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_ -� �� � �� �- _} �� CITY(7F LIIAMOND BAR -�-�"��-" DEPARTMENT QF COMMUNITY&DEVEL(3PMENT SERVICES � 2166Q E.Capley Drive Suite 190 ��" (909)864-3195 Fax(909)$61-3117 /� � PRESS �'�� BUII,DING PERMIT APPLICATION FIRMLY � ADORESS �� �" �L �'��'j ��/J�� APPLICATION �� PERMIT �` P!C /�C., `"a � G � C, RATE NUMBER # �1 � APN �OT TR G ISSUE TYPE OCC � {� J —�_—._ C7ATE CONS7. GROUP p OWNER IG Oj�/--� G3/.�J/i/�_.. p AdDRE$S 2�`Z- ZONING SETBACKS r W GITY��h. ZIP TEI. - SZ FftQNT RW ❑_ � APPLICANT (�.�- �aT�LQ� TEL� Z..( REAR ❑y � SlDEtSIQE STREET RW ❑_ r� CONTRACTOR_ SIDE �_�� � C6DRE8S ZIP TE�. PROPOSED USE ti�'►b ! �.J� r��u ARCHlENG/ L � DfSIGNER� NO.pWEL. / NO. ( NO. ADpRESS UNIFS t STQRIES _(_.. BEDRdqMS � CITY ZIP TEL. � xn DESCRIPTIdN SQ.FT. FACTOF2 PSF ADJ.AREANALUATION p� OWNER-6UILDER DECLARATION SFRtADDiREM �p I HEREBY AFFlRM UM�E%PENALTV OF PERh.IRv TNAT I AM EXEMPT FROM THE CONTRACTORS U� G2fdgelCflfp4rt W CENSEUWFOR7HEFIX.L�WINGRF�SON(3EC�D31.68USINESSANDPROfE5510N5GODE:ANYGTY4R {f) U CWNTYVhi1CHRE0UlRE5APERM(FTOC6NSTAUGT,ALTEii.iMPROVE,DEMOLISH,ORREPA�ftANYS7RUC- W P8I10/DBCK � NRE.7RKlq TO ffS ISSUMICE,ALSO REOUIRES THE APPIICANT FOR SUCH PERMIT TO FILE A SIGNEO W � STATEMENT TNAT HE OH oNE is tiCENSED P4IRSUAN7 Tq THE AR4VISIONS OF YHE C�'TRACTORS li� CEN9E UW(q-NP7ER e(ibidMENCiNO wITH SECTION 7906)OF DIVISION 3 OF TME BUSINESS ANo PRO. u' POOUSp9 �� FESSI(NISOI�DE)QRi}1ATHEOfl5ME15E%EMPTTHEREFROMANDhfEBA518FOfiTHEALLEGEDEI(EMP� � � Ti�N.NiYYKK.ATqMOFSEGTfCJN7031.58YANYAPPIiCANTFORAPERMiTSi.iBJECTSTHEAPPGCANTTb Z R8-ROOf � �CML VENALiv OF NOT NIORE THAN FNE HUNDREp Od.LAFs(f5oo).): � ❑I,ASOWNEROFTHEPROPEATY.ONMYEMPLDYEF.SWITNWAGESASTHEIRSOLECAMPEN9ATKNJ, � ��merciai YML D�TNE WOAK,liF�ME STRllCTURE IS tbT MTB�IDE�i}R OFFERED i"OR SALE(SEC.�044,BUSf• J � NES$AND PFpFESSIONS OODE:7NE I:ANTRACTORS LICENSE LAW DOES NOT AiplY TO AN OWNEfl OF � PpOPERTY Wl1�BUILDSOR qAPF10VES TMEREON,ANDNN4 DOES SUCH WOftK HItdSEIF Ofl HERSEIF 4R Cr 7HROt,16HiiISORHEqQWHEMPLOYEES,PROViDEOTHATSUCHIMPR6YEMENTSAREN07MTENDEDOR m ' Q OFFERmFORSALE.IF,FKNNEVERTHEBUILqNGORIMPROVEMENTISSOLDWITHINONEVEAROFCOMPLE- ` � TqH,THE C1WNEf1�9tIH.QER WiLL MAVE mE Bi7ft4EN Oi�PR4YIMG THAT HE OR SNE Di0 PIQT 9Ui�D OA 91 � IMPROVE WNTME PURPCMSE 6F SILLE), – Gf �� W C71,A40WNEflOFTHEPpqPERf'/,MIE%CIUSIVELYCONtMCTIN�N7THlICENSEDCONTRACTOpS p� ra ca+sTaucrnt�vRwECT{5Ec.�uu,Bus�NEss ar���ssroNs coaE:Tws caNrauaraRs u� Vaivation .�ADJ. REA 611 GENSEUWDOESNOTAPI'LViqANOWNEROFAPPOPEFlTVWNOBU7LDSORIMPROVESTHEREi?N,AND � WNOWNTRACTSFORSUCx1PqQlECTSWITNACONTRACTOR(S)LIC£NSEDPVNSUANTTOTHECpNFRAG Q(JANTITY DESCRIPTION �E � 70R3 Uc9isE uW.i. . � IJ i AN£%EMPT UNDER S6C. 8.&P.C.F�fl TMIS REASON Q � o�rE �3_. ..i x; avnaes J��������aA �t,/"''bv-� v jl ����� z � � CIGENSED GONTRACTORS 6ECtARATION w CC IHERESYAFFIHMUNQEfl?EN/1.NOFPERfURYTHATiAMLiCENSEDUNDEftPNOY1510N50FGNAPTEH d 9(COt�MhENCWO WITH SECTqN 10W)OF ONiBpN 30F ri1E OVSiNfSS pND PROFE5510NS GO�E,AND Z � J / �� MV LICENSE IS IN FUII FOFiCE AND EFfECT. � 4 � LICENSE CLASS___ LIC.NO, j � J ,�y DA7E_... CONTR0.CT4R_„ _ n- ���-- W � WORKERS'COMPENSATtON DECIARATtON a � i HERE6V FfFIRM UNDER Pf_NKTY OF PEFilUFiY OkEOFIHE F6LLOYf3NG OECLAAATlONS: z f� `IMAVEANDWILLM/JNIAINACERlIFICATEOFCON$ENT70SFlK-INSIIRECpRWORKERS' ¢ L y,� CAMP9t$117KK�,A:PRQV�ED BY SECTlON 3�0o G7F 7HE LAHOR CODE,FOR THE P£RFORMANCE W � OFTHE WKIiiK FOp WHICH iH15 PERAIIT IS 135UEp. � � �1 HAVE AND WILL MI.INTAIN WOPKERS'COMPENSATbN INSUMNCE.AS REOl11RF�8V SECTION .L -'"f �,../ '�y d alop OF iME LABtlR CODE,FOfl 7HE PERFORMANCE OF THE WaRN FbR WHIGH iN15 AERMIT IS �'] �U � tSS41ED.MY WORKERS'COM�ENSATION iN3UAANCE CARPoER XNO POLiCY NNAOfRARE: CONSTRUCTICSN ��� r yc�ppiea PtAN REVlEW . � POLIGYNUMBEH_ ELECTRIC - _� � (RYSS[tMaJNC-�rprBECO/.RE7E�OFTHEPERIMISFY?RONElAN�Df�lEDOU.U�as(Sloo)opLEss� PLUMBING _ ��� �. � I CERTiFYTNAT iN TiiE PERFORNANCE OF TNE WORK FpR WHICH THiS PERM�T i5155UED,i MECHANICAL _, _.�• � SHAI.I.NOT EMPl6V ANV PERSINI IN ANY AIANNER SOAS TO BECAME 9UBJECT TO THE WOflNERS'CDI.kPENSATIUN UWSOF CAiifORNiA,ANO AtlREE TttA71f i SMQULQ 0EC6ME �NSPEC��IC}N FEE .�.�L.�c'' � SV&lECTTO THE NXJpKERS'COMPENSATIpN PRpV1510NS OF SECTION 3]OQ OF THE LABpR i !/� CAbE ISHALL FOflIHWITH GOMPLV WITMTNOSE PHOVISIONS. �$csUANCE __ t t /J� � SMIP p _ APPLICANT: _.. *. — UATE � W0.RFNNG:FAIlUR6 TO SECItqE WORN£RS'Ol3MPENSAiION COVERAGE IS UNIAWFVL,ANU SHALL BE ENERGY WC ._�i� _ ,. ___„ ^7' ,,,, „ _ �y S�flIECTANEMPLG7VERTOCRIMINALPENALTIESANDCIVILFINESUPTOONEHUN�HEDTHOUSAND +lF�!'����z,+���1� f)OLtAP$(=tq�,v00},IN ADQITipN T�THE C4STffF GOMPENSATION,DA}AAGESAS PflOYl0E0 FOR(N ENERC�Y PERMIT ___ � SECTN7N370BOFTHELA80HWOE,MTEHE*af.ANDATTORNEV'SFEES. FETENTIONFEE: � ._.__.�.�_�_� � CONSTF#UCTiON LEPIpING AGENCY PRE L F �CI� , ,_.__ � 1 HE0.EBY AfFIRMS UNDER PSVM,TY OF PEiUtlRV THAT THERE 15 A GQN51"RUGTION I.EN�71NG AGENCY _ _ KOR TNE GEPWRMANCE OF THE WORK PoR WHICH THIS pEflM1T IS IS5UED(SEC.3087,CN.C.�. �yy " _ � I,ENDER'SNAME „�_,,,, ,� � F— IENDER'SAODRE55 -- W TOTAL FEES �p�,�., - � '� ICERTIFYTHATIHAVEREADTHISAPPIICATK?NANQS7ATETHATTNEA90VEINFOFUiAT1IXiISCARREt;2 ^���"""}}} �� � 1 AGREETO COMPLV WITH ALL CRY AND COUNTv ORDINANCES ANO STAiE UWS RELATING TO BUII.DING ��,/� �'�/�,..� � C:ONSTRUCiION,AND HEREBYAUTHORRE REPRESENTATNES OF THIS COUNT'TO ENTEF UPON THE T /YaR�7 Y 1 A8C}Y£-MENTKJNEb PROPERTY FCNilNSPECi'AN PURFOSES. j C/ ���..f�� � , COMMENT ,,,,,__ � ������ � _ - d (�ER,6�1�rTi7E)E�NAM�{"RIMT� � //{'`' .l.. ,.!'-T-. _—` -�'���..... ') �CJi �1 / � L.L.. � 51(ii1JATUREOFPEflMI7TEE AATE �'F1��N �J�,. � RECPT.NO. 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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 .n' PRESS FIRMLY WHITE-Oepartment Copy,YELLOW-Finance Copy, PINK-sesso GOLDENROD-File opy,GREEN-Applicant's C r CITY OF DIAMOND BAR INSPECTION RECORD DATEINSPECTC3RINSPEGTIDN DATEINSPECTC>R 001-: r� � .-,