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� �� CITY OF DIAMOND BAR '�� �� �'` � ` --��� DEPART2�IENT OF COMMUNITY&DEVELOPMENT SERVICES g� ( 21660 E.Copley Drive 5uite 190 l rJ ��1 �I l A � w (909)860-3195 F3z(909)851-3117 PRESS A�°... BIIQ,DING PERMIT APPLICATION _ —_. . .. .,. ,, FIRM�Y ... . . ..... . .. . _ � JOBSITE i"�� P� � APPLJCATION "' � � PERMIT ]�/,„� P/C Q ADDRESS '�� �-�-.+ DATE_ � NUMBER� # c� ISSUE TYPE OCC APN L07 ACT DATE � _CONST. GROUP p OWNER � ADDRESS � ZONING SEl"BACKS 0 � CITY ZIP J�TEL - FRONT RW ❑ APPLICANT T REAR ❑_ SIDElSIQE STREET RW ❑ � CONTRACTpR SIDE ❑ O ADQRESS .� l PRdPOSED USE � CITY ZIP �'EL. � S�i I L�� wo ARCH/ENG/ � DESIGNER NO.DWEL. NO. Np. a ADpRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.FT: FACTOR PSF ADJ.AREANALUATION � � OWNER-BUILDER DECLARATION SFR/ADDiAEM O p 1 HEREBY AFFlPoA UNDER PENALTV OF PERJURV THAT I AM EXEMPT FROM THE CONTqACTOFS LI- Gflfe9B/C8�0lf W CENSEIAWWPIHEFOL10WiNGREA50N(SEC.7031.68U51NESSANDPROFESSIONSCAOE:ANYpNOR (n U pOUNfYWHICHREWIRESAPERMITTOCONSTRUCT,ALTEF,�MPROVE,DEMOLlgH2ORREPAIRANVSTRUC- W pdti0/DBCk WTURE.PRIOR TO RS ISSUIWCE,A�50 REDUIRES TME APPLICANT FOR SUCH PERMIT TO FlLE A SIONm .� STATEMENi THAT HE OR SHE IS UCEt�EO PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI- � CEN5E LAW(CFiAPTER B(COMMENCIN�WITH SECTION 700D)OF D�YISION 30F THE BUSINESSAN�PRO- LL" POOVSP2 FESSqNS CODE)OR 7NA7 HE OR SHE IS EXEMPT THEREfROM AND 7HE BAS�S FOR THE ALLEOED EXEMP• V TION.MlYVpU710NOF5ECTION70J1.5BVANYAPPLICANTFORA7ERMITSUBJECTSTHEAPPLICANTTO Z RB-Fl00� � ACIVILOENALNOFNOTMORETHANFNEHUN�REODOl1.AR5(f50J).): � ❑I,i440MMEROFTHEPROPERTV,OHM4EMPLOVEESWITHWAGESASTNEIRSOIECOMPENSATION, � ComRl6fCl71 ' VALL 0�7NE WORK,AND THE STRUCTURE IS NOT IN7EWED OR OFFEFEO FOR SA�E(SEC.7D44,BU51- J NESSAND PAOFESSIIXJS CODE:hiE CONTRACTOfiS UCENSE LAW OOES NOT APPLV TO AN OWNER OF � VHOPERTYWl108UILDSOPINPROVESTHEREON,ANDMMODOESSUCHWORKHIMSE�FORHERSELFOR � � iH(qUCiHHISOFlHEHOWNEMPLOVEES,PROVIDEDTHATSUCHIMPROVEMENTSMEN�iINTENDE00R m QOFFEREOFORSILLEIF,FpWEVER.7HE8UILDINOORIMPqOVEMENTI550LDWITNINONEYEAROFCAMPLE- Z �TION,THE ONMER�BUAAER Wlll HAVE THE 6URDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR = IMPROVEFOHTHEPURPOSEOGSALE). ❑I,ilS OWNEH OF THE PROPEHTV,AM EXCLUSIVELY CANTRACTINO WITH LICENSED CONTRqCTORS � TO CONSTRUCT TH[PFiWEC7(SEC.7011,BUSINESSAND PROFESSIONS WDE:THE CONTRAC7pP5 LI- V01u8�1W1 ADJ.AREA W CENSELAWDOESNO7APPLY70ANOWNEROFAPROPERTYWHOBUIlO50RIMPROYESTHEREON,AND � WFIOCONTMCTSFORSUCHPRQlECTSWI7HI1CON7RACTOR�S)LICENSEOPURSUANTTOTHECONTRAC- QUANTITY DESCRIPTiON FEE � TORSLIGENSELAWJ. J O ❑I AM EXEMFT UNDEfl S�C. B.8 P.C.FOR THIS REASON U 3 — � � DATE OWNER V W � UCENSED CONTRACTORS DECLARATION �y � I HEpEBY AFFIRM UNDER PENALT'OF PERIUHY THAT I AM LICENSED UNOER PROVISIONS OF CHAP7Efl � r � 9(CAMMENCINfiWITHSECTIDN700D}OFOIVISION30FTHEBUSINES&ANDPROFESSqNSCODE,AND Z �� UY LICENSE IS IN FULL FORCEAND EFF C7. +� /'� m �7 O ,/ � � � UCENSE CLAS3 LIC.NO. 1"__ J U DATE CONTRACTOR a W � WORKERS'COMPENSATION DECLARATION ¢ = U � I HEREBV AFFIRM UNDER PENALTY OF PERJURY ONE OFTNE GOLLOWMG DECLARATIONS: � Z � __IHAVE17..^^II��DWILLMAMTpiNACERTIFlCATEOFCONSENTTOSELG-�NSUREFORWORKERS' 2 � COAt➢ENSATION.ASPROVIOEDBYSECTION37ooOFTHELAeORCODE,FORTl1E7ERFORMRNCE W J�R�E WORK FOR WHICH THIS VEAMIT IS ISSUED. � W �I HAVEAND YYILL MAINTAIN WORKERS'COMPEN3ATION INSURANCE,AS REQUIRED BY SECTION Q 3700 OF THE I.ABOR COOE.FOR THE PERFORMANLE OF THE WORK f-0R WHICH THIS PERMITIS ISSUED.MYN'OPoCEflS'COMPENSATIONI URANCECARfl RAN POLIC NUMBERARE: CONSTRUCTION j � - �� PLAN REVIEW CARRIER � ��� Z POLICV NLIAIBEH � g ELECTRIC Q Q (iHSS[CTIONNE�NOTBEQOA1PLEfEDOFiHEPERMRSK%iCNEHUNORED00LU1RSt5�ao)ORLESS} PWMBING � __� Z I CERTIFV THAT IN THE PERFORMANCE OF THE WORK FDR WHICH THIS PERMIT IS ISSUEO,I MECNANICAL (•j SHALL NOT EMPLOY ANY PERSON IN ANY MqNIVER 50 AS TO BELOME SUBJEGT TO THE Uj WORKERS'COMPENSATWNLAWSOFCALIFORNIA,ANDAGREETHATIFISHOULDBECOME INSPECTIONFEE _�_A T�� _� S SUBJECTT THE RKERS'COMCENS PROVISIONSOFSECTION87000FTHELABOR � ��/, COO�Ec.I 6 F HW TH COMPLY WI THO I510 ���Y ISSUANCE � � /� SMIP p DATE: `� � �PIPLICANT. � _._ . . � ENENGY P/C � J WARNING FAILURE TO SECURE MlORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL BE .._ � SUBJECTANEMPLOVERTOCRIMINALPENALTIESANDCIVILFINESUPTOONEHUNDREDTFpU5AN0 ENENGYPERMIT�j .. 1 OOLURS(S1ao.000).IN ADDITION TOINE COST OF COMPENSATION,DAMAGES AS PROVIDFO FOR IN � SECTION 3708 OF THE IABOR CODE,INTEREST,AND ATTORNEY'S FEES. RETENTION FEE:��g ��.g� pW„ CONSTRUCTION LENDING AGENCY PRE-ALT FEE: ` � i � 1 HEREBV AFFIRM UNDER PENALTV OF PERJURV THAT THERE IS ACANSTNUCTION IENDING AGENCV � FORTHE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT�S ISSUED(SEC.3097,CIV.C.). Z W � LENDER'S NAME F— LENDEfl'SAD�RESS W7CERTIFYTHATIMAVEREADiHISFPPLICATIONANDSTATETHATTHEABOYEINFORMATIONISCARRECT. TOTA�FEES , � IAGREE TO COMP4�WRH ALl Cm'ANO COUN'N ORDINRNC AND STATE LAWS REIAT�NG TO BUILOING � CONSTPUCTION,ANDHEREBYAUTHORREFEPRESENTATIVE OFTHISCOUNT'TOENTERUPONTHE z A80VE�MENTIONEO PROPERTY GOF INSPECT PURPOSE COMMENTS 0 J � ¢ PERMITTEE NAME(P �- � Uj SWNATUREOFPER E UATE � � RECPT.NO. 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