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�� CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES �AY �� ����
21664 E.Copley Lhivt Suite 194
(904)860-3195 Fax(9Q9)$61-311� PRESS
�p�f BUII.DING PERMIT APPLICATION FIRMI.Y
�� JOBSITE �Q'�Q C'�i/��,(`��J }�� r7�� APPLICATIO � � PERMIT /�L���� P!C
AQpRESS �J L" 1�° ✓ j�E �' pATE Nt7MBER�. #
� ISSUE ! n ) TYPE OCG
APN l4T_ TRACT DATE t»�r� COIVST. GROUP
�j OWNER _..(��. �� -
c, ADDRESS_ _��, y,,,._�;�,�L���(-.�_'� ZONING SETBACKS
� GITY ' Z�P TEL. R�QRT RW � ._
APPLICA TEL g�p�{StdE STFEET RW C:)
� CONTRACTqR . � ' i SIDE ❑__
� ADDRESS 'A Ld,r�E;J�rC ' PftOPOSED USE � .�' ! �. �
CITY_,.,.�,�,��_�'aZIP��.�,k$t'� TE� .
� ARCWEN '���'�
z pESIGNEFt NO.DWEL. NO. NO.
ADDRESS UNETS BTORIES BEDROOMS
� CITY_ ZIP TEL. '
� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREA/VALUATIdN
as
� OWNER-BUILDER DECLAHATION SFRJADDIREM
O
[] 1 HEREBY AFFIRY UNDER PENALTV OF PERJUpV THAT i AM EXEMPT FROM THE CONTRACTORS l.l� � Garage/Carport
L1� CENSE UW fQRSHE FOI.LOWING REASON{SEC.TL11.5 BUSINE53AN0 PROfE5510NS CADE:ANY GITY OR
t,� COUN'iVWNiCHREOUiRESAPEflAi�TTqCONSTRUC7,ALTEfl,IM�ROVE,pEM�U5H2OflFiEPAiRANYSTRUG� W P8110/�BCk � �
WTURE,PRIOFl TO 1T9 ISSUANCE,AL56 REWIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNEp W .
STATEMfNT THA7 HE Ofl SHE tS LlCENSEO PURSUANT TO THE PR�VISIONS OF THE CON7RACT4RS li�
� 4ENSE UW I��'TEfl B(COMMENCINp WITN SECTION 7CN10)OF DIVISN7N 3 OF THE BUSINESS AND PRO� � Po0USp0
FESSqNSCUDEIORTHATMEOftSHEISEXEMP7THENEFROMANOTHE8A5ISFORTHEALLEGEDEXEMP� (�
71IXV.ANYVpLATpMOFSECTiON7�31.58YANYAP7lICANTFORAPEFiAAiT5U8JECTSTHEAPPUCANT70 Z qe�Roof
. � A qVl4 PENALTI OF NOT MORE THM!FIVE HUNDREb Oa.LAPS(f5oo�.): �
� f]I,ASQYlNERQFTHEPHOP£RTY.�NMYEMPl.OYEESWfTNWAGESAS11fEIRSOLECbMPEhlSATIDN, � {�`ptpR}grCi81
WFtL O6 TXE WOPoC,ANb THE STAtiCTURE IS NOT�NTENDED LSR OFFERED F4R SALE{SEC.7DAa,BUSi� _1
� NESS AND PFIDFESSWNS CODE:THE CONTqACTOR5 LICEN3E I.AW DOES NOT APPLY t0 AN OWNEq OF � .
VPOPERTY Yh108UND54R IMPflOYES THEREON,N1D WM4�OES SllCN WOfiK HIMSEIF Oii HERSEIF OR
L'L iHRpA}OMH�BORMEROWNEMPLOVEES,VHOYIDEbTH11TSUCHIMPROVEMENTSARENOTiNTENDEDpR m
� OFFEREDWRSN..EIF,MOWEVERTME@UILDINGORIMPROVEMENTISSOLDWITHINONEYEAflOFCQMPLE�
� TIOH,THE OWfiER�lSU#tDEft Yfit1 HAVE TME BURQEPt OF PR4YING'MAT HE OR SHE��NOT 8UIL4 6R
� IMPRQYE FOR TNE PURFOSE OF SALE).
W UI,ASOWNEROFTHEPROPERTY,AMEXCLUSIYELYCANTRACTINCWITMLICENSEDCONTMCTORS
(r TO CONSTRUGT THE PRQIECT isEG.J��t,BUSiNESS ANb PHOFESSIONS IX::nE:THE CONTRACTORS ti- Nylt12(IOI1 ADJ.AREA
W CENSELAWPOESNOTAPPLYTbANONMEROFAPqOPERTVWNC1BU14PSORIMPROVESTHEREON,AND
� Wr�ocoNTw�cis�'oasuct+cacufcrsw�rH�ca�TrucsoR{s�ucsNs�oeuruuu+TTomecor+Twa Q{�ANTITY DESCRIPTI6N FEE
� TORS tlCENSE UW).
J
C7 1 J4M fXEMPT UNDER SEC. 8.3 PG,FOR THIS REA54N �
� ._��._ �
� OATE _ OWNEH�,._ ' '__ U
� �ICENSED CONTiihGTORS DECt1tRATtON -'
� w _
i HERE9Yl1FFU7lS UNDER PEWLL7Y OF PERJUPY 7HAT tAM UCENEED UNUER PRQVISIOti54F GriAPTER �
(i p(COMMENCiNO WffN 56CTiOFt)006)OF DN�SNN 8 OF THE BVSINESS AND PROFESS�ONS 4:O�F,ANO Z
u; MV IICENSE IS IN NlL FOI7CE/diq EFpECT +� j �f' m
'��' UCENSE CI,ASS_�__ LIG.N�._••/�'Y-1'�13',�iL__...,._ �
VOATE� '� CONTRACTOR �
�, \���'ii-���_-.
� W6i2KERS'COMPENSATICSN DECLARATIp � �
� U
� i HERE9Y.i�E'1M4 VNDER PENAI.TY Oi PERJUNY ONE i?r 7NE FOItOWitJG D LAFATtON: — i
(n
Gl _,,,.1 HME ANO WILL MAINTAIN A CERTIFICATE QF CONSENT TO SELF�INSIJRE F9 '
'� COFiPENSATIOM.AS PROViDEb 9Y SFCTiON 3J66 GF THE 1A80R C6pE,�Oii THE PERFOftMAMCE
OF TNE WpRK FOR WHICH iHl5 PEHI.�IT IS I&SVED.
0
� I MAYE ND WILi MAIMAIN WORKERS COMPENSATfDN IN5UqANCE,AS REQUIRED BY SECTION
� �3700 qF THE LAB4R CODE.FOR THE PERFCIRMANC'.E 7F 7HE WORK FOR WHiCH TH�S GERMIT IS ��
4SSUE0�.FiY WORK£RS'CANPFNSATKNa MSURANCE CAHRIER�AND�/PIX�SC�Y NyUM6ER AftE: CONSTRUCTION _ _ __ ,
� CAHRIFR �� �.�f `�`� f LL'Rf_ ' (EW __. ..... ..��.. •
� PJLICY4UMBER___—�.�L. ..�_F7_ r Je�TRIC
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� (RYuSEGik."NNEFDNO78EaMRE7IDC3FiY�PEfiAYTISFORONE DOl LE ). u�LtlMBI
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� fcEsiT�fvtNAruarHEPEctFa�uuacEaFT�Ewoax�aawwp+T EaM�ris suE�,� CHANtCA� _..__.,�,,,
(� SMALI NOT EMPLOY ANY PERS4N IN ANY MANNEF SOA5 TO BECOME S �
U} WOflKERS'4"AMPENSATK7NLAWSOFCAl1FORNIAANDAGREETHATifiSHOUL08ECOME 1NSPECTIONFEE ._,
SUBJECT Tq THE WORKERS'09MPEt3SAT1dN PFOYISIONS Oi SECTION 3]OOOF TM1E LABOR 7,/��C�`'� (�/^�/�
� CO/[lE,1 SNALL FORTNWITH CbMPLY WI7HTHOSe PROVISIONS. ISSUANCE , ,� -�-'�/-�.,"^,�„
p DATE:__`d��_"f.""'.�__' APPLJCANT: _��, � . SMIP � .
� � � ENERGY P1C ..' . ` ' ; ',;
J WARNING:FAICURE TO SrCl3RE WORKER5 GOMPENSATIdN YERAGE�S VNLAWFUL,ANp SHpLL BE i' � �
�y Sl1fllECTANEMPL4VERTOCRIMlNALpENALTIESANDCIVILfINESUP?QONEHUNDflEDTNUUSAND ENERGYPERMIT ^J
OOLIARS(fi0D,W9j.INADRiTlONT07NECOuTOFCRMPENSATqN,QAA9AGESASPHQYI6EDFOftiN - . "" -'
� SECTqN]IOBOFTNELA80RCpDE,�N7EREST,ANpATTOflNEY'SFEES. RETENTIONFEE: T ,
d C6NS7RUCTtON l.ENpiNG A6ENCV PqE-ALT FEE: .
� _._..-- -.. ...._....
� i NER£8Y AFFIAM 1)NDER PENAlTY OF PERIUFIY TNAT THERE IS ACONSTRUCTiON LENOtNG AGENCY _ _
FOq THE PERKfRAlANCE OF 7HE WOpK FOR WHICH THIS PERMIT�5 ISSUEO�SEC.30B'/,GV.C.j.
� _
W �.... .. ..
� tENDER'S NAhfE__,_, —._...... __—�...
� IEMDEWSAD6RE5S ... --. C //�,,�
� !CERTIFY TNAT t HAVE REA�THIS APPLICATIOM ANO STATE THAT TME ABOVE INF4flMATKNi IS CAftftEGT. TQTAL�E[�S j/J�
4 I AGREf TO COFAGIY WiTH ALLCITY AND CAUNTY ORbMANGES AND STATE LAWS RELATiNG i0 BUILDING `rC
CAN5TRUCTION,AND HEREBV AVTHOqIZE REPRESENTATNES OF THIS GOUNTY TO ENTEfl UPON THE
� RH6VE-MEMTIONED PPOPERTY FQft iNSPECTKJN PU9P0.SE5. GOMMENTS_ _____
�
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� PEFMITTEE N E iiINT) .
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� ��� ���'v66 `�t��. �
� SIGNATURE PE 1 OATF ��
� RECPL NO.� PAICt 8Y ____ VALIDATIdN
WHITE-Department Copy,YELLOW--Finance Copy,PINK-Assessor Copy,GULDENRCIp-Pi4e Gopy,6ftEEN-ApplicanYs Gopy
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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
EXPIRED
MAY 0 9 2003
PRESS
FIRMLY
2
I
F CC� 1705 4
�C4 12&r
ADDR
ESS
V
-f
APN LOT TRACT
OWNER
ADDRESS A!!L�,��
CITY JILA TEL.
APPLICANT'TEL.
CONTRACTORi
ADDRESS 1114.4-4
CITY_(
ZIP J TE(
ARCWEN
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 REQUIRESA 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 FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS($500).):
C 1,AS OMMER 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).
C I,AS OWNER OF THE PROPERTY.AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC. 7544,BUSINESS AND PROFESSIONS COTE:THE CONTRACTORS LI-
CENSE LAW DOES NOTAPPLY TORN OWNER OFA PROPERTY WHO BUILDS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS WITH ACONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAC-
TORS LICENSE LAW.).
C 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 FORCF./INQ EFFECT.
QY
LICENSE CLASS
LIC. NO
_-�n'
DATE CONTRACTOR
WORKERS'COMPENSATION DECLARATIO
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING D . LARATION
I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR
COMPENSATION,AS PROVIDED BY SECTION 3700 CF 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 ER L'/-VFT4 wft"
POLICY NUMBER
(THIS SECTION NEED NOT BE IXA50.ETEDOF THE PERMIT IS FOR ONE LE).
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH T ERMIT IS SUED,I
SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SOAS TO BECOME S
WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME
SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 37000F THE LABOR
CODE.I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS.
DATE: �4" H APPLICANT:
WARNING: FAILURE TO SECURE WORKERS'COMPENSATION VERAGE 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 3708 OF THE LABOR CODE. INTEREST,AND ATTORNEYS 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.
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.
PERMITTEE PR
1 4 Ad
SIGNATURE PEWAIINEV' DATE
APPLICATIO(,0 PERMIT/C;/P/C
DATE NUMBER! #
ISSUE/q }TYPE OCC
DATE I/t7 CONST.GROUP
ZONING SETBACKS
FRONT RW
REAR^
SIDE/SIDE STREET RW^
SIDE^
PROPOSED USE-Y ! --
N0. DWEL. N0. N0.
UNITS STORIES BEDROOMS
DESCRIPTION SQ. FT. FACTOR PSF ADJ.AREAIVALUATION
SFR/ADD/REM
CO Garage/Carport
W Patio/Deck
LL PooVSpa
0
Re-Root
Z
0 Commercial
Ib
Valuation ADJ.AREA
QUANTITY DESCRIPTION FEE
J
U
W
-J
0
Z
Fn
2
J
CONSTRUCTION
IEW
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Ve
gt
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L
/
(PLt1MBl
CHANICAL
INSPECTION FEE
ISSUANCE
SMIP e
ENERGY P/C
ENERGY PERMIT
RETENTION FEE:
PRE-ALT FEE:
TOTAL FEES
COMMENTS
REC PT. N0. PAID BY VALIDATION
WHITE-Department Copy,YELLOW-Finance Copy, PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy