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Home My WebLink About10809 � , - CITY OF DIAMOND BAR � � � 'T � COMMUNITY DEVELOPMENT DEPARTMENT �' ?,_� . 21660 E.Copley Drive Suite 190 PRE�J+S (909)860-3195 Fax(909)861-3117 """" BUILDING PERMIT APPLICATION FI RM LY o�r JOBSITE �� ICEGt`��- I�� - /J�/J DATEICATION/O � �/ NUMBER/V(/�/ #/C � ADDRESS o ISSUE �J �y TYPE OCC °� APN�,_ LOT TRACT DATE /'" � "� � CONST. GROUP p OWNER �r f..�• �A��F'�� ADDRESS ZONING SETBACKS ZCITY�n�P r�� ZIP TEL FRONT RW ❑ � APPLICANT TEL. REAR ❑ o SIDE/SIDE STREET RW ❑ m CONTRACTOR /�@.KJ �✓-� �� /�C.� . SIDE O �: ADDflESS � �.� F s pROPOSED USE ��`''�� '��"�' � � CITY tid lt��s ZIP�� TEl � /"S � _ w ARCH/�G/ �- W DESIGNER NO.DWEL. ' NO. NO. n., ADDRESS. UNITS STORIES BEDROOMS _� CITY ZIP TEL._ � '. _ � �ESCRIPTION SQ.FL FACTOR PSF ADJ.AREANALUATION � � - O OWNEP-BCILDER DECLARATION . � - SFR/ADD/REM � � � .. � . I HER�Y AFFIRM UNDEFi PENALiY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI- �- ��_ ..G0fa9B/CBfpOfl � � - � - W CENSEL4WFOPTHEFOLLOWINOREASON�SEC.7037.SBUSINESSANDPROFESSIONSCODE:ANYCIiYOIi �- . U COUNTYWHICHREQUIRESAPERMITTOCONSTflUCT,FLTEF,IMPflOVE,�EMOLISH,ORflEPAIRANYSTftUC- ' W Pafio/Deck � � '� z- TURE,OPIOR TO I7S ISSUANCE,AL50 RE�UIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED W W STATEMENT THAY HE OR Sf{E IS LICENSEO PURSUANT TO THE f'flOV!SIONS OF THE CANTflACTORS LI� � '� CENSE LAW(CHFPTER e(CAMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSMESS AND PRO- ' u' POOUSpB � FESSIONSCODE)ORTHATHEOFSHEISEXEMPTTHEREFROMANOTHEBASISFORTHEALLEGEDEXEMP- - - .�' TION.ANYVIOLATIONOFSECTION7o31.58YANYAPPUCANiFORAPERMITSUBJECT&THEAPPLICANTTO � Z� R2-ROO� - �� ACIVILPENALTYOFNOTMOflETHANFIYEHUNDREDDOLlARS(55o0).): , � ❑I,ASOWNEROFTHEPROPERT',OPMVEMPLOYEESWITHWAGESASTHEIRSOLECOMPENSAT�ON: �� COmmeroiel - . � WIIL DO THE WORK,AND THE-STflUCTURE IS NOT INTENDED OR OFFERED FOR SAI.E(SEC,7044,BL1SI- - J � NE55 PND PHOFESSIONS CODE:THE GONTFqCTOflS LICENSE LAW DOES NOT APPLY TO AN OWNER OF ! _ � PROPEPTYWHOBUIL�SORIMPROVFSTHEREON,AN�WHODOESSUCHWORKHIMSELfORHERSELFOR � �- THROUGHHISORHEROV7NEMPLOVEES,PROVIDEDTHATSUCHIMPROVEMENTSAPENOTINTENDEDOR'� .� m ' _}_-__ .._�_.Q_-AFFERFAFORSl�LEIF,HOWEVER,iHEBUIIDiNGQRIMPROYEMENTISSO�,DWITHIIJONEYEAROF,_COMPLE �.,_ ': __. ._..._ . _. .. .. .__. . ..__..__ . .-. . .. -._ Z TION,THE OWNEFl-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR � q � � IMPROVEFORTHEPURPOSEOFSALE). ❑I,ASOWNEHOFTHEPROPERTY,AMEXCLUSIVEIYCONTRACTING.W�THLICENSEDCONTRACTOFS.� ., , � TO CANSTRl1C7 THE PflQ1ECT(SEC.7044.BUSINE55 AND PROFESSIONs CODE:THE GONTqACTOflS LI-� • ValuatiOfl AOJ.AREA W CENSEtAWDOESNOTAPPLYTOANOWNEROFAPROPERTYWHOBUILOSORIMPROVESTHEREON,AND ; . � � WMOCONTRACTSFOflSUCHPROJEC75WITHACONTRACTOR{S)LICENSEDPURSUANTTOTHECANTRAC- `- QUANTITY DESCRIPTION - FEE , _ Y TORSLICENSELAWJ. /}f/+�/� �— �� OIAMEXEMPTUNOEflSEC. B.&P.C,FORTHISilEASON. � Q. C/ ✓ � �rl � � � Sl��//�G-�S LL oarE owNEa_ F z w . .. � LICENSED CONTRACTORS OECLARATION W - � 1 HEREBY AFFIRM UNOER PFNALTY OF PERJUFIY THAT IAM IICENSED UNDER PROVISIONSOF CHAPTER � / � /� - d 9(COMMENqN6 WITH SECTION 7000)OF DIVISION 30F THE BUSINESS AND PROFESSIONS CODE,AN� � Z, � �J - X -MY LICENSE IS W FULL FORCE AND EFFEGT. fy m ' �� S�T S f�.7� - - � �LICENSE CLASS LIC.NO. �� J �9l� V s�� /1 , U^/�'+n/J��+S /(7-�JV U , DATE � � CONTRACTOR-�-��-�`�°�'L`-�'y � -a: �'� _. LiJ . � .: . � � . ;" � � . WORKERS'CQMPENSATION DECLARATION Q �/� . �' �� = U � � I HEREBV AFFIRM UNDER PENALT'OF PERJUFY ONE OF THE FOLLOWMG DECLARATIONS: � Z Q O IHAVEANDWILLMAINTRINACERTIFICATEOFCANSENTTOSELF-INSUREFORWORKERS' _' - COMPENSATION,ASPPOVIDEDBYSECTION37�OOFTHEIAeORCODE,FORTHEPERFORMANCE U , Q OF THE WOFiK FOR WHICH THIS PERMIT IS ISSUED. , _ � � W I HAVE AND WILI MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION /J/J Q 3�0o OF THE LPBOfl CODE.FOR iHE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS- '' ' � h}� ISSUED.MY WOFKERS'COMPE SATION INSURANCqCAARIERAND POLICI'NUMBERARE: ONSTRLJCTION � /✓�./ ��D � +�,¢. CARRIER �"w ��'�E� �� C'�- PLAN REVIEW / / �� , z POLICVNUMBER V � �� "'� Y ELECTRI , • ��,..— -- - ¢ (MISSECTKKJNE�NOTBE�APLEfEDOFTHEPEW�tITISWRONEHUnDREDDIX.IAfiS(S10D)ONLESS} LUMBI v � ` � ��` � Z �CERTIFYTHAT IN THE PERFOflMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I ECHANIC L �� f (� SHALLNOTEMpLOYANYPERSONINANYMANNERSOASTOBECAMESU8JEC7TOTHE , ' WORKERS'CAMPENSA710N LAWS OF CALIFORNIA,AND AGREE TMPT IF 1 SHOULD BECOME INSPECTION FEE f � SUBJECTTOTHEWORKERS'COMPENSATIONPROVISIONSOFSECTION37000FTHELA80Fi �/ �•✓^ � ~� CADE,ISHALLFOftTHWITMCOMPLYWITHTH�` PROVISIONS. " '� � ISSUANC �� O.. y - ,�/O I J . � �. ..� /. �O � � p DATE: - 2 �` APPUCANT: T[ �fa�+..�. �hO..� SMIP I s" ,�`4 � ENERGY P/C �T J- WARNING:FAILURETO SECURE WORKERS'COMPEN5ATION COVERAGE IS UNLAWFUL,ANO SHa.I.BE �- SUBJECT f N EMPLOYEP TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNORE�THOUSAND ENERGY PERMIT _ �OLLARS(E1tln,000).IN AD�ITION TO TNE COST OF COMPENSATIDN,�AMAGES AS PflOVIDED FOR IN � ' �'. SECTION3�o80FTHELABORCODE,INTEREST,ANDATTORNEY'SFEES. - r "�'T.� RETENTIONFEE: �_��`^`�' �, w s� � �� CONSTRUCTION LENDING AGENCY PRE-ALT FEE: `` �� IHEREBYAFFIRMUNDEFiPENALTYOFPERIURVTHATTHEREISACONSTRUCTIONLEN0INGAGENCY g � � FOR THE PERFOFMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC.3097,CIV.C.). Z. 8 W Y LEN�ER'S NAME _.- � � - � F_- LENDER'SADDFE55__._.. - . - � ICERTIFYTHATIHAVERFADTHISAPPLICATIONANDSTATETNATTHEABOVEINFORMATIONISCORRECT. TOTAL FEES ' ,��/�� -Y � I AGREE TO COMPLY WITH AlL CITY AND COUNTY ORDINANCESAND STATE LAWS REIATING TO 9lllf DMG . . - - . � � CONSTRUCTION,AN�HEflEBYAUTHORIZEREPFESENTAT!VESOFTHISCOUNTYTOENTERUPONTHE �j �� /i/A f�_ Z A80VE-MENTIONEDPROPERTYFORINSPECTIONPURPOSES. COMMENTS. ��S�r �� K� � /°�fi�� t �e�t<'7"e�� ST�G t C/4L .G�j��/Lo�.K= i";G � /�/J � m' PERM EENAME(PAINT) � �IQ��'j�Sy ' — � ��..� � �� f��2,1�� „ � S�f t•TATUflEOF RMI7TEE �� AT '- - _ . RECPT.NO. 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