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.-._ . I___. _. ._. ._ . _ . . — CITY OF DIAMOND BAR � COMMUNTI'Y DEVELOPMENT DEPARTMENT � �"'- .:,,� . 21660 E.Copley Drive Suite 190 PRESS (909)860-3195 Fax(909)861-3117 �"""' BUILDING PERMIT APPLICATION FIRM LY _ o- ADDRESS .��� ' �L%UO!/[� �QLZiC/ DATE � �� ` NERMIT ,: � ' P/C � JOB5ITE / APPLICATION P UMBER # � ISSUE TYPE OCC � APN LOT TRA DATE CONST. GROUP p OWNER p ADDR S ZONING SETBACKS Z CITY ZIP TEL. FRONT RW ❑ o APPLICANT T�C. SID SIDE STREET RW O � ADORESS rB.I. �I�C.., SIDE , ❑ m CONTRACTOR �c' � CITY ,y�I TEL, � PROPOSED USE w ARCWENG/ i a �7��� z DESIGNER NO.DWEL. NO. NO. , � ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. v DESCRIPTION SQ.FL FACTOR PSF ADJ;AREANALUATIqN p� OWNER-BL'ILDER DECLARATION SFR/ADDlREAA ° O .p. I HEREBY AFFIRM UNDER PENAITY OF PERJUflY THAT I AM E%EMPT FflOM THE CONTHACTORS LI- �� G9t9gB/Ce�p01t � � W� CENSEIAWFORTHEFOLLDWMGqEASON(SEC.7o31.5B11SMESSAN�PNOFESSIONSCOOE:ANYCITYOR (n - � ��- � �Z� COUNTYWHICHRE�UIRESAPERMITTOCONSTRUCT,ALTER,IMPROVE,DEMOLISH,ORREPAIRANVSTHUC-' W P8I10/DBCK . ' ' ' ;w TURE,PRIOR TO ITS ISSUANCE,ALSO REQUIflES THE APPLICANT FOR SUCH PERMIT TO FILE A'61GNED W � �� � � �� � �STATEMENT THAY HE OH SHE IS LICENSED PURSUANT TO THE PROV1510N5 OF THE CONiFfACYORS LI- � . ,,�' .CENSE LAW(CNAPTER 9(CAMMENGNG WITH SECTION 7000�OF DIVISION 3 OF THE BUSINE55 ANO Pfl0• V"' POOVSPd � � ' 0 �FESSIONSCADEJORTMATHEORSHEISEXEMPTTHEFEFPOMANDTHEBASISFORTHEAILEGEOEXBr1P• .(� :U�� �TION,ANVVIOLA710NOFSECTION7o37.58YANYAPPLICANTFORAPERMITSUBJECTSTHEAPPLiCANTTO Z Re-FlOOf � ���' � .� �A CIVII PENALN OF NOT MORE THAN FIVE HUNDRED DOLLAq$(t5oo�.); . Z � ❑I,ASOWNEROFTHEPROPERN,ORMVEMPLOVEESWITNWAGESASTHEIHSOLECOMPENSATION, Q (�`pmmBfCiBI ' �� � .,,WILI OO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFEFlED FOR SALE(SECJo44,BUSI- J � "�NESS AND PROFESSIONS CODE:THE CONTRACTORS IICENSE U1W DOES NOT APPLV TO AttOWNER OF � � ' 'PROPERTYWHOBUIL�SORIMPROVESTHEflEON,ANDWHO:�0E5SUCHWORKHIM3ELFORHERSELFOR � � ��,THROUGHHISORHEROWNEMPLOYEES,PPOVIDEDTMATSUCHIMPROVEMENTSARENOTIN7EN�EDOR m � ,OFFEREDWRSALEIFHOWEVER,THE9UIL�INGORIMPFOVEMENTISSOIDWITHINONEYEAROFCOMPLE- ' � .Z I TION,TNE OWNEH�BUILDER WILL HAVE THE�BUHOEN OF PROVIN(i THAT HE OR SHE DID NbT BUII�OR . � . � �(IMPROVEFORTHEPUHPOSEOFSALE). . ❑,I,AS 06VNER OF THE PROPEFTY,AM.EXCLUSIVELV CONTRACTWG WITH LICENSE�CANTRACTOFS � '��.TO CONSTRUCT THE PROJECT(SEC,7044,BUSINESS ANO PROFESSIONS CODE:THE CON7RAC70RS LI- V81u8f1011 ADJ.AREA � ''W �;CENSEIAWOOESNOTAPPLVTOANOWNEROFAPROPERI'YWHOBUIL�SORIMPflOVESTHEREON,AND ' �,'I�WHOCONT0.4CTSFOFSULHPROJECTSWITHACONTRACTOR(SJL�CENSEOPURSUANTTOTHECANTHAG QUANTITY DESCRIPTION � . � � � FEE �� TORSLICENSELAW.). '. � � 0 � ❑IAM E%EMPTUNDERSEC. � B.8 P.C.FORTHIS REASON Q � � } U � . ;�. ': � '�� . �LL DATE OWNER � � ' �. .�0�'�., .. . . . .W . . . .. :�,, , LICENSEDCONTRACTORSDECLARAl10N W � Q, �� �� .IHEREBYAFFIRNUNDERPENALTYOFPERIURYTHATIAMLICENSEDUNDEHPROVISIONSOFCHAPTEH � , � � �f , ���� � 9(COMMENCING W17Vi SECTION 7000�OF 01VISION 30F THE BU5INESS AND PROFE5S10N5 CADE,AND � XW MV LICENSE IS IN FULL FORCE AND EFFECt ., m � ,. ���, LICENSE CLASS�� IIC.NQ�� �� � V� DATE��CONTRACTOR � - d �. W s� �� ' WORKERS'COMPENSATION DECLARATION j'Z--���/ a � � �d t? � 1 HEREBYAFFIRM UNDER PENALTV OF PEflJURY ONE OFTHE PoLLOWING DECUIiATIDNS: Z , C1�� _IHAVEANCWILLMAINTAINACERTIFICATEOFCONSENTTOSELFdNSUREFORWORKERS' �_ - ' � Q COMPENSATION,ASPRWIDEDBYSECTIONa7o00FTHELABORCODE,FORTHEPERWRMANCE �U . Q OFTHE WORK FOR WHICH THIS PERMIT IS ISSUED. � �� _IHAVEANOWILLMAINTAINWORKERS'COMPENSATIONINSURANCE,ASRE�UIREDBVSECTION Q, 370o OF THE LABDR CODE,FOFl THE PERFORMANCE OF 7HE WORK FOfl WHICH THI3 PERMIT IS ISSUED.MY WOflKERS'CAMPENSATION MSURANCE CARRIER AND POIJCV NUMBERARE: CONSTRUCTION' j caqRiER PLAN REVIEW Z'�,' POLICY NUM9ER . E . � � � �i ¢ c� �r , ��,', (fNI55ECTI0IVNE�NOTBECtiMoLEfE00FTHEPEPhYTBFORONEHUNDREDDOIWiS(51Q010plE55�. LUMBI - 2 ICERTIFYTHATINTHEPERFORMANCEOFTHEWOHKf-0RWHICHTHISPERMITISISSl1ED,l MECHANICAL �� � C.�.S', SHALLNOTEMPLOVANYPERSONINANYMANNERSOAST08ECAMESUBJECTTOTHE � F.� �. y, WORKERS'COMPENSAiION LAWS OF CALIFOFNIA,ANDAGREE THA71F I SHOULD BECOME INSPECTION FEE _� SU&IECT TO THE WORKEflS'COMPENSATIO ISIONS OF SECTION 370o OF THE LABOR 0.,, CO�E,I3HALlFOFTTHWITHCOMPLYWIT OSEP OVISiONS. ISSUANCE p'�, DATE:�?-//9� APPLICAN7: ���� _.,— SMIP �k � ' J I, WARNINO:FAILURE TO SEWRE WORKERS'COMPENSpT10N COVER4GE IS UNL'AWFUL,AND SNALL BE ENERGY P/C �� � � � �',. �SU&IECTANEMPLOYEHTOCR�MINAIPENALTIESANDCIVILPINESUPTOONEHUNDREDTHOUSqNO ENERGYPERMIT �. �OLLAHS(510o.oa01,IN ADOITION TO THE WSiOF COMPENSATION,DAMAGES AS PRQVIDED FOR IN . J!�i �SECTION37080FTHELABORCADE.INTEREST.ANDATTOHNEY'SFEES. - ¢°; RETENTION FEE: - - a! CONSTRUCTION LENDING AGENCY PRE-AI.T FEE: . OI' �, 0.�(" IHEREBVAFFIRMUNDERPENALTYOFPEAJURVTHATTHEREISACONSTRUC710NLENDINGAGENCY � FORTHEPERFORMANCEOFTHEWORKFORWHICHTHISPERMITISISSUE��SEC.3agl,Clv.C.). Zli w � LENOER'SNAME - ' I'-" LENDER'SADOHESS ' ��'.. ICERTIFVTHATIHAVEHEAUTHISAPPIICATIONANDSTATETHATTHEA80VEINFORAAATIONiSCOqRECT. TOTAL FEES �. ����/� - W'�'�1 AGREE TO COMPLV WITH ALL CITYAND COUNTV ORDINANCE5.4ND STATE UIWS RELATING TO BUILDING - G�'� ��" CONSTRUCTION,AND HEHEBYAUTHORIZE REPRESENTA7IVES OFTHIS COUNTYTO ENTER UPON TH � - ' . . ' � . E Z''�,i, ABOVEMENTIONED PROGER7Y FOR INSPECTION PURPOSES. COMMENTS ' � ' 0':'' J �, �". PERMITTEE NAME(PRINT) � - . . � �. !h � •�� 6-i/�� ;, �I�. SIGNATURE OF PERMITiEE ' DATE � � ' � � RECPT.N PAID BY __T'VALIDA710��� � WHITE—Department Copy,YELLOW—Financa Copy,PINK—Assessor Co ,GOLDENR06—File Co .GREEN— �icaM's Co �� . � PY PY� 1WP PY „,,>„ ,.. . , , r-...,�- �:. �,:+„a �',�5�:'�y��a„e „"t'�v >-� �.':., �.�':3�a,� . .e��G r�.h,w=�3�?"�,u,At�;,;`.;n nso-�r::r; ,:3� , . .. �” .. . , . , . �� c�5 ��L� �����`���..- ' � ... . ... . , _ . . :.. . , ��������€��� ������ � � � � � � �b � �'. � � 8 f ��� , � "� ��ti � d � _� �! �°C���C?��S1���� � , �L�5�4�.�G���d ` - } L I ��P��c�i�'�"� � . , ., , , ;1 , , „. . , ,. . ._, ����,°���������� 5 I u������.������� � � ,, ,: ,, ; ����s����,������� � � ur����j'�:�������i_��i�� . : �, a :..s.� �..� :._: ,! °ri9 �,u.x�wj�y � -- -- -- ��6�a'�.��t���^ .... . � .. . i '�����''L_�".��lm��.,.€���:a���i , ': .j'� . � . 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