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1 I I�'I .y i CITY OF DIAMOND BAR COMh4UNITY DEVELOPMENT DEPARTME �( ., . 21560 E.Copley Drive Suite;190 PR�fj+s (909)860-3195 Fax(909)861-3117 "�"" BUILDING PERMIT APPLICATION FIRMLY � JOBSITE %� � `"'�� ' APPLICATION `�, °�, � PERMIT' P/C ` o ADDRESS !' � , � C�` DATE NUMBER � � # o ISSUE TYPE OCC �° APN LOT TRACT DATE CONST. GROUP �p OWNER � J` C.. !- ' , p ADDRESS � �CJ � ZONING SETBACKS P���h �oCITY Z!P TEL., FRONT RW LJ� APPLICANT EL: REAR ❑ o SIDE/SIDE STREET Vr/ p ¢ 1 CONTRACT � ' SIQE ❑ � ADORE55 �l � � �r 0 PROPOSED�E� K�`�'. � �l CITY -' G_ ZIP TEL. � � I Q ARCH/ENG/ � iz DESIGNER NO.DWEL NO. NO. a ADDRESS UNITS STORIES BEDROOMS = CITY ZIP TEL. � DESCRIPTION S4.FT. FACTOR PSF AbJ.AREANALUATION � C. . OWNER-BI:ILDER DECLARATION � SFR/A��/REM �� ' ; �� � � ' � 0, I HEREBY AFFlRM UNpER PENALTY OF PERJURV THAT I AM EXEMPT.FROM THE CONTRACTORS ll- � .G8ldQ0/C8fpOfi � � � � � W CENSELAWFORTHEFOLL�WINGREASON(SEC.7031.SBUSINESSANDPROFESSIONSCODE:ANYqTYOR � U� COUNTYIVHICHREOUIRESAPERMR7000NSTRUCT,ALTER,IMPROVE,�EMOUSH,ORREPAIRANYSTRUC� W ' P8CI0/�BCk � ' ' Z' TURE,PRIOR TO ITS ISStJANCE,AL50 RECUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED w �. . � STATFMENT 1'HAY HE OP SHE IS LJCENSEO PUftSUANT TO THE PflOViSIONS OF THE CONTRACTORS LI-- pOOUS fl ' " ' CENSE LAW CHAPTEF 9 COMMENCING WITH SECTIOM 700o OF�IVISION 3 0F THE BUSINESS AND PR0- � P . , ,. . 1 ( ) ��. �' SCO HA ORSHESEXEMPTTHEREFROMANDTHEBASISFOflTHEALLEGEDE%EMR . �� � � FESSION DE ORT THE I ) o� TION.ANYVIOLATbNOFSECiION!7a31.56VANYAPPLICANTFORAPERMIT5U8JECTSTH'eAPPLICAVT70 Z Re-Roof � � ' � ACIVIIPENALNOFNOTMOFETNANFIVEHUNOREDDOLLARS($5oa).j: . o WILLDOAH6WORK�AN�THEOT�FTY,ORMVEMPLOYEESWITHWAGESASiHEiR50LECOMFENSATION, � CortlmefCial n, ' Z�, RUCTURE IS NOT INTENDE�OR OFFEFED FOH SALE(SEC.7044,BUSI- J NE55 AND PROFESSIONS CODE:THE CONTRACTORS LICENSE LAW�OES NOT APPLV TO AN.OWNEp OF � � PROPERTVWHOBUILDSDRIMPRQVESTHEREON,AU�WHODp_SSUCHWORKHIMSELFORHEflSEIFOFi � � CC THROUGHHISORHERDYJNENPLOYEES,PflOVIDE�THATSUCHIMPROVEMENTSARENOTINiENDEDOR �m w�'� OFFEREDFORSALE.IF,HOWEVER,TNE9UIl�INGORIMPRDVEMEMIS50LOWITHINONEYEAROFCOMPLE- ' '' �,�i� , Z' TION,THE OWNER-9UILDER WILL HAVE hIE BURDEN OF PROVING THAT HE OR SHE DID NbT BUILO OR � . = IMPROVE FOR iHE PUPPOSE DF$AL�. � , W. ❑I,ASOWNEROFTHEPROpERN,AME%CWSNELYCONTRACTINGWITHLICENSE�CONTflACTORS , ., . . ', �[ TO CONSiRUCT THE PROJECT(S�C,7a44,BUSINESS AND PROFESSIONS CO�E THE COM1TRACTORS LI- VdIUOfiOf1 ADJ.AREA � � W CENSELAWp�ESNOTAPPLYTOANOWNEROFAPROPEflTYWH�BUILD50FIMPROVESTHEREON,ANO i, �' WHOCONTRACTSFORSUCHPROJECTSWIiHACONTRACTOF;S)LICENSEDPURSUANT'fOTHECONTRAC- QUANTITY DESCRIPTION ��FEE ' � TORS LICEN3E IAW,). � O I AM E%EMPT UN�ER SEC. B.&R.C.FOR THIS REASON Q ' � �. - V . . . ., . � � OAiE OWNER ' U �. Z W � ,� _ LICENSED CONTRACTORS DECLARATION w , � �� � ' ¢ � '� IHEf1EBYAFFiRMUNDERP[NALTVOFPERJURYTHATIAMLICENSEDUN�ERPROVISIONSOFCHAPTER � � � � ��" 9(COMMENCINGWITHSECTION7oDo)OFDIVISION30FTHEBUSINESSANDPROFESSIONSCODE,AND z �, `X MY UCENSE IS IN FULL FOFCE NO EFFECi s� ��' m . � � �� UCENSE CLASS - ��� LIC.NO.� '" � � � q 7� J U DATE Z+"� �T/ CONTRACTOR � d . . LJ.J � . � . . . . �� WORKERS'COMPENSATION DECLAR N Q � � IHERE6YAFFIRMUNDEPPENALNOFPERJURVONEOFTHEFOLLOWINGOECLARATIONS: ' z � Oz _IHAVEAN�WILLMAINTAINACERTIFICATEOFCONSENTTOSELF-INSUREFORWORKERS' _ ¢ COMPENSATION,ASPROVIDEDBYSECTION3/ooOFYHELABOPCO�E,FORTHEPERFOPMANCE UW Q sa 'O�A'�-IE WORK FOR WHICHTHIS PERMITIS ISSLIED. � w vIHAVEANDWILLMAINTAINWOPKERS'COMPENSATIONINSl1RANCE,ASREQUAEDBYSECTION !/ � Q 37000FTHELABORCODE,FORTHEPERFORMANCEOFTHEWORKf-0RWHICHTHISPERMITIS f � ISSUED.MY WDqKE 'COPM„�'ENSATION INSURANCE CARRIERAND POLICY NUMBE9ARE� - - CONSTRUCTION � C �/ j CARRIER ��T ��'� :� PLAN REVIEW __�____ _ '�. Z poucv NUMeEa - � � � ELECTRIC ¢ -o �n+��,ssEcnoNn�mrare�oaNa�ErE�oFn-�EPERnuxiswaori�HuwoaEooa.uRs�aioo)oa�Essa PLUMBING Z I CERTIFYTHAT INTHE PERFORMANCE OF THE W FK FOR WHICHTFlIS PERMIT IS ISSUED,I MECHANICAL (.'3 SHALLNOTEMPLOYANYPERSONINANYMANN SOAST06ECOMESU&IECTTOTHE µ �O' � WORKERS'COMPENSATIONLAWSOFCALIF R ,ANDAGfiEETHATIFISHOUiDBECOME INSPECTIONFEE = SUB,;ECJ'TO THE LVOFiKERS'COMPENSATI VI51 OF SECTION 37000F THE LABOIi j CODE, SHALLFQ�7HWITHCOMPL'/WI1H P ISIONS. ISSUANCE o /�y —_� p DATE: � t g APPLICMIT: SMIP � WARNING:FAILURETOSECUftEIVORKERS'COM ATIONCOVERAGEISUNL4WFUL,AND�SHALLBE ENERGYP/C ¢ RP � SUBJECTAN EMPLOYERTO CFIMINALPENALTIE3 D CIVILFINES UP i00NE HUNDRE�THOUSAND ENERGY PERMIT DOLLARS(5100.oW),INADDITIONTOTHcCOSTO COMPENSATION.DAMAGESASPf1OVIDE�FOflIN � 5[CTION37oeOFTHELABORCODE,INTEREST,A onrronNsrsFEEs. � - RETENTIONFEE: � -O CONSTRUCTION LENDING AGENCY PRE-ALT FEE ' � IHEftE6YAFFIRMU4DERPENALTYOFFERJURYTHATTHEFiEISACONSiRUCTIONLENDINGAOENCY ' � FORTHEPERFOFMANGEOFTHEWOHKWFWIiIGHfHiSPERMITI51S5UED�5EC.30W,GN.C.�. . Z W = LENDEP'S NAME - � � � � H LENDEF'SA�DRESS � - � � TQTALFEES � IGEFTIFYTHATIHAVEREADTHISAPPLICATIONANOSTATE7HATTHEABOVEINFOFMATIONISCORRECT. � - W I AGREE TO CONPLY WITH A'._L CITY AND COUNTY ORDINANCES AND STATE lAWS RELA7ING TO B�ILDING � - � ' � � � CONSTRUCT N,AND HEREBV AUTHOR2E REPRESENTATlVES OF TF,IS COUNTV i0 ENTEf1 UPON THE � , � ABOVE-ME NEDPROPERTYFOflINSPECTIONPURPO5E5, . COMMENTS � O J � __ __ m PERM E E(PRIN � - - ' ' � � ,� �J ; � � '� SIGNA OF PERMITTEE � - TE � - ! �- �� � _ � - RECPT.NO. PAIDBY `�—G � ��VALIDATION � ~ - WHITE—De artment Co YELLOW—Finance Co PINK—Assessor Co GOLDENROD—File Co GREEN—A licant's Co - � P pY. PY, PX FY, PP PY , , , . , .:; . . � , .� � � , _;- �_:�;, .� ,,.. ,.. , ..:. _ , . ,,. i► � �° i ' � � � � ���� ����� m � � � � .. � ��� �� � � � � � � �. � � ��T�:��,�'a � ' . �L����,��!��" ` ; �ta��!=t�!��a��1S?���� ��--- �.__.._-�..��;� ��t��r� � � �--~_�"._.._._.__.�._.. � ._ _�__.._ � t..p�..�sei"ta�'s��.�.���2 !___.�_..._�� __( � ��''���#�' �L'�����a°"sg .._..__.{k �._ _{_._�,__.� .�_. —.J ��—G-1��L"9�i�. ��,.�..E?1r�i�F,�lf . .� � �(—�,SI���.'�S�I'iL��'l�".�i'�}z�,��:'IJI3. .. !, . ( . a +��' ��a�.;�t��"" ,�j'�. ',�� . � ,... � � r^"?,�'1���...�{�'.r�.�'v�.Y��.}}��E�i�' .r, ' �� ����t' ��i�&F�� � � "'"�`"�.�_.... �� C'�."�4��i..�v���I�����3� }'. � � !._ _. � .. '� � , _ .�__�.. . , �—. 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