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� . ' _!� CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY&DEVELO � ai�o E.c�iey n►�;�e su�c�i90 PRESS (909)860-3195 Fas(909)861-3117 ��`'^N'� BUII,DING PERMIT APPLICATION FIRMLY o DDRIESS� 1 � L:-���' DATE CATION f C .-�-� p NUMBE��� ` � #JC t ISSUE TYPE OCC � � APN--�-�— LOT TRACT �ATE CONST. GROUP � p OWNER � �J � i ��P�F�D � ADDRESS ���aS, \ {��` ``j ZONING SETBACKS g CITY `G`n q;�("ZIP TELI �P�3���.- °.�(� REART � � APPLICANT TEL. � SIDE/SIQE STREET_�� V1�fln11 ❑ � CONTRACTOR ���T t�\I�� �Zr{�' o � SIDE p _,_ � p� ADDRESS � ' "'�: ' � �� t .ROPOSED USE j ;'� C% �• " ' ��'1�� � cirr �� l�i�'�t�, ZIP i i"li3� TEL.L : t�i��i a � :a�i ARCWENG/ ` ,y W DESIQNER NO.DWEL. � O. NO. � CDDRESS Z'P �L UNITS '' STORIES ' BEDROOMS � cn DESCRIPTION SQ.FL FACTOR PSF ADJ.AREANALUATION Q OWNER•BUILDER DECLARATION SFR/ADD/REM O �. I HEREBY AFRRM UtiDEP PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI� . G8f898/C8lPOlt til� l�NSEUWFOflTHEFOLLOWINGRFJISON(SEC.7037.58USINESSAN�PROFESSIONSCO�E:ANYCITYOP (� U COUNTVW}IK7{q[.p�IRESAPERMRTOCONSTRUCT,ALTER,lA/PROVE,DEMOLISH,ORREPAIRANYSTRUC- � - -..W.' -TURE,PRIOR TO 1T9 189UANCE,PLSO RE4UIHE3 THE APPLICPNT FOR SUCH PERMIT TO FILE A SIGNED - W PaNO/OBCI( �: STATEMEFR TMAT HE ON 5HE I5 LICENSE�PUFSUANT TO7HE PROVISIONS OF THE CAMRACTORS l4 � SSS� CENSE UW(q1APTER e{COMMENCINO WITH SECTIOY 7000)OF DIVISION 3 OF THE BUSMESSAND PRO- POOUS{18 �-. FESSIONSCODqORTFIATHEORSHEISIXEMPTTHEREFROMANDTHEBASISFORiHEALIEGEDEXEMP- � � . TION.ANYVpLAT10NOFSEC710N7W1.50YANYAPPIICANTFORqPERMITSU&IECTSiHEAPPLICANTTO . RB-R00} r_ A CML PENAL7YOF NOT MORE THAN FNE HUNDRED DOLLARS(SSoo�)� - - -��: ❑I,A60WNEROFi}IEPROPEf1TV,OflMYEMPLOYEESN7THWAGE5A57HEIR50LECqMPENSATION, - COfil(f16�Ga1 = - . W1LL DO TNE WOHIC,AND TXE STRUCTURE IS NOT IMENDED OR OFFEflEO FOR SALE(SEC.7044,6U51� J . �. NES4 A.YD PROFESSIONS CODE THE CONTflACTORS LICENSE LAW DOES NOT APPIY TO pN OWNER OF � PHOPERTY WFiO BURDS OR�MPROVES THEflEON,ANO NMO DOES SUCH WORKHIMSEIF OR HEflSELF OR . -��. THFqUGHMI50HMEROWNEMPIDYEES,PROVIDEDTHAT3UCHIMPROVEMEMSAREhOTINTEN�EDOR m - Q .OfFEREUfORSN.EIF,HOWEVEiLhIEBUILDINGORIMPROVEMENTISSO�DWfTHINONEVEAROFCoIUPLE - � - ---Z-. TION,THEOWNER$UIIDERWILLFtAVETH58URDENOFPROVING-THATliEORSHEDIO-h0T8U1LAOR- --- - - -� _ - _ - - - . _��� IMPROVE FOR 7ME PURPOSE Of SAIE). - - . . W.. ❑I,A$OWNEHOFTHEPROPEHTY,AMEXCLUSIVELVCONTRACTINGWITHIICENSEDCONTMCTOHS /^+y'��.� � �-: TO CONSTRUCT THE PRO.IECi(SEC.706d,BUSMESS AND PROFESSIONS CODE:THE CONTRACTORS U- -VdlUdtiOfl �s'°•✓ RDJ.AREA - -W--. CENSEUWDOESNOTAPPLYTOM'Ori'NEflOFAPROPERTYWHOBUILD30RIMPHOYES1HEflEON,AND - -_�'- NRIOCONTMCTSFORSUCIiPROJEGT5N7THACONTflACTOR(S)LICENSE�PURSUANTTOTHECOMRAG - QUANTITY DESCAIPTION FEE - . �� TORSUCENSEUW.�. � . -��- ❑I AM EXEMPT UN�Efl SEC. 0.&P.G FORTHIS FEASON Q - .-��. V .. .. . , . . - . . LL ¢ DATE OWNER U OW - --�,,,._ LICENSED CONTAACTORS DECLARATION �W - . ��- IHEREBYAFFIRMUNOERPENALNOFPE0.IURYTHATIAMLICENSEDUNDERVROVISIONSOFCHAPTEfl � --'--a-- 9(COMMENCINCiWfiH3EClIQN7oa0)OFDIVISNJN30FTHEBUSINESSANOPROFESSIONSCADE,AND Z ;X- MY LICENSE IS IN FULI FORCEAN�.EFFECT. - m 1d.1 'J�(�'� �p�, ��.. UCENSEp CLASS �y��cl-� LIQ NO. �(�TsCqJ�������i� - j _V: DATE !A—�7-*'1� CONTRACTOR�'7FE',lt�� 1Cl@.1��� n:. . w Li., ,�_ WORKERS'COMPENSATION DECLARATIDN tt ��! 6 I.. g . . . ��.�._. -IHEHEBYAFFIRMl1N�ERPENALTYOFPE0.NRYONEOFTHEFOLLOWINGDECLARATKKJS: � � - � -G-�. IHAYEANDW1LlMAINTAINACERTIFICATEOFCONSENTTOSELFiNSUREFORVlOqKEfl5 ay -�i--; - COMPENSATION,ASPROVIDEDBYSECilON37000FTHElA80RCO0E.WRTHEPERFORM�NCE ,U OF 7HE WOflK FOR WHICH iH�S PERMIT IS ISSUED. � �i -�� I HAVE AND WILLMAIMAIN WORKER9'COMPENSATION INSURANCE,A9 RE�UIRED BY SEC?�ON { / ��+� Q-_: 370o OFTFiE IABOR WOE,FORTHE PERFORMANCE OP THE WORK f-0R WHI.H iH!S PEflMIT IS r f1(/� yyJ � ISSUED.MY WORKEFAS'COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE: CONSTRUCTION t (/ I t � - �j.- caaaiEn - �c�{�[1���� _ , .�� PLAN REVIEW - � ;Z; pouCV NUMBER ��"�L�J " �7r �"�� ELECTRIC _._ d ---0' mnssEcnaur�xo7eEmr.w.ErmaFn�aEw�ur�sFoaoriE��nr�000uaas�s�ao�oa�ss�. PLUMBING - -w- _ .,z, i CEflTIFYTHAT IN THE PERFORMANCE Of THE WOflK FOR WHICH THIS PEPMIT IS ISSUED,I MECHANICAL ' ��j� SHALLNOTEMPLOYANYPERSONINANYMANNERSOA5T08ECOMESU0.1[CTTO711E - =�_-_ -WONKERS'COMPENSATIONLAW50FCN.IFORNIA,ANDAGReETHATIFISHOU �9ECOME � -�NSPECTIONFEE- - - - SUBJECiTO TH WORKERS'COAIPENSATION PROVIS OF SECTION 37 F�HE LA60R ;�- CODE,i ORTNWITHCOMPLY WITH SE ONS. ISSUANCE r `O,. � --. .���' SMIP d - DA7E:/ APPLICANT: �_�.:_ WMNING:FAILUREiOSECUREWORKEHS'COMPE�N� VERAGEISUI C,-AND5HALLBE ENERGYP/C ����]'S_ZL r v _�; SUBJECTANEMPLOYERTOCHIMINALPENALTIESANDCI ILFINESUPTOONEHUNDREOTHOUSAND - L�I���li1 � � � �OLI.ARS(5100.00�).IN AODIiION TO THE C0.5T OF GOMPENSATION,DAMAGES A5 PROVIUED WR IN ENERGY PERMITB,�T_B � :-J; SECTION97080F7HELABORCODE,INTEREST,ANDATTORNEI"SFEES. RETENTIONFEE: �- eQ' __ . _."_'__ . �.::d: CONSTRUCTION LENDING AGENCY pRE-ALT FEE: s-0= -^Qr IHEREBY0.FFIRAAUNDERVENALTYOFPERJURYTHATTHEREISACONSTFUCTIONLENDMGAOENCY -- '��� GOR THE PERF-0RMANCE OFTHE WOflK WR WHICH THIS PEfiMIT IS ISSUED(SEC.3087,qV.C.). . . .Zi;. `W'i. - LENDER'SNAME � - '�`, :.F-'.-�- LENDER'SAODRE55 `�t ICEflTIFVTHATIHAVEREADTHISAPPUCIITIONANDSTNTETHpTTHEABOVEINFOFlMATIONISCAflRECT. TOTAL FEES . . � - 'W� IAGHEETOCOMPIVWITHALLCITVANDCOl1NNORDINANCESANOSTA7ELAW5RELATIN6TOBUIL�INO - - - - ���� CONSTRUCTION,AN�HEREBYAUTNORIZEREPRESENTATNE60FTHISCOUNTVTOENTERUPONTHE - - - . ��ABOVE-MENiIDNEO PROPEHiY FOH INSPEGTION PUflPO5E5. � COMMENTS - � :_ ..'��t�: - �m PERM� P - Q. �-�r ��y ,S . _ ' SNiNA R OF � �__ � ,�_,___ RECPT.NO. PAID BY � VALIDATION - - - HITE-0epartment Copy,YELLOW—Finance Copy,PWK—AssessorCopy,GOLDENRO�File Copy,CaREEN—Applicant's Copy _ � �������� ;. _i...�. t�..; �,._.� T � j�� 4I �,• j �-- � �� r�� � �,E°-'t -r i �....� E" ..f . . -.�. .�._..c .._.' 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