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� 9 CITY OF DIAMOND BAR "' � -��'��— DEPARTMENT OF COMMUNITY 8r.DEVELOPMENT SERVICES �� a 21660 E.Copley Drive Suite 190 (909)860-3195 Fas(909)861-3117 PRESS �"�°��`' BUILDING PERMIT APPLICATION FIRMLY`° �� JOBSITE ;��y�r ,. e �,���� 1�� "t DATECATION�I � � ^ NUMB R' ��� #/C ADDRESS_v\V�V��- . rJ ti $ ISSUE �TYPE OCC -- APN LOT TRACT rs DATE CONST. C�ROUP o OWNER _ R� h � C(A `t p ADDRESS ��,g�.�'Z.��,^sC�Y�`afl�' --�� ZONING SETBACKS W CITY ZIP TE ��`�b"1��e� ,: FRONT RW G �. APPtiCANT TEL. REAR ❑ SIDE/SIDE STREET RW ❑ �y CON7RACTOR SIDE ❑ Q ADDRESS—\r�__` � _. , i r- �_ p ; PROPOSED USE ��t _ CITY COiCf�Cn� ZIF��_ TE � o ARCH/ENG! � �` � � Q � DEStGNER NO.DWEL. N . NO. _ a:. ADD `i UNITS STORfES BEDROOMS �` CITY ZIP��, TEL. a ` J r-. ,. �= - - �; - DESCRIPT{ON SQ.FT, FACTOR PSF ADJ.AREA/VALUATION Q��, OWNER-BUILDER DECIARATION - � � SFR/ADo1FiEM � � - I HERF$V AFFlRAI UN�EH PENALTY OF PERJURY THAT f pM EXEMPT FROM THE CON7'RACTORS LI � � .Gdfe9e/CefpOff , W `CENSELdWFORTHEFOILOWINRREA50N(SEC.7031.5BUSINESSRNDPqOFES510NSW6E:ANYCITYOR Y' (n . .C�„;COUNTYWHICHREOUIRESAPERMRTOCONSTPUCT,ALTER�MPROVE.OEMOLISN,ORflEPAIRANYSIAUG 4 W Paiio/Deck �� L TURE.PRIOR TO ITS ISSUANGE,ALSO REOIJiflES THE APPLICANT FOR BUCH PERMIT TO FILE A SIGNED F � �BTATEMENT THAT HE OR SHE IS LICEN9ED PURSUANT TO THE PROVISION3 OF THE CONTRACTOR9 ll W � 'CENSELAW(CHAPTER9(COMM9VCINOWITHSECTION700a)OFDIVISIONSOFTHEBUSINESSANDPRO- ' � PooU5pa� %FE&SpNS LbDq OR7HAT HE OR SHE i&EXEMPT THEqEFROM AND THE BASIS FOFiTHE ALLEGEG EXEMP , �,�,TION.ANYVIOIATIONOFSECTION7031.58YANYqPPLICANTWqAPERAIITSUBJECTSTHEAPPLICpNTTO. R8-R � �-ACIVILPENALTYOFNOTMONETHANfIVEHl1N�REDDOlLARS(fsm).�: . - �: ; ❑I,ASOWNEflOFTHEPROPEftTY,ORMVEMPLDYEESWITNWAG[SASTHEIRSOLECAMPENS0.TION �' L��,COt17R18fCIflI " WflLDO THE WORK.AND THE STRUCTURE IS NOT INTENbEU OR OFFEflE�f6fl SPLE(SEC.7Qu,BU31 : � - . ��: NESSAND PtWFESSIONS COUE 7HE CONTRACTOflS UCENSE LAW DOES NOT APPLY TO AN OWNCR OF " g � �PROPERTVWF106UIIDSORIMPROVES7HEFEON,ANDYMODOESSUCHWORKHIMSELFORHERSEIFOR ��'� �- C[ TMROU(it1HI50RHEROWNEMPLO7EE5,PqOV10EDTtIATSUCHIMPROVEMENTSARENOTINTENOEDOR °i m - � W�,.�.,OFFB7EDFORSALEIF,HOWEVERIMEBUILOINGORIMPROVF.MENTISSOLDWITHINONEVEAROFCOMPLE- � -TION,THE OYfNER$UILDER WILL HAVE THE BURDEN OF PHOVING TNA7 HE OR SHE DID NOT BUILA OR �: IMPROYE FtlR THE PURPOSE OF SALE). � DI,ASOMMEflOFTHEPAOPER'iY,NAEXCLUSIVELYCONTRACTINGWITNIICENSEDCONTRACTORS ' '' �. TO CONSTRUCT THE PqQ1ECT(SEC.7oN,9USINESS AND PROFESSIONS COOE:?HE CANTRACTORS U- ` V8I118110ti ADJ,AREA - W .CENSEUWWESNOTAPPLYTOANOMIhEFiOFAPHOPERTYbYHUBUIL[/50fl1AAPNOYESTHEflEON,AND � � � NM1iOCONTMGiSFOR5Ud17R0.7ECY5WI7HACON7IiFCTpR(5)LICENSEDPURSUMiPTOTNECQhTAAG QUANTITY DESCRIPTION FEE i� �� T�UCENSEUWJ. - o ❑I AM E%EMPT UNDER SEC. 8.a P.C.FOR THIS REASON � '�� . . , , . .�... .. . t y', . . . .. , ... . �.. . :.. . ;� �, .��, . . . �� I g � � �' DATE oWNER . �"'� . . � Z- J U � o �� , F_ LICEN5ED CONTRAC70R5 DECLARATION � �;. ::�;iMEREBYAFFIflMUN�EAPENALTYOFPERJURYTHATIhMUCENSEOUNDEflPROVIS10M1SOFCHAPTER -�� �@@@ � ie�OOMMENGINGYdiSH3ECTiON7WoJOFDIV1510�30FTH[BUS�NESSANDPPOf[SytONSCOD[,AN� Z� � �MY LICENSE IS IN FULI FPRCE AND EFfECT. tt! m. �� 'UCENSECLA S LIG.NO. _ ����� _ ��-j. - �p ~ ` 1 J B: U .DATE d� ` CONTPAC70R Q- . ldJ. '�. _ . � � �� WORKERS'COMPENSA710N D£GLARATI(�N —� - - . - - �_ _ ' � � 'IHEflEBYAFfIR1AUN�ERPENALlVOF7ERJURYON60FTNEFO�IOWINGDF�RqTiONB: - G� a . � -�_IMMEANtlWILIMAINTAIt3ACEqTtFICATEOSCANSENTTOSEIF-INSUSSEFpRY.'OPKERS' �� -2 � �� � - . :.. �� � . COMPEN$Al'ION,ASPRO�Ap,EDBYSECT10N3�ooOr7HELA60RCADE.FORTHEPEflPoPMANCE a .;_� , . _ OFTH6WOtiK�FORI'iHiqiTl115-PFAMITIS.ISSUEO . , :- � � , � _ . . . . % .� ` .. ' ..'-:; , .: ° � � � . .__.IHAVEANbMflLLA4AINTAINWORKEAS'COMPE4iAT10NIN5URANCE ASRE(7111RE�RYSECTION �q(��^y� .��f�� . p - 87000FfHEU60RCUDE;it1R'fHE:PERWNatANCEOF7HEWORKWRWHiCMTHiS�PERMITIS ' � �i-, �!'/1" �� � 13SUEO.MY4NORKER4EGOMPENSA 'INSUflANCECARRIEFAMIIPJLIGYNUM8ER0.RE: �CONSTRUCTION _ . ,__._ �. . j * CAHfl1EFi_�._� :� i �. .. -'� .PLANR6VIEW'',• - . � � �k, : aa.�crauMeeA '�'�� ������"Y �l�'\ � �{�T� � ELECTRIC .. .. . � � �� . � .,:... -,, � : . . o pwssecrtct�t�norr�cor.u�ErEo�'�t�a�avrrsFcflaraFr�rna�oa.inns�Sioo;oa�Ess� -PLUMBING ----._------ . , � I CERTIFY TNAT INTNE PFRFORIAANCf Of THF WORK FOft WHICH TNIS PERMIT ISISSUEO.I -MECHANICAL � � � ('3 SHAlLNOT EMFLO'f ANY PERSON IN ANY�IiPNNER 50 AS(O BECOME Sl1BJECT TO TH[ ' � (n WORKERS C(HAPENSATION LAWS OF CAL�FOFNIA,/ND AGP[E THAT IF 1 SNOUID BECOME 1NSPECTION FEE �'�^!`'��- -�-;-- - � SU&IECTTOTHEWORKERS'COMPENSATIONPROVISION50FSECTION370oOFTHELA80R _--"�� �—���/)/ - � � CODEJSHALLFORTHWITHCOMPIYWI h105EPROVI510NS. ISSUANCE _ ._ _ � ti� 4� O , SMIP p OATE: V r APPLICANT: ���. . _ W- FNEAGY P!G 6 Y J WARNINCFARURETOSECUREWOPKERS'COMPENSATIONCOVERA SUNLAWFUL,ANOSHALtBE --- .� LL SUBJECTANEMPWYERTOCRIMINALPENnLT1E5AN�CIVILFMESl1PTOONEHl1N�RE0TMOUSAND ENERGYPERM�T @ �LUHS(SiO�,oao),INMDITIONTOTHECOSTOFCOMPENSATION,�AMAGESASPftOVIDEDFOAW -----�-a� -����'-� ��^P`+��'��;- -- J SECTION37a00PTMELABORCO�E,INTEflEST,ANOATTORNEY'SFEES. ' RETENTIONFEE: @'•'� �� � CONSTRUCTIONIENDiNGAGENCY �3�ygg��� �� y ��J PRE-ALTFEE: g:b�-.YtifV.+•.�} �' O � IHERE6YAFFIRMUNDERPENAlT1'OFPERJURYTHATTHEFE130.CONSTRUCTIONLENOINCiAGENCY _ ._____ - z FORTHE PEHFOHMANCEOF THE WORK FOR WHICH THIS PERMIT iS ISSUEO(SEC.30B7,CIV.C.). W � IENDER'S NAME - ' f R Fr IENDER'SADDRESS fff / � �' ICEfiTIFYTHATiHAVEREADTMISAPPI.ICRTIONRNDSTATETHATTH6ABOVEINFORMA'f10NI5CAf1RECL �OT%L f�EES / � �y „J.� . w tAGREETOCAMPIYWITHALICINANOCOUNTYORDINANCESANDSTATEIP.WSRELATINGTOBUIL0ING � ✓ ( � � CONSTpUCTION,ANOHEREBVAUTHORIZEREPNESEN7ATIVESOFTHISCOUNTYTOENTERl1PONTHE . . �. ZABOVEMENTIONED DROPERT'FORINSPECTION�UPVDSES. COMMENTS � ��ei��,��� �`�— -- m PERMITTEEN Ae(Pfll��� ��� � � � ¢ �� 1� � � �916NAtUREOFPERMITTEE ^��—� DA^ TE��� �"��� I = RECPt NO. � PAID BY _ _VALIDATION_�_____ ; �" . 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