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- ___ _ ___ .-- __ . _ _ __ _. - --_---- _ _ ___ -- --- ---r----- ----- _ �'`M� - CITY OF DIAMOND BAR �" '�� � � COMMUNTTY�EVELOPMENT DEPARTMENT / �%' ;;:�,_� 21660 E.Copley Drive 5uite 190 � �R��� (909)860-3195 Fax(909)861-3117 � "vri' BUILDINGPERMITAPPLICATION -/f FiRMLY o� JOBSITE �7��„� ` �,J/IfR,�C t„ F��I/ dATEGATION,. �X � NUMBER� :�� #�C ADDRESS i/.r�� ��pt V1 o ISSUE TYPE OCC °�° APN LOT TRACT DATE CONST. GROUP , °C OWNER O p ADDRES "�s' «� ZONING SETBACKS z CITY ZIP TEL. � ` FRONT RW L'' � APPLICANT TEL REAR C o SIDE/SIDE STREET RW ❑ I� Q CONTRACT R � fS� SIDE C �w A HES a a ZI � TEL. PROPOSED USE s��W"�'�D SI���"' � � ��� z DESIGNER NO.DWEL. NO. NO. � ADDRESS UN1TS STORIES �, BEDROOMS ', � CITY 21P TEL. ' � DESCRIPTION SQ.FT. I FACTOR PSF ADJ:AREANAEUP.71C1N. ' � , �'.� � OWNER-6CILDER DECLARATION - SFR/ADD/AEM � � � �� � ��� � � Q �� �, Q . I HERE6Y AFFIRM UNDER PENAL'n'�F PERJURV THAT I AM E%EhIPT FROM THE CONTRACTORS LI- � GdfflgE/Ca1pOfl � �� W CENSEUIWWRTHEFOLLOWINGFEASON(SEC.7031.SBUSINESSANDPROFESSIONSCO�E:ANYqNOR � � CDUNTVWHICHREQUIRE5APERMIiTOCONSiRUCT,ALTER,IMPROVE,�EMOLISH,ORREPAIRANVSTRUC- W �gil0/D2CI( ' ' i w 7URE,PRIOR TO ITS ISSUANCE,AL50 REQUIRES 7HE APPLICANT FOR SUCH PERMIT TO FlLE A SIGNED W , � STATE6AENT THA7 HE OF SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI- , . ,� � CENSE LAW(CHAPTER 9(COMMENGNG WITH SECTbN 70Co)OGDNISION 30FTHE BUSINESSAND PRO- LL' POOUSp3. I � FESSIONSCO�E)ORTHATHEORSHEISEXEMPTTHEREFROMANDiHEBA5ISFORTHEALLEGEDEXE�dP- , U TION.ANYVIOL4?IONOFSECTI0�70915BVANYAPPLICANTFDRAPEFMITSUBJECTSTHEAPPLICANTiD Z R2-FCAf �., � ACIVIIPENALiYOFNOiMORETHANFIVEHUNDR'cDDOLL4fiS�$5oo�.j: e � �, O, ❑I,ASOWNEFOFTHEPflOPErIN,ORMYEMPLOYEESWITHWAGESASTHEIRSOLECOMPENSATION, G Commercial � � �. z WILL 00 THE WORK,AN�'HE STRUCTURE IS NOT INTENOE7 OR OFFERED FOR SALE(SEC.7o44,BUSI- J NESS AND PFiOFESSIONS CODE:THE GONTftAGTORS LICENSE LAW DOES I�iAPPLY TO AN OWNER OF �'i � PROPERTVWHOBUILDSOFIMPPOVESTHEFiEON,AIJDWHOQOESSIICHWORKHIMSELFORHERSELFOR � � � i Q[ THROUGHHISORHEROWNEMPIOYEES,PROViOEPTHATSUCF'IMPROVEMENTSARENDTINTEN�EOOR m , I W pFFERE�FOflSALE.IF,HOWEVER,THEdUILDINGORIMPROVEMENTISaOLDWITHINONEYEAROFCOMPIE- ' �� �� � 710N,iHE OWNER-BUILDER WILL HAVE THE BUflDEN OF PROVMG THAT HE OR SHE DI�NOT BUILD OFl �� � ���� Z IMPROVEFORTHEPURPOSEOFSALE�. � _ ❑I,ASOWNEROFhIEPROPEf7TY,AMEXCWS'��VELYCONTRACTINGWITHLICENSE�CONTRqCTOflS � TD CONSiRUCTTHE PROJECT�SEC.7o44,BUSINESS AND PROFESSIONS CODE:THe CDNTRAC70RS LI- VBIUflf10[1 'ADJ.AFEA � �� W GENSEIAWDOESNOTAPPLYTOANOWNEROFAPROPERiYWHOBUILD50RIMPROVESTHEREON,AND � �WHOCONTRACTSFORSUCHPROJECTSWITHpCONTRACTOA(S)LICEN3EDPl1RSUANTTOTHECONTRAC- QUANTITY DESCRIPTION - 'FEE .. " ' Y TORS LiCENSE LAW.J. . ,, � � ❑I AM EXEMPT UNDER SEC. B.&P.C.FOR THIS REASON U ' , � � � OATE OWNEfl ._____ V . . � . ' .. i Z W !i � LICENSED CONTRACTOFS DECLARATION - W � � �' � � 'I ¢ � IHEREBYAFFIRMUNDERPENALTYOFPcRJURYTHATIAMLICENSEDUNOERPROVISIONSOFCHAPTER �. � 9(COMMENCING WITH SECTION 7000)OF�IVISION 3 0FTi1E BUSINE55AND PFOFE5510N5 CODE,AND Z �I `X MY LICENSE IS IN FULL FORCE ANO EF:ECT. . m � , �� � LIGENSE CLAS LIC.NO. � � � � � F– � U DATE CON7RACTdR � a . I� w � � WORKERS'�OMPENSATION DECLARATION � � ,'I , � I � IHEREBVAFFlFMUN�ERPENAL7VOFPERJURYONEOFTHEfOLLOWINGDECUWATIONS: � � � Z I�I 0 ^IHAVE{WDWILIMAINTAiNACERTIFICATEOFCONSENT70SELF-INSUf1EFORWORKEflS' 2 � � I'i �' � COMPENSATION,ASPROVIDEDBYSECT:ON3�ooOFTHELABORCODE,FOPTHEPERFOFlMANCE U �' a OFTHE WORK FOR WHICHTHIS PERMIi IS ISSUm. �I ��, I � �I HAVEAND WILLMAINTAIN WOFKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION } �c^/q �i, � 37000FTHE.A00RCODE,FORTHEPERFOFi41ANCEOFTHEWORKFORWHICHTHISPERMITIS [ � � ISSUED.MVWORN _S'EOMPENSATIONINSUR CECARRIERANDPOLICVNUM6ERARE: CONSTRUCTION ___, /,�_._� � J �x'^ 'I j caaaiEa �' _ PLAN REVIEW 'i, � PDLICY NUMBER � ELECTRIC � ¢ (I}iI55EGlI0NNEmNOT6ECOA1FLEfEDOFTHEPERMRISFORONEHUNDflE�00LIh3S(5100)ORLESS). PLUMBING �II 0 IIi ��, Z ICERTIFYTHATINTHE?ERF-0RMANCEOFTHEWORKFORWHICHhiISPERMITI515SUED,I MECHANICAL �' I'' I (!S SHALLNOTEMPLOYANVPERSONINANYMANNERSOASTOBECOMESUOJECTTOTHE I� {J� WORKERS'COMPENSATION'_AWSOFCALIFORNIA,AN�AGREETHAiIFiSNOULDe'=COME INSPECTIONFEE " ? SU6JECTTOTHEWORKEflS'CON�PENSATIONPROVISK]NSOFSECTION3�o00FTHELABOR CODE,I$ FOR7HWITH COMPLY'JJIiH THOSE PkGVISI0A5. �SSUANCE e a �� �I � r SMIP p �ATE: APPLICANT: - I J� � ENERGY P/C � - I J WARNING:F ECUREWORKERS'COMPENSATI , OVERAGEISUNLAWFUL,ANDSFiALLBE SUBJECTAN E P YERTO CRIMINAL PENALTIES AND CI FINES UP TO ONE HUNDRED iHOUSAND � ur ENERGY PERMIT � OOLLARS(SiW.oWJ,INADPITIONTOTHECOSTOfCOMPENSATION,DAMAGESASPROVIDEDFORIN J SECTION3�OBOFTHELA90RCWE,INTEftEST,ANDATiORNEY'SFEES. RETENTIONFEE � I � !��� CONSTRUCTION LENDING AGENCY PRE-ALT FEE: _ . IO� . . .. .. - .. -- - --- - � '�, �I � IHEREBYAFFIRMUNDERPENAL?YOFPERJURYTHATTHEFEISACONSTRUCTIONLENDINGAOENCY a- FORTHEPEPFORMANCEOFTHEWORKFORWHICH�HISPERMITISISSUE�(SEC.30W,CIV.CJ. �I I Z . . � . . . �I i W ' � LENDER'S NAME - � ' I � LENDEft'SAD�RESS . �f �I� w ICERiIFYTHAiIHAVEREADTHISAPPLICATIONANDSiATETHATTHEAdOVEINFORMATIONISCORREC(. TO�l`1L FEES /� y`J� � ✓ :�� ' i � IAGREETOCOMPLYWITHALLCITYANOCOUNTYORDINANCESANDSTAiEL4W5RE1A7INGTOBUiL�ING /Ay s a Ppp �G� _ _ � � � CONSTRUCTION,ANDHEREBYAUTHORIZERcPRESENTATIVESOF7HISCOUMViOcNTERUPONTHE p/+ � i' , �� �I � ABOVE�MENTIONEDPROPERTYFO NSPECiIONPURPOSES. 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