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CITY OF DIAMOND BAR ' — � DEPARTMENT OF COMMUNTI'Y&DEVEL4PIv�NT SERVICES � I I � � � _ . 21825 E.Copley Drive +- (909)860-3195 Fax(909)861-3117 PRESS '"%.����' BUILDING PERMIT APPLICATION FIRMLY � JOBSITE �,/ f ApPLICATIO PERMIT P/C o ADDRESS�-DC,C. r G�it/�/f✓J/'�C� ��� DATE �L NUMBER�� # o� ISSUE TYPE OCC APN LOT TRACT DATE CONST. GROUP p OWNER f�f,t L �-�l/�'1 ADDRESS �--44L �'�.(('iLsflr�� l�l�� ZONING SETBACK5 oCITY .��A-n/Gb.rf��aQ ZIP TEL(�G���c/6-�I3�'� FRONT RW ❑ APPLICANT TEL. REAR ❑ � , A SIDElSIDE STREET RW ❑ m CONTRACTOR �7d h7�a` 'T�}TI�^ SIDE ❑ � 'ADDRESS 'z k'^ PROPOSED USE �t"3, I�-�P p f....� �� /? G�L Q cirv €�ra�P"�)�—�-v ziP �7 pre�.�, �t�,�—t�3� � o ARCHlENG! W DESIGNER NO.DWEL. NO. NO. n� ADDRESS UNITS STORIES BEDRQOMS � CITY ZIP TEL. cn � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER DECLARATION SFRlADDlREM � O p I NEREBY AFFIRM UN�ER PENALTY OF PERJURY THAT I AM EXEMFT FROM THE CONTRACTORS LI- � Garage/Carpon � � W CENSELAWFORTHEFOLLOWINGREASON(SEC.7o315BU5iNES5AN�PROFE5510NSCO�EANYCIiYOfl �� U COUNTYWHICHREOUIRESAPERMITTOCONS7RUCT,ALTER,IMPROVE,DEMOLISH,ORREPAIRqNYSTRUC- W Patio/Deck ��� w TURE,PRIOp TO ITS ISSUANCE,ALSO RC-0UIRES THE APPLICAM FOR SUCH PERMI7T0 FILE A SIGNED W STAiEMENT THAT HE OR SHE IS UCENSED PURSUANT TO THE PROVISIONS OF THE CONTqACTORS LI- , �, 'CENSE LAW(CHAPTEfi 9(CAMMENCING YlIiH SECTIOV�DDOJ OF�IVISION 30F THE BUSINESS AND PRO- � POOUSPB �FESSIONSCODE)ORTHATHEOFSHEISEXEMPiTHEREFPOMAN�THE9A515FORTHEALLEC+E�EXEMP- � � � TION.ANYVIOLATIONOFSECTION7031.5BYANYAPPLICANTFORAPERMITSUBJECTSTHEAPPLICANiTO Z Re-Rooi � � ACIVILPENALT'�OFNOThAORETHANFIVEHUNDRE�00lLARS(SsW).): ' � ❑I,ASOWNEROFTHEPROPERN,ORMYEMPLOYEESWITHWAGESASTHEIRSOLECOMPENSATION, � Commercial - Z WILL DO iHE WORK,AND THE STRl1CTURE IS NOT INTENDED OF OFFERED FOR SALE(SEC.7044,6U51- J NE55 AN�PROFESSIONS CODc:THE GONTRACiORS 410ENSE LAW�OES N07APPLY TO AN OWNEft OF � PqOPERTVWNOBUILD50RIMPROVESTHEREON,AN04YHO00E55UCHWORKHIMSELFORHERSELFOR � � 'THflOUGH HIS Ofl HER OWN EMPLOVEES,PROVIDE�THAiSUCH IMPROVBr1ENi5 ARE NOT INTENpED OR m Q .OFFEREOFORSALE.IF,HOWEVEF,THEBUILDMGORIMPROVEMENTISSOI.�WITHWONEYEARDFCOMPLE- Z��'.TION,THE OWNER-BUIL�ER WILL HAVE THE BURDEN OF PROVING TMAT HE OR SHE DID NOT BUIL�OR � IMPROVEFORTHEPUFPOSEOFSALE). ❑I,AS OWNEROF THE PFOPERTY,AM EXCW SIV'cLY CONTRACTMG WIiH LICENSED CONTRACTORS / Q' TO CONSTFiUCT THE PROJECT(SEC.�a44.fiU51NES5 AND PPOFESSIONS CODE:THE CONTRACTORS LI- V81Uet10t1 ���� � ADJ.AREA J e W CENSELAWDOESNOTAPPLYTOANOWNEROFAPROPERTVWHOBUILDSORIMPP,OVE6THEREON,AND � � � WHOCONTRACTSFORSUCHPROJECTSWITHACONTRACTOR(S)LICENSEDPl1flSUANTTOTHECONiRAC- QUANTITY DESCRIPTION FEE Y TORS LICENSE IAW.�. 2 —� � ❑I AM EXEMPT UNDER SEC. B.8 P.C.FOR THIS REASON �Q � U � � onre OWNER U Z W �, LICENSED CDNTRACTORS DECLARATION W ¢ � I HEREOV AFFlRM UNPER PENALiY OF PERJURY THAT IAM LICENSED UN�ER PROVISIONS OF CHAPTER � . d; 9(COMMENqMGWIiHSECTION7o00)OFDIVISION30FTHEBUSINESSANDPROFESSIONSCODE,AN� Z � MV lIC[NSE IS M FULL FOflCEAND EFFECT. ,3 m � LICENSE C/L�ASS �+7 � �IC.NO. ��`�,'����v�p� �y�� j . U �DATE�/�-I P�2..tfri� CONTRACTOR "/� !'TG"� �aT�V� �- lYJ � � � WORKERS'COMPENSATION DECLARATICN -� � ¢ � I HcflEBV AFFIRM UNDEH PENALTY OF PERJURY ONE OFTHE FOLLOWING�ECUIRATIOHS: Z ' 2 _I HAVE ANO WlLLMAINipIN A CER7IF:CATE OF CONSENiTO SELF-INSUpE FOR WORHERS' _ CAMPENSATION,ASPROVI�EOBVSECTION3]OOOFTHELABORCO�E,FORTHEPERFOPMANCE U Q OF THE WDRK FOR WHICH iH15 PERMIT IS ISSUED. W � � W _1 HAVE AND WILL MAINTAIN WORKERS'COMPENSATI�N INSURANCE,AS REOUIRED BY ScCTiON p Q 370oOFTHELABORCDOE.FORTHEPERFORMANCEOFTHEWORKFORWHICHTHISPERMiTIS / ��� � ISSUED.MVWORKERS'COMPENSATIONINSURANCECARRIERANDPOLICYNUh�ERARE: CONSTflUCTION lia j � cnRaieA - �T��� ��iV'.8� PI.AN REVIEW z.', POLICY NUMBER L����"'U ELECTRIC ' ¢ (I}IISSEC710NNEmNDiBECOMPLEfE�OFTHEPEflMiTlSWRONEHUNDREDDOLLARS(y10�)ORLESS). PLUMBING - p ' W Z I CERTIFYTHAT IN THE PEflFDRMANCE OFTHE WORK FOR WHICH iHIS PERMIT I5 1�SUE�,l MECHANICAL (�j SHALLNOTEMPLDYANYPERSONINANYMANNERSOASTOBECOMESUBJECTTOTHE � - (�/j'. WORKEftS'COMPENSATIONLAWSOFCALIFQRNIA,ANDAOREETHATIFISHOUL�BECOME INSPECTIONFEE r'� Sl1BJECTTOTHEWORKERS'COMPENSATIONPflOVISIONSOFSECTION37COOFTHELABOR � C�E � "" � " � CO�E,ISHALLFORTHWITNGOMPLYWITHTHOSEPROVISIONS. ISSUANCE b� `� r �l�� � - � DATE: �� `O� APPLICANT: SMIP ' �n ._ r�b w WARNINa:FAILURETO5ECUREWORKERS'COMPENSAiIONCO4ERA0EISUNLAWFUL,ANOSHALLBE ENERGYP/C . � _�.:. — SUBJECTAN EMPLOYER TO CRIMINAL PENA�TIES AND CIVIL FMFS 11P TO ONE Hl1NDPED THOUSAN� `---'-�- -� LL�� ENERGYPERMIT - -- --�-�-`-�-�--� DOLLARS(S1oo,oaOJ,INADDITIONTOTHECOSTOFCOMPENSATION,DAMAGESASPflOVIDEOFORIN �� ���"�� J � SECTION3�oBOFTHELABORCODE,INTEREST,AN�ATTORNEY'SFEES. RETENTIONFEE: �' ' O' CONSTRUCTION LENDING AGENCY PRE-ALT FEE: ¢. I HERE9YAFFIpM UNDEfl PENALTV OF PERJUaV THA7 THERE IS ACONSiRUCTiON LENDING AGENCY � FORTHE7EPFOFMANCEpFTHEWOflKFORWHICHTHISPERM�TISI55UED(SEC.309],CIV.CJ. W �, LEN�ER'SNAME 1- LEN�ER'SADORESS � ICERiIFYTHATIHAVEREADTHISAPPLICATICNANDSTATETHA7THEABCVEINFOPMATIONISCORRECT, TOTAL FEES �/ P �� � IAGREE TO COMPIY WITH ALL CIiY AND COUNTV ORDINANCES hND STAiE LAWS RELATING TO BUIL�WG j � � CONSTFUCTION.ANDHEREBVAUTHOHIZEftEPHESENTATNE50FTHI5COUNTYTOEN7EftUPONTHE z ABOVE-MENTIONE�PROPERTY�ORINSPECTONPUFIPOSES. , / COMMENTS � Y�.1 �"�'"t?i ���' m PEflMITTEENAME(PRINS)...,� � ¢ j t+ // UJ , f �a'^// ��G� (n SIGNATUREOFPERMITTEE � DATE'�— j = RECPT YO- PAID BY �/ VALIDATION ~ � WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Gopy.GOLDENR06-File Copy,GREEN—ApplicanYs Copy , fi . � , . � E � �.�� . w , �:� p a"g� �#'�:. � �"E,� r, `'. : � � '� � •;� a s;�x * � c:'A'� s a �' •'.:. � m��' � �' '� �� s q' ,� °'� ° �'^ '�. %:s a K' y." x Y �y � �"I R t .K At��' � 7 �. .x Y'', ��„� d 1 E 'X �� q �� 'P '� i t x .x ������ i ,.�+;r a� �. � �k� .a' � .n`�*� � � ��. � �.� ��f�� ��� . � � . � a. , � � t 0 _ x ' '� ,�,� � � a.; r .r m: x..1 .,,.: . ,"a:^ .�.,a w.�:. k. � r. _..+� _ u'�.... t „...�.�.,: . �.,:4 i. x t,s. �. .;�.� : .+..,: s . 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