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CITY QF DTAMOND BAR —���a
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CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERV MAY 09 21660 E. Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
PRESS
FIRMLY
APPLICAT N PERMIT P/C
JOBSITE��
DATE����p
ADDRESS•I UU to a'-y��/ItCT pf.�SFe ERMIT 4
(f^'/
I
NUMBE
#
APN
ISSUE-I )U
TYPE OCC
LOT TRACT DATE CONST 11(•
OWNER f II_cI.0 CQM/211/ GROUP
ADDRESS F r%-Piaz&-IC LcCXJ ZONING SEfBACKS
CITY T-fi'ne-ZIP'12 t"I TEL �?" '477 731 FRONT RW^
APPLICANT 11 KLft126 TEL.q lq 7.tA-I111cT1 REAR I]
SIDE/SIDE STREET RW
CONTRACTOR- SIDE
ADDRESS ff
USE&e C e.
CITY ZIP TEL.
ARCH/ENG/
r�l r
DESIGNER�
J
ADDRESS Ac ur IJ- +So N0. DWEL. 0. N0.
UNITS
CITY J44,It ZIP 22-(012,TEL.q 9-7 STORIES BEDROOMS
OW DESCRIPTION S0. Ff. FACTOR PSF ADJ.AREA/VALUATION
NER-BUILDER DECLARATION SFR/ADD/REM
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
(n
CENSE LAW FORTHE FOLLOWING REASON(SEC. 7031.5 BUSINESS AND PROFESSIONS CODE:ANY CITY OR
COUNTY WHICH REQUIRES A PERMIT TO CONSTRUCT.ALTER. IMPROVE,DEMOLISH.OR REPAIR ANY STRUC-
TORE
W Patio/Dock
PRIOR TO
T
I
LLI
S ISSUANCE,ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE
CONTRACTORS LI-
CENSE LAW
CHAPTER 9
LL
COMMENCI
G
�
�
N
0 Pool/Spa
WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSIONS CODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TION.ANY VIOLATION OF SECTION 7031.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
Z Re-Roof
A CML PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS($500).):
^I,AS OWNER OF THE PROPERTY.OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
0
Commercial �!�
WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC. 7044,BU51- J
NESS AND PROFESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BUILDS OR IMPRO
E
V
S THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE IF,HOWEVER THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF COMPLE-
TION,THE(OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
^ I,AS OWNER OF THE PROPERTY,AM EXCLUSIVELY CONTRACTlNG WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC. 7044, BUSINESS AND PROFESSIONS CODE THE CONTRACTORS LI-
Valuation ADJ
AREA
CENSE LAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAC-
QUANTITY DESCRIPTION FEE
TORS LICENSE LAW.).
^ 1 AM EXEMPT UNDER SEC. B&P.C. FOR THIS REASON J
-- U
pC
DATE
OWNER- U
LICENSED CONTRACTORS DECLARATION W
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER U
0
9(COMMENCING WITH SECTKKJ 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND
MY LICENSE IS IN
FULL FORCE AND EFFECT.
U
DO
S
LICENSE CUSS LIC. N0. .
/
DATE CONTRACT
OR
{I
WORKERS
COMPENSATION DECLARATION U
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS: Z
I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'
COMPENSATION.AS PROVIDED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE 0
OF THE WORK FOP WHICH THIS PERMIT IS ISSUED LU
I HAVE AND WILL. MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION
3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WORKERS�COMPENSATION INSURANCE CARRIER AND POLL Y NUMBER ARE.
CONSTRUCTION
CARRIER
PLAN REVIEW
9 Ate . ��
POLICY NUMBER ELECTRIC
(1115 SECTION NFEONOTBECYMR.ETEDOFTFE PERMIT IS FOR ONE HUFDREDDIXIARS($100)OR LESS).
PLUMBING-T
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
MECHANICAL
SHALL NOT EMPLOr ANY PERSON IN ANY MANNER 50 AS TO BECOME SUBJECT TO THE
WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME
INSPECTION FEE
SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTlON 37000FfHE LABOR
CODE,I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS
DATE
ISSUANCE G d
APP
SMIP
IC
Aonffi
L
ANT:
ENERGY P/C I
L
WARNING: FAILURE TO SECURE WORKERS' NSATION COVERA S U WFUL,AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO HUNDRED THOUSAND
ENERGY PERMIT? �)
DOLLARS($100,000),IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3700 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. - �1
RETENTION FEE:
CONSTRUCTION LENDING AGENCY PRE-ALT FEE:
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED
SEC
�
V IL
. 3097,CIV.C.).
LENDER'S NAME
LENDER'S ADDRESS ca-Z'-A
$
+
/�
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
TOTAL FE S
1 AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
1
}
IV
/
CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR INSPECTION P i
J'
URPOSES. COMMENTS
PE EE NAME(PRINT)
(PRINT)
1
D
URE OF PER
DATE
RECPT N0. U- U
1 2 PAID BY-VALIDATION
WHITE-Department Copy,YELLOW-Finance Copy, PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy