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---�`'�— CITY OF DIAMOND BAR ,- �� COMMUNITY DEVELOPMENT DEPARTMENT �-- _ 21660 E.Copley Drive Suite 190 PRES+'S+ � (909)860-3195 Fax(909)861-3117 ����" BUILDINGPERMITAPPLICATION � FIRMLY . :._: . ... �. 1,._, .: } J08SITE /� ) ,�`, � ,,�i,:� APPLICATION� a-2, - � PERMIT � C o ADbRESS l�J-� l"`�. 1� � <..� � DATE NUMBER� # �, ISSUE TYPE OCC °r°- APN LOT�_ �— TRACT DATE CONST. GROUP p OWNER �I�-J '�`H k:.� -�.-�_./�b✓ " ADDRESS S v`'�"!°�n�J� ZONING SETBACKS 0 oCITY �i � ZIP ��, TEL.��"�'�l«�'�- �� ,y REORT RW O o APPLICANT TEL. SIDE/SIDE STREET RW ❑ m CONTRACTOy, '�%�Z' � SIDE ❑ � ADDRESS� ]' "' ` • PROPOSED USE a CITY�. Z.� eZIP f��t� TEL%'iS� Z7 w ARCH/ENG/ zDESIGNER NO.DWEL. NO. NO. � ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.F1'. FACTOR PSF ADJ.AREANALUATION cn � OWNER-BI:ILDER DECLARATION SFR/ADD.�REM Q p I HEREBYAFFIRN�IJNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM TNE CONTRACTpRS LI- � Garage/CarpoR W CENSELAWFORiHEFOLLOWINGREASON�SEC.�o31.58USINESSAN�PROFE5S10NSCOL]EANYCITYOR —. . U COUNTYWHICHRE�UIRESAPEFMITTOCONSTFiJCT,AL7ER,IM�ROVE,DEMOU5H,0AREPAIRAN'f57RUC� W Patio/Deck ' � TURE,PFiIOR Tb ITS I5SUANCE;ALSO pEOUIRES THE APPUCANT FOR SUCH PERMIYTO FILE A SIGNED � � STATEMENT THA7 HE OR SHE IS LICENSE7 PUFSUANT TO THE PROVISIONS OF THE CONTHAC'f01�S ll� � CENSELAW�CHAPTEfl9(COMMENCINGWITHSECTION7o00)OFDIVISION30FTHEBUSINESSAND�PRb- � PDOUSPe � FESSIONSCOOE!OR7HATHEORSHEISEXEMPTTHEREFHOMANDTHE9ASISFORTHEALLEGE�EXEMP- U TION.ANVVIOLATIONOFSECTION7031.5BYANYAPPL',CANTFORAFERMITSUBJECTSTHEAPPLICANTTO z Re-RoDY � -A CIVIL PENALTV OF NOT MORE THAN FNE HUNDRED DOLLARS($500).): - "'"�- �'�-� � -� Q ❑I,tiSOWNEROFTHEPROPERTY,ORMYEMPLOYEESWITHWAGESASTHEiR50LECOMPENSATION, d COflII718fGi8I Z WILL�D THE VIORK,AUD TF'.E STRUCTUR'e IS NOT INTENDED OR OFfERE�FOR SALE(SEC.)oA4,BUSI- J NESS AND PROFESSIONS CODE:THE CONTRACTORS LICENSE lAW DOES NOT APPLY TO AN OWNER OF � PROPEFTYWH08UILOSORIMPROVE57HEREON,AN�WHODOESSUCHVlORKHIMSELFORHERSEIFOR = � THROUGHHISORHEROWNEMPLOYEES,PROVIDE�THATSUCHIAAPftOVEMEMSARENOTINTENOEDOq � W OFFEREDFORSPLE.!f.HOWEVER.THEBUILDWGORIM?ROVEMENTISSOLDWITHINONEYEAR6KCAMPLE- � TION,THE oWNER.eUILOER wILL HAVE 7HE BUfl�EN OF?ROVIN�THAT HE OR SNE DI�NOT BUIIA OR Z IMPROVEFOFTHEPURPOSEOFSALE). � � GI,ASOWNEROFTHEPROPERTV,AMEXCLUSIVELYCONTRACTMGWIiHLICENSEDCONTRACTORS � TO CONSTFiUCT THE PROJECT(SEC.�044,BUSINE55 AND PROFESSIONS COOE:THE CONTRACTORS U- VeltJfffiOn ADJ.AREA W CENSELAWDOESNOTAPPIYTOANOWNEROFAPflOPEfiTYWHOBUILDSOR�MPRDVESTH[REON,AND ' � WHOCONTRACTSFORSUCHPROJECTSWITHACONTRACTOR(5)LICENSEDPURSUANT?OTHECbNTflAP ' QUANTITY DESCRIPTION FEE � 70RS LICENSE LAW.). � J O ❑I AM EXEMPT UN�ER SEC. __8.8 P.C.FOR THIS REASON �� � � � � DATE aM'NER h Z W � LICENSED CONTRACTORS DECLARATION w OC IHEREBYAFFIRMUNDERPENALTVOFPFR.IURYTHATIAMLICENSEDUNDEROROVISIONSOFCHAPTER � �/"'}a�. '� '. ,`r's � �y . � � 9(COMMENCINGK'ITNSECT'�.ON7o0o)OFDIVISION30FTHEBUSINESSANOPROFESSIONSCODf.AND Z �-r rw \S �X MY LICENSE IS IN fULI FORCE AND EFFECT. , c,� Cs m � LICENSE CLASS7 �" �� LIC.NO. ��'/�J � � U DATE �'G-J�"'�� COMRACTOR d i1J r � WORKERS'COMPENSATION DECLARATION ����'� —� = a u� U � IHEREBVAFFIRMUNDcRPENAITYOFPERJURYONEOFTHEFO�LOWING�ECLAAATIONS: z Q � I HAVEAND WI'�L MAINTAIN ACERTIFICA?F.OFCONSENTTO SELF-INSURE FOR WOAKERS F = CAMPEM1'SATION,AS PROVI�ED BY SECTION 370D OF THE IABOR CODE,FOR 7HE PEFFOFlMANCE 'i U � OF 7HE WORK FOR WHICH THIS PEfiMIT IS ISSUED. � O w 1 HAVE A�D WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS FEGUIRED BY SECTION Q �3�OOOFiHELABORCO�E,FORTHEPERFORIAANCEOFTHEWORKPoPWHICHTHISPERMITIS � ISSUED.MY WORKERS'COMPENSATION INSURANC/E0 CARRIEF AND POUCY NUMBERARF:-'- ' � CONSTRUCTION � CARRIER ������A ��.�'�A PIAN FiEVIEW z POUCYNUMBER 7� ^ .. ' , E�` G / � � (iHISSECiIONNEmNOTBECOMP�EfE�OFTHEPERMfrISfORPYEHUN:JR�DOLLAFlS($1oo�ORLEaS).� � LUMB'IN • � I CERTIFYTHAT INTHE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUE�,I MECHANICAL (3 SHALLNOT EMPLOYANV PERSON IN ANY MANNcR SOAS YO BECOME SU&IECTTOTIiE � WORKERS'COMPENSATIONLAWSOFCALIFORNIA,ANDAGREETHATIFISHOUIOBECOME �' �NSPECT7ONFEE ___ SUBJECTTOTHEWORKERS'COMPENSATIONPROVISIONSOFSECTICN37000FTHELABOR � '...,1 �w wy�mrq, � CODE,I SHALI.FORTHWITH COMPLY WITHTHOSE PROVISIONS. �SSUANCE �".r' f�h.'� �"�-. �i p �ATE: .•�:�`�� APPLICANT: .w+�-�^�__—..___._____ SMIP ��.`'�•4�.., J WARNING:FAILURE TO SECVRE WORKERS'COMPENSATION COVERAGE IS VNLAWFUL,AND SHALL BE ENERGY P!C � SUBJECTANEMPLOVFR70CRIMINALPENAL7IESAN�CIVILFINESUPTOONEHUNOREDTHOUSAND ENERGYPERMIT RsC'�I� �S !'Y �q � DOLLARS(5100,OOD),IN AODITION TO 1'HE COST Of COMPENSATION,OAMAGES AS PROVIOED FOR IN -�-p���7�� � SECTION37aeOPTNELABORCO�E,INTEREST,ANDATTORNEY'SFEES. RETENTIONFEE: ��� � -� � a CONSTRUCTION LENDING AGENCY PRE-ALT FEE: O � I HEREBYAFFIRM UNDER PENALTY OF PERJURY THATTHEFiE IS AGONSTFI:CTION LENDING AGENCY m- FORTHE PERFORIAANCE OFiHE WORK FOR WHICi-THIS PERMITI5155UE0(SEC,3097,CIV.C.), ��-"�-""--—- '--------- Z W S LENDER'SNAME _ � H- LENDEF7'SADORESS _ _ , „ ,_. ¢ ICEFTIFVTHATIHAVEREADTHISAPPIICATIONAN�STATETHATTHEABOVEINFORNATIONISCORREC'. T�TAL FEES '� � IAGREETOCOMPI_VWITiiA�LCITVANDCOUNTYOR�INANCESANOSTATEL4WSFEL.4TINGT09UILDING � � � � CONSTRUCTION,ANDHEREBYAUTHORIZEREPFESENTATIVCSOFTHISCOUNTYTOENTERUPONTHE � � ABOVEMENiIONED PROPERTV FOR INSPECTION PUPPOSES. z COMMENTS 0 P'e ,sA � - ' . — 1 a .�i�w m --��—�.� — P.flMITTEE NAME(PRINT) `°' /'C""' --�'.,Z� ��'__.- . � SIGNATUREOFPERMITTEE - DATE ' - � y' +^"� = RECPT.NO. PAID BY VALIDATIO ~ WHITE—Department Copy,YELLOW—Finance Copy,PINK--Assossor Copy,GOLDENROD-File Copy,GREEN—Applicant's Copy� � - ' . r �:: r .�.. < � ��.,. ..�,.; . ,. . . . ..�.`., : .... ._ �..�. .':,: .,.. 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