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� �� ----1�``°�-- -- CITY OF DIAMOND BAR � � � COMMUNITY DEVELOPMENT DEPARTMENT 21660 E.Copley Drive Suite 190 PRESS (909)860-3195 Fax(909)86]-3ll7 """" BUILDING PERMIT APPLICATION FIRM LY �; JOBSITE /I� r i,��N �r APPLICATION �. r �. PERMIT C� P/C Q� ADDRESS /ll� t CA,I�1 J"C.( t �F ' �J I� 1 p; DATE NUMBER }� `� ISSUE TYPE OCC `Or°' APN LOT TRACT DATE _CONST. GROUP p OWNER � (� � ADDRESS - .if ZONING SETBACKS o ' z CITY ZIP y i 7.�TEL - 7 " FRONT RW ❑ o APPUCANT - Cr= c�' TEL.�a ��{!![ S DE/SIDE STREET��1�( p�.�.� � Z SIDE °�^i���fl!"I l ❑ ' Q CONTRACT R ' > 1� i�l _ ADD E,S 'C' ' � CI Z�p C�`�Q� E l PROPOSED USE ' �s ARCHIENG/ � z DESIGNER w NO.DWEL. NO. NO. a: ADDRESS � CITY ZIP TEL. UNITS STORIES BEDROOMS � __ cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION - .�� OWNER-6CILDER DECLARATION - SFR/ADD/REM O I HEAEBV AFFIRM UNDER PENALTY OF PEFJURV THAT 1 AM EXEMPT FROM THE CONTRACTORS LI� G0f7 JB/G8lpOrt , �W CENSELAWFORTHEFO.IOWINOREASON(SEC.7031.SBU3ME33ANDPROFESSIONSCODE:ANYCRYOfl (n - U- COUNTYWHICHREQUIRESAPERMIT10coN5THUCT,ALTER,IMPROVE.DEMOLISH,ORREPAIRANVSTFUG - ' W' TURE,PqIOA TO ITS ISSUANCE.AL50 REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED W Patio/Deck STATEMENT THAY HE OFi SHE-IS LICENSED PUflSUANT TO THE PftOViSIONS OF THE CONLRACTORS LI� , � �' CENSE LAW(CHAPTER 9(fAMMENqNG WITH SECTION 7000)OF DNISION 3 OF THE BUSINESSAN�PRO� � POOI/Sp8 . � FESSIONSCODE)ORhIATHEORSHEISEXEMPTTHEREFFONANDTHEBASISFOFTHEALLEGEDE%EMP- � - V: TIO4.ANYVIOLATIONOFSECTION7o31.58VANYAPPUCANT�OflAPERMITSUBJECTSTHEAPPUCANiTO Z Re-Roof ACIVIL PENALiY OF NOT MORE THAN FNE HUNDREO�OLtARS(5500).): - �. ❑I,ASOWNEROFTHEPROPERTY,ORMYEMPLOVEESWITHWAGESASTHEIRSaLECOMPENSATION, � COI11II7BfC181 . Z WILI DO iHE WORK,AN�THE STHUCTURE IS NOT INTEN�EO Oq OFFERED FOR SALE(SEC,7o44,BUSI- J gi � NE55 AND PflOFE5510N5 CODE'.THE CONTflACiOflS LICENSE LAW�OES NOTAPPLY TO AN OWNEfl OF = ( . . PROPERTYWHOBUILDSORIMPpOVESTHEflE6N,ANOWHO�OF.5Sl1CHWOFKHIMSELFORHERSELFOR � -� �� THROURHHISORHEROWNEMPIOYEES,PROVIDEDTHATSUCHiMPROVEMENTSARENOTINTENDE00f1 m � _ 0OFfEFEOFORSALE.IF,HOWEVEfl,THEBUILDMGORIMPROVEMENTI550lDWITHINONEYEAROFCOMPLE- Z- TION.THE OWNER�BUILDER WILL HAVE THE BURDEN OF PHOVING 7HAT HE OR SHE�I�NOT eWLO OP �;�;._'� �, IMPROVEFORTHEPURPQSEOFSALE). ❑I,AS OWNER OF THE PROPEfl7Y,AM EXCLUSNELY CONTRACTING WITH UCENSED CONTqACTORS ,"�-`�, � TO CONSTRUCT THE PROJECT(SEQ 7044,BUSINESS AND PFOPESSIONS CODE;THE CONTRACTORS LI- V81U8fi0n ADJ.AREA �i-.. W CENSELAW DOESNOTAPPLYTOANONMEROFAPROPEPT'WHOBUILDSOpIMPROVES7HEPEON,AND = WHOCONTRACTSFORSUCHPROJECTSWITHACONTRACTOR(S)LICENSE�PURSUANTTOTHECONTRAG QUANTITY DESCRIPTION FEE `� ~' TORS LICENSE IAW.). � - � Q J /r o O I AM E%EMPT UNDER SEC. B,fl P.C.FOR THIS REASON Q f � U � - LL � � DAiE____ _... OWNER_.___ __.__– __ U .__..__ _____. . Z W � . �- LICENSED CONTRACTORS DECLARATION W - � �� I HEREBYAFFIRM UNDER PENALTY OF PERJURYTHAT 1 AM LICENSED UNOER PROVISIONS OFCHAPTER � � 9�COMMENCING WITH SECTION 7a0o)OF DIVISION 30F THEBUSINESS AND PROFESSIONS CODE,AND z `X_ MY LICENSE IS IN FULL FORCEAND EFFECi. ' m - -- � LICENSE CCASS l.—�� LIC.NO.� j U DATE CONTPACTOR - - � � WOFKERS'COMPENSATION DECLARATION si r����Q �f v a� -y�,h �. .� } 1 ^�o t V � IHER YAFFIRMUNDERPENALTYOFPERJURVONEOFTFIEFOLLOWINGDECLAPATIONS: Z � � � � IHAVE0.N�WILLMAINTAINACERTIFICATEOFCONSENTTOSELF-WSUREFORWOflKERS' _ � - Z CAMPENSATION,AS PROVIDED BV SECTION 37o00F THE IAeOR CODE,FOR THE PERFORMANCE U ' � OF TME WORK FOR WHICH THIS PERMIT IS ISSlJEO. � , W _IHAVEANOWILLMAINTAINWORKERS'COMPENSATIONINSUR0.NCE,ASREQUIREDDVSECTION - � , Q 370DOFTHELABORCODE,FORTHEPERFORMANCEOF7HEWORKFORWHICHTHISPERMITIS - ISSUED.MV ORKERS'l�p�M�PENSATION INSURA E CAR�R�IER A/N�D POIICV NUMBER ARE: CONSTRUCTION ¢ � �-IL3 �/� ` ��f/UJ ' �a1� PLAN REVIEW ] CARRIER �E L. YC l.�.L�A. �- Z POLICYNUMBER `�� ��I ��� " � ELECTRIC __ �Tl Q �- - �. 0 (IHISSECTKKJNEmNOTBEWN�PLEfEDOFhIEPERMfTISPJRONEHUNDFEDDOl.IN7s(E700)ORLESS). PLUMBING - - Z ICERTIFVTHATINTHEPERFORMANCEOFTHEWORKFOPWHIC HIS ERMITISISSUEO,I MECHANICAL ` - � - - C'3 SHA�LNOTEMPLOYANYPERSONINANYMANNERSOASTOOEC MES�JECTTOTHE - �� (n WORKERS'COMPENSATIONLAWSOFCALIFOflNIA,ANOAGREET p7�Fl HOULDBECOME INSPECTIONFEE —__' i . SU&IECTTO THE WORKERS'COMPEN 71 N PROVISIONS OF SF TION 3700 OF THE LABOR - .�. CO E,I S ASlFO THWITM COMPIY HOSE PROVISLONS. . ISSUANCE ' �r � ����`�� � SMIP � p DATE: C APPLICAN W . �. - . J WARNING:FAILURETO SECURE WORKERS'COMPENSATION CAV AG UNLAWFUL,AN SHALL B ENERGY P/C ____ __. - � SU&IECTANEMPLOYERTOCRIMINALPENALTIESANDCIVILFINES OONEHUN�REDT ENERGYPERMIT - OOLLARS(Si00.000�,INADDITIONTOTHECOSTOFCOMPENSATION,DAMAGESASPROVIOE�FORIN .. . .r_1 SECTION 3�08 OF THE LABOR CODE,INTEREST,ANDATTORNEY'S FEES. RETENTION FEE: � - � � CONSTRUCTIONLENDINGAGENCY PRE-ALTFEE: p – -- - � IHEREBYAFFIRMUNDERPENALTVOFPEPJUPVTHATTHEFEISACONSTRUCTIONLEN�INGAGENCY . FORTHEPERFORMANCEOFTHEWORKFORWHICHTHISPERMRISISSUED(SEC.30W,CIV.C.). Z tl1 . � �ENDER'SNAME - H LENDER'SA��flE55 ' � ICERTIFYTHATIHAVEREADTHISAPPLICATIONANDSTATETHA7THEABOVEINFORMATIONISCOHRECi TOTAL FEES 4 4 � - w I AGREE 70 COMPLY WITH AlL CITY AN�COIJNTV ORDINANCES AND STATE L4WS RELATING TO BUILDMG - ' � � CONSTRUCTION,AND HEREBY UiHORIZE REPRESENTATIVES OFTHIS COUNTYTO ENTEH UPON THE � -� z A8 TI D PRDPERT FQ�i INSPE TION PURPOSE. . � COMMF_NTS � ��O � LC�. � f.�� ,. /? � m C NP.ME(PRINT� � . ��"– Q � N `�, � SI NATUR FPERMITfEE � -� . AT . � _ � � - - " � - RECPT._NO. PAID BY VALIDATION �'�_ � WHITE—De artment Co YELLOW—Finance Co PINK—Assassor Co .GOLDENROD—File Co GREEN—A licani's Co - � P PY. PY. PY, PY, PP PY ��-- , _;-��__ ,W--� _, � ' . � _ � , .—�--- -T---�j r—� ' �.�_ � .�._..�.... _._� � � � � ���� ��� � � � � '�� �� � � � ���§ _ � � ���—�� � � ���� '��� �. , - I � � �. 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