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�---- _1� CITY OF DIAMOND BAR _ ' DEPARTMENT OF COIvIPvIUNI'�Y&DEVELOPMENT SERVICES ., � y 21660 E.Copley Drive 5uite 190 PRESS (9Q9)860-3195 Fax(909)861-3117 �.. . , ,� BUII.��t�P�121VTYT A1'Y'LICATTON � '� "' ..- .:�. . �.....1.. .,� . . ..:: ....... ... . ..... ..i�.�. . .�..i��. . ., .;: � . .�. a,.�. i..::_-.i ..�:^'"a- :4..a¢k��:`s.� : >,�.,.�y ,bi�.�xr, x�. �r: . .� ;;: , . ,, : ,,..;��, FI } . : �m .�.. � JOBSITE • < } APPLICATIdN �" -� 5' A � pE'�I��ulll�' D P/C �, o ADDRESS ���� �/������� ��`1� � DATE,�,�_�� NUMBER �� # � ISSUE �TYPE OCG APN LOT TRACT DATE l CONST. GROUP °C pWNER O _ o ADDRESS�,� ���-��__ ZONING SETBACKS � :.'� ''C� �- ;--' Z CITY � Z P TEL. R�O�NT RW � — g APPLICANT TEL. _— SIDEISIDE STREET RW ❑ � ts, ��/ch::d.;�i2'l_v°`/ C. SIDE __ ❑ � CONTRACTOR � . � —7, ADDRESS ' �-,f��` j � CITY `� j IP�, --- TEL L�J/ -� � PROPOSED USE w ARCWENG7�/, CC���r$/%° e+a��T c � DESIGNER " � NO.DWEL. NO. NO. a ADDRESS UNITS STORIES BEDROOMS � C�Ty ZIP TEL � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � � OWNER-SUILDEA DECLARATtON SFR/ADD/REM O I HEREBY AFFIRM UNOER PENALTY OF PERIURV THAT 1 AM E%EMPT FFOM THE CONTRACTOp$LI- Gafd9B�C8fj70fl L�iJ CENSELAWf-0RIHEFOLLOMVINGflEASON(SEC:703t.58U51NES5ANfS�PFOkEST�IONSCODE:ANYCITYOR (n _ C.7 COUNTVWHICHREOUIRESAPERMITTOCONSTRUCT.ALTERIMPROVE,DEAAOOSH,CPREVAIR0.NYS7RUG . W PSIiO(DBCk � NRE.PRAR TO tTS ISSUANCE.ALS�REqUWES THE APPLICANT FOR SUCH PEqM17 TO FILE A SIGNED W � 6TATEMENT TtAT HE OR SHE IS UCENSED PUfiSUANT TO 7HE PIiOVIElONS OF THC C,ONTRACTORS LI� � CENSE lAW(CFiAPTEH 9(CbMMENCINa WiTH SECTION�OOu)OF OIVISION 3 OF THE BUSINESS/1NO�PRO� �'�' PoOVS� FESSIONS CODE�OR THAT HE OR SHE IS EXEMPT 7HEREFROM ANO'THE BA515 FOR THEAILEGED E%EMP- TION.ANYVIOLATIONOFSECTION7031;SBVANYAPDLICANTFORAPERMRSU&1ECT5THEAPPI.ICANT70 Z RB^ROpf � 11CMlVEN/LL.TYOFNO?MOFE7NANFNEHUN'JRFADOLIAR$(5500J.). �'"� � �i,ASOWNEROFTHEPROGERN,ORMYEMPIOYEESWITHWAGESASTHEIRSOIECOMPENSATION, � Commercial WILL DO THE WORK.AND THE 5TRl1CTURE IS NOT INTENDED oFl OFKERED FOR SAIE(SEC.7oaq BUSI- _I � NESS RNO PROFESSIOY.S C�DE:TME CAN"Rd.CTORS L'�.CENSE LNN DOES NOT APPLY 10 AN OWNER OF j PROPER'�YWIiOBUILD50RIMGROVESTHEREaN,ANOWHOpOESSUCHWOFKHIMSELFORHERSECfOfl m pC THROUCJiFPSORHEROWNEMPLOYEES,PFOVIDEOTHArSUCHIAdPROVEMENT5ARENOTINTENUE00R � OFFEREDFOR3ALEIF,HOVIEVERTHEBUIIDINGORiMPROVEMENTiS50LDW17HINONEYEAROFCOMPLE- TION,THE OWNER-BUICDER WILL HAVE THE BIJR�EN OF PRdY1NC�THAT HE OI�BHE�ID NOT BUILO OR � IMPROVE FORTHE PURPOSE OF SALE). � W ❑�,ASOWNEROFTHEPqOPER'f'/.AMEXCLUSIVELYCANTFNCTINGWI7HLICENSEDCONTRACYORS � TO CONST.iUCTTHE PFiOJECT(SEC.�]o44.9l1SINESS AND PRbFE9SIbNS COC15:7HE�CON7fiAC70A5 LI- ValUetiDn ADJ.AREA CENSE lAW DOES NDT APPLYTO AN OV/NER Of�A PROPERN WHO 9UILO5 OR Ib1PFOV[S THEf1EON,AND r WHOCONTR4CTSFORSU�HPR0.IECTSWITHACONTRACTOR(S)LICENSEDPURSUAMTTOTHECONTRAC- QUANTITY DE.�,CRIPTION FLE TORS UCENSE LAW.1. 0 ❑I AM EXEMPT UNDEF7 SEC, B.6 P.C,FOR THIS REASON U � � l8" DATE OWNER V .r_. - � __ . . ' , t . -��.."��_. Z W a LICENSED CONTRACTORS DECL4RATION —� � W I HERE6Y AFFIRM UNDER PENAI.TY OF PEFiJURY 7HAT i AM LICENSED UN�ER PROVIS�ONS Of CHAPTER � n, 9(COMMENCING WITH SECTION 7000)OF DNISION 30FTHE BUSINESS ANO PROFESSIONS CODF,AND� Z X AIY LICENSE IS IN FULI FORCE AND EFFECL m � LICENSECiASS�'Q`�? ��� LIG.NO. V����"'�� � � � V OATE�.` ,Qc�. , °� CONTRACTOR_-.�,.-h•<---�:_�.� � �- , � ,s;• . ,r+.4✓' ..� !�. C�C� w ' d�' � l �" � � C� WORKE 5'COMPENSA7lON DECLARATIOfd t�l..r Q (;riVj�" - � _ cJ� � 1 � 1 HEREBYAFFIRM UNOER PEIdAIT'OF PERJURY ONE Of THE FOI�OWING�ECIARAT10NS�,� _ `—I � V � Z� i- � _IHAVEANDWILIMAINTAINACERTIFIGATEOFCONSENTTOSELF-INSl1REFORWOitKFRS' ;L � COMPENSA710N,AS PROVIDED BV SECTION 370o OFTHE LABON CO�E,FOR THE PERFORMANCE �U OF TME WORN FOR VJHICH THIS PEPMIT IS ISSUED. c� � W ,1 HAYEANO Wlll MAIMAIN WOPo(EAS'COMPENSATION INSIJqpNCE,AS FEQUIRE�BY SECTION �S 370aOFTHBLABOflCODE,FORTHEPEHFOARIANCEOFTHEWORKFORVJHICHTNISPERMITIS � ISSUEO.MV WDAKERS'COMPENSATION INS�RANCE CARRIER AND POLICY NUMBEF ARE: CONSTRUGTION . ¢y cnr�AiEA �/�' ' PLAN REVIEW � POL�Y NUA6ER�E�7 ^" �3�����' ���� � ELECTRIC . IL p (lNSSEG't1�NNE�FAT9EOJMP�ETEDOFTNEPEPNf1'1SF�iONEHU^AFtEDCIX�.�RS(S�Oo)ORLESSI. PL�Ur�M-•BING��; _ r_-�/q ZI CEFTIFV THAT 6J THE PERFORMANCE OF THE WOPK FOfl WHICH THIS PERMIT IS ISSGEO,I�-�� �/�CHANICA ,,.s� � w � "l_,_....—,..--..�. SHALL NOT EMPLOYANY PERSON IN ANY MANNER SOFS TO BECDME SUBJECT TO THE INSPECTION FEE �j WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHCULD OECOME y S SUBJEC?TOTNEWORKERS'COMPENSATIONPqOVISIONSOFSECT'ON37a�OFTHELAEtOR SUlSNCE �5��?* , CA�E.1 SHAl1FO`RhiWITH CAMPLY WITH7H E PROVISbNS. � � �'� ��/C�' /! ✓6..✓�9r' FiI�P..... p DATE:��_1�r�� APPULANT: — � � � ENERGY P!C J W A R N I N G;F A I L U R E T O S URE WOflKERS'COMPENSATION COVEPAGE IS UNLAWFUL,AND SHALI BE " LL SU&IECTANF.MPLOVFRTOCRIMINAl7ENAL7IESANDCIV'LFINESUPTOONEHUN�REDhfOUSANp ENERGYPERMIT OOLLARS($to0,000�.W�ODITION TO THE COSTOF COMPENSATIOk.DAMAGE°AS PflOVIDED fOR IN J SECTIOM1 37oa�f THE LABOR CO�E,iNTEREST,ANDATTORNEY'S FL-E5. fjETENTlON FEE: � W d CONSTRUC710N LENDING AGENCY PRE-A�T FEE: 1 � p v A.��, ti � 1 HEREBVAFFIRM UNDER PENALTV OF PERJURY THAT THERE IS A CONSTRUCTION LFNDINO AGENCY �'� •����� n- FORTNEPERFORMANCEOFTHEWORKFORWHICHTHISPERMITi51S5UE0(SEC.3o9t,CIY.C.). . � �-- W � LENDFA'S NAME F— LENDER'SADOFESS - � � ICERTIF/THATIHAVEREADTHISAPPLICATIONAND9iATETHATTMEABOVEINFORMATiON�SCORRECT. TOTAL FEES " � 1 AGREE TO COMPIY WITH Al�CIfY PNO COVNfV OR�INANCES AND STATE L0.WS RELATWG TO BUILOlNG � GONSTRUCTION.ANDHEREBVAU7HORREflEPRESENTATIVE50FTH15C0UNTYTOENTERUPONiHE ,. ��� � AeOVE-MENTfONED PROPEHTY FOR INSPECTION PURPOS�. t � �� Q � � 1 -� COMMENTS e � —' r�t e>>2.a -^-�---,�_ , �� � �'���q�� � ��� �� � PERMITTEE NAME(PRINT) — �� Q N � ,r ji. '� I �ri�6� N nV..;, :, �J $IGNATUREOFPERMITTEE P ���� RECPT.NO. _ PAIO 8Y �AUDAYI�ON H VVHiTE--Department Copy,YELLOW—Finance Copy,PINK-Assessor Copy,GOLDENROD--File Copy,GREEN—Applicant's Copy . . . . . ..,. . ..., � � .. � . � .. .. .., .. . . . . _ . . . „ ;'a�,• . . .. � ��� � �� �� � � . - ,. � � ,.�.. �,' ��� ... : .. ..... .. :. :�„�-,_....� , � � .. ; . �,,.,,_ ,. .,.,.�r.,. :,t:.. �. - ..... . : :x::.,... : � - . �.. - �.... � �.�.. � . � � � � ;: � �' : ,�:� v .. � - .... �.." u, ' °��� ���'��°z , ( ( �L�C)���"1>`t � 3 � _�.�. � � __._. —-- - � — _ __.. _ _ _.� __� _ � 1 �?°� �''. +"`���t?..�f����.� ��-- ;� �=ri�k r'���E��r� � � � � y �'}?'� g� �� __�__�_ .�..� g (_'�___+.'^_�_�."'_]_(}_�.q j �_ ��._..._____wd__ �L�'"�A,.E���Y�"l4fS�:t'�� 3 � ' i 6d?°$4./L..`�T S Lb.F�3l �@:.8�Y�� V � � ...,.... .... ...-.r.�-___.' 1__.....,.._.»,..._._._...._�.._._�..... . . .. . ....�....m .�............._.._�_._._�__.......__._...�..�_ s. i 3 i �� ��`�,�i a.; �'� ����?���i � , i.9€����? ��.�C?��,��'��sl���" ' : ..-.,„.� �.�� -�_ � E _ _ � _ _ _.—___ —___. �� .�.— ...._..___.__ � .� �'����a`�t,� ° i � ` t=!3���'L,��;�:=�?���"�`?a��+ i _.��.�..__��__. --; --_.�_. _..�..__.___ .__a___.________.�._�____�.�._.._� "�"= �F- �C,:�1�� __._ � i� �- '�� LA,� ���3�l�����a� i� � _. _ ._____ �. _ __._.___�._� �������. ,���� � � . . . _______'' 1 � C��#T.�C���?���>h; , _ �.�_..�...�_u _ _`..,... __ —_—.___. � �a��2f � :s�??�?�l� i i � i�� �E:�[`�!€3����e?1 � .._______-�_._-___ ! .__ u.�_ ._u�_ .� _ ,�.__. �_�_.. �?�r����t.�;ti,��r��;-�� r �-�r���,,g` i €='��I g����6"; s`��=�',� --�--9-----_ _.�...__ ___.___ .���s _ , __ _ ____..� ___ �._�_ _.��_,� �.�_. � _,.____�__.,._-�_�.___ s"��)�r' ��,t�u? € �r�`�c_�.a:�t°���`',1� i � `� �,i"s�'.,.,e�"'a"�CY 8�"`�E�"F. .,.��_.......m�.'_�'�.._. �,9t��� _�' ..��...._.. � ...„�...-d 7 � ' ma �_� �'��$ � '"�,���t`��s; '. ; ; �;'�?)���-#�°a�'��'"'�:� � � a. �-- __am__ �e. ___._. _� __� .__�.w�._� _ . - �___ _ _ — --.-__�__�.. __ �_. j �� ,�3:� � � �;����.�s i �t.��.�:a�a�m� � _ I �4i�ik.��Z`i�-,�i1�1� ____ _�.�.._. : --r------...�m�„�j_ ��>?-�i �F'�"`�'I�� ��'��`~ �_l._ i'C�C:t�.WL.��:�"r'd�.�� I �.� � ._ ..._.�......._(,�„. ..»..i,-m�-+....-�m.... h...«........eR_i �^^� .. ...__.._..__i �'�° f,jp"` �3i dd:�'S ` � 2 ��7�,ta.. ��'�."3.�✓��34k i � ...�..._�.._.._,... � �_._.�._._� �.1'��.�.�����' "� ��u+ _�__..__ � _� '_�t���_i���"�� � �__ ..____._'� __—_._____._ ._e._._____w_u�� �e�P?� G���`!.,��m�?`=���3 ; I ; i �.aP-�"�'-€���f��_______ .�._.; _j_ __ W.__� �_.__ _...._ __ __�___' _.__ _._��_ �_ __ �'s��'4��,';. 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