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�� _ CITY OF DIAMOND BAR
� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
c . � 21660 E.Copley Drive Suite 190
� (909)860-3195,;Fax(909)861-3117 _ PRESS
���y�'� BUILDING�ERMIT APPI:ICATION FIRMLY
( N JOBSITE / A �. APPLICRTION PERMIT /C
� ADDRESS ,/��a� Jl� ��'�c�OCt L A/' DATE � � NUMBER �� #
$ ISSUE TYPE OCC
APN LOT TRACT DATE CONST. GROUP
p OWNER �[,l7�j�T'f�` �C�AiC7(•x�.�'
o ADDRESS �C3/1- - C, C.N° ZONING SETBACKS
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cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION
�t O-. OWNEFl•BUILDERDECLARATION SFR/ADD/REM
o I HEREBY AFFlflM UNOER PENr1LTY OF PE0.NRY THRT i AM EXEMPT FROM THE CONTRAf,TORS LI- G8f8QB/C8f(IOfI
,f W CENSEUWFORTHEFOLLOWINGREASON(SEC.]a31.SHl1SMESSANDPROFE55bNSCODEANYCITYOR (n
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LL� TUflE,PRpR TO ITS ISSUANCE,AL50 RE�UIRES TME APPLILANT FOR SUCH pEflM1T TO fILE A SIGNED W
� STATEMENT THAT HE OR SHE IS LICENSE�AURSUA�4T TO THE PROVISIONS OF THE fANTRAL'TORS LI-
¢ CENSE LAW(CHAPTER 8(COMMENCING WITH SECTION 1000)OF DIVISION a OF TH[BUSINESS AND PRO- LL' PooUSpa
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� ACIVIL�ALTYOFNOTMORETHANF�VEHUNDREDDOLLARS(E500)J:
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Z� N7LL DO THE WORK.AND iHE STRUCTURE IS NOT IN7ENDE0 OR OFFERED FOH SALE(SEC.7044.BU51- J
NE6S AND PiiOFESSIONS CWE:7HE CAMRACTOHS UCENSE UW DOES NOT APPLV TO AN ONRJER OF <
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Q iHHOUGH HISIXi HEROWN EMPLO7EE5,7HOVIDEO TN117 SUCH IMVROVEMENTSARE NO7 INTEN�E00H
'� Q .OFFEREDFORSALE.IF,HOWEVERTHEBUII�INGORIMPROVEMEN71550LDWITHINOI.EYEpROFCOMPLE� 4
:� z. TqN,YHE OWNER-BUILOER WILL HAVE THE BURUEN OF PqOVING THAT HE OR SHE�10 NOT BUILD OR
Y �= IMPROVE FOR THE PUHPOSE OF$ALE�.
U I.AS OWNEH OF THE PqOCEHiY,AIA E%CLIJSIVELV CANTRACTINC WRH LICENSFA COMPJ CTORS �
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� W; CENSEUWDOESNOTAPPLYTOANOWNEROFAPftOPEfiTYWHO�URDSONIMPROYESTMEREON,AND
r3 �; WNOC�NTpACTSFORStJCHPHalEC7SWITHACOYfRACTOR(S)LICENSEDPURSUPMTOTHECONTRAG QUANTITY DESCRIPTION FEE
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� ❑I AM E%EMPT UN�ER SEC. B. P.C.FORTHIS REASON Q
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da� LfCENSED CONTaACTORS DECLARATION w
� ¢ 1 HEREBY AFFIRM UNDER PENALTV OF PERJURY THAT 1 AM LICENSED IiNDER PNO\'ISIONS O`r CHpaTER � --_— —
'�' e(GOMMENCING WITM SECTION 7oa0)Of 01YISiON 3 OFTHE BU51NES5 0.ND PFOFE5510�5 COUE,AND Z
W UCEN9E IS IN FULL FORCEAYD EFFECT m
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� �..�;. WORKERS'CDMPENSATION DECLARATION � � —
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��N' I HERE9Y AFFIRIA UNDER PENALTY OF PERJUHY ONE OF THE FOLLOWING DECLARATIONS:
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� :'0 _IHRVEANDWILLMAINTAINACEHTIFICATEOFWNS[NTTOS'cIHNSURF.FOPWORKe'(lS' _ -- ---- _
.� COMPENSATION,AS PROVIDED 8Y SECTION 370o DF THE LAHOfi COUE,FOH TH[PENFOflMANCE W _
OF THE W09K FOH WHICii THIS PEHMIT IS ISSUED. �
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� W ,_I HAVE AN�WIIl MAINTAIN WORKEHS'COMPENSATIIXJ INSURANGE,AS REOUINED BY Si:CTIGN p��
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�;,�,. ISSUEC.MV WOflNERS'COMPENSATION INSUfiANCE CARHIFR AND POI,ICY NUMBER ARE�, CONSTf�UCTION ___,�,'��r t _ ��;� ,
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:�; aoucvNUMeEa_.___.__.__.._.—. ELECTRIC ( ._...___
�4 (f}USSECIIOVN[EDNO7RECOMPLETEDOFTHEPEk4tlfISFORIXJEI�NNOREDWILNiS�EtIX7)ORLESS? PLUMBING �1%{. �i i :�'i F�,�vi.: _.—...__."'_ __ _—.___..._____—
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z,;, I CERTIFYTHAT IN THE PERFOAMANCE OF THE'NORK FOR WHICN THIS PERMIT IS ISSUED,I MECHANICAL ,. . r, �"�°�f i� ]�,l\ _ __ �
', („j' , SHALLNO'I'EMPLO'fPNYPEfl50NINANYIRANNERSOASTOBECAME3UBJECTTOTHE �Y��'� , , i -' " �, ;
.'���, WORKERS'COMPENSAlIO�LAWSOFCALIFOftNIA.ANUAGHEETHATIFISNOUlUB[COME INSPECTIDNFEE+�-^ - �c���_„
.-� 6U&IECi TO TriE WORNERS'COMPI"NSATION PROVISIONS OF SECTION 37000F THE LAPOR '�j�;��-t1}�1��, f � :1_ �'���—
,,,� COOE,ISNALLFORTHWIMCOMPLYWITH7HOSEPROVISIONS. - ISSUANCE - •
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�..p� DATE: APPUCANT: _____"."_.'_' � — .
��w� ENERGY P/C
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',.�y; SU&IECTANEMPLOYERTOCRIMIN�LPENALTIESANDqVIIFINESUPTOONEHUNDHFDTHOUSAND ENEHGYPERMIT
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'���;, SECTIDN37oeOFTHELABOfi00DE,INTEREST,ANDATTOFNEY'SfEES. RETENTION FEE: ___ _._.______._.__._. -__. -
w� CONSTRUCTION LENDING AGENCY PRE-ALT FEE:
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'���: I HEREBV AFFIRA/UNDER PENALN OF PERJUFY THAT THERE IS A CONSTRIJCTION LENDING AGENCY
� a-�' FOF THE PERFORMANCE OF THE WORN FOR WFIICH TNIS PERMIT IS ISSIIED(SEC.3097,CIV.C.�. ���'�-'��
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„�� LEN�ER'S NAME _.___—__-"_ _"__—'
...F=�� LENDER'5A�DRE55______ .-._...'_'_-.._._ I � ♦
�'�? ICERTIFVTHATIHAVEREAD'fHISAPPUCFTIONANDSTATETHATTHEA90VEINFOFMPTIONISCORRECT. TOTAL FEES
W' IAGREETOCbMPIVWITh1ALlCITVANOCOUNTYORDINANCE5AN�5TAlELAWSRF:LATINGT08U1LOWG
� '�� CqNSTRUCTION,PND HER[BV AUTHpq�Z[REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
-Z� ABOVE�MENTIONEO PROPERTY FOft INSPECTIOY PUFlPOSES.
� COMMENTS_._,._
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,,= RECPT.NO. PAID BY __,_____ __VAIIDATION.._.__ __
���~ WHITE—Department Copy.YE —Finance Copy,PINK—Assessor Copy,GOLD NRO ile Copy,GREEN—Appiicant's Copy
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