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--.. _.__,._. ,,r^''� t �a CITY OF DIAMOND BAR �� ^--�� DEPARTMENT OF COMMiJNITY&DEVELOPMENT SERVICES �� _ a 21660 E.Copley Drive Suite 190 (909)860-3195 Fax(909)861-3117 PRE$S �'':.9�'`' BUII,I)ING PERMIT APPLICATION FI.RMLY � JOBSITE 9� APPLICATION I � PERMIT �`� PIC o ADDRESS � ^ ��I�°°����� �` ��-� DATE � i � NUMBER �� �� � # � ISSUE TYPE OCC APN LOT TRACT DATE CONST. GROUP p OWNER ����,���' �'�-�.'J,;'1"��r ADDRESS ,� � ZONING SETBACKS Z CITY ZIP TEL: � � f'� FRONT RW ❑ g APPLICANT TEL REAR � � SIDE/SIQE STREET RW ❑ � CONTRACTO'R � �- �m`2{"� �"�^""z ��^ SIDE ❑ p� ADDRESS � ^.`' �•, O CITY � ,' ZIP TEL.� `��a PROPOSED USE C , V G�C i Q ARCW NG/ z DESIGNER NO.DWEL. NO. NO. � ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.FT. , FACTOR PSF ADJ.AREA7VALUATION ' u� Q OWNER-BUILDER DECLARATION SFR/ADD/REM � � � O Q ' 1 HEREBY AFFIRM UkDER PEI3ALN OF PERJURV THA7 I M9 E%EMPT FROM THE CONTRACiORS LI- � GaragelCarport � � �. � W. CENSEWNWRTHEFOLIOWIN6REA90N(SEC,7031.5BUSINESSANDPROFESSIONSCODE:FNYCINOR U, GWNfYNTi1CFSREQUIflESAPEHMITTOGONSTRUGT,PLTER,IMPflOVE,DEMOiJSH,ORREPAIRANYS7flUG W� PgIlO/DBCIC W�, TUFE,PRIOR TO ffS ISSUAPICE,ALSO RE�UIRES THE APPIICANT FOR 5UCH PERMI7 TO FILE A SIGNE� � �, STATEA�NT THAT HE OR SHE IS LICENSED PUFiSUANT TO THE PROVISIONS OF THE CONTFACTORS L4 . . � � CENSELAW(CHAPTER9{OOMMENCINGWITHSECTION�OOoJOfD1YI510N30PTHEBUSINESSANDPRO- � POOVSp2 FESSpNS CODE)DA THAT HE Ofl SHE IS EXEMPTTHEREFROM AND THE BASIS FOR hIE ALLEGED EXEMP- V TqN.ANYVIOLATIONOFSECTION7o37.5BYANYAPPLICANTPOHAPERMITSU&IECTSTHEAPPLICAN7T0 Z Re-Roof � � ACMLPENALTYOFNOTMORETHANFfVEHUNDflEDDOLLARS�5500J.�: , , � ❑I,ASOWNEROFTHEPROPERTY,OHMYEMPLOYEESWITHWAGESASTHEIRSOLECAMPENSATION, 0 COR1R12lCI31 � . " NIILL DO THE WDRK,ANO THE STRUCTURE IS NOT INTEN�EO OR OFFERED FOH SALE(SEC.7044,BUSI� J �; �.NESS AND PROFESSICNS CDOE:THE CANTRACTORS LICENSE LAW DOES NDT APPLY TO AN OWNER OF � . . �.PI'�PEfiNWHOBUIIOSORIMPROVE5THEREON,ANDWHODOESSUCHWORKHIMSEIFORHERSELFOR '�" �7HRIXIGHHISORHEROWNEMPLAVEES,PROVIDEDTHATSUCHIMAROVEMENTSAFENOTINTENDEDOR � - " ,Q',: �,�OFFEREDFORSALEIFHOWEVERTNEBUILDINGOFiIMPROVEMENTISSOI.DWITHMONEVEAROFCAMPLE- z „�710N,THE OWNEfl•BUILDER WILL HAVE THE BURDEN OF PROVINO THAT HE OR SHE DID NOT OUILU OR � '',IMPROVE FQR TNE PURPOSE OF SM.E). W�. � ❑I,ASONTIEROFiiiEPROPERTY,AMEXCAUSIVELYCONTRACTINGY/ITMLICENSEDCONTRAC70R5 . . �'�� ',TO CONSTRl1CT 7HE PNOJECT(SEC.7044,BUSINESSAND PROFESSIONS CODE:THE CONTRACTORS LI- VBIUflIIOfi ADJ.AREA �,W " CENSEUW�OESNOTAPPLYTOANOWNEROFAPROPERT/NHOBUIl.65aRIMPROVESTHEREON,AND . � YYHOCONTR0.CTSFORSl1CHPROJECTSWITHACONTRIICTOR�S�LICENSEDPUASUANTTOTHECONTRAG QUANTITY DESCRIP710N FEE � � ,. � TORSUCENSELAW.). /"��� o � ❑I AM EXEPiPT UNDER SEC. B.&P.0.FOR THIS REASON Q �" `��9 '"�"" � � p � � � k� � �... �. , � oaTE owwEa c�, �. � e c � owrv s o LICENSED CONTRACTQRS DECLARATION W � IHEREBYAFFIRMUNDERPENALTYOFPERJUf1YTHATiAMLICENSEDUNDERPRO'dlSiOh30FCHAPTEH /� g'�'�y p*' p �{y � e(COMMENCINCIWI7HSECTION7000)OFDIVISION30FTHEBUSINESSANDPHOFESSIONSCADE,AND Z '�1��7�° � � G��/ �.r X_ MYUCENaE IS IN FULL FOACEAND E.FFECL � Lld 3 m o LICENSE CU1SS�LIG.NO. ��e a 4� � � j� . U �ATE P��' GOPlTRACTOR � �. ^—1,�'ii�...v � W � NlORKERS°COMPENSATiON DECUaRATION � � . �� IHEREBYAFRFMUNDEflPENALTYOFPEAJURVONEOFTHEFOLLOWINGDEClARATIONS: U � Z O� IHAVtANDWILLMAINTA�NFCERTIFlCATEOFCONSENTTOSELF-INSUREFORWORKEAS' ¢y � P �� � �COMPENSATION,ASPROVI�EDBYSECTION37000FTHEUBORCODE,FORTHEPERFORMkNCE C.� Q � OFTHE WORK FORKM1iICH THIS PERMIT IS ISSUE�. � � � �I HA4ElWO WILLMAINTAIN W�RKERS'COMPENSATION INSURANCE,AS RE�UIRED BV SECTION g�Q� d ¢ 0 37000F 7HE LABOR CODE.FOR THE PEFFORIAANCE OFTHE WORK FOR WHICH TNIS PERMI715 �dg�+ f� � � i�f� �e� .. ISSUED.IAY NLDEMEHS'COMPENSATION INSLJRANCE CARRIEP AN�POLICV NUMBER ARE� . CONSTR�JCTION °'� ° �� °"� �"° 6� ti F � CARRIER PLAN REVIEW ��'s�'����'--+'�=�.'$.�.r�3�E�G,'T a�.�.��� QPQLICYNUMBER ELECTRIC ��������R,�:�f��°,::a�aw�n<�I'�'s� Q jfH5SEC7KJNNE�NOT9EIXMaA.EfEDOF'fF7EPEFL4�llSFOflONEHUl�(iEDWLLARS(EtW)ORLESS). PLUMBING vA� � ICERYIFYTHATINTHEPERFORMANCEOfTHEWORKFORWHICHTHISPERMiTI51S5UED,1 MECHANICAL (,'�� 5HALL NO7 EMPLOY ANY PEft50N IN RNY MANNER SO AS TO BEGOME SUBJECT TO TH ��(jy', WORKERS'COMPENSATIONLAW56FCAUFORYIA,AND FE TMATIFISHOULDBE ME INSPECTIONFEE � SUBJECTTO'fHEWORKEflS'COMPENSATIOIVPROVl51 S CTION370�OFTH IABOR �{� = CADE,ISHAL�FOFTHWITHCOMPLYWITHTH - � I51 5. iSSUANCE :.�n� `�' SMIP .Q� ORTE: " � HPPLIC - � . J. WARNING FAILURE TO SECURE WORKEPS'COAIPE. ATION COVERAGE IS UNLAWFU AND SHALL BE ENERGY P/C � SUBJECTANEMPIOVEiiTOCRiMINALPBJALTIESA CIVI�FINESl1PTDONEHUND �THOUSANO ENERGYPERMIT DOLLAFlS(S7ao.aoo),IN ADDITION TDTHE COST OF MPENSATION,DAMAGES AS PROVI�ED FOF IN J'�;. SECTION 3708 OF THE LABOR CGDE.IPlTEREST,AND ATfORNE1"5 FEES. RETENTION FEE: �'.' ���:. CONSTFUCTION LENDI NG AGENCY pREALT FEE: OI ��' IHEREBYAFFfRMUNDERPENALTYOFPEiUURYTHATTHEREiSACONSTRUCTIONLENDINGAGENCV ' FOftTHE PER WRMANCE OflHE WOflK FOR WH!CH THIS PERMIT IS ISSUED(SEC.3097,CIV.C.). � - . Z W'. �2� LENUER'6NAME � �- - � 1.='�. LENDER'SADDHE55 \ � � ICERTIFYTHATIHAVEHEA�THISAPPUCAT70NANDSTATETHATTHEA804EINFORAfAT10NISCARREC7. TOTAL FEES 8"'d ���� W� IAGREETOGOMPLYWI7HALlClTYANDCOUNTYORDINANCE9ANOSTATELAW3RELATIN6TOBUILDING - ' �. �'� CONS'RUCTION,AND HEREBYAUTHOR�ZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE � - Z;. ABOVE-MENiIOfdEO PflOPERTY FORINSPECTION PURPOSES. COMMENTS - �a�l''��� _ ,�..�'"'/�. ��"°•� ��`i�'". � . - � � - . �I m'�," PE I EE NAME INT) � Q �' ��/y SI DATE � . �., RECPT.NO. 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