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_ � � � �� � CITY OF DIAMOND BAR � COMMUNITY DEVELOPMENT DEPARTMENT 21660 E.Copley Drive Sui[e 190 PRESS (909)860-3195 Fax(909)861-3117 j """' BUILDING PERMIT APPLICATION FIRMLY � `� JOBStTE � APPLICATION 9 PERMIT ����,-� P/C ':o ADDRESS DATE NUMBER # c� ISSUE ,,a' '�� TYPE OCC APN LO � T�FACT DATE '� CONST. GROUP °C OWNER �./J�.(/ .�G/P�_ LLO ADDRES ZONING SETBACKS Z CIN ZiP�TEL FRONT RW ❑ p APPLICANT TEL. 5 DElSIDE STREET RW �7 z Q CONTRACTOR � ' SIDE ❑ O ADDRESS v •, n! CITY fitlt. '(�17R9 TEL. PROPOSED USE w ARCH/ENGI W DESIGNER NO.DWEL. NO. NO. a_ ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. r� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION .Q. OWNER-BCILDER DECLARATION SFR/ADD/REM O p_ I HEREBV AFFIflM UNDEfl PENALTY OF PEHJURY THAT I AM E%EMPT fROM THE CqNTRACTOR3 LL - Gfll890/C8(POR Ll.l CENSELAWFORTHEKOLLOWWGREASON(SEG7o91.58USINESSANDPROFESSKKJSCODE:ANYGT'OR . (n- C7 CIXINTYWFtICHREWIRESAPERMITTOCONSTflUC7,ALTEfl.IMPROVE.DEMOLISH.OflREPAIRANYSTflIJC- - W patio/Deck � TUflE,PRIOR TO lT3 ISSUPNCE,AlSO REQU�RES THE APPLICANT FOR SUCH PEFMIT TO FILE A SIGNEO ` -W STATEMENT THAT HE�R SHE IS LICENSED PUHSUANT TO THE PROVISIQVS OF TNE CONTRACTORS L6 -- W - -:� CENSE LAW(CMRPTER B(COMMENdNG WITH SECTION 7000)OF DIVISION 3 0F THE B1/51NE55 AND PRO� -- �LL' POOI/SP8 FESSIONS(bDE)ORTHATHEOPSHEISEXEN.PTTHEHEFROMANDTHEBASISFORTHEALLEGEDEJ(EMP- - �.(� -� TION.ANYVIOLATIONOFSECilON7097.58YANYAPPLICANTFORAPERMiTSUBJECTSiHEPPPLiCANTTO ' Z R8-HOOf ACIVII PENALTV OF NOT MORE THAN FNE HUNDRED DOLLARS(ESoo).): - � ❑I,ASOWNEROfTHEPROPERTY,ORMVEMPLOYEESWITHWAGESASTHEIRSOLEC6MVENSAT�ON; �;. -� COfllmefClBl -�--. WIll00 THE WOHK.AND THE STRUCTUpE IS NOT�NTENOED OR OFFERED FOR SALE(SEC.7044,BUSI� = J N._ NESS AND PROFESSIONS�DE:THE CONTpACTORB LICENSE LAW�OES t�pTAPPLV TO AN OWNEROF c �_. - PROPERTYWHOBl11LD50HIMPFOVESTHEREQY,ANOWHODOE55UCNWORKHIMSELFORHERSELFOR : --��- THHWGXMISORHEROWNEMPIOYEES,FFiOVIDEOTHATSUCHIMPROVEMENTSARENOTINTENDEDOq ��; -m. W-: OFFEREDFORSALEIFHOWEVERTNEBUILDMGORIMPROVEMENTiSSOLDWI7HINQUEVEAROFCOlAPl6 �-- �0- TION,THE OWNERAt11lDER WILL HAVE TF7E BUPDEN OF PROVMG THAT HE OR SME DID NOT BUIID OR - . _ . . _ .._�._. IMPqOYEFOATHEPURPOSEOFSALE). - - - - - - ❑I,ASOWNEHOFTNEPROPERTY.AMEXCL�SIVELYCONTp0.CTING,YfITHLICEN5EDCONTRACTOHS � �� TO CONSTqUCT THE PRQIECT(SEC.7oa6,BUSINE55 AND PflOFESSIONS WDE:THE CANTMCTOflS LI- �/dlU8fi0� ADJ.AREA .W. CENSEUWDOESNOTAPPLYTOANOWNEROFAPROPERNWHOBUILOSORIIAPROVESTHEflEON,AND € ��-- N?IOWNTRACTSfOq5UCt1PRWECTSY/�THACONTflACTOR(5)LICEMSE�PUHSUANTTOTHECONTHAG :�- QUANT�TY DESCRIPTION FEE TORS UCENSE LAW.). Y ���- ❑I M1 EXEMPT UNDER SEC. B.S P.G FOR THIS REA^uON = Q - O U � CC �DATE OWNER .__�_ � U � W _� L�CENSEO CONTRACTORS DECLARATION ' W - �• IHEflEBYAFFIRMUNDERPENALNOFPERJURVTHATIAlALICENSEOUNDERPROVISIONSOFCHAP7EH -(L.. 9�COMMENC�NG WITH SECTION 7oW)OF OIVISION 3 OF THE BUSMESS AND PflOFE5510N5 COOE AND Z C. x MYUGENSE IS M FULI fOqCE AND EFFECT. - W: m �`- UCENSE CIASS LIC.NO. ' j ~- DATE CON7RACTOR d CS=- w � ORKERS'COMPENSATION DECLARATION ` Q _ � U � IHEAE9YAFFIRMUNDERPENALNOFPEiL1URYONEOFTHEGOLLOWINGDECtARATpNS: ' �' Z �:�- I HAVEpND WILL MAINTAIN ACERTiFICATE OF Cl,AYSENT TO SELFdNSURE FOR WORKEfl5' . 2 - � �COMPENSATION,ASPflO�iDEDBY5EG7fON37000FiFIElA80RCODE.FORTHEPERf-0HASAhCE U = ¢� OF THE WORK FOR WHICN THIS PERMIT IS ISSUED. - - � O' W-- I HAVEAN�WILL MAINTAIN WORKERS'CAMPENSATION INSURqNGE.AS REWIRED BY SECTION O__ 3�oUOFTHELABOflCODE,FORTHEPERFOPMANCEOFTHEWOflKfOflWHICHTHI3PERMiTIS " ISSt1ED.MY WORKERS'COMPENSATION INSURANCE CARRIER aND POUCY NUMBEfiAHE: CONSTRUCTION �- J �:-. CAflflIEfl PLAN REVIEW ��: POI.IGYNUMBEP . E �IC " � d: ' (iHLSSEC7pNNE�NDTBEODMPLEfEDOFTIEPEFiMTISKN7Q�IEMRDRED001.1A9S(E10D)ORtESS) PLUM8ING � - � ` �• �� £ i Z � �CERTIFYTHATMTMEPERFORMANCEOFTHEWORKFOflWHICHTHISPEflMITI5155UED,1 ME NICAL � � '-. �) - SHAL4NOTEMPLOVANYPEHSONINANYMANNER_SOASTOBECAMESUBJECTTOTHE . ��: - � :: WORI(EPS'CDMPENSATION LAWS OF CALIFORNI0.0.NDAGREE TF1AT IF I SHOULOBECOME - ( TION FEE �i j � SUBJECTTOTHEWORKERS'CAMPENSATIONPflO ISIONSOFSECTION37000FTHElABOR t� g� �'�^' �... � - CADE.ISHALIGORTHWITHCOMPLVWI7H� Jp�� / _ �� /� SMIP � . p::DATE:���l�� APPLICANT. �G.�' '�e'' . w ENERGY P/C J�-WARNMlG:FAILURETOSECUflEWORKEfiS'COMPENSA710NCAVEPAGEISUNLAWNL,ANDSHALLBE ' �y SUBJECTANEMPIOYERTOCflIMINALPENALTIESIWDCIVILFINESUPTOONEMUNDREDTHOUSAND _ ENERGYPERMIT ` DO{.LAFiS(Si00.OW).IN ADOITION TO THE COST OF CAMPENSAT�ON,DNAAGES AS PROVIDEO WR IN t. J -SECTbN310BOFTHELA90RCODE.INTEREST,ANDATfORNEYSFEES. - - R�ENTIONFEE: � �_ CONSTRUCTION LENDING AGENCY pqE-ALT FEE: " - � IHEREBVAFflHMUNDEIiPENALNOFPERIURVTHATTHEREISACONSTRUCTIONLENDiNGAGENCY FOR THE PEflFORM/WCE OF TME WORK FOR WHICH TMIS PERMIT IS ISSUED(SEL.30W,CIV.C.). � W � LENDER'S NAME F_- LEN�EHSAODRE55__ . w ICEflTIFVT1A7iHAVEREADTHISAPPIICATIONANOSTATETHATTHEABOVEINFOqMATIONISCORRECT TOTAL FEES ��• � - �y IAOPEETOCOMPLYWITNALLCIT'ANDC011NTYORDINANCESANDSTATELAWSRELATINGTOBUIL�ING � CONSTRL1CilON.ANOMEREBYAU7MORIZEREPRESENTATIVESOFTMISCOUNiYTOENTERUPONTHE � pBOVE�MENT10NED PROPERTY FOR INSPECTION PURPOSES. � COMMENTS 0 J � � PEHMITTEE NAA1E(PflINT� ¢ -�.� ��� � � 61GN�TUHEOFPERMIT7EE UATE �� - �j _ � RECPT.NO.������s PAID BY�� ���� VALIDATION �"' WHITE—Department Capy,YELLOW�inance Copy,PINK—Assessa Copy.GOLDENROD--File Copy.GREEN—ApplicanYs Copy �.n_R ..� _::_ � .. _n , ��I_� _.��_..__._ . 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