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11373 (5)
_ _ _ _....___,..._._ ._-,..,._.� - . ._._..1 ._.,..,_._..... . �. �1 � � CITY OF DIAMOND BAR � - COMMUNITY DEVELOPMENT DEPARTMENT � _ 21660 E.Copley Drive Suite 190 (909)860-3195 Fax(909)861-3117 �RESS '""° BUILDING PERMITAPPLICATION �,7y� p .I..�.�y��Cy� FIRMLY o DDRIESS �� � G��°`�✓�'l�I ''' �f•� I I APPLICATION � � � PERMIT T �`�J P/C DATE NUMBER •-� # � ISSUE TYPE OCC r APN LOT TRACT DATE CONST. GROUP p OWNER �.h.L.Y'o1.R.an [5� 1/�� �`_QJ��L� ADDRE$S ��,:a.-,.��-�� ZONING SETBACKS z CITY ZIP TEL FRONT RW ❑ o APPLICANT ' TEL. SI�SIDE STREET RW ❑ z ¢ CONTRACTOR SIDE ❑ � 'ADDRESS PROPOSED USE G � CITY ZIP TEL. o ARCH/ENG/ w DESIGNER NO.DWEL. NO. NO. � ADDRESS UNITS STORIES BEDft00MS � CITY ZIP TEL. �, u� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION �� ��p��� ���� - - OWNER-BUILDER DECLARATION - SFR/ADD/REM � -� � ��� � � �� O I HEREBV AFFlPM UNDER PENALiV OF PERJURY THAT 1 AM EXEMPT FROM THE CONTflACTORS LI- G8f8 JB/CBfpOfl �, W CENSELAWFORTHEFOLLOWINGREASON(SEC.7o31b9U51NESSANOPROFESSIONSCODE:ANYCiTYOR (n ��� � " "" �� C.) WUNTYWHICHREQUIRESAPERMITTOCONSTRUCT,ALTER,IMPROVE,DEMOLISH,ORREPAIRANYSTqUG .1 � .Z�, TURE,PqIOR TO ITS ISSUANCE,ALSO REQl11RE5 THE APPLICANT FOR SUCH PERMI7 TO FILE l SIGNED W� �8ti0/DOCk � - � � ,STATEMENT THAY HE OR SHE IS LICENSE�PURSUANT TO THE PROVISIONS OP THE CONiRACTOFiS LI- " �-�� CENSE LAW(CHAPTER 9(COMMENCING WITH SECTIDN 70�0)OF DIVISION 3 OF THE Bl1SINE5SAN�PRO- '� POOUSRB � ' FESSIONSCODE)ORTHATHEORSHEISE%EMPTTHEFEFROMANOTHEBASISFORTNEALLEGEDE%EMP- � , „� ,iION.ANVVIOLATIONOF5ECT10N7a31.58VANVAPPLICANTFORAPEflMITSUBJECTSTHEAPPLICANiTO z RQ-R001 '� , � .. � ACNILPENALiYOFNOTMORETHANFIVEHUNOR=DDOLLARS($500).): - �� � ❑I,ASOWNEROFTHcPROPERTY,OP.MYEMPLOYEESViIIiHWAGE5A57HEIR50�ECOMPENSATION, 0 COffIfflBfCIBI ' ' ' ' Z'-'�WILL DO THE WOF.K-,AND THE STRUCTURE�5 NOT INTENDm OR OFFERED FOR SALE(SEG.7044,9U51- J "' , � ��NE55 AND PROFESSIONS CO�E:THE CONTfiACTORS LICENSE LAW DOES NO7 APPLY TO AN OWN'eR OF � , , .� , �„PROPEHCYWHDBUILDSORIMPROVESTHEREON,ANDWHODOESSUCHWOHKHIMSELFORHERSELFOFi � � �.THROUGHHISOFHERONMEMPLOYEES,PROVI�EDTHATSUCHIMPROVEMENTSARENOTINTENOEDOR m � � w� OFFERE�FORSALE.IF,HOWEVEP,THEBUILDINGORIMPROVEMENTISSOLDWITHINONEVEAROFCOMPLE- ' � �� � � �� '0' iION,iHE OWNEfl-BUILDER WILL HAVE iHE BUR�GN OF PPOVING THAT HE OR SHE DID NbT BUIID OR 'z IMPFOVEFOFITHEPUfiPO5EOF5ALE�. ' _� ❑-I,AS�WNEROFTHEPROP=RTY,AMEXCLUSIVELYCONTRACTINGWf�HLICENSEDCONTFACTOflS W.. , �.�, TO CONSTRUCTTHE PROJECT(SEC.7044,BUSINESS AND PROFESSIONS CADE:THE CONiRACTORS LI- ValUation ADJ.AFEA �W� CENSELAWDOESNOTAPPLY70ANOWNEROFAPROPERTYWHOBUILDSORIMPROVESTHEREON,AN� � �. � � ��� ��WHOCONTRACTSFORSUCHPROJECTSWITHACONTRAC70R(S)LICENSE�PURSUANTTOTHECONiflAG QUANTITY DESCRIPTION � � FEE Y iORSI,ICEN5El4W.). � ❑I AM EXEMPT UNDEF SEC. 0.&P.C,FOFTHIS REASON J ' � � o � ,�, . . � � � . . . , LL DATE � ��" OWNER � F' � � , ��. �.,. _ _... ` w . '� '� - ' . �,.. ., LICENSED CONTRACTORS DECLARATION _ W � � ¢ � IHEREBYAFFIRMUNDERPENALTYOFPEPJURYTHAiIAMLICENSE�UNDERPflOVISIONSOFCHAPTER � " ',,,,'��'� �� ���.,� 9(COMMENCING WI7H SECTION 7000)OF'DIVISION 30FTHE BUSINESSAN�PftOFE5510NS CO�E,AND Z , �� �X' MY UCENSE IS IN FULI FORCEAN�EFFECi. ' W,, m '' � LIGENSE GLASS LIG.N0. � � � � ', V��� DATE coNTRACTOR'-- � � a , W, - . � . ' �. I, ��. WORKERS'COMPENSATION DECLARATIDN Q ', �. IHEREBYAFFIRMUNDERPENALTYOFPERJURYONEOFTHEFOLLOWWGDECLARATIONS: z , �, Z���' IHAVEAN�WILLMAINTAINACERT:FICATEOFCONSENiiOSEIFdNSiJREFORWORKERS' 2 � � , ¢ CAMPENSATION,ASPROVIDEDBVSECTION3�o00FTHEL480ACODE,F-0RTHEPERFORMANCE U ,I Q OF THE WORK FOFi WHICH THIS PERMIT IS ISSUED. � �' �� _I HAVEANO WILL MAINTAIN WORKERS'COh1PEN5ATION INSURANCE,AS RE�UIRED BY SECTION �'I Q'�, 37000FTHELA90RCODE,FORTHEPERFORMANCEOFTHEWORKFORWHICHTHISPEFMITIS -I`� , ISSUED.MVWORKERS'COMPENSATIONINSURANCECARFIERAN�POIICYNUMBERARE CONSTRUCTION l J ��,, j CAflRIER PLAN REVIEW 0 POLICY NUMBER ' - � . Z ELECTRIC ¢. ' (�}IISSECTA�NNEmNOTBECOMPLEf�OFTHEPERMfTISWRONEHUNOREDDOLLAfi6(5100!ORLESS). PLUMBING W a Z I CERTIFY THAT IN TME PERFORMANCE OF THE WORK FOF WHICH THIS PEflMIT IS ISSUE�,I MECHANICAL - �� � �i � C`S. SHALL NOT EMPLOYANY PERSON IN ANY MANNER SO AS TO BECAME SUBJECTTO THE � ��� WORKERS'COMPENSATIONLAWSOFCALIFORNIA.AN�AGREETHA7IFISHOl1L�eECOME WSPECTIONFEE - - � Sl18JECTTOTHEWORKERS'COMPENSATIONPROVISIONSOFSECTION37000FTHELABOR �,�, CODE,ISHALLFORTHWITHCOMPLYWITHTHOSEPROVISIONS. - ISSUANCE �. . � �y p� �ATE: APPLIGANT. SMIP ��� � s �i . �, J�' WARNING FAILURE TO SECURE WOPKEAS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL BE ENERGY P/C ' LL". SUBJECTAN EMPIAYERTO CRIMINAL PENALTIES AND CIVIL FlNES UP TOONE HUNDFED iHOUSAND ENERGY PERMIT � DOLLARS(E100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDE�FOR IN � J'��,' SECTION37080FTHELABOHCODE,INTEflEST,'ANDATTORNEY'SFEES. � flETENTIONFEE: - �', - �. CONSTRUCTION LENDING AGENCY PRE-ALT FEE: O' ��', I HEREeY AFFIRM UNDEF PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY FORTHE PERFORMANCE OFTHEYJORK FOR WHICH iH15 PEflM1T IS ISSUE�(SEC.3097,CIV.CJ. ZI W � LENDERSNAME � � . � F—��� LENDER'SADORESS �� .ICERTIFYTHATIHAVEREADTHISAPPLICATIONANDSTATETHATTHEABOVEINFORMATIONISCORRECT. TOTAL FEES � ��,. �I IAGfiEE7000MPLYWIT'rIALLGTYANDCOUNTVORDINANCESANDSTATElAWSRELATINGTOBUILDiNG ' , . ' �'�. CONSTRUCTION,ANDHEREBVAVTHORREREPRESENTATIVESOFTHISCOUNTVTOENTERUPONTHE . . ' - Z,i A90VE-MBdTiONED PROPERTV FOR MSPECTION PURPOSES. COMMENTS� - 0' {,y/�+�,i /� � p b y p°-}�-/��s p^� �-+ p� /� ��. I!`.�I 7C.�I �/ All� � 1 ! L/h !—\C� !`�./7 —_ .¢� PEFMITTEE NAME�PRINT ' . C!9 �"R�leGi'y'�+'�Li, 4�` �� ' . �� SIGNATURE OF PERMITTEE �ATE � -w �, j-1�•- RECPT.NO. PAID BY � - VALIDA710N ;;��� - - WHITE—Deparlment Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—ApplicanYs Copy � _ <. : ,�;;x�� :� _.., . _ . . .. . _. . .. . y .. ��, .-;.,..', ._ F , . .. �� '.�:. �� 9 . �'��i�� .�'u:@. . . : . . ' �, �� �������� ������� _ _ � � � � � � � �. . . � "':.`� �+ ,� .. �� � � � � ��"����^€� i ` _� ! , �`,��^�� ° � _ , , z �">I;.�- � . 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