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Home My WebLink About18164 �'" CITY OP DIAMOND BAR `��` DEPARTMFNT OF C4MMUNfTY&DEVELOPMENT SERVICES ��;,�. i ✓ ,�� 21825 E.Copley L)rive (909)860-3195 Faac(909}Sb i-3117 PRESS � �Y�� BUILDING PERMIT AFPLICATION FtRMLY � JQBS(TE �� N f G�� /� # O�ti � �L.1 � �L r APPL�CATIt7N ! PERMIT P/C � ADpRESS�_ ✓1� r QqTE UMBER #--Ry� ._ � ISSUE � j �� TYPE OCC APN LOT TR CT DATE � N5T. GROUP �-�j OWNER ��" � d ADDRESS � � " J " r ZONING SETBACKS z CITY � y'2!P _�1'EL � FRONT RW O p APPLICANT _ � ' T L. t^ � REAR ❑ � SIDEl51BE STREET RW C] � CONTRACTOR^ _ S�pE U ADDRES5_� '� CITY ZIP TEL. ^ PROPOSED U5E w ARGH/ENG/ � 2 DESIGNER M� '4 `"L�� —�`'��,`-�a��--=�:;— NO.DWEL. NO. NO. _ �DDRESS��C�.-�_�� T�` �` UNITS STORIES BEDROOMS _ �'t;�� 6-�—�� . � { - cNn DESCFtlPTffJN S . ACTOFi FSF ADJ.AREANALUATICiN � OWNER-BUILDER�ECLARATION SFR/ADDlREM � {� O (� i HEAEBY AFF�RM VNDER PENAt,TY OF PERJUflY TMAT 1 AM EXEMPT FflOM THE CONTRACTOflS L4 G8f8 J8/C3fPOfI W CENSE LAW FOR THE FOIL�]WINq REASON(3EC.�037.5 BUSINE55 AND PROFESSION5 CODE:ANV CITYOR (n C.� CAUNTYWNIGNftE4UtRESAAERMITTOGIXJSTRUC7',AITER,NiPftOVE.DE�USH.ORREPAiRANYS�RUG (jJ pafio/Deck W 7VRE,PRION TO ITS ISSUANCE,ALSO PEQUIRES THE APC�ICANT FOR SUCH PERMIT TO FILE A SIGNEp w _ +� STATEMENT THqT HE OR SHE IS LICENSED PURSUANT Ttl THE PROVISION5 OF THE CONTRACTORS LI� � .�,r CENSE tAW(CHAATER 9{COhfMENClNG WITH SECTI6N 7006}oF O�VISlON a OF 7HE BUSiNESS AND PRO� POOUSpd � FESSICSNSCODE�ORTHAT�iEORSHEISE%EMPTTNEREFROMANOTHEBASISFORTHEALlE6EDEXEMP• (� TION.ANYVIOLATIQNQFS4:CTIQNT031.66YANYAPPLlCANTFORAPEfkAITSV�JECiSTNEAPPLiCRNTTO Z (je^R�}}f A CIVII PENAL7V OF NOT ih�RE THAN iiVE HUNDRED DOliAfiS(3500�.): C'�I,ASOVINEROGTHF:PROpERTVORMYEMPl.0YEE9WITHWAGESA51}IEIRSC7LECbMPEN$ATION, Q � Commsrcial Wlil D(J THE V10AK,AND THE STRVCTURE!S N4T!»TEN�ED OH OFFERED FOR SAtE(SEG.7obd,BUSI� J � NESS AND PROFESHiON3['ADE:THE CONT(iACTONS LICENSE lAW DOES NpT APPLY TO AN OWNER OF � PROPERTV WHO BUILDS ON IMPROVES THEfiEON,AND WNO DOES SUCH WOFK HIMSF.LF Ofl HERSELF OR CC TNRtJUGNHtSOftHEROWAtEMP�OYEES,GftQViD£CITHATSUCHiMPRQVEFdEN'SARENOTM7ENOEDOR m � OFfEREDFORSALE.IF,HOWEVER,THEBUILDINGORIMPROVEMENTISSqlDWITHINONFYEAROFCOMPIE� Z TION,THE OWNER�9UIL�Eq WILL HAV[THE BURDEN OF PROVING 7HAT fiE OR SME DID NOT eU4LD OR � IMPF�VE FOR THE FURPO£E OF SALEj. � '� W ❑I,ASbWNEROFTH[PROPERTV,AMEXCLUSIVELVCONTRACTiNOWITHLICENSEDGUNTRACTOflS �'[ TO CANSTflUGT TNE PR6JF_CT(SEC.704a,BUSINESS ANO PROFESSIONS C90E:TNE GONTRAClORS�I� V2IU8ti0ti ADJ.AREA_„ W CENSF Uw 60ES N4TAPPlY T(7hN pWNER OG A PROPERT'WHD BUIt�S OR iMPR(7VE5 THEREON,AND ` - � WHOCONTRACTSF4RSUqiPROJECiSwITNA,�pOt;RRC CENSEDPURSUANI'TOTHECONTRqC- QUANTI DESCRIPTIQN FEE 'TORS tiCENSE LAW.j. ��:'"� � � �J I AM EXEMpT UNOER 5 �_ 6.6 P.C.FOR THIS REASON Q ( 3 u / " I.L .. . Q �, , . � DATF ,u_i__„_ ,_OrikER' U L �' ' . � .... W °. ,,n. ^.,. _., i � �IGENSED CONTRACTOF46 DECLAF4ATION � CL� I HEqEBVAFFIRM UN�ER PF:NAI.TY OF PERJURY TNAT I AM UCENSED UNDEH PflOVI$IONS OF CHAPTER � i (Z 4{COMMENGWGWITNSECIION?OW}OfDiViS10N+OFTHEBU57NE55At�Aft6FESS�ONSCODE.AND Z �X MV LICENS[i9 M FUIL FOflCE AND EFFECT. m � � v ,,LL � LICENSE CiASS,�,_ ,,,_LIC,NO.�, „ � �� _�� .....—....._ � ' � ,. _. . � J � �e,."..�' . V pATE, „__ ^� CON7RACT4ft,,,_ a- � W � WORKERS COMPENSATtON DECIARATiON Q r� --�YL � .j ` � I NEREB�AFFIqM UNOER PENqL7v OF PERJURY ONE OF iHE FOLIOWING DECLAPATl�NS� z `� " � C1 IHAVEANOWILLMANTAINACERTIFIC.ATE6KCON9ENT70SELf-INSUREFORWORNERS' ¢ + � Z. � \" Q �GOMPEMSATI�N,AS PROVIDEb BY SECTION a?4o Of TH£IReOR GOOE,fOft TNE PEHFQRMANCE 'U OF TNE WtlRK FpR WHVCIi TNi9 PEqMiT IS ISSUED. � � � � _t HAYE AND WiL�MPJNTAIN WORKERS'COMPENSATION INSt1AANCE.AS REOUIRED BY SECTIDN ((""''�] { r , Q 3700 OFTHE LAB(7R CODE.FOR THE PERFORMANCE OFTHE WQRK FpR W411CH THIS PEHMITIS -�{ � ISSUED.MY+NUftKE135'COMPENSATIONiNSURR4CECAftftiERANCPOi.IGYNUM6EftARE CONSTRUCTION t _ � caaqiEa`�_, PLAN REVIEW �) �, - . D� ��—�� cauCVHOMasR.____. � ELECTRIC _ ` ¢ a �7tasSEcrc1NNEEDN�iBEo�dpl.EiWOFTHEPERh6TI5wRct�cn.a�OFtEDR�.tARs(f�aolca�Ess). PlUMB7NG _ ... W �� I CEAT7FY THAT W TF��.E PERFORMANCE OF THE WpfiK fOR WHICH THf9 PEftMiT IS iSSUcD,1 MECHRNICAI .,. , („f SHALi..N(�T EMPL+JV dNY PERSqN�N FNV MANNCi1$O AS TO BECOME SUBJEC7 TO TNE � WORNERS'COMPEN'3ATIONLAWSOfCALIFC7RNIA,ANOAGREETNATIF'ISHUULDBECOME INSPECTIONFEE _ � F SUBJEC?TOTHEWCRHERS'COMPEYSATIONPROY1510NSQFSECTIOh37G00FTHEtA84fl —yC-� = CO�E,I SHALL FOflTHWITH COMPLY WI�H THOSE PPOVISIONS. �$�UANCE „ 1� 4 SMIP p UATE: . . APPLIGANT�. _�_ --- �� --- . J WARNING:FAIIURE TQ S'eGUqE WQP,KGI15'CCIMPENSATION GOVERAGE t5 UNtAWFUI.,ANp SHA�l.BE ENGRGY P/C ,,,, _ . _, � SUBJECiAN EMPLOVERTO CRiMINA_GENALTIc'S ANp ciVI1.FINES UP T40NE HUNDRED THpUSAND ENERGY PERMIT DOLURS(f 100.000),IN AbDI110N TD THE cOST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN - ^-� � SECTKrN 3i08 OF THE IRSOP VODE,iNiERES7.AR70 AiT4RNEYS FEFS. RETENTION FEE: � � CONSTRUCTION�ENDING AGENCY PflE-ALT FEE: � Q —T � IHERE9YAFF�RMUNDERPEPIALTVOFPERJU%ViHATTHEFlEISAGONSTHUCT'IONLENOINGAGENCY fOR THE PiRfORMANCE OF�LI{E WQ4K fOft WHIGH THIS P[RMIT IS ISWED{SEC.309],CIV.C.). � W — S I.ENpE@'S NRME � i' ._. _..._ ..._.__.._��___ F;- t,EN�ER'SAbOfiESS_..._Tr...... � � � 1 } � ICERTIFVTHATIHAVEREAD'fHISAPPLICATIONANf/STATETHATTMEA90VEINfORMA�lON15CORRECT. TOTAL FEES �� --� • � IAGFIEE?�COMAi.YW)THR�I.CiTYAYDCGUN�YOftDiNANG€SRNp5TA7'�EL+.WSREIATlNGTQ6U11.DING ��++,,�{t,} • � CONSTRUCTNJN,ANDIiEREB'IAUTHORIZEREPRESENTaTI .hRISC ENTEflUPON'HE �� Y � ` // e»<�� ABOV6MENTIONEO PROP�RI V FOR INSPEGTIO � ��aL}G' I COMAAENTS `�'� ��" a _�� . � .....— � _ }��-.-_ � � � PERMITTEE M1hME(PftINT) ' Q �- i�,�'� _. (I� � �..�/�[�� -- �n 91GNAiUREOF7ERMITTEE DATE y[�! '�,. t , = RECPT.RO. _.[�....V'�) _. PAID 8Y _. ��4 VAItDAT10N ~ WHITE—pepartment Copy,YELIOW—Finance Copy,PINK—Assessor Copy,GpLDENRO[?—File Copy,GREEN—ApplicanCs Copy �� ,�q. � f t�.:r�?y� � - �. � `��y �'d ry.� , . . ;, -., .} ��e�'.:'t'i/�..r�� .. �.a�"i� '�s`^ .-i �.� � . �� - � //��/�/d.-, � � . . .. ... . . �rl. . ... . ... .. . . ._ .. .. .. � �. . < . . . � .. :. .. ... .... ..... ._ .. .... . . � . .. .. ... ... .. ... .. . . , , . .; .g��. a� . .. .... ... . . . ._ . .. . . . .._ .. .. . ��. �. ;a�r w.�;°b��c�°�` '. �jzc�p3 ��-`�e., ��,KT ��.3 .��-rY z��Y�� y.�ba� � �i�� TrGS � �~ _ _ _ _ _ a , � �� t � �� .n � � � x �z� � �s�� ' ��` �.. �� ,_�� *��,�e �� 'i�a T , : — _ .; G�4.� I �^'�. i' s: � � ,, � k � ^�� .... _ . .. .... . .. . . . . ... . . .. . . .. .. . . . .. . .. .. .. ; i , -� i" � � a. . ,� � ��+�:. � �� G�� i� �� '��:+,� t�"'�:�ai�=` . .. .. . . . .. .. z`.U' � � �l� a+' .. ,'. ��e � �a�r �, � � � r,y��t�rE��, ��, � _ � iia�� t �� ;z' e . s�- ',�r�.a�. ��,s�gt, "`� s .. .... ...... . _... ... .. . . . . . .. . .. _. � ... , ��. ��.�m= : _. DLIMOJD BAR I I 3" ADDR ESS I 4 APN LOT TRACT OWNER'.e% ADDRESS 4 0 CITY � 1/ZIP TEL. •� APPLICANT T L. CONTRACTOR_ ADDRESS CITY ZIP TEL. ARCH/ENG/ 1 D 4 Y . LLL�, DESIGNER 1 -4 ADDRESS ^ I CITY Z4P yTEL{ 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 REQUIRESA PERMIT TO CONSTRUCT,ALTER.IMPROVE, DEMOLISH,OR REPAIRANYSTRUC- 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).): U I,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 YEAR OF 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). U I,AS OWNER OF THE: PROPERTY.AM EXCLUSIVELY CONTRACTlNG WITH LICENSED CONTRACTORS TO CONSTRUCTTHE PROJECT(SEC. 7044, BUSINESS AND PROFESSIONS CODE'THE CONTRACTORS LI- CENSE LAW DOES NOTAPPLY TOAN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND WHO CONTRACTS FOR SUCH PROJECTS WITH A,>wpMLR11CTL1 CENSED PURSUANTTO THE CONTRAC- TORS LICENSE LAW.). 0 I AM EXEMPT UNDER S 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 SECT ION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND MY LICENSE IS IN FULL FORCE AND EFFECT. LICENSE CLASS LIC. N0. DATE CONTRACTOR WORKERS'COMPENSATION DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS: I HAVE AND WILL MA NTAIN 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 (THIS SECTION NEED NOT BE COMPLETED OF THE PERMIT IS FOR ONE HUNDRED DOLLARS($1 00)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 WC RKERS'COMPENSATION PROVISIONS OF SECTlON 3700 OF THE LABOR CODE.I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS. DATE.APPLICANT. WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL 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 3709 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 CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION I5 CORRECT. AGREE TO COMPLY WITH ALI. CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATI ENTER UPON THE ABOVE MENTIONED PROPERLY FOR INSPECTIO //� PERMITTEE NAME(PRINT) y- ��1V SIGNATURE OF PERMITTEE DATE CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES 21825 E.Copley Drive (909)860-3195 Fax(909)861-3117 BUILDING PERMIT APPLICATION PRESS FIRMLY APPLICATION I/ljl P DATE,4 I �v/C UMBER ISSUE 0 I 1,(Y- OCC DATE I-CONST.GROUP DATE ZONING SETBACKS FRO NT RW^ REA R^ SIDE/SIDE STREET RW^ SIDE^ PROPOSED USE N0. DWEL. N0. N0. UNITS STORIES BEDROOMS DESCRIPTION SQ. FT. ACTOR PSF ADJ.AREANALUATION SFR/ADD/REM U) Garage/Carport LU Patio/Deck LL PooVSpa 0 Re-Roof Z Commercial M Valuation ADJ.AREA QUANTI DESCRIPTION FEE Q W L e'i � W Z ts, [0 �" 1 � i. I < r�YY c U k4 Z � � Q 2 I W 11� CONSTRUCTION PLAN REVIEW --- ELECTRIC PLUMBING MECHANICAL rl EV INSPECTlON FE E ISSUANCE SMIP rf ENERGY P/C ENERGY PERMIT RETENTION FEE: PRE-ALT FEE: TOTAL FEES rut:a ^+ COMMENTS RECPT N0. PAID BY VALIDATION WHITE-Department Copy,YELLOW-Finance Copy, PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy rl t 44/03 cux)5--6,c(-c zL•L J-jy JAi 5M-rOC X Pf ci 7ii )