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, ,_ _1,�� CITY OF DIAMOND BAR ���� �'� ^ ,� DEPARTtv1ENT OF COMMiJNITY&.DEVELOPMENT SERVICES _ � . 21660 E.Copley Drive Suite 190 � �! ���� az(909)851-3117 �q�f . . . ,..._ ., BUILDING PERMIT APPLICATION ___ � QJOBSITE ��' ���^�(�,y� �� J DATE y � NUMBER �""-��� # ¢ ADDRESS � �� � APPLICATION PERMIT P/C � ISSUE � ' /^� � TYPE OCC APN LOT TRACT DATE lf'V CONST. GROUP p OWNER o ADDRESS C� - ZONING SETBACKS �W CITY l3" ZIP ��jTEL. La FRONT Ryy ❑ APPLICANT b TEL. - REAR � SIDE/SIDE STREET RW ❑ � CONTRACTOR CC� �G�� l SIDE � O CDDRESS �" Z�P ,TEL. � PROPOSED USE o AFCH/ENG/ � DESIGNER NO.DWEL. NO. NO. � CDDRESS Z�P TEL. UNITS STORIES BEDROOMS cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-BUILDEH DECLARATION . - SFR/AD0/HEM � O p I HEHEBY AFFIRM UN�ER PENAUV OF PERJURY THAT I AM EXEMP7 FROM THE COMRACTORS ll- G81'8CJ0/C8/(bR W CENSELAWFORTHEFOLLONANOREASON(SEC.7o31.5BUSWESSANDGROFES510NSCADE:ANYCI7YOR (n U COUN7VWHIp{qEpUIHESAPERMITTOCONSTRUCT,ALTE0.IMPROVE,DEMOI!6H2ORREPAIRANVS7RUC- W PetiO/DBCk � 7URE,PRIOR TO ITS ISSUANCE,ALSO BEQUIRES THE APPLICANT FOR 3UCH PERMIT TO FiLE A 516NED w � STATEMENT THAT HE OR SHE IS LICENSED PUR3UAN7 TO TME PROVISIONS OF THE CON7qACTOqS LI- � � CENSE UW(CHMTER B(COMMENCIN�WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO- PoDUSpa FESSIONS CODE)OR IHAT ME OR SHE IS EXEMPT 7HEREFROM AN�THE 9ASI5 FOR THE ALLEGED E%EMP- TION.ANYVKK.ATIONOFSECTION7031.SBYANYAPPLICANTFORAPERMITSU&IECTSTHEAPPLICANTTO z Re-Raof � A CML PENALTY OF NOT MORE THAN FNE HUNDRED DOLLARS(t500).): � ❑I,ASOWNEROFTHEPHOPERTV.ORMYEMPLOYEESWITHWAGESASTHEIRSOLECAMPENSA710N, � ColnrttefCial -- WILL DO 7HE WORK,MI�THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(5EQ 7046,BUSI- J � NESS AND PROFESSIONS CDDE:THE CONTRACTORS LICENSE LAW DOES NOT AVPLY TO AN OWNER OF ? PROPERTY WVIO BUNDS OR IMPROVES THEREON,AND NMO DOES SUCH WORK HIMSELF OR HERSELF OR � 7HROUGHHISOHHEROWNEMPLOVEES,PROVIDEDTHATSUCHMPROVEMENTSARENOTINTENOEDOR m Q OFFEREDFOR3N.EIF,HONrEVER,h1EBUILDINGORIMPROVEMENTIS50lDWITMINONEVEAROfCpMPI.E- Z TqN,THE OWNER$UILDER V11LL HAVE THE BURDEN OF PROVIN�THAT HE Ofl SHE OID NOT BUILD OR � IMPROVE FORTHE PURPOSE OF SALE). � ❑I,ASOWNERaFTHEPROPERIY,AMEXCLUSNEIYCANTMCTINGWRHUCENSEDCOMRACTORS TO CONSTRUCT THE PRO,IECT(SECJ0�4,BUSINESS AND PROfE5510NS CODE:THE CONTqACTORS LI- Veluation ADJ.AREA CENSE UW DOES NOT APPLV TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON.AND � WFIOCOMRACTSFONSUCHPRO.IECTSWITHACONTRACTOR(S)LICENSEDPURSUANTTOTHEOONTRAC- QUANTITY DESCRIPTION � roas uc�sE uw.�. FEE ❑I AM EXEMPT UNDER SEC. 8.8 P.C.FOR THIS REASON J � a �! V lL � DATE OWNER � � LICENSED CONTRACTORS DECLAFiATION W J I HEREBYAPFIRM UNOER PENALTY OF PERIURY TNAT I AM IICENSED UNDER PqOVISIONS OF CHAP7ER � ��. � � 0(COMMENCIN[3WITHSECTION700�)OFDIYISION30FTHE9l151NES5ANDPROFESSIONSCO�E,AND Z � Lj X� A1Y UCENSE IS IN NLL FOPCE AND EFFECL m —, LlJ /"� C-� �� 0 LICENSE CLASS �� � LIC.N0._�_(,1y�7�� _ U DATE " _ CONTRACTOR d W � WORKERS'COMPENSATION DECLARATION Q � I HEREBV AFFINM UN�ER P OF PER.IURY ONE OF THE FOLLOWING DECLARATIONS: Z � _IHAYE ILLMAINTAINACEiRIFICATEOFCONSENTTOSELF-INSUflEFOftWORKERS' a _ COM SATION,AS PROVIDED BY SECTION 3700 OF 7HE UBOR CO�E,FQR THE PERFORMANCE U Q HE WORK FOR WHICH THIS PERMIT IS ISSUED. � . � _I NAVE AND WILI MAINTAIN WORKERS'COMPENSATION INSUMNCE,AS REQUIRED BY 3EC710N Q370o OFTHE IABOR CODE,FORTHE PER RMANCE OF THE WORK FOR WHICHTHIS PERMfT IS Q ISSUW.MYWORKERS'WMPENSA710NIISURANCECARR RAN�POLICY I �. CONSTRUCTION > CARRIER� L - �' .�� PLAN REVIEW � POUCYNUMBER i �lt� � ELECTRIC i� � (n�ssEciaNN�rareE�rmoFn�rEa'.arsroaoriE�E000uAnsmao�at�Ess). PLUMBING j�+ Z ICERTIFYTHATINTHEPERFOqMANCEOF7MEWORKFOflWHICHTHISPERMITI5155UED,l MECHANICAL CD- SHALL NOT EMP�OY ANY PEHSON IN ANY MANNER SOAS 70 BECOME SUBJECTTO THE � WORKEftS'COMP SA710NLAWSOFCAI RNIA,ANDAGREETMATIFISHOUTABECOME INSPECTIONFEE � SU&IECT TH WDRKERS'CWAPENSA ON ISIONSOFSECTION370oOFTHE - " O CO ,1 qLL Oq7HW17H COMPLY WIT Ti0 E P SION CE �� / p DATE: �4 APPLICANT. SMIP W � WARNIN6:FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,M�SHALL BE ENERGY P1C pq�,�^ i° �� LL SUBJECTANEMPLOYERTOCRIMINALPENALTIESANUCIVILFINESUPTOONEHUNDREDTHOUSAND ENERGYPERMIT ��d d G1'�" ��y,p 7�� DOLURS(5100.00o�.IN ADDITION i0 THE COSTOF COMPENSATION.�AMAGES AS PROYI�ED FOR IN S/A---d��d�, ��� wSECTION37080FTHELABORCO�E,INTEREST,ANDATTORNEV'SFEES, �Rr���T�� Tt� p� RETENTION FEE: +��si� ��� ��hr � d<0 m�r O CONSTRUCTION LENDIN6 A6ENCY �"' PRE-ALT FEE: � 1 HEREBY AfFIRM UNDER PENALTY OF PERJURY THAT 7NERE IS A CDNSTRUCTION LEN�ING AOENCY FOR THE VERFORMANCE OF THE WORK FOR WHICH ThIIS PEHMIT IS ISSUED(SEC.3087,CIV.C.). Z w � LENDER'SNAME 1— IENDER'SADDRESS � TOTAL FEES 3�" � w ICER71FY7HATIHAVEREADTHISAP7LICATIONANDS7A7ETHATTHEA VEINFORMATqNISCORRECi . � IAGREETOCOMPLYWI7HALLCRVANOCOUNTYOR�INANCESANDST ELAWSRELAJINGTOBUILDING - � _J//���J�� � CONSTRUCTION.ANDHEHEBYAUTHORIZEREPRESENT0.TNESOFTH OUNTYTOENTERUPONTHE ��/�ry,�"���� ��/f�� �1""_' 'L ABOVE- PROPER7Y FOR INSPE T P POSES. /%OL� f Z COMMENT ��'�� � p � i � m PERMIREENAAIE( I ' // Q „m � � SKiIUNREOFPERMI`E DAT � � RECPT.NO. � PAID BY VALIDATION WHITE—Department Copy,YELLOW—Financa Copy,PINK—Assessor Copy,GOLDENFOD—File Copy,GREEN—Applicant's Copy ,. ,, . . ;. .,,. , ,�. , . ,, ,: M, . ��� � � � ����� � � . �� . _.,. ' .. �� :. � � � , , . � ... � �� � � $ � � .. � . � . � � �� o. m. � �.� . �� �,.. . s.. �� y�., , ,.. � � . . ,�� �� ��:�. �� � �:s � �_:, � <a � `�f' .�.: � I i E i ��.�C�;-i,�C���'€� r '�t . �rvi ,- .'�. � __ �__ ___.�.______ . 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