWFORiHEFO1.RAYlR1GF1Flt£AN(SEC.7031.59US�NESSANOPF�ESSXJNSCODE:ANYCITY4R (j) �
G,� pOUNTYWHICHREOUWESAPERMITTOCONSTRUCT,ALTER.IMOpOVE,DEMOLISH,ORREPAIRANVSiRUG W Patio/Deck
`Z TUAE.PRIQR TO ITS ISSUANCE,ALS4 REW IPES TNE APPUCAN7 FOR SUCH PERMIT TO FILE A SIGNEp �
,� STAT£MENT 7HAT NE ON SNE i&110Eti5ED PURSUANT TO THE PROYISIONS OF THE WNTftAGTORS 41�
� CENSE UW(CFIAPTER 9(COMMENqNp Wihl SECTION 70(w)OF DIVI510N 3 OF TME BUSINESS AN�PRO- LL' POpVSPO
F£SSpNS t%'IDEj W17MAT HE 4H SHE IS EXEi.�T TNEREFftOM AND 7NE BAS�S FOR TNE ALIbGED EXEMP�
TION.ANYVIfN.�TIOf10FSECfION70.31.58VAK�'APVLICANTFOFlAPERMITSU9JEGTSTHEAPPLIGANTTO Z Re�Roof
r A CIVII PENALTV OF NOT R10RE TW W FNE MUNDRED DOLLAFiS(f5o0).):
� ❑CASOWNEROFTHEPRCWEK?Y,OktAYEMP�OYEESWiTNWAGESASTHEiRS4lFCOt.iaENSATioN, C� CommerCiai
WILL d0 TME WORIC,AND TFIE S7RUCTURE IS NOT INTENDm bP oFFERED FOR SALE(SEC.7at�.BUSb J
� NESS AND Vf10FES510N5 CODE:TF1E WNTRACTORS IICENSE lAW 06ES NO7 APpI.Y TO AN OWNER OF �
PR(WERTY YhiO8UKD50iY NAPqOVE6lHEREON,AP#}WtiO DOE5 BVGY{KK3RK FBMSELF 6R HERSEIF OR .
C[ TMROUGHNISORNEROWNEAIPLOVEES,VROVID6D7HATSUCHIMPRbVEMENTSARENOTWTENDED4R m
W pFFEAEpWpSKE.IF,h%iWEVER,h1EBU�DINQORIMPFWVEAtENTiS� •WfTHW6NEYEAti4FGOMPIE-
`? TqN,'iHE f?WNfN-6UM1AER WILL HAVE THE BURDEN Oi PflOViNG iHAT HE OR SHE DID NOT BURD 6R
� MPRKIVEFOR7HEf'UHPQSEOFSALE).
� pi,l30WNEAOFth1EFROPERfY.AME%CLUSiYEITCKINTFiACTiNCiWkTHtiCENSED�lJNTRACTORS
[L TO CONS7RUCT TiE PRQIECT(SEC.7014,BUSMESS N�10 PROFESSIONS COOE:THE CONTRACTOFiS 41� V211Uation ADJ.AREA _
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UCENSED CONTqACTORS DECLARATION �
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!kEAE6Y�iGFRW t1NDER FEF7h1.N QF PER1l7RY TNAT I MA UCEN5ED UNDER PROViS�6N5 Of CNAPTEfl �
� Y(COMMENCINO WITH SECTION ioao)OF OIVISION 3 OF THE BUSINESS AND PROFESSIONS COOE.AND Z _
MY lJCENSE IS IN Fl1LL FORCE ANC EFFECT.
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� WORKEfiS'COMPENSATION DECLAFiATIqN ¢ " "�/ ' J
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� I NEREBY AFFIRiA VMD£R PENAI.T'OF PER7URV ONE OF TNE FOILOW�NG DECURATIONS: Z _—
t3 _tttAVEANDY11lttMIM7AiNACEfliIFiCA7EOFCANS@JTTOSEtf-{NSUftEFpflWORKERS' S
� COMPENSATION.AS PROVIDEp BY SEC710N a7oo PF TME LA84�i CODE.FOR THE PERFORMANCE �U
OF TNE WQP1S FOP WMICH THIS PEFMIT IS�SSUED. �
,_�I HAYE AND V/ILL MAINTAIN W4RNER3'GOMPEN5ATION INSURANCE,p5 flE4UIRED 8Y SECTION
� 37000F TME 1A80A COOE,FOR ItiE PEFlFOAMANCE QF THE WOHK FOR WfiiCH THIS PERMkT IS —
ISSUED.MY WORKERS'COMPENSATION INSURANCE CARRIER AND PQLICY NUMBEP AaF: CQNSTRUCTION
� cu=cuE� PI.AN REVtEW —_
� POI.ICYNUM6ER_ __ ELEGTWC __..._
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I CEFiIFV TH�T IN 7HE PERFORMANCE Of THE VJl)RK FbR WHICH THIS PERMIT IS ISSUE�,I MECHANICAL �
� -��
SHALI NOT EM?LOY ANY PERSON IN ANY MANNER SO AS TO BFCOME SU&JECT TO THE 4NSPECTION FEE
{q WOi'�(ERS'COMPENSATIONUWSbiCALiFORNiA,ANDAGqEEiNA�iFt5H4VLD8E�ME � . , ... ��
_ SUBJECT TO THE WORKERS'UOMPENSATION PRt7VISIONS OF SECTION 310o OF THE IABOR ISSUANCE
s CAOE.t S l�ll FORTHWt7}{fAMPLY WITH THOSE PROY,13,�. — -'.....
O � � - - SMIP �. _p�"�-��T�
� DATE: y � ��, iAPPLICANT: _ --... C'�--q � �
� � �� ENEROY P7C ��!.1 ' '^' -�`�i�-. �+� _ .
J WARNINO:FAILURE T SECURE WORKERS'COMPENSATIpN AGE IS UNLAWFUL,ANp SHALL BE
LL St161ECTANEMPIOYEATOCRIMINAi.PENALTIESAN SUPTOONEHUNDREDiHOVSAN� ENERGYPER� �
MX.LAftSt;t00,Wp}.M7A6DRiOFI70THECOSTOFCOMPENSATpN.6MiAGESASPROVIpEDFORM . j"j,'�"",
� SECTNJN310BOFTHELA90RG170E,MTERE9T,ANDATTORNEV'SFEES. RETENTIQNFEE: - �j�Y'� [ ' ..__
� CONSTRUGTION LENDING AGENCY PRE-ALT FEE: Y�°'"4���� -
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CL t HER£8Y AFflRM lIh1�Ef2 PENAITV OF PERJURY TH0.i THERE IS A CONSTRUCTION IENDiNG AG6NCY ,,, __.
� FOq THE PEpFON1AANCE OF TNE WORK FOR WHICH THIS PERMIT IS ISSUE�(SEC.3tl61,CIV.C.). �
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� LENpER'S NAME
F� LEN�ER'SADDRESS„� (� • (/^��
� ICERT�YiNATiHAVEflF.MTFtiSAPM.iCATiONANdSTATETHATTHEABCIVEWFORMAT%NlISCQRRECT. TllTA�FEE� �� ""'
� 1 A6REE Tp CXJAIPI.V NAYH ALL CITY AND CAUNTV ORDINANCES ANO S7ATE LAWS RGLATING TO BUILDING
CONSTRUC7IQV,AND HERESY AVTiiORIZE fiEPRESENTATNES Of THIS COUN'fY T4 ENTEfl UPO!!THE
� PBOVE�AIENTIONEp GROPEqTY fOR MSPECTiON PURPOSES. _
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RECPT.NO. PAI6 BY VALIDATION
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DLlllll%11 BAN,
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ADDRESS. Gf
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APN LOT TRACT
OWNER/r�fu 1 L»
ADDRESS
CITY//�"lu/+t'/�PN zip T---
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APPLICANT TEL.
CONTRACTOR,�/GVA'/C.20,-4 1-/
ADDRESS
CITY/lIG'/Zi-L�i.l ZIPyiu/(TEL. 'Z
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 REOUIRESA PERMIT TO 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 FORA 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).
^ 1.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.
LICENSE CLASS LIC. N0.
/•/
TOR I/L-CfJ�/
DATE CONTRA
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 3700 OF 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'COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE:
CARRIER
POLICY NUMBER
(THB SECTION NEED NOT BE COMPLETED OF THE PERMIT IS FOR ONE HUNDRED DOLLARS (($100)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 SECTION 3700 OF THE LABOR
CODE. 1 S ALL FORTHWITH COMPLY WITH THOSE PROVI (�.
DATE: n N)APPLICANT.
WARNING: FAILURE T SECURE WORKERS'COMPENSATION AGE IS UNLAWFUL,AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AN ES UP TOI 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
1 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.
/
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PERMITTEE NAME RINT
SIGNATU EE ATE
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21660 E.Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
EXPIRED
MAY 0 9 2003 PRESS
FIRMLY
APPLICATION V rl n,0 PERMIT
7C{
P/C
v
I
DATE
#
NUMBER 1 J
ISSUE TYPE OCC
DATE C1 CONST, GROUP
ZONING SETBACKS
FRONT RW ^
REAR ^
1 SIDE/SIDE STREET RW
�
L
SIDE
�
PROPOSED USE
N0. DWEL. N0. N0.
UNITS STORIES BEDROOMS
DESCRIPTION SQ. FT. FACTOR PSF ADJ.AREANALUATION
SFR/ADD/REM
Co Garage/Carport
W Patio/Deck
LL Pool/Spa
a Re-Roof
Q Commercial
Valuation ADJ.AREA
QUANTITY DESCRIPTION FEE
J
U
w
w
CD
a
a t/
Z
S
W
CONSTRUCTION
PLAN REVIEW
ELECTRIC
PLUMBING
MECHANICAL 0
INSPECTION FEE
ISSUANCE
SMIP
ENERGY P/C.,._ 1 kR
ENERGY PERMIX-1
RETENTION FEE:'Nil)31
PRE-ALT FEE:
TOTAL FEES
COMMENTS
/10111
RECPT N0. PAID BY VALIDATION
WHITE-Department Copy,YELLOW-Finance Copy, PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy