HomeMy WebLinkAbout16539 �` CITY OF DIAMOND BAR + /�'
DEPARTMENT OF COMMiJNITY&DEVELQPMENT SERVICES r
2166D E.Cap2ey llrive 5uite 190 t
�9ov)aFo-3 r4s���s�o9>s6i-�i i�r PRESS
'°N'� BiTII.DING PERMTI'APPLICATION FIRMLY
� JOBSITE ^� n� �-y �����1 �. #— /
Q ADDRESS�,� JJ���Y PJ�� /7�}L� i S C �t��T DATE CATION � NUMaE� 1 ��. Prc ;_�� �, -
g issuE nrPe oc�
APN LOT,�--�--- TFiAGT j DATE CONST. GROUP
p OWNER �= % LYt i NCJ' Ci Zy^f�,%N�I.Ft=
o ADDRESS�[,�;�,,,'� ZONING SETBACK8
Z CITY 7�r�t.t.•n r:3s-.,s�� Z!P . 1 ' REAR7 RW ❑�
S APPLICANT TEL: — �--
� SIDEISIQE STREET RW ❑
CONTRACTOR_ _� �_` SIDE �
ADORESS_;� — - �' �,,,, �
� ClTY _Crt}-,�V T]�I�- �Rn�lA. ZIP �jT� PRQPOSED USE { � �" '' � � �
� ARCHlENG/ �' � � t � � €" �
�a
dEStGNER� NO.DWEL. NO. . Nd. �,'�
� ADORESS UNlTS STORIES �I BEDROOMS_
� CiTY Zlp TEL.
cn
cn !—' DESCFSIPTIdN S�.�T. FACTOR PSF ADJ.AREANALUATION
� OWNER-BUILDER DECLARATIpN SFRtADDJREM
p �HEREBV AfFlR1A UNOER PENALTV OF PERJURv TNRT I MA ExEMP7 FpOM THE CON7RACTORS LI� GdfageJCBtpOrt
� CENSEIAWFORTNEFd.LOWINGHFA.SON(SEC,�031.SBUSINESSMfDpROFE5510N5GCDE:A{iYGSYQR (j�
COtINTYWHIGHREpUtRESAPERMtTTOC6N$TRJCT,u7Ep,tMPqoVE,DEMOLiSH,ORREPAIAANVSTRUC� W py�i0/DBCk
TURE,PRIOR TO fTS ISSUANCE,�LSO REW IHES THE APPLICANT FOH SUCH PERMIT TO FILE A SIGNED �
'� STATSMETlT TNAT NE Oft SHE iS IiCENSEO PURSUeWT TO TME PfiOVSIIX+iS 6F TNE COryTR4C70RS U.
CENSE UW(CHIIPTER 4(COMMENCINO W17H SECTION 7U00)OF DIVISION 3 Of THE BUSINESS AND PRp, U' POOUSP2
� FESSqNS CODE)OR THAT hIE Ofl SHE IS EJ(EMPT THEREFROMAND THE BA515 FOqTHEA44EGED EXEMP- (�
�) 710N.N/YYqLA7pNOfSECTKKiT43t.58YAtiYAPPL�ANTF6ftAPERM4TSUB.iECTS�NEAPPUCANTTO Z RB-R001
� �CIVI4 PENALTY OF NOT MORE TNAN FIVE HUNDRED DOLI,ARS(%500).):
� UI,ASOWNEK40F7HCPHtlPEAT,'.QRMYENPLOYEESWITNWAGESASTr{EfRSOLECOMPEMSAT:OM, � �ORirtt@tCifll � ..�I j
WY t 00 TNE NIQRK,!�FHE STNUCtURE iS tJ3T 4MENDEO OR OFFCRED FOR SALE(SEC.7oA4,BUSI- J
� NESS AND PqOFE5S10N3 IbD6�.7HE CONTMCTORS LICGNSE LAw DOES NtlT APGLY To AN OWNER OF �
PflOPEATY Mh100U�D5OR IMPAOVES THEREON.M!D WMO QOES SVCH WOHK HtMSEIF OR FiERSECF QFi
(,� TftROU6NHISORHEApWN6MPlOVEBS,Vfl4VIDED7MAT5�qifMPF(IVEMENiSARENOTINTENDEDOP m
OOFFEpED�ORSALEIF,HOWEVER,THEBUILpINGORIMPROVEMENTI55QlDWITHINONEVEAROFIXIMM.E
� TqtV,THE QWNER-6UN.UER WIU NAYE THE BllftOEN OF PF�ViMG 7HAT HE QR SHE 6�N�T BUlID OR
� MPROVE PoR 7HE PURPOSE OF SALE),
� ❑I,ASOWNEROFTMEPROPERTY,AME%CLUSNEIYCONTRAC'fIN6WITHUCENSEDCl.M1TMCTOfl9
� ro corisravcrTne vAoaECT{sEr..7ou,�sFxEss u-m aaor�ssiars coaE:Tr+E caaraacroRs u- Valuation . }`�...�...1 ADJ.AREA_
41 CENSElAWU0E5NOTAPPLYTqANO'MJEROFApFqPERTVWHOBUILO50qIMPROVESTHEREON,AND -- \
� WFqCONTMCTSFORSUCHPROJECTSWIFNACON7RACTOR{51UCENSEDPUPSUtNTTOTHECONTRqG QUANTITY DESCRIPTiON �E�
� TOHSUCENSELAW.}.
� G 1 tM E%EMPT uMDEH SEC._ B.b P.C.FOR fH35 REA50N Q � i- L'.�- l�.
'�► . _,.._ � � ,`�'. i
� t- c. 7
OATE ,�,,,__,�` OWNER_ U
� � '
� UCENSED CANTRACTORS DECI AATlON W
�
� W
1 HEREBY AFFIRM UNDER PLNAL7Y Of pEFJURY THAT I AM IICENSED UNpER PROYi51ON5 CJF GMhNTER � �� E�
� 9{C6MAIENCINO WITN SEC'�'iON JOooJ OFDIVIS�N a OFTNE eUS�NE55 ANO PROFES8fON5 CODE,AND Z -
X MY UCENSE IS IN GULL F4PCE AND EFFECT. m 2 1
; j �? � r,
p., LICENSE CLASS�� LIC.NO. � �
� F}ATE��,�i_,_�tJ1 CONTRACTOR d !� �� �
� .� �- <_ ( 1�� r
� WC?RKERS'COMPENSATFdN DEC�ARATIOM t � Q
� t HERE6Y AFFlPM UNDEft pE:NAtTY OG PER.AtRY ONE tzFTME F-0LlOW1NG DECIAflAT���• Z ^-�-, i •,,
Q w I,
Gl _IHAVEANDWILLMAINTAINACERTIFICATEQFCONSENTTOSEIF-INSUf1EFORWOFlHEAS' = t h/j"
,��, 07MP£PlSATION,ASPRQVfDE06YSECTION3To00FTHEtA80PC6DE,�ORTHEPEftFORMANCE U ia�
� OF THE WOHK FOR WHICH 7HIS PFRMIT IS ISSUEO. � � �„
w ,�`_i HAVE ANp 1MLL MA�MAIN WORKERS'COMPENSATION INSURANCE,AS RE�UIRED 9Y SEGTION
4 3]Ob qF TNE lAB6R COf1E,FGFITHE PEflFORMANCE OF THE WQPK FOR WNICH TNIS PERMIT IS I� t J- �` �� ' �
� ISSUEO.AAY4VC}RNE�S'Gbi.iPENSAT%Ni tNSURANC£CARRiER AND AOI.�CY NUMBER AftE CONSTRUCTI(JN �• j ��
� :7;...t -. . —,.:�----_-� _�.
� c�aaiea___,---- - - PCANREVIEW _ t .-... _,;-� �
� POLICVNUMBER,,,__v � � \- ` I �- �E"'����C!`4, ------'-----�1���
4 - ELECTRIC ..._...... �
�"��--T�'—
� @+�SSEciICMJNearNoraEooMX.EiEooFiHEVEw.IiA5R7ftoNElnx.DREODJI.t.,uiSrytm)�fiLEssb PLUMBING ��'�� i �"C�' 1 '� �' �'
�-�--- .�.._
� i CERTiF'f THA7�1 T}IE F'ERFORMiNCE OF THF.VXIRK FOR WNICH THIS PEFMiT CS 19SUED,i MECV{ANICAL �"� } � t. j-t���+
(_} SHAL4N01 EMPLOV ANV GERSON INANV MANNER SOAS T08ECOME Gl10JECT TOTHE � �� �'—
(J� WONKERS'GOMPENSATK?NIAWSOfCAl1�ORNIA,ANDAGREETNATifiSHQUiRBECDMt �NSF�EGTfCN'IFEE � •'"� .
� SUBIECTTOTHEKKSRfCEPS'CCSMPEN6ATIpNPROViS10NSOFSECTfON3]a017f7MELHBOR
� CODB.I SHALL FOflTHWITFI COMPLV NATH TH E PROVISIONS. ISSUANCE �"J�j�
a PATE:�„��Q- APPLIGANT: � SMIP � ��"'
WWAWiHJCa:FAt(.URE TOSECURE WORK6R5 CQMAVENSATi COVERAGE iS VNLAWFUL,AND SHALL BE �NERGY F/C �j �. �-.. . j �
� $U&IECT AN EMPLOVER i0 CFIMINA:PENALTIES ANp CI Il FlNES UP TO ONE HUN�RE�THDUSANO ENERGY PERMIT —_---'�a
DOl1A�i5 iflm.ma}.M!M1DiT1pN TO THE COST aF COMPENSATICM.DAMAGES AS PROVIOEO FOR tN
� SECTf4N 3�08 OF THE U00R CODE,IN7EREST,ANp ATTOflNEY'S FEES. _ ' ^ �) �
� RETENTION FEE: -�. .__,_�_{L,�L
. ,._�.
� CONSTRUCIiON I.ENDING AGENCY PRE-ALT FEE/:.... ... \�— - - ^,_;,,'_ , _
� IHEAE9YAFFIflMUSJPERPENALTYOFPERtUNYTHATTHEflE15AWtJSTRUCtiONLEN0INGAC�FNCY 'J � � _~ _�_
Ff3RTMEPEftFORMRNCEOF(HEWORKGdRWHiCH7WSPEfiMITiSiSSUEO(SEG.3D9).CIV.C). _ � ��� ?�C
� i 1 . �
� tENOER'SNMiE_ __...._. I�������k ,
I ��..
_�
k�- I.EN�Efl'SApDkESS
� --- _ TQ7AL FEES '; ; r ��_ t�iG� '
� I CERTIFY TMAT I 4AYE AEAD'�"HIS APPLICATIONAND STATE THAF TMEA50VE MFORMATpN IS COARECT.
p„ IXGREETOCCSMPIYWiTHAii.CITYAN6CWNTYOR0INANCESANDSTATEIAWSREI,ATMGTO6VLDING , )'- . ` '
� CONSTRUCTIC7N.ANO NEREBY AVTHOF2E REPRESENTATIVES OF TMIS COUNTY TO ENTER UPON THE �
PAOYEMENTlbNED PROFEPTY fQft iNSPECTK?N PVflP4SES.
� ; , o
COMMENTS_
� � �`�{�_—�� —
¢ pERMITTEENAME PRINT� 1 _
� :,_��� .�
V-j SIGNATUflEOFPF I �— OATE _
= FiECPT.NO. -J PAID 8V VALI6ATION
� WNITE—pa artment Co YELLQW---Finance G
p py, opy,PINK—Assessa Copy,GO��NRQ6--File Capy,GREEN—Appiu:anYs Copy
�l�'� �3� C�1.� � ��� �� �
Iird����T�t�� ����J��
���� � ,.k
� �� � t � . . �! � ` � .�����"�t
,
; ��� �, ,,..�. , � l �-���r��� nM�� �
� ..c. it._;,=< f , �. , .*�< s i _ �
___ _ _ _. .� �_. ._ � _,_ __ ,
m.. _ __ . _.._____.___, — __
`. �T�"�.�'",����.�1�, ����'�.t :_ ' �i s —t� «,�t,'IT� � �
� __. __ � -_ -- �,—_._ —_ ���..__�_ ..e__ _— _
� � € `
E F�t_�.�T�-i�C .�f'a'�r„ j�� �; ,1€ f', € t t �
_ _�,�''"'� � __ � .... � —
e _ _ � -
f _.,.�,r ��h�..., ,�a E:S " � '7a ,,,�> �..�,K�._.�.-J ' i,t d r')� }'. w.+f't a s ,- R ,f�I`;"
�.;. � ��.. ,., ., 5 6-1 �_'-�t.�`_ �'�� - .. _�, . . .. ._ _ ,.. .._ _. ... ..
_ _... �. ..... , _ --� . - ..
� r= zC'E ,'-: � ��_�s✓� I"w�i "-��. �zi .1{� ,_.
F ;"'t_,�C. _ . 4 .. 4 . . ... .. .. . ... .
a-.-�,.. _. �.... ....._... ,_.�._ . ._......_.... . _..�. . .� . . -.._ - - .
� -;- r, ,,, � � R c t �.�.t � ��`,g r r �..��n
i f r '�� , - __ _____. .. _ _ _. .. �
— . _. __ ___ _
(___
�.A#�:T�-rs G�; .2 ,f m � f r 'f;. t`�'��' ''� � �
� '� . __...,,� . _ ., _�. .�_____.._._.....__.. . . _ _
.
��:�;.:f_{_r '6" .r,.,,,�'&4z ? . d�i� �+vJ�vs.' ��..�°tt° , ..._.. ._._ ... ._ ._._ .... ,
. ._ ._.. ...__ _._ ..�---,- . ._ _... �.,_.._..,__._ _ ,,._ ._. ._ ..�.r ._. , ..
..
.
j�}'���4'.�l��`�.t , �1#�#��e, PC"li� ; t 7 1 "a�''��t£d:w�4�`� : . ... .. ... . .
4_ ..,
_. ..... .�__.,... _ __. , o-.._ ____._,._ ... .-.. . _.. _ .. .....�_, . �_ . _ _..
E :�t if 4� t � � a i'^' �`r 7��'��'R .. ... . .. ... . .
` _,' ..,.._ _ w�_ _ .�_. --�- ..__.� _ ._ __— .. _. ..
._ __ .. _ e..
� +a` t �d� x;- '�' t'l"Et'� _.T ...._ ~—�.__ �-� �� �?�7 � ._. . _ __ ._ . . . . .. .. . ..
3 __ . . .-� .._ . � . ...�.... F
"�..�"r}7��,�6&C �'S�, ' - T , ��'•��a . - '�.
f,� -, �,�
�_._ _ �`:��C�{��'�--.�' � � _: � _
� _.f �a�
; ��iE�€,hr 'r i�,.,�,.;�a'z : --'"� � � � �., _
._�.. . �.,_ ��.__ ._.. . ._
. r,� - : �.., ' t iy,
. �. w_ .�:� �
<� :
„ ,_ ,
,_ r..t ,.... ..r t> e ,_,. . _...._ .�...._.., _.. .�-.�._ _._--_ _ ..__ __.. _ ... .. _
.. ._ . .. ..�_�_.� ...... __.�. .. _._.___. �,_._.._..._.. _ _ .
._.... .. . , ,�,�,w .
}� a t:'... 'st}��".� i . � ^t . . c'��4a. �,��� ...
. �v.. _ .�.. � . .... _...__...� ....... _ i.. .__._ ._.... _.. _._. ... .... . ..
._...._.... ..__... , ..-_..,d..M..._....__.._ . _ .__-_ _..�t...�-._.
_., ,
� ul�� r (a= k ;x:� ;,t � , : � � � f� 1 , ��rY.�
�9 , �, `fiy r. �i z � Pw _,........ ___ . _. . ..._.., __. _ .._. .. . .. ..
- _,_ ....�.... .. ._.._,._ _.._�....._.._ ...._ .. _
�
. ... .. .. _ p
..
+ x,, rv,. .�.. '.. rv. .. � } . .�. nh 7w.
. : � - + , �, .z ''... rt.F ,l_ �'
'.�_,. r� _, , ,4 x . . = ._ . ...... . _... ... .... . ._.. . .. . .
.. _ .__. _r_...._.._ ....�_ ._._ p ... .. . .
_ _ .-..
Fv� � r,- ! ,�1�.�� ; }i St�fEd"x
-� ° s�`�� t�7 = _ __ ._ __._. _ _ .
�- �_. _ _ _ . .__
__ - — r , - ,, ' �
' ��, R . ",k I. F . �' ,_�'_i al.�. .
' ` __ ..__.... _ _ .._.. ._ _ __.._ . � ._... .,.. ... . . . . _.. _. .
.._ _._.__.__. . __. ..___...._...._._ �` ..r ,-.
� � . _ .. . � .. _ ._._ � .
�a4,e c =. ,`a'z _ �� ^�s r.'t ° _
_ __. - _ �_.___._ .____- --- _ T__,__ .. _,.___ _ �. �__ __ � _. __ __. _v.. __ _
t'- ; �� ,
. h z�
, ' �
; ..,;��. ___ �;
_ __ __.._..�_ __ .._.__ _�___ _� __._�.�.� .� —.- — �
- ��- = c , -_.
z..�,
,.� 6 ,
-, , „, ,� . �
, - _ _ _ _
_ �._ �.___. _ _
�� ;� i
� � _
_ __ _ ,�� _.__ ,-��-�' �w..,
_ _ �{� ,
; � �_� , __ �
.
� �
. . . __r,,�,57 '"" :.y,.....� ._. ,.�- "
!
`L. _ ..,_ _ + . _��Y- .._,..�_....�. ._ � •_ • �.t . . .
�.i
. � .-._..., _V r�— �. . , ,_ .— . _..- ..._- .
�.� �. � .. . . . .
,'� „t .: 5: '��.�..� .
. ..... .. ...... ...._ _..� �._ .... ..., .. . ._.... . .... ... . . . .. . ...
,��'�-�._.�il�4�_.. t_._,_ ���' . _. _ , .
� �.
p,�� _ . .__. .��.�'_dt _. , _.. _. �_, '��'«s �� ���"� _
i_"".txS'�
n , �.
° '�"x'�r �' � _ _._ _
t. _ .. . _�.. —__ _ _ _ _ __ �. ... ._ _ _...__ __.. . __ _ _
;______. __.__..____ _.__... _ _ __ _.__. d..m�____ �.__�__.�_. _ _ ___ _. --- .
c__..._..____ __ . _ , __�. .�..__._ _.___.__ ,w __ _. _ __.. � ..___ �._ _ _ _ _ __
;—_�_ ..,_._- _._-
i
�
�__._.. .-- �.._ ___ _-__ _.____ . _._�_ ._�.__. . . __ __ _ T.____ _ _. _
y
• �-_____ ,_.___ . ___._._ _..__,____.._ ._ .__. _, -- —.____ __ _.._ � .� .__ _._ __ __.- --- __
S
_ _.._ __.__._ _. _. __ _ __ _� _
t__ __ _. __ .., _ _
� _ _ . __. _ _ ________---- ____�_ .0 _ _ __ _
�._� ;.- ;��
� ���' € , e
� ,�a,,?�s '.,> A,
� . . ..� _ . ._.. ._.. . ._. . ... .. . . .... . . . ... . . ..
_. _r.m. . .___"'_._ ._. . ...
.. __
_,.,�., ,..., ._ .�. „_ _..�._._m.� ..�. ..
� x. �. _ ... _.v.,
: j�iy�(�"��'�P�I�"���,�"t�y�i�l,� 8.�' ,�"``' _ __ __ — -- . _ � _ _ . _�_ __
+
� , I
� _____ . __ _ _. _ __ _ -- — _
� _.__�_.__ __ __�___ __ .._._ . _ . __ __ _ _ _ _
a
i
4 . ......_ _ .......... ........_ ........ .. _..... , ....._ _...._.... ...... _..... ... ... ... . . . . .. ..
�S
f
� �.__�_ _ ...._�._. ..._.....,___. .._.. _.._. . .._. .._.._ ..... ._... .. .. ._ . _ _. . . ...
S
� _ .. .... . . . . .
_.....__.._ . .._. .... _..� . .. _.. _..
t
� .. . . ... .,.,., .. >......._ ,_. . . � ... . _.... ..... .. .� ... ... .� .. . ._......�
c.___.�..m�.__..,��....,..»..<.,�..,.d,.,.�_......_...�.�..,...�.._,�.».,__..,..e......,.._,..,..�., . ...��....,e...,.,w........... .. ...�....... _,m_.__._.... ,.._,w.._n..,_ m, ,,.�... _.. .., . .
II11II111XU BAR i
JOBSITE ry�
ADDRESS c IJ//�f e?4j.6 8,4L3
APN LOT
TRACT
,_--�-
OWNER % 11� i do C Z ff�%/�Ii.Ff
ADDRESS
CITY ZIP T).
APPLICANT TEL.
CONTRACTOR_0, PMAM.
ADDRESS L-
CITY j4-441,4-ZIP TE
ARCWENG/
DESIGNER
ADDRESS
CITY ZIP TEL.
OWNER-BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE LAW FOR THE FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE:ANY CITY OR
COUNTY WHICH REQUIRES A PERMITTO CONSTRUCT,ALTER. IMPROVE, DEMOLISH,OR REPAIR ANY STRUC-
TURE. PRIOR TO ITS ISSUANCE,ALSO REQUIRES 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 CML PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS($500).):
^ I,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-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
^ 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 A CONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAC-
TORS LICENSE LAW.).
^ I AM EXEMPT UNDER SEC. B.a P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECL RATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
9(COMMENCING WITH SEC-ION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE.AND
MY LICENSE IS IN FULL FORCE AND EFFECT.
LICENSE CLASS LIC. N0./D
OATS 4-i 19 6?/CONTRACTOR
WORKERS'COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATK 1
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
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
^.I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION
3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WORKERS'COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE.
CARRIER
POLICY NUMBER
(THIS SECTION NEED NOT BE 0 M'LETED OF THE PERMIT IS FOR ONE HJPDREO OOL.LARS($100)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 LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME
SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR
CODE.I SHALL FORTHWITH COMPLY WITH THE PROVISIONS.
DATE:APPLICANT:
WARNING: FAILURE TO SECURE WORKERS'COMPENSATI N COVERAGE IS UNLAWFUL.AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CI IL 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
I CERTIFY THAT I HAVE READ-"'HIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTION
D PROPERTY FOR INSPECTION PURPOSES.
E
PERMITTEE NAME PRINT)
SIGNATURE OF PF I DATE
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21660 E.Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
PRESS
FIRMLY
APPLICATION 3_j 0)PERMIT
P/C
DATE II
#
NUMBE
ISSUE TYPE OCC
DATE CONST. GROUP
ZONING SETBACKS
FRONT RW ^
REAR ^
SIDE/SIDE STREET RW ^
SIDE ^
PROPOSED USE- i
6J . a
N0. DWEL. N0. N0. N'
UNITS STORIES BEDROOMS
DESCRIPTION SQ. FT. FACTOR PSF ADJ.AREANALUATION
SFR/ADD/REM
U) Garage/Carport
L J Patio/Deck
L
LL Pool/Spa
Z Re-Roof
IJ Commercial I .I
M
Valuation ADJ.AREA
QUANTITY DESCRIPTION FEE
71
-J
Z ,Et .
Q
t C; U
L
I
W
W
L) zz
a
I
Q ! I. )
MAY
0
Y '
I
CONSTRUCTION 1
6..--\..
PLAN REVIEW :
-f�
0
ELECTRIC (J
PLUMBING
MECHANICAL
INSPECTION FEE
ISSUANCE
SMIP
ENERGY P/C•�)� _ --, �1 {{
ENERGY PERMIT 7�
RETENTION FEE: 1
PRE-ALT FEE:,,,
TOTAL FEES
COMMENTS
RECPT. N0.
-I PAID BY VALIDATION
WHITE-Department Copy,YELLOW-Finance Copy, PINK-Assessor Copy. GOLDENROD-File Copy,GREEN-Applicant's Copy