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CITY OF DIAMOND BAR � � ^--�— DEPARTMENT OF COMMUNTTY&DEVELOPMENT SERVICES '�~ � W 21660 E.Copley Ihive Suite 190 � ��.,;� � (�)s6o-3i9sF��9oa)g6i-3ii� PRESS BUII.DING PERMIT APPLICATION FIRMLY :- _ _ ---_ �:: _ � JOBSITE � I� � ,� /���� � APPLICATION �� PERMIT ���� P/C a' ADDRESS. � ��� DATE NUMBER # � � ISSUE TYPE OCC APN LOT TRACT : pATE CONST. GROUP :�,. OWNER "; � LL A�DRE�S �► ZONING SETeACKS `�"' c�Tv �31ki ��dn ZIP TEL. SF � FRONT RW ❑ �: APPLICANT ��"r"�[��jant9`I TELfn�l� 4��;���9z3 ' SIDEJSIDESTREET RW ❑ �' CONTRACTOR � F/�tf�v SIDE p �" ADDRE S T�-�` �' �a' CITY ` � ZIP � TEL.�6��Zf � PROPOSEDUSE :��' -�' �� 2�� , '��t$T (�y rQ AACH/ENGI • r z;' QES�GNER �� '� CO� 5 47'lr '!:V W' ADDRESS r NO.DWEL. NO. NO. ;>�-j. UNIT9 � - STORIES �_BEDROOM5�_ „;�� CITY ZIP TEL. ;cns, y� � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATIQN . �pC; . . OWNEfl-Bl11LDER DECLARATION , SFR/ADD/AEM O' .Q} 1 HEREBYAFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM TNE CONTRACTORS U '' �. GdfBge/CflfP01t ��W�: CENSEU1WFOflTHEFOLL.OWINGpEA50lJ(3EC.T031.58USINESSANDPROFESSIDNSCA�E:ANYCIiYOR -U`� COUN'iYWliICHREWIRESAPEqM�TTOCONSTRUCLALiER,IMPflOVE,DEMOLISH,ORREPAIRANYSTRUG - � �Z�' TURE,PPoOH TO ITS ISSUANCE,ASO RE4UIRES THE APPLICANT FOR SUChI PERMIT TO FILE A SIONED- xi W PefiO/DBCk V"�^ STATEMENT THA7 HE OR SHE IS LICENSED PURSUANT TO TNE PROVISIONS OF THE CONTRACTOpB L4 F W . �` GENSE LAW(CMA7TER 9(COMMENqNO WITH SECTfON 7000)OF 01VI5ION 9 OFTHE BUSINES$AN�PRO� � POOVSp9 �'� FES3qNSCOOE)ORTHATHEORSHEISEXEMGTTMEREFROMANDTHEBASISfOFTHEALLEGEDEXEMP� �- 110N.ANYVKKATIONOFSECTION703159YANYAPPLICANiFORAPERMITSUBJECTSTMEAPPUCANTTO �°_Z Re-Root � ACMLPENAL7VOFNOTMORE7fiANFNEHUNDREDDOlLARS(SSOOj.): ' �,:�; ❑I,ASOWNERORTHEPROPERN,OFMYEMPIOYEESWITHWAGESASTHEIRSOLECOMPENSATION, '�C] Commefcial - - ` . .Z: WILl00 THE WORK,AND THE STHUCTUpE IS NOT IMEN�E�OR OFFERED Wfl SALE(SEC.)Odd,BU51� .J ��-_' NE33 AND PROFESSIONS C06E:THE COMflACTORS LICENSE LAW DOES NOT APPLY TO AH OWNER OF ;? � ' FROPERTI'N'HOBUIIASORIMPqOYEBiHEREON,MIDWHOD�ESSUCHWORKHIMSELFOqHEFi5ELPOR- -�-`: THFWU6HHISORHERONTIEMPLOYEES,PROYIDEDTHATSUCHIMPROVEMENTSAflENOTINTENDEDOR ' �'m .:�.,i OFFEREDFORSPLEiF,HOWEVEq,THEBUILDINGOFIMPROVEMENTISSOLDWITHMONEVEAROFCAMPLE - .�- TION,THE(JWNER$UILDEq WILL HAYE THE BUHDEN OF PqOYiNG TNAY HE.OR 9HE DIO NOT 6UILD OR �- IMPROVE fOR 7HE PURPOSE OF SAIE). - _�(,=(,){t ❑I.ASOWNEHOFTFIEPROPEflfV,PMEXCLUSIVELYCONTRACTIN6WITHLICENSEDCbNTflRCTORS� ' ��; TO CANSTRUCT THE PROJEC7(SEC.)016,BUSINESS AND PROFESSIONS CODE:THE CONiRAC70RS LI- ValUBilO� ADJ.AREA_. W:�; CENSEUlWDOESNOTAPPLYTOANOWNEROFAPHOPERTYWHOBULLDSOPIMPHOVESTHEREON,AND -- — — . -`�� WHOIX7NTRACTSFORSl1CHPROJECTSWITHAOONTRACTOR(S)UCFNSEDPUR5UANiTOTHEWt1TPAG QUANTiTV DESGRIPTION FEE TOpSUCENSEUWJ, .� . �-�,' ❑IMfIXEMPTt1NpERSEC. B.BP.C.FORTHISREASON � Od �: � �-LL't' DA7E � OWNER �"' Z: W �,-= LICENSED CONTRACTORS DECLARATION - � � :��� IHEREBYAFFl({MUNDERPENALTYOFPEflJURYTHATIAMLICENSEDUNDEflPROVi5loN50FCHAPTEft - � :p,,;- e�COMMENCMHIWIT1i5ECT10N7000�Of0���6pN30FTHEBUSINESSpNOPROFESSiONSCOOE.ANO Z X MY LICENSE IS IN FULL FORCE AND EFFECT. UJ' �(/.�., .�\('� m �'�;_ UCENS SS - :� . . LIC.NO. (/-�...J -� � j , -�� DATE CON7flACTOR � �'. . p �[�� WORKERS'COMPEN5AYION pE RATION �ry ,�'1,/ , �; ��� ��� IHEREBYAFFIRMUNDEFPENA4TYOFPERJURYONEOFTHEFOLLOWWGDECLARAT S: � I � �' _IHAVEANDWILLMAINTAINACERiIHCATEOFCIXJSENTTOSLlFINSUREF WORKERS' - -�9 COMPENSAiION,A3PROVIDEDBYSEC71A497ooOFTHEUBOqCADE,FO THEPERWBMANCE � OF THE WORK FOR WH�CH YHIS PERMIT IS ISSUED. ..--"�� -W IHAVEANDWILLMAtMAINWORKERS'CONPENSA:IOYINSUqANCE,ASftEQU10.ED FON � r"'� j� � Q� 37000FTHELABOflCOUE,F�R7HEPERFOHMANCEOFTHEWOqKf-0RWHICHTHISPERMITIS; � �{�1} ( / ¢. ISSUED.MY WDRN 'COMPENSATION IN RA CE CA�ERRN�POLICYNt1M8£R�E:��'� %� CyryST�IUC ON �/� > GAPRIER 4��� � � U N R EW �- PIXICYNUMBER " . . .' R!C � (itOSSECtqtJNE�ND78EWhF1EI�moF'niEPf.NNi1SFORONEHIA�oIiED (s�aol ��1 LUMBING W . . . _—. . ___ Z ICEHlIFYTHATINTHEPERFORMANCEOfTXEWORKFORWHICHTHISPEflMI ISSUE � MECHANICAL �� � C�S Sl7ALL NOT EMPLOYANY PEfl50N IN ANY MpNNER SOAS TO BECAME SUBJECTTO "` ��,., , N WORKERS'COMPENSA710NIAWSOFCALIFOftNIA,ANDAGflEETHATIFISHOULDBECOME �NSPECTfONFEE � SU&IECTTOTNEWOHKERS'COMPENSATIONPROVISIO, OFSECTIDN37aoOFTHELAB /�� � CODE, SHALLF THWITMCOMPLYWITHTH PR iows. ISSUANCE �-�YtJ_ o n F � � ��.g� ��� p� DATE: � . � �APPLICANT: �� . SMIP . ���� � : - W ENERGY P/C " '-� WARNING�FAIIUFE TO SECIIRE WOflKEAS'COMP 5FTION COVERAGE IS UNIAWFUL,AND SNfLL4 BE 7g��yq "� � � Sl1BJECTANEMPLOYERTOCRIMINALPENALTIESAN�CNILFINESUPTOONEHUNOREDTHOUSAND EN6RGYPERMIT �zo � ����'dJX? DOLLARS(5100,DW�,INADDITIONTOTNE COSTOF COMPENSAPION,DAMAGESAS PROVIDED FOF IN -g — ¢' SECTION37oeOFT11ELA80RCODE,M7EREST,ANDATTORNEVSFEES. RETENTIONFEE: d_i ��T��yq,`�'-�A.� t6 -d CONSTRUCT�ON LENDING AGENCY PRE-ALT FEE: O , � IHEREBVAFFIRMUNDERPENAL7VOFPERJURYTHATTNEREISACONSTRUCTIONLEN�INGAGEhC7 FOR THE PERFOFMANCE OFTHE WORK FOR WHIGH THIS 7EPM1T IS ISSUE�(SEC,3987,qV.C.�. . � _�� :_'_ "— �� LENDER'SNAME_._ F- LENDEfl5A�OPESS � ICERTIFYTMATIHAVEREA07HISAVVLICATIONANDSTA7ETHATTMEPBOVEINFORMATIONISCOflRECT. TOTAL FEES .j • �� W 10.GREETOCOMPLYWITHALLCITYANDCOUNT'ORDINANCESANDS7ATEtAWSREIATING708NLDING � CONSTHUCTION.ANDNEREBYAUTtiOR12EREPRESENTATIVESOFTHISCAUNT/TOENTEHUPONTHE . . ' ZABOVE-MENTIONEDPROPERT'WPINSPECTIONPURPOSES. 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