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Home My WebLink About10590 _ � �.,. .. .� ,�� CTI'Y OF DIAMOND BAR � COMMUNITY DEV$LOpMENT I��PA�'�MENT � -,,,,y 21660 E.Copley Orive Suite]90 PRE� (909)860.3195 Fax(409)861-3117 ' �""`� BUILDINGPERMITAPPLICATION FIRMLY � ....:„ . .. , ,. � JOBSITE APPUCATION PERMIT P/C o ADDRESS DA7E NUMBER � # " ' ° � � � " ISSUE TYPE OCC � APN T R T DATE _l�� GONST. GROUP p OWNER 11 ADDRES ZONING SETBACKS z CITY IP r TEL. FRON7 RW ❑ g APPLICANT TEL REAR ❑ � SIDE/SIDE STREET RW ❑ a� CONTRACTOR • ' • �C• SiDE ❑ � ADDRES5 PROPOSED USE 0 CITY '' 1A►�Inu�l�� TEL. Q ARCH/ENG/ z DESIGNER NO.DWEL. NO. NO. � ADDRESS UNITS STORIES BEOROOMS � CITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-BI:ILDER DECLARATION SFRlADD/REM O I HEHEev AFFIRM UNDER PENALTV OF PERJURv THA71 AM E%EAIPT FROM THE COM'RAC70RS L6 GB�PgB/CBf�)Ofl W CENSELAWFORTHEFOLLOWINGREASON(SECJ031.s8USINESSANOPfiOFESSION3CODE:ANYCITYOR (� �p - � COUNTYWHICHREOl1iRESAPERMITTOCANSiRUCT.ALTEfl.IMPROVE,OEMOLISH.OfiREPAIRANVSTRUC- W 7UqE,PRIDF TO I75 ISSUANCE,ALSO REOUIRES THE APPLICANT FOR SUCH PERMIT TO FILEA SIGNED PatiolDeck .LWr STA7EMENT THAr HE OF SHE IS UCENSED PURSUANT TO THE PpOVI510NS OF THE CONTRACTURS LI- � g CENSE UW I�PTER o(COMMENCING NATH SECiqN 7000j OF D�NSION 9 OF THE'BUSINESS AND PRO � PO01/Spe FESSION3 CO�E)OH TNAT HE OR SHE IS EXEMMTHEREFFiOM AND THE BASIS FOR THE ALLEOED EXEMP� � TION.ANYVIOLq710NOFSECTION7031,58YANYAPPLICANTFOHqPEHM1TSU&IECT,STNEAPPLICpNT70 z qe-Root A CNiL PENALTY OF NOT MORE THAN FNE HUNDREO Dd.C/iRS(i6�).): � �� - Z ❑I,ASOWNEROFTHEPROPERTY,ORMYEMPLOVEESWITHWA0E5A5THEIRSOLECQMPENSATION, 0 CORIfI1BfCi21 WILL DO THE WORK,,WD THE STRUCTURE IS NOT IMENDED OR OFFERED FOR SAIE(SECJOda,BUSI� � NESS ANO PHOFESSIONS CODE:7NE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF = PROPERTY WH09UIL�5 OR IMPROVES THEREON.AND WHO DOES SU(Xi WORK HIM1iSELF OR NERSE4F OR � THftOUGH HIS OR HER OWN EMPLOVEES,PROVIDED TNAT SUCII IIAPROVEMENTS AIiE NdT IMENDED OR m � OFFEREOFORSALE.�F,HOWEVER,THEBUIIDINGORIMPROVElAENTIS3dD141THIN'ONEYFAHOfCOFiPCE- Z TION,THE OWNER-BUILDEfi WILL HAVE THE BUFOEN OF Pl10VING TNA7 HE OR 9HE DID NOT BUILD OR � IMPROVE FOH THE PURPOSE OF SALE). w ❑�,ASOWNEROfTFiEPROPERTY,AMEXCLU51VElYWNTRACTINO,WRHLICFNSEDCONTRACYOliS � TO CONS7RUC7 7HE PROJEC7(SEC.7044,Bl1SINESS AND PpOFE5510N5 COOE�77iE CONTRACTORS LI. V8W8lian � AOJ.AREA W CENSELAWDOE5NOTAPPLYTOANOWNEFOFAPROPERYYWHOBUIL�SOFIMPIiOVESTHEREON.AND � WNOCONTRACTSFORSUCHPROJECTSWITHACONTRACTOR(S)LICENSE�PURSUANTTOTHECONYRAC• QUANTITY DESCRIPTION FEE Y TORSLiCENSELAWJ. ,.J � ❑I AA1 EXEMPT UNDER SEC. 8.&P.C.FOR THIS REASON s[ � U W � DATE OWNER � 0 W � LICENSED CONTqACTORS DECLARATIDN W ¢ � I HEREeV AFFlRM UNDER PENALTV OF PE0.IURY THAT I AM LICENSEO UNOER PROVISIONS OF CHAPTER �, � e�COMMENCING WITH SECTION 7000)OF ONIS�ON 30FTHE BUS�NE$S AND PROFESSIONS CODE,AND Z ?� MY UCENSE�S IN FULL FORCE AND EFFECT. m � UCENSE C�,(�SS �� UC.NO. j � J U DATE � CON7fiACTOR_'�� - W ;. :,.,.,.. .-�... .:: ...:.:: � WORKERS'COMPENSATION DECIARATION ¢ � IHEREBYAFFIRMUN�EHPENALTYOFPERJURYONEOFTHEFOLIOWING�ELLAMTION5: Z Z _IHAYEANOWIL4MAINTAINACERiIFICA7EOFCONSENTT03ELF-INSUfiEFORWORKERS'- _ COMPEJSAT�oN,ASPROV10EDBVSEC710N37000FTHElABOpCOOE,FORTHEPEFFORMANCE C) Q OF TME WORK iOR WHICH THIS PEflMIT IS�ISSUEO. ' � Q w ,IHAYEANDWILLMAINTAINWORKERS'COMPENSATIONINSURANCE,ASREWIREDBYSECTKNJ � s7oo OF THE LABOR CODE,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIi IS ISSUE�.MY WOFUCERS'COMPENSA710N INSURANCE CARRIEfi AND pOLICY NUMBER IiFtE: � � CONSTRUCTION J j CARRIEa PLAN REVIEW � POLICYNUMBER ' � .. ..;,..�- .......,: -..�.:...... ........_:. ,,._....._�... �_.�......_.. .. .. Z ELECT�?�C � ¢ �nnssEenor�N�rroreEo�ErmoFn+EaeaMrr�sroaauEtnirrne000uus(Eto�oai.Fss). PLUMBING -�}��.��4.-.��-f,��. T�� Z ICERTIFYTHATINTHEPERF-0RM0.NCEOFTHEWORKFORWFIICHTHISPERMIT�SISSUED,1 MECHANICAL �� o�""' `+ a �� (3 SHALL NOT EMPLOV ANY PERSON IN ANY MANNEN SOA6 TO BECOME SUBJECT TO THE (/J WORKERS'COMPENSATION IAWS Of CALIPoRNIA.AND AGfiEE THAT If�SHOUlO BECOME INSPECTION FEE = SU8JEC7T0 THE WORKERS'CAAIPENSATION PROVISIONS OF SECTION 3)0o OF THE LA80R COOE.ISHNAFORTHWITNCOMPL�N9THTHO�SEEROV150N5. � � �SSUANCE �r � // p DATE:��T APPLICANT. ��G SMIP � WARNING:FFILURE 70 SECURE WOHNERS'CqMPENSATION bOVERAOE IS UNLAWFUL,ANp SHALLBE ENERGY P/C �y SUBJECTANEAIPLOYEHTOCRIMINALPENALTIESANpCIVILfINESUPTOONEHl1NDRE�THOUSAND ENERGYPEftMiT DOLUflS(5100,000).IN ADDITIONTO THE COST Of COMPENSATION,�AMAGES AS PROVIDED FOR IN -- � SECTION370BOFTHELABORCODE.INTERESLANDA770RNE7'SFEES. RETENTIONFEE: a CONSTRUCTION IENDING AGENCY PRE-ALT F6E: O � I HEREBY AFFIRM UN�ER PEN/1LTV OF PERJUHV THAT THERE IS ACONSTRUCTIIXJ IENDING A(3ENCY � FOR THE PEiiFONMANCE OF THE WOFN FOti WHICH 7HI5 PEqMIT IS ISSUED(SEC,3097,CIV.C.j. Z W � LENDER'S NAME - _ F— IENDER'SADDRESS ¢ ICERTIFVTHATIHAVEHEADTHISAPPLICRTIONANOSTATETHATTHEPBOVEINFDRMA7tON�SCORRECT. TOTAL FEES �� .,�/� � w 1 ARREE 70 COMFLV VATH AlL CI7Y AND COUNtY ORbINANCES ANO STAYE LAWS RELATING YO BUILDING .,;�i � CONSTqI1CTION,AND AUTNO 1ZE REP SENTA7IVES OFTHIS COl1NTY TO ENTEP UPON THE - - Z ABOVE�MENTIONEDP OPERTYFO SPEC URPOSES. �� r COMMENTS �: 0 . i-. J � m PERMITTEE NAME(PFINTI ��. q.'. ¢ /��_,e� _��r2-- � N SIONATUREOFPERMITTEE ��— DATE � � �;z „ . � � RECPT.NO. 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