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� CITY OF DIAMOND BAR �--����'� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES 21660 E.Copley Drive Suite 190 (909)860-3195 Fax(909)861-3117 PR E$S �"A�' BUII:DING PERMIT APPLICATION FIRMLY � JOBSITE �r ,� AP LICATION ° PERMIT nP/C � o ApDRESS ,�i� � aYJ����J� �6� TE NUMBER � # � ISSUE TYPE OCC � APN }-OT TRACT DATE CONST. GROUP � OWNER LI 4�� I� " ADDRES 7� ZONING S ACKS ' z CI7Y ZIP �' 'E�. i�> Ca FRONT RW ❑ g APPilCANT I TEL. S DE/SIDE STREET RW ❑ � �� SIDE p CONTRACTOR � ADDRESS � PROPOSED USE ' CITY Z1P�_ TEL. w ARC NG/ �`�'7'' 'W DESIGNER NQ DWEL. NO. NO. a ADDRESS UNITS STORIES BEDROOMS �1 CVTY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION en , O O'WNER-BUILDER DECLARATION SFR/ADD/REM .'[�� !HEREBV AFFIRM UNDER�NAl,T/OF PERJl1RV THAT l AM FXEMPi GpOM THE CONTRACTOHS Lb � GaragelGamort - � W CENSELAWFORTNEFOLLOWIN REASONf5EG.7931.58U51NE55ANDPflOPE5510N5CODE:ANYCITYOF ��.�',�.�. bWNfYYYHfCHREWiRE9APER ITTOCONSTRUCT,ALTER,.IMPROVE,�EMOLiSH,OR%EPAIRANYSTRUG W PgiIO/DB6k .W' NflE,PRIDfl N ITS ISSVANCE,ALSO fiEQL'IRES TNE APPLICANT fOR SUCH PEAMIT TO FILE A SiGNED � ��', STATEMENT TNA7 F�OR SHE IS LICEPJ;SED PURSUANT TD THE PqOVISIONS OF THE CANTRACiORS LI- ��.' CENSELAW(C4iAPTER B(CQMPA NCING WITH$ECTION T000)OF DIVISION 3 DF THE BlJ5ME55 ANI]PP.O- u" POOUSpd '�'�FESSI�NSCODE)ORTHATMEOHSHEISEXEMPTTHEREFAOMANDTHEBASISFORTHEALLEGEDEXEMP- (� -U. TlON.ANYVWLATWNOFSECTI 7091.5BYANVAPPLICANTFORAPERMITSU&IECTSTHEAPPLICANTiO Z pe•Roof � A GIML PENALTY OF N07 MOp,E THNa FIVE HUNDRED�OLLAqS�t50o).): ❑I,ASOIVNEROFTHEPROP��6RTV,ORAlYE0.1PlOYEESLYITHWAGESA5THEIRSOLECOMPENSATION, A CaRIR18CCi0I " "'�,�� WILL W 7HE WOPK,AN�THE STrll1CTIJRE I6 N671PoYENDEU Ofl OFFERED FOR SALE SSEC.7044,BU51- ._I 'NE55 Ml�PpOFE5510N5�E:7ME CQNTRACTORS LICEN5E LAW DOES N07 APPLY Tp AIJ OWNER OF ''y ��PflOPEPiYWFiOBU1LO50RIMPROYES7HEREIXJ,MI�NM1iODOESSUCHWORKHIAASEIFORHER6ELFOR � '�[' �TNROUGHWISORHEAOWNENPIOtlFES,PROVIDEDTHATSUCHIMPROVEAIENTSARENOTiNTENDEDCR m . ��,,Q� ,OFFEREOFORSALEIF,HOWEVE0.NE9UILONGORIMApOVEMENTISSOI.OWITHINONEVEAROFCAMPLE- �,�, �'TION,7FiE OWNER-Bl11LDER WILL HAYE�THE 6UROEN OF PflOVING TF!hT HE OR SHE DID NO',BUIW OR �.�� IMPflOYEFOR7tlEPURPOSEtlF8ALE1•' � � ��,', ❑I.A60YaNEAOPtHEPPO�ERTV,�APRE%CLUSIVELVCAMRACTINOWRHIICENSEDCCNTRACiORS - Q[� TO CANSTRUCT THE PR0.16CT( C.70Y4,BUSdhc55 AND PpOFE5510N5 CODE:THE CONPRACiOR5 LI- V91U8YIdfl � ADJ.AREA � ''61A.. �,CEFi5EL1WDOE5NOTAPPLVTOANOWNER�FAPHQPER7YWHOBUfL�50RIMPhlOVE5YF1EflEON,RND '� NTif1CONTRNC75fORSUCNPRCI'ECTS,WlTHAGONTflACTOR(S)LICENSEDPURSUANT70YHECONYRAG QUAPITITY DESCRiPTION FEE - ,� TC7H5LICENSEUWJ. II . ❑IAA1 E7(EMPTUhiOER SEC.' 6.&P.C.'rOFTN15 REASON Q �� � /� �� � U � � . , �'2_ � � .-s � DATE I 'OWNEfl . Z U W �� � LiC�NSED GONTRAC7�RS DEC VIRATI6N y � ' � ',1 HEFlE6VAFFIRN UNDER PENAL'f�OF PER.fURV THAT I AM LICENSED UNDeR PRQVISIONS OF CHAPTER � d 9(COA4AENCINOVdITHSECTION7d00)OFO�VISIDN30FTHE6USINES5qNDQNOFE55IONSCADE,AND Z MY LICENSE i5 Ifi FULL FORCE ANd EFFECT. �; ����s J ��e� (� � � UCENSE CLAS ---���--,.—LIG N0. �°�/ �"L v � . , rj� ;�ATE CONPRACTOR f�@ -� i1J i �� WORKEbS'COMPEtdSATION DECLARA?IOtJ � �tHEREBVAFFIRMUN�ERPENALFYOFP6R/URYONEQFTHEFOILOWINGDECLA TION � � � �. l,sIHAV6ANDWILLMAINTAINIIACERT7FICATEOFCONSENT'fOSELF-IN5URE RWORK RS' y �„ COMPENSA750N,A5 PAOV�DED BY SECTION 37W Of YHE LA3OR C09E,FOR ERFORMANCE U. OF7HE WORK FOIiINHICHTHIS 9EPoUIT IS:SSUF.O. """""' �... � �.I HAV6 ANO WILiFAAlNYAIId WORl�RS'COMPENSA7lON IMSURANCE,q5 REQUfRED BY SECTION i�, 37WOFTHELASOf2CODE,FORTHERERFORMANCEOFTHEWORKFORWNICHTNISPERMITIS J/JY' ��. i55UEp.MY WORKEAS'� PEN$ATIC7N INSURAI'dC5 CARRIER ANO POLICY NUA6ERARE: CONSTRUCTION � @ ����' j��. CqqRIE9, � � PLAN REVIEW ��t '��,yit' �', ���, aoi.�crwu:neEq i ' ELECTRIC --�---- — ---��� � �., (iH�S€CfpNNE�NOiBE4Yfr'PLEfEDOFhIEPERMII'ISWRONEftt1P,Of1EDCCUAR6(Si00)ORLESS� PLUMBING � 1 CER7IFV iHAY INTHE PERIFORM'ANCE OF THE WORK FOR WHICH THIS PEPMIT IS ISSUED,I MECHAMICAL -e�i.,. ��, $HALLNOTEMPLOYAPIYP�FSONINpNYMANNER50A5TO8ECOME5l1BJECTTOTHE ��'�,b� �+„�°'> , ud WOHKEPS'COMPENSAT70fJLAWSOFGALlfORN1R.ANDAGREETMA71FI5HOl1LDBECOME INSPECTIONFEE . -�i�a :`u� � SU&lECTTpTHENIORHEqS'WNPENSA710NPROVISIONSOFSECTI N37ooOFTHE�BOR �SSUANCE � � CAQ ISr1 F�WiTFfICCMPLYWITHT &EPqpyl810� �� � P G,ry DA E: � AP�IlCAP1T: - SMIP M 9 � '�,_�� _—, W . . ., . � � �' - J,", WARNINO:FAIL RE TO SECURE WOIRKERS COASAENSRTpN VERAGE IS UNtAWFUL,ANO SHALL BE E�dERGY P/C �x�1�� y4 31 �...3' �I'. SU&IECTANEMPiOYEqTOCRIMIN�,LPENALTIcSANOCIVILFMESUpTOONEHUNOREDTHOUSAND �..,�'^p�S �� � `�-��',�+ - ��� D�OI.lARSISi0o.o00),INA�DIiIONTOTHECOSTOFCOMPENSATION,DAMAOESASPflOVI�EDFORIN ENERGYPERMIT ��" �Y� d J�� SECTqN 37od OF THE LABOfl CODE,INTEPEST,AND ATfONNEI"5 FEES. s�'�,�'+�F��"'e��,�� � r�°M�� "� � RETENTION FEE: Q�, CONu�TRUCTION LENDING AGENCY PRE-ALT �,��',`��,-�^'����y ��' IHEREBVAFFlRMUNDERPENALTVOFPCPJURYTHAT7HEREISACONSiqUCTIONLENDMGAGENCY FOR iHE PERWRMANCE OF TNE WkIRK FOfl WHICHTHIS 7E�MIT IS ISSl1ED(SEC.3o91.CIV.CJ. , Z � LENDEA'S NAME _,�M,,,.. 4ENDEH'SAD�RESS � � y ���'1��,,// �'� ICERTIFYTHATIHAVEREADTHISAPPUCATIONANDSTAiETHATTFiEA90VENFd9MATIONI3CARRECT, TOTAL FEES ' ` � �' ' ��`/�- �7 `� �,.,'��, IAGREEiOCAMPLYWIFHALLCITVAN�CDUNTVORDINANCESANDSTpTELAWSRELATINGTOBUILDWG � �. CANSiRU TION,AND HEREBV AUTF{ORIZ�iiEPflESENTATNES OF THIS COUNTYTO ENTER UPONiHE a�, BOV€� �NYIONE�PROPER FOF�I PEC ION PURPOSES. 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