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CITY OF DIAMOND BAR f�. �---��� —� DEPARTMENT OF COMMUNITY&.DEVELOPMENT SE,RVICES . 1�� 21660 E.Copley Drive Suite 190 � w PRESS ,�q�;.. (909)860-3195 Fax(909)_861-3117 BUILDINGPERMITAPPLICATIUN . .__.. ; FIRMLY y JOBSITE f�? �,� APPLICATION PERMIT / /c��� P/C a ADDRESSJ-°t �f�� � ��:!�_i.v�^'r�.�� .f.�.;� DATE NUMBER ! � # � APN LOT TR CT DA EE � �� `�� _ONST. GROUP p OWNER 9'"'v�fJ�✓�'J i�. �43 � p ADDRESS /+'� ,�.��._�_,��` + t'� I"Z.F ZONING SE7BACKS � CITY -�`a�a..s,-,� j�r� ZIP`� '�TEL.��'��'�C".J°� FRONT RW � APPtfCANT TEL. REAR C SIDE/SIDE STREI=T RW ❑ � CONTRAC7 R �� /�j� , •: -?... SIDE ❑ o ADDR SS r� PROPOSED USE CITY ' ~ �. Zf �;,�TEt. ""s o ARCWENG/ �/' � W DESIGNER NO.DWEL. NO. NO. � ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION ¢ OWNEF-BUILDER DECLARATION SFWAOD/REM O � I HEREBY AFFIflM UNDER PENALT'OF PERJURY THAT I AN E%EMPT FROM THE CONTRACTORS LI� Gaf2QBIC8fpolt W CENSEUWFORTHEFOLLOWIHGNFASON(SECJo31.5BUSINESSANOPROFESSIONSCODE:ANYCITVOR (n U COUHTYWHIqiqEWIRE3APERMYfTOWNSTqUCT,AL7EF,IMPROVE,DEMOlISH,ORflEPAIflANYSTRUC ,{J,J P3�j0/�9Ck WTURE,iqIOR TO ITS ISSUANCE,RL50 REOUIRES THE APPLICANT FOR SUCH PERMIT TO fILE A SIONED w � STATEMENT 7HAT ME OR SNE IS LICENSEO PURSUANT TO THE PqOVI510N5 OF THE CONfRACTOR9 LI• � CENSELAW(CNAPTERY(COMMENCINGWITHSECTION�000)oFUIVISION30FTHEBUSINE55ANDPRtr LL Pao�Pa FESSIONSCODE)ORTHATHEORS4EISEXEMP7THEREfROMANDTHEBASI5FOR7HEALlEGEOEXEMP• (� TION,ANVVIOLATIONOFSECTIDN7031.SBYqNVAPPLICANTFORAPERMIiSUeJECTSTHEAPPUCANiTO Z pe-Roof � AqVILPENALTYOFNOTMORETNANFIVEFNNDREDDOLL4RS(f600J.�: � OI.ASOWNEROFTHEPROPERTV,OpMYEMPLAYEESWITHWAGESASTHEIRSOLECOMPENSAiION, � CommBfCial " MfILL DO THE WORK,ANO hiE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE�SEC.7p9a,BUSI- J NESS AND PROFESSIDNS L'ODE:7HE CONTPACTORS LICENSE LAW DOES NOTAPPLY TO AN OWNER OF � PqDVERTVW1108UILP50R1AiPR0`/E57HENEON.ANDVn10O0ES5l1CNWORKHIMSELFORHERSELFOR � Q TMHOUGHHISOFiHERDWNEMPLOVEES,PROVIDFATHATSIKHIMVROVEMENTSAflENOTINTENDEDOR m � OFFEFlEDFORSALEIF,HOWEYERNF9UILOINGORIMPqOVEMENrI550LOWITHINONEVEAROFCOMPLE- Z TION,iHE OWNER-BIJIIDER WILL HA4E THE BURDEN OF 7ROVING 7HAT HE OR SNE DID NOT BUILO OR � IMPROVEFORTHEPUHPOSEOFSALE). . C I,ASOWNEfl OFTHE PROPEiii`!,AM E%CIUSIVELYCANTMCTING WITH LICEN6ED CANTPAC70RS � TO CDNSTRUC7 TT1E PRQlECT(SEC.704t.BUSINESS AND PROFESSIONS CODE�THE CONTRACTORS LI- VaWd110f1 _ _ADJ.AREA W CENSEUWOOESNOTAPPI.YTOANOVYNEROFAPROPERTYWHOBUILDSORIMPROVESTNEAEON,AND � WHOCON7RACTSFORSUCNPpOJECTSWITHACONTRAC70R(S�LICENSEOPUR3UANTTOTFIECONiRAC- QUANTITY DESCRIPTION FEE Y TONSUCENSElAWJ. / y � G I AM EXEMPT UNDER SEC. 6.8 P.C.FOH TNIS REASON Q � ! � G`���.6 �� �� �.Zf �` 4 �L D � U � � a .� t-> y�-�' ,� .'�- 6:`l O 4' �A7E OWNER _ U W � . LICENSEO CONTRACTORS DECLARATION W � I HEflEB�'AFFlflM UNDER PENALTYOF PERIURY7HA71PM LICENSEO UNOEA 7ROVISIONS OF CHAP7Eq d, B(COMMENCING WITH SECTION 7000)OF DIVISqN 3 0F THE OUSINESSAND PROFE5510N5 CO�E.AND � MY LICENSE S IN F11LL FORCE AND EFFECT. R . o UCENSE CLA55 ��� � LIC,NO. � � V DAiE ` , CONTRACT � � a � � 7~�t�WO�KE�COMPENSATION DEClARA710N � Q � IHEfiEHVAFFIRMUNDERPENALTYOFPEPJVRYONEOFTNE�FOLIOWINGDECLARATIONS: � � � _INAVEANDWILLMAINTnINACERTIFICATEOFCONSENTTOSELF�INSUREFOPWORKERS' COMPENSAT�ON,ASPROVIDEOBYSECTION3�OOOFTHEUBORCOD�FORTHEPERFORMANGE � OF 7HE WOAK FOF WHICH THIS Pf.RM1T IS ISSUED. � � 0 � __I HAVE ANO WILL EWNTAIN WOPo(ET.S'COMPENSATION INSURANLE,AS RE�UIRED BY SECTION Q 9700�FTHELABORCODE,FORTHEPERF-0RMANCEOFTHEWORKFORWHICHTHISPERMITIS ---` 155UEO.MYWOR7CER5'COMPENSATIONINSURIINCECMRIERANDPOLICVNl1M6ERARE: CONSTRUCTION J � PLAN REVIEW _ CAPPoER Z POLICY NUMBEF7 ELECTRIC �jr g �'0 Q p (f115SECTICNIJEB)t�qTBEQ7MFLETEDOFhEaEWAilSsoRohEHuroa'eDoa1AR56�oolatLESs). PLUMBING _ - ZICERTIFYTHATINTHEPERFORMANCEOFTHEWOPoCFOflWMCHTHISPERMIiI515SUE0.l MECHANICAL �� SHALLNOTEMPLOYANYPERSONINANYMANNERSOASTOBECOM'eSUBJECTTOTFiE _ WORKERS'COMPENSA710N LAWS OF CALIFORNIlt ANO AGREE iHAT IF I SHOULD BECOME INSPECTION FEE � SU&IECTT07HENK1RKEflS'COMPENSATIONPROVISIONSOFSECTI0�3]OOOFTFiEL4BOfi �SSUANCE �S•�� � CODE.ISHALLFORTHWI7HCOMPLYWITHT}IOS�FPROVISIONS. J� p DATE: � �''�� APP4ICANT�,�,.,���i�"!• SMIP � ENERGY P!C __._.� WAflNING:FAILURE TO SECl1RE WORKERS'GOMPENSATION GOVERAGE IS UNIAWFUL SHALI BE � SlJ&IECTAN EMPLDYER To CRIMIWLL PENALTIES NND GIVIL FINES 11P TO ONE HUN�fl D THOUSAND ENERGY PERMIT _ DOLUflS(5100.000),INADOITIONTOTHECOSTOFCOMPENSAT10.N,DAMAGE5A5PROVI�EDFORIN — - � SECTIDN37oeOFTHELPBORCODE,WTEREST,ANDATTORNEVSFEES. RETENTIONFEE: � ¢; � d CONSTRUCTION LEN�ING AGENCY pREALTFEE: _ �:�� "' O , � I HEREBYAFFIRM UNDER PENALN OF PERJURV THATTHEIiE IS ACONSTRUCTIDN LENOING AGENCY FON TME GEFlFORMANCE OF THE WOPK Fb�WHICH iHIS PERMIT IS ISSUE�(SEC.309�,CIV.G). 1 ( Z W +rr�• � LENDER'SNAAIE F�- I.EN�ER'SIDDRESS . � � ICER7IFYTHA71HqVEREADTHISAPPUCATIONANDSTATE7WRTNEABOVEIhFOflMATIONISCOqRECT. TOTP,L FEES ����O � I AGREE TO COMPLY WITH ALLCRYAND COUNTYOflDINANCES AN�STATE IAWS REIATNG TO BULDING CONSTRUCTIIXJ,AN�HEREBY AUTFIORRE qEPRESENTATIVE3 OF iHIS GOUNTY TO EN7ER UPON THE � AEOVE-MENT70NEOGpOPERTYFOflINSPECTbNPURPOSES. COMMENTS__ � �� R m PERMITrEE E(PflIM) ' � � �� � � 5 NflEOFPERMiTfEE � OATE = RECPT.NO. PAID BY VALIDATION ~ WHITE-Oe artmant Co YELLOW-Finance Cop.PINK-Assessor Co GOLDENROD-File Co GREEN- P PY. Y PY. 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