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_ _ ,.._.: ._ . . .; ...:_:�,�:_,__._�_N.�..u,w;��_._ , ;. ----;�- ^___1„� CITY OF DIAMOND BAR � ' `� , DEPARTMENT OF COIVIMUNITY&DEVELOPMENT SEFLVICES 21660 E.Copley Prive Suite 190 ' " `� - �=�' PRESS (909)860-3195 F�(909)861 31ll '����� BUILDING I'�RM1'I"A��ICATION �" , FIRM�Y ' "' �., ,s_ .. . . ... :... �;, �; ,:, .. . _�.. .. . . .t � �. .. . � ,.� � „,�.,� �,.k .� .,� ,,. ,..-,. �. � JOBSITE <. '`" ` ' � g�t�' APPLICATION �� � "��Rlilfl'`I` �j P!C o ADDRESS 'c f � DA7E NUMBER IL� # � ISSUE �S �' TYPE OCC APN LOT TRA T DATE CONST. GROUP p OWNER � p A�DRESS t:� r ZONING SETBACKS ��A �� � . , � FRONT RW ❑ � CITY .tJ � P E AI�PLICANT TEt. REAR ❑ SIDE/SIQE STREET RW ❑ � CONTRACTOR � . ���G` �A,� .. SIDE ❑ o AbDRESS C CIITY '-` G" ,. ZIP'�'� -�' " �TEL. PROPOSED USE o AI�CH/ENG! + W DESIGNER NO.DWEL. NO. NO. a AI�DRESS UNITS STORIES BEDROOMS � CE7Y ZIP TEL. � ' DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-BUILDER DECLARATION,„ SFR/ADD/REM O I HEREBY AFFIRM UNDEH PENALTV OF PERJURY THA71 AM EXEMP7 FqOM THE CbNYRACTOHS LI� Gdfd9B/Cd�(?Of[ W CENSELAWFbA7FIEFblLOW1NGREASON(SEC.7a31.6BUSIT�IESSANDPROKESSIUN5Cdb�-:ANYCITYOR (n C.� CWNTYWHICHHEQUIRESAPERMITTOCONSiRS1cT,AL,TER�IMPROVE,DEMOUSH,ORflEpAIq�qNY5TRl1C� W Patio/DBck z TUpE,PNIOR TO ITS ISSUANCE,ALSO RE�UIRES THE APPLICANT FOR SUCH P@FMIT YO fiLE A 57GNED W STATEMENT TMT HE OR$HE IS LICENSED PURSUAN7 TD"TNE PROV510NS OF THE Cb47pACTORS U- W � CENSE LAW(CMAPTER 9(COMMENCINQ WITH SECTION 7Wb�OF OIVISION 30FYHE 9UAiNESSAND PRo� �'1' PooI/S(J2 FESSIONSCADE�ORTHATNEORSHEISEXEMPTTHEREfROMANbTHEBASISFOR7HEALLEGEDEXEMP- (� � TIbN.ANYVIOLATIONOFSECTION7031:6BVANYAPPGCAN7FORAPERMITSUBJEC'STHEAPPLICANTTO � Re•Roof F AC:IVILPENALTYOFNOTMORETMANFNEHUNDREUOOLUIRS(S5C0).): ' � �' �� � ""-�- �� � ❑I,ASONRJEROFTHEPROPERTV,OpMVEMPtAVEES'WITHWAGESASTHEIRSOLEC6KAPENSATION, C, Corflme/Ci81 ' WII,LDOiHE WOFlIC,AND THESTRUCTURE IS NOT INtENDED OR OFFERE�'FOR�SALE(SEC�JOa4.�BUSI- J NESS AND PqOFES510N3 CODE THE CONTRACTORS LICEAYSF LAW OOES NOTAPpLY 7D AN�OWNER OF � PpOPERTYWI�IOBULOSORNIPROVESTHEREON,ANDWNdDOESSUCHWOpKHIM$��F`OftHERSELFOfl = LL THfl9U(3MHISORHEROWNEMPLDYEES,�PPOVIDEDiHA75UCNIMpROYEM�kTS'AFEhI6TiNTENDEDOR m Q OFFRiEDFORSAl.E1F,FbWEVERTMEBUILDINGORMPROVEIAENTISSOLOWITHIN'DNEV'�AROFCOMPLE- � TICNJ,THE OWNER-BUIIAER WILL HAVE THE BURDE7J OF PR'OVIN'G YHAT HE Oq�SHE OID NtlT BUILD pR . = IMPpOYEWRTHEPURPOSEOFSALEI. ��. '. . �:�, "'. ..'��. ❑I,ASOWNEROFTHE PpOPERTV,AM EMCLUSIVELY CONTRACYING WITH LIC6NSE[�CbNT'RACTCSRS � TO'CANSTRUC7 THE PR0.IECT(SEC:7oH,BU3INESS PNp pqOFESSIONS CtSDE:TkE CbIJ1'PAC70RS Lb VBIUBIIon ADJ.AflEA___. � W CENSEUWDOESNOTAPPLYTOANOWNEROFAPROpEftTWWHO9UILDSdqIMPfiOVES7NEREON.AN� � WFIOCONTMCTSFopSUCHPROJECTSNIITHACONTRACtdA(S)tICENSE0I�URSUAMTO7HEBbNTRAC QUANTITY DESCflIPTION - - FEE Y TORSUCENSELAW.�. ..�. .' . o O I AM E7(EMPT UNOER SEC. 8.8 P.C.FOR THIS REASON d � � � V LL � DAiE OWNEA U O LICENSED CONTRACTORS DECLARATION W � IHI_REBVAFF�RMUNDERPENALT'OFPERJURV7HATIAMLICENSEDUNDERPROWbION50FCHAPTER � �i p'_ e(IXIMMENCINpWRHSECTION7oou�OFDIVI510N30FTHEBJ51VE5SANOPROFE55lON5CO�E,ANO � , - yc AdY UCENSE IS IN FULL FoqCEAND EFFECT. �ry {� � � . ....�ld'f� ,� J� m a� iry LI<IENSE CLASS � LIC.NO � j �,..;�.:��.»��5 V DATE� �" CONTRALk7�OH�..::.....� d. . . .. It l v� WORKERS'COMPENSATION DECLARATION d � U � IHIoREBYAFF�RMUNDERPENALttOFPERIURYONEOfTHE'FOLL0441NGDEbLARATIONS:��'��� `� �� — : � � � __IHAVEANDWILLMAINTAINACERTtFICATEOFCONSEMTOSELF-INSUflEFOPWORKERS' 2 . .. .,,,:,=p�j„� � ,�' . ` i k � �i�� COMPENSA710N,ASPqOVIDEDBYSECTICMJ370oOFTHEI'ABOqCODE.FOR7H�PERfdRMANCE � " " "- �� - "•�*"¢ ��1"' '"' �,F.. _ OFTfIF WORK FOR WHICHTHIS PEAMITIS�SSUED. � �� � � v 6J�.B � �EANP WIILMAINTAiN WORKERS'COMPENSATION INSVRANCE,AS RE(2UiRED BY SECTION � 37ooOFTNELPBORCODE,FORTHEPERFORMANCE�OFTHEWORKFORWHICHTNISPERMITIS ISSUED.MYVdORKERS'COMPENSATION�NSURANCECAqRIERAN,DtP_O�UCVNUMBERARE: CONSTRUCTION ?J ����i. PLAN REVIEW . _.. ,,,4,.� .�»-.—�.t CARRIER_ � .e, .. .... .. . . � POL�CYNUM6ER__.���y � � � � ELECTRIC B � (IHISSECIK.PINF�NOT8ECq4WLETE�OFiI$PEMSTISfOHIXJEHUt�DfiEDOIXlAASIS'.ao)QqLE55). PLUMBING 9� �' z I CERTIFY THAT IN THE PERFDRMANGE OF TNE WORK FOfl WHICH THIS PEFM�T I$ISSUED,I MECHANICAL �L4 ('j SHALLNOTEMPLOYANVVERSONINANYMANNERSOASTOBEC-0AAESU6JECTTOTHE T�� � WORKERS'COPAPENSAT�ONUIWSOFCALIPoRNIA,ANDAGREETHATIFISI10UlD�BECOME INSPECT�ONFEE SU&IECTTO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 370o OF 7HE LABOF ~ CADE, SHALLF RiHWITHCOMPLYWITHTHOS PROVISIONS. ' ISSUANCE � o DATE: ` � ,�PPLICANT. SMIP __ +��y,�'�� . � WARNINGFAIIURETOSECUqEWORKERS'COMPENSATIONCOVEFlAGEISUNLAWFUL,ANDSHALL9E ENERGYP/C � + ' �� � ✓'�" � SU3JEGTANEMPLOYERTOCRIMINALPENALTIE5ANDqVIlFMESUPTOONEHUNORED7HOU5ANp ENERGYPERMIT DCUAPS(51oD.0007.IN AbDIT:ON TOTHE C�ST OF COMPENSATION.DAMAGES AS PROYI�EC FOR IN { ' � SEC710N 37ae OFTFIE LABOR CODE,INTEREST,AND pTTORNEY'S FEES. (�E7�NTION FEE: �L ���� a CONSTRUCTION LENDING AGENCY PRE-ALT FEE: ''�e�� � - O ' � I HfREBVAFFIRMt UN�ER PENALTY OF PERJURYTHATTHERE,IS ACONSTRUCTION I.ENDING AGENCV , FORTHEPERWRMANCEOFTHEWORKFOFWHICHTHISPERMITISISSUED�SEC.30s7,CIV.CJ. ., . - . Z W � LB��ER'S NAME � " � LE40ER'SADORESS �� w ICERTiFYTHATIHAVEREADTHISAPPLICATIONANDSTATETHATTHEABOVEINFORMATIONISCORRECT. TOTAL FEES � �� �� � IAGFEE i0 COMPLY YVITH ALl CRY AN�COUNTY OR�INANCES AND STATE LAWS flELATING TO BUILDING ,�,� �� ^ �" I�"�11'� - � COh1STRUCTION,AND HEREBYAUTHORI2E REORESENTATNES OF THIS COIINTYTO ENi'ER UPON 7HE �� ' ��� � �� �� j p��.�, � Z A6iJVE-MENTIONEDPROPERTV�FORINSPEC71ONPU OSES. L"" ,i,j:z^� � —�� � ��� COMMEN?S - � m PEI3MITTEE NAME(PRI ) . � � � SIGNATURE OF PERM�ITE """" - " � ' -" ' = RECPT.NO. 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