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� CITY OF DIAMOND BAx `�
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21660 E.Capley Ikive 5uite 190 '
(�os�abo-�t4sF��so9)s6i-3ri� �%V'�n�� �, ,.--` PRESS
•�'"".f BLTII,DING PERMIT APPLICATION � ' �•� FIR Y
o� JOBSITE � t� �p � APPLlCATION i /�,� G NUMBEA���_ #�
ADDRESS��� �I�l`-���!�Cac.F-" �lJ�.-- DATE� �
� APN �OT_ TAACT �SSUE /� 't'ypE p�C
�� p DATE u CONST. GROUP
p 4WNER _�_>�l.�,M--��-��,__is..t3.��� '
o AdDRE5S� � ZONiNG SETBACKS
�W CITY �g�'J��ZIP • }�j TE a FRONT Rqy U
j APPGlGANT �E�,�„_�,Q_�� TEL � SIDFISIQE STREET RW ❑
� CONTRACTOR_ �" � SIDE _ �
� ADdRESS1� % -.--
CITYS� .�l�}t s � ZIP � ' TE .1� r �- ts PROPOSED USE
� ARCWEN�a! -
� DESIGNER i NO,DWEL. NO. NO.
� AQDRESS UNITS STORIES � BEDROOMS
y CITY ZIP TEL.
N DESCRIPTION SQ.Fl: FACTOR PSF ADJ.AREANALUATIQN
� OWNER-BUIl.DER pECtARATiON SFRlADD(REM
O
p i HEpEBY AFFlRM UNDEfl PEMAL�V OF PER1UqY THAT 1 MA E%EMPT fROM THE CONiRACTORs l4 •(�ragBJCgt'pOh.
W CENSEtAWFOq77fEFOLLQWINGAEASON(SEC.7a31.58USiNESSANOPROFESSIONSCOQE:ANYqTYOR (f�
« OOINffVNkiK;tiREp11RESAPERMRlOCqNSTRUGT;ALTER,IMPRdYE,bEMGUSH,qRRF.i+AiRANYSTRUP I,[,I patio;Deck
�� TURE,Pfi1QR T4 RS ASSUANCE,ALSO qEpU�qES TFIE APPItCANT rOR SUCN PEflM1T TO fILE A SIGNED �
STATEMENT'f}1AT HE OR SNF IS UCENSEO M)RSUAN'i TO TNE PAOV1510N5 OF THE CON7RACTOHS LI-
� CENSE LAW{CHMTER a ja�1dMENCiNa WITH SECTION 7a.w)OF OiViSi6N 3 oc THE BUSINESS AND pR6- �'1' PoOVSpd
FESSIONS WpEy OR iHAT HE OR SHE IS EXEMPT TNEREFROM AND THE 9ASIS FOR THE/U.LEGEO EY(EMP� (�
TMDN,ANYVKK,ITIONOfSE�:TK7N7037,58VANYAPPLICANTFORAPERAi�TSUB,IECTSTHEAPPUCANT7Q z Ae-Roof
r AGMI pENALiY OF NO7 MORE 7'F1qN FIVE HUN�AED DOI.I.ARS(SS W).)-
� ❑I,lSOMMEqOF'THEVROPERTY,ORMYEMPLOYEESWlTHWAGESASTHEIR50LECQMPENSA710N, COmmefCi2l
WILL D��HE WOFiK,pP7p THE STHUCTUAE�S NpT tNiENDED OR OFFERFD F1JR SALE fSEC.70a1,Bti51- �
� NESS AFH)PROFESSIOMS tX�pE:iHE CONiRACTORS UCENSE!„AW ppES NOT APPLv 70.W OWNEA OF =
PPOPEFiTY rihlt�eUlLpS OR IMPROVE5 THEAECJN,ANp WFtO DOES SUCH wORK HIM5ElF OR HERSEIF OR
fS TNpOUtW MIS qR HER9MfiJ FAIPI.OYEES,PROVIpED 7HAT SUCH IMPROVEMENTS ARE NOT INTENDED OR �
� OFFEHEDKJRS�IEIF.tiOW&VERIMEBUIlDIN60RIMPpOVEMENTIS50{.pWITHINONEYENROftAMP�E-
TION,7HE OWNER-BLIILDEq WILS.MAYE TNE BURDEN OF Pq4YM/G THAT NE OR SHE DID NOT fiUILQ OH '
� IMPROYE WH THE PUqPOSE 8P SALE).
❑�,AS OWNER OF THE PR(?PEH7Y,M/E%CLUSNELY C9NTRACTINtl W1TH ItCENSED C6NTRACTQRS
(L TO CONSTRUCT T}I�PqW�Cr[SEC,70M,9USINESSAMQ PRpfESSiONS CODE iHE WNTAACTORS U- Y81t18tiOf1 ADJ.AREA
W CENSEUWDOESNOTMPLYTOANOWNEROFAPROPERTYWNO@UM.DS4NIMPROVES7HEREON,RNO "' —
� N1iOC�MRAGTSfQflSUCHDROJECTSWITIAGON!'RACTpq�S)UCENSEDPURSUANTTOTNECONlfUG- Q(JANTI7Y DESGRIPTION
Toqs ucEriss uw.1. FEE
QU 7 Mi EXEMPT UNDEfl SfiC. ,_, fl d A.C.FOR TN�S REFSON Q y�„� O 'r+
'� L�
ZOATE.�, _oWNEA . � _" � .
� LiCEWSED CON7RAGTQflS DECLARRTfdN �
� 1 NEREBY AFFlRM UNOER PENN.TV OF pEfl.IURY THAT 1 AM I.ICENSeD VN6ER PROVISlONS Of GHAPTER � �
(� CjO�MMENCVICiWITHs^ECTqNtotltl�OFDiVt5WN30FTNEBUSINESSANOPqOFESSiONSCODE,ANO z,
Lii W LICENSE IS 1N f ULL fORCE AtJD EFFECT, /^ m �
� LICENSE CLASS,�-p G�._�,__ L�C.NO.__�'j,_� iV �� _, j "-- , �
� UATE 1- ..L Z r�' CONTHACTOR ,._,_�_ � �
W
� WORKEiRS'COMPENSATIpN L/ECLARATION Q �-
� !HEpEBY itFFiHM UNDER PfiNAL7l'Of PEHJURY ONE OF THE FOL�OWIN6 DECLARATqNS: �
G� Z
� _'NAVE M14 W141 MAlNTAIN ACERTIF�C.ATE OF CON5EN7 TO SEtF-ItdSURE FOR riOPKERS' �
� iXA.iRENSATKKJ,AS PqOVIDED 9Y SEC7:iJN 370a OFTHE LA60R CQQE.fOfl 7HE VERFOHMANCE V
4 /�jF TNE WOtiK FOR WM�CH THiS PERMI7 i515SUE6. �
Q _Z._1 MA4E ANU M/iLL WUMAIN`N6RKERS'CQAIPENSATKNI iNSUiiANCE,AS RE�UIREC eY SECTqp1
3700 0F 7HE LABOA CWE,-0F 7HE PERGORMANCE qF THE WORK FOR WMiCFi TFi�S PERMIT IS
ISSUED.MV WORK�ER.�S'-Cy�O,,M,PENSA7KN�lNSURAweE CARRIEp AN6 POl4CY NUMBER ARE: GONSTRUCTlON
jc�a1�ER__,��Z_�' � `/!V� __�� PLANREVIEW '._ .
Z Pa�crNUMBER I S".�I�r � „��_-`3— _.� ELECTRIG `_ —
y4 �
� (TFNssECfqNNE'�NoiBEaNfLEiE00fri�aFnX7'tsFqRXJEttN[7REDb7uaas(3�ao7�LE55) PLUMBINf.i _. i �
w —
� I CERT;G`/TNAi IN TFiE PERFORMANGE OF THE WORK fOR WHICH THIS PEWAlT IS IS5UED.i MECHANICAL �
SFULI NOT EMPLOY ANY PERSbN Ml ANV MANNEft SO AS TO eECAME SVBJECi TO THE f,
[,p WOAKERS'COMPENSATIONL4WSOFCN.IFOHN ANDAGFE6THATIFISHWIDBECOME �NSPECTIQFIFEE ` � '�':J � ' ����
S SU&IECTTO THE WORKERS'(bMFENSATiON P VISIONS OF SECTION 3100 Of THF.IABOR
CODE.tSHALLFqqTHWITHCc)MPf.YWifNTH05 HOVISiONS. �SSIJAM1ICE '���7i
� -��y i +� .
4p OATE: �..-+`�,[-U� AFPLICANT:� SMtP ,i�_����.��% ..�."..,�„y��+�`,1_
� ENERGY P/C , � ` ti� +R �.�'�-f . ._.�_
WARNiNO:FhiLURE T�5ECURE WOflKF_RS'OOMPENSAT�O CQYERAGE IS UNIA HALL BE _:���-'+-
yi SU&1EC7AN EMPIOYER TO CflIMiNAL PENAl71E5AN0 CIVII ftNEs UP TOONE MUNDRED THOUSAND ��.jERGY PEFIMIT
.�,_ DOl.LApS(ft06,o00j,IN PDOITION Tq 7HE CAST OF C6MPENSATION,OAMAGES AS PpOYtOED iOR iN -�. __.� _
SEC7pN 3T08 OF iHE LABOF CpDE,INTEREST.AND A7TORMEYS fEES.
2� FETENTION FEE:
� CONSTRUCTION lENpiNG AGENCY PRE-ACT FEE: ` ' ,.
� 1 HEREBY AFFlRM UNDER PENAIN OF PEfi.lUAY 7HAT THERE i5 A CANSTRUCTION LENDINO AGENCY
FOP 7HE PEflFOflMANCE OF THE WORK WR WNIGH TH�S PERMIT 1S ISS(1ED{5EC.3087,C�V.C J. - —
c� LENDEASNAME_ .__ '__' —_ �'._. �_
J
h- LENDER'S/1D�HHESS, �_ _ ,
WICERTlFVTHATIHAV�READTHISAPPLIG4TIONANpSTATETFtAi7MEAHUVEMFOftMATIONISGORRECT. TOTAL��GES �r�/'�) ///��Y((\)
� i AGREF TO COMPLY N7TH AL�ClTY AND COUNTY ORDINANCES ANL1 STATG UWS RELATiNG TO BUILDING Y y/� �V W/
f.ONSTRUCTlKJN,RND HEREBY hUTHOR121:REPRESENTATIVES OF THIS COVNTY Tp EMER UPON TkE
ABOVE�MENTtONEO PROpERTY FOR INSPFCTKK•i PURPpSES. GOMMENTS
� . � _
� �,_�_�pL,nl• ��`1�,. .
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� PEfkh17T NAME(PRINn _. _.
� �� SiGNATUflE F PERMI EE DA7E
� RECPT.NO. PAID BY _ YAUDATtON
WIiITE-Depanment Copy,VELLOW-Finance Copy,PtNK-Assessw Copy,GOLDENPOD�-File Copy,GREEN-Applicant's Copy
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JOBSITE
ADDRESS� �F-(?,'k i--�-
APN LOT
-TRACT
OWNER.tf
ADDRESS i +-
CITY D&M prjD ZIP-91 'TEL(o
APPLICANT I,' Ej_Ali ��A4�7 E'tt_TEL+
CONTRACTOR".1
ADDRESS 1 i '�---
CITY.,4 1 ZIP TE. ��
ARCHIENGI
DESIGNER
ADDRESS
CITY ZIP TEL.
OWNER-BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM EXEMPT FROM THE CONTRACTORS LI-
CENSE LAW FOR THE FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE:ANY CITY OR
OOUNTY WHICH REWtRESA PERMIT TO CONSTRUCT,ALTER,IMPROVE, DEMOLISH,OR REPAIR ANY STRUC.
TURF, PRIOR TO ITS ISSUANCE,ALSO REWIRES 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).):
O1,AS OWNER 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-BU(LDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
a I,AS OWNER OF THE PROPERTY.AM EXCLUSIVELY CONTRACTlNG WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC. 7044, BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI-
CENSE LAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS WITH ACONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAG
TORS LICENSE LAW.).
0 I AM EXEMPT UNDER SEC. S. &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 FORCE AND EFFECT.
�y(� L
LICENSE CLASS A- F3 L lj LIC. N0.
OATE I-Z Z-r2-L-CONTRACTOR
WORKERS'COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS.
-I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'
COMPENSATION,AS PROVIDED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE
THE WORK FOR WHICH THIS PERMIT IS ISSUED.
--le AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTlON
3700 OF THE LABOR CODE 70R THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 15
ISSUED. MY WORKERS'COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE:
CARRIER- r Ff[tv P
POLICY NUMBER
(THIS SECTION NEEDNOT BE OCIMPLETEOCF THE PERMIT IS FOR ONE HUNDRED DOLLARS MOD)OR LESS}
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE
WORKERS'COMPENSATION LOWS OF CALIFORN AND AGREE THAT IF I SHOULD BECOME
SUBJECT TO THE WORKERS'COMPENSATION P VISIONS OF SECTION 3700 OF THE LABOR
CODE,)SHALL FORTHWITH COMPLY WITH THOS PROVISIONS.
DATE: I �-�_0}APPLICANT:_
WARNING: FAILURE TO SECURE WORKERS'COMPENSATIO COVERAGE IS UNLA ALL 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 ATTORNEY'S 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
1 CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
1 AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
CONSTRUCTION,AND HEREBY AUTHORIZI)REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES.
tJX17L�
PERMITT NAME)PRINT)
SIGNATURE OF PERM EE DATE
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CD
7i
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21660 E.Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117�12
BUILDING PERMIT APPLICATION •�
PRESS
FIRMLY
APPLICATION n I,PERMITS Ifl r� �_P!C
DATE�i V NUMBER V'� #
ISSUE�y TYPE OCC
DATE U CONST. GROUP
ZONING SETBACKS
FRONT RW^
REAR^
L
1
SIDE/SIDE STREET RW^
SIDE p
PROPOSED USE
N0. DWEL. N0. N0.
UNITS STORIES BEDROOMS
DESCRIPTION SQ. FT. FACTOR PSF ADJ.AREANALUATION
SFR/ADDIREM
U) Garage/Carport
W Patio/Deck
LU
LL PooVSpa
0
Re-Roof
Z
CI Commercial
5
Valuation ADJ.AREA
QUANTITY DESCRIPTION FEE
crS p
Sj_
cc
0
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V.
11
C2
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CO
CONSTRUCTION
PLAN REVIEW
ELECTRIC
PLUMBING
MECHANICAL
INSPECTION FEE
ISSUANCE
SMIP
ENERGY P/C
ENERGY PERMIT
RETENTION FEE:
PRE-ALT FEE:
TOTAL FEES 1,01
COMMENTS
RECPT. N0. PAID BY VALIDATION
P
WHITE-Department Copy,YELLOW-Finance Copy, PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy
CITY