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_�� CITY OF DIAMOND BAR �' - DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES � __� . 21660 E.Copley Drive Suite 190 (909)860-3195 F�(909)861-3117 PRESS � ��'9N°� � BDILDING PERMIT APPLICATION FIRMLY �h' JOBSITE �}�,�f Q o�; ADDRESS /'�I�� ���x.��lr � DATEICATION�/_/����/ NUMB R /"'"`� #JC U���� P �= APN LOT TRACT ` D TEE II`I�'"� /a ONST. GROUP O- OWNER �'.f-nl,��.va� t�XAJyiJ�9XR�//y �N "' ADDRESS_ �#d�L DE=Z�c�T ZONING SEfBACKS 0 Z=, CITY �lst+��j�!'L ZIP `��7�� TEL. �'d�'"6�° FRONT RW ❑ g APPLICANT�11/� Pla/�'r% TEL. .S"55�77tf REAR ❑ � SIDE/SIQE STfiEET RW ❑____ CONTRACTOR ���� ,iJ'Js+4 �i►�+�:7� �`jj/i� Q�u;7 SIDE C ife �' ADDRESS :�'dj E. �iJ�/s/+f.f�c; tJpJYi' �A►'��C�' ..wtN `� p' CITY _�./ .!liawit ZIP !'7 TEL. ,s`°�'i9�''I7�' PROPOSED USE �3+�r"�7�PN�"G � �lL w i ARCH/ENG! (+�1�-�as-Ae.!� �.�J icH clfi�tc'� z: DESIGNER t��N;� NO.DWEL. NO. NO. pW.; ADDRESS y!i`/ �•�3F/>li� 1�= � UNITS I STORIES L BEDROOMS � �- CITY _S7l�/�l.�+�S ZIP �/7x7 TEL.•.S'9�i-77�' _ y DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANAlUAT10N �;. �, OWNER-BUILDERDECLARATION . -SFR/ADDlREM - - O: �:- I HEREBV AFFlRM UNDER PENALTV OF PERNRY THAT 1 AM E%EMPT FROM TFiE CONTRACTORS LI- GdfBQB/C8f(70fI �- . W' CENSELAWFOPIHEFOLLOWINGREASON(SEC.7o3t.5BUSINESSANDPHOFESSIONSCADE:ANVCIttOfl (n U;�COUMYNRi1CMRE9UIflESAPERMfr7000NSTRUCT,lLLTEH.tl.!PROVE,DEMa1SH,OflflEPAIRANYSTRVG W pp�ia/Deck - �: Z> 7�JqE,PRIDR TO ITS ISSUANCE,ALSO HEEQl11RES THE APPLICANT FOR SUCH PERMIT TO FILE A SI6NED H W' �.STATEMENT THAT NE OR SHE IS LICENSED PURSUANT TO THE PPOVISIONS OF TNE CONTRACTORS LI W - �'�. CENSEUW(CHAPTER9�COMMEfiCINOWI7HSECTION7000)OFDIVISION30FTHEBUSINESSANDPRO u- PooUSpa iF � FESSIONSCOD�ORTHATHEORSHEISEXEMP7THEREfROMAN07HEBASISFORTHEALLEGEDEXEMP- (� i�__ q �-TqN.ANYVIOLITKKiOFSECT10N7071.58YANYAPPUCANTfORAPENMITSU&IECTSTHEAPP�ICANTTO Z R8-ROOI - - - - # �_ 'ACML PENALTY OF NOT MORE TrIAN FIVE HUNDflED�OLLARS(f500).j: �__ 0_ ❑I.ASOWNEHOFTNEPROPERtt,ORMYEMPLOYEESWITHWAGESASTHEIRSOLECOMPENSATION, - 0 COmmefCial -� Z,_ .WILL UO THE WORI(M1D THE STRUCNRE IS NOT INTENOED OR OFFERED FOR SALE(SEC.7044,BU51 J - � NF55 ANO PRDFESSIONS CADE:THE fAYTRACTORS LICENSE lAW COES h'OTAPP.YTO!W OWNEROF - � . PROPERTYN7fO8UpD50RiMPF�YESTHEREON.ANDWHODOESSl1CNWORKHIMSELFORHERSELFOq -- � �i'r- IL�$ - �� 1� �� THROUGHHISORHEHOWNEMPLOYEES,PROVIDED7HATSUCN�MPHOVEMENTSARENOTIN7EN0EDOR- ' m � j.- W- OFFEfiFAFOR3A�EIFHOYlEYER7NEBWlDMGORIMDROVEMENTISSOLOWITHMONEYEAHOFCOMPLE- - - � 0' -TKKi.THE OWNEH-BUIIAER WILL HAVE iHE BUROEN 6F PqOVING THAT HE oN SNE DID NOt BUII.0�R � I� . �._ IMPROVE FOFTHE PURPOSEOF SALE). - . - !�- ❑I.ASONMEROF7}�EPROPERTY,AME%CLUSIVEIYCOMMCTINGWITHLICENSEDCOMRACTOR3 ' - ��- TO CONSTRUCT 7HE PHOJECT(SEC.7041,BUSINESS AND PROFESSIONS CODE:TME GONTRACTORS ll- - Vditla}I0� d ADJ.AREA (� W- CENSELAWOOESNOTAPPLYTOANOWNEROFAPROPERTYWHOBUILDSORIA7PflOVESTHEREON,AND : � Z N4qCOMMCiSFORSUCHPROJEC7SWtTNACONTRAC70R;S)L�CENSEDPURSUANTTOSHECONTRAP � QUANTITY DESCRIPTION FEE . F' TORSLICENSEIAW.). - �/ /'} 1.- �� ❑I MS EXEMPT UNOER SEC. B.&P.C.FOR TMS REASON : 'Q �� � !� ��( �D d/ '�� � I� I � DATE oVlNER F" Z. W_ �_ LICENSED CONTRACTORS DECLAflATION W . �-.-'I HEREBYAFFIflM UN�ER PENpLTY OF PER/URY THAT IAht LICENSED UNDEfl PFOV�SIONS OF CHAPTER � - �_ �9(CQUMENCPHIWIPHSECTION7UOO��FONISION30FTHE8USWESSANDPROFESSIONSCADE,AND z. XL' "MY LiCENSE IS M FULI FORCE AND EFFECT. LLI m o uc�se c��u,s(s�_(E�"_( ua No.�ii i Sd3 . � ; . � -DATE__j.LIL�1,3;�( CONTRACTOR YJ'i�IKL.G[W� a":. W > � � - a . _ _ i` _ � WORKERS'COMPENSATION DECLARATION � Q �: � IXEREBY0.FFlRMUNDERPENPLT'OFPEPJUPYONEOFTHEFOLLOWINGOECLAMTIONS: U - � Z � Q - �.. IHAVEANDWILIMAiNTAINACERTIFICATEOFCONSENTTOSEIF-INSUREFORWOPKERS' _ � �- COMPENSATION,ASPROV�EDBYSECTION37000FTHELABOfiGODE,FOflTHEPERFORMANCE �U OF THE WORK FOF WHICH THIS PERMR IS ISSUEO. � W.;: � _I HAVEANO WILLMAIPITAiN WORKERS'COMPENSATIO�J INSUMNCE.AS REOt11RED BYSECTION �_ Q� � 57000FiMELABORCOOE,FOflhiEPERWRMldiCEOFTHEWOIiI(FORWHICHTHISPERMITIS �I� J/� 0- ISSUED.MY WORKEHS'COtdPENSATION INSUflANCE CARNIERAND POLICY NUMBER ARE: CONSTRUCT�ON ! //�� � ¢ �' cnaA�en � PLAN REVIEW ��i b� � Z� � : aouCYNUMaER ELECTRIC �'• ¢ �. (IHLSSECTpNNE�NDTBE ,PERAY�ISFORONEHUNDRED0."7LLPAS(Stao)ORLE55� - PLUMBINCa � Z ICERTIFYiHATINTHEPERFORMAN WORKFORWHICHTMISPERMITIS�SSUED,1 MECHANICAL (,�J- SHAllNO7EMPLaVANVPER50NIN MA RSOASTO MESU&IECTTOTHE �_ WOPoCERS'COMPENSATION LAWSOF 0.kN� THA'IF I SHOULD BECOME INSPECTION FEE -� SU&IECTTOTHEWORKERS'CAMPENS NPROVIS FSECTION370oOFTFiEIA�OR �_ CADE,ISH�LLFORTHWITHCOMPLYWITH ISSUANCE ��0� � oA�: i-i � gr �)°►'����,� sM�P o �, f' APPLICANT: - W_ - ENERGYP/C _ WARNING:FAIIUHE TO SECURE WOflKEHS'CAMPENSA710N COVERAGE IS VNLAWFIIL,AND SHALL BE --- �. SU&IECTANEMPLOYERTOCRIMINALPENALTIESANDCIVILFMESUPTOONEHUNDREDTFiOL'SAND ENERGYPERMIT /61 OOLLARS(f700,000).IN AD�ITION TO TNE COST OF COMPENSATION,DAMAGES AS PROVIOED FOR IN �` -J� SECTION37080FTHELAOORCO�E,INiEREST,ANDATTOPNEI"SFEES. (aE7ENTIONFEE: nt■ " (\ •t6lil� J OO Q: . d� CONSTRUCTION LENDI AGENCY PRE-ALT FEE O � IHEREBYAFFIHMUNDEflPENALTYOFPERJURYTHATT FE ACAN5TRUCTIONLENDINGAGENCY - - - d FORTHEPEHWRMANCEOF"fHEWOPKWRWHICH ISP ITISISSUEO(SEC.9097,qV.C.). - W � .�- LENDER'SNAME � F—�- LENDER'SADORE55 . �- ICERTIFVTHATI VEREADTHISAPPLICATION OSTATE7HATTHEA90VEWFORMATIONISCARRECT. TOTALFEES / � IAGREETOfA L-WITHALLqTYANDCOU RDINANCESANOSTATEIAWSRELATINpTOeUILDING (/''} :� CONSTRUCTI .AND HEREBY AUTHOR ESENTqTIVES Of THIS COUNTY TO ENTER UPON THE �S���{,/ }E . .Z ABOVE-MEM PROPERTV WR CTION PURPOSES. COMMENTS - _ � � _ � I"�.�Y4� 4�y 3.3� . . . -m PERMITTEE NAME(PRI - : .� . 11 �e� _ �� -SIONANREOFPERMITfEE DATE � _ RECPT.NO. 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