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< >- ^ - �-_,-,.,.., _..„,. ,�. ._.v„� �„�..,,•�j '"� . . .,.�,,.-N...���-., ,,,,...,_____--_ . s� i , ,::-.�.....�^,�-. ._�... �'+� -� �� .----1'�--. CTTY OF DIAMOND BAR .: � COMMUNITY DEVELOPIVIENT D�PARTMENT `'� " � � _;;,,,w . 21660 E.Copley Drive Suite 190 P� �' �RESS (9D9)860-3195 Fax(909j 861-3117 r r ",�H�"��' BUILDtNG PERMTT APPLICATION � tv � "�'� FI R M LY � JOBSI7� � � , ARPLICATION PERMIT; p1C o ADDRE5S DATE " '"NUMB�R "�J �_ # � APN LOT TRACT D TEE � �� CONS7. GROUP p OWNER 4 � ZONING SETBACKS ADDRESS erL 1 �a�� ��-G�° oCI � ZIP � TEL. RE�ART RW ❑ o APPLICANT TEL. SIDE751bE STREE7 RW ❑ , �. ¢ CONTRACT a SIOE ❑ o CDORESS Z� �'''".� TEL.�,` !'.�' 'l'�9�"y� PRQPOSEDUSE w ARCH/ NG/ �� DE5IGNER NO.DWEL. NO, Nb. ADDRESS UNITS STORIES �EI�ROOMS � CITY ZIP TEL `n DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION v� � OWNER-6CILDER�ECLARATION SFR/ADDlREM G7 p I HEREBY AFFIRM UNDEF PENALTY OF PERJURY hIA7 t qM E%EMPT FROM THE CO,N7qaCYfyq9 LI- � QgraQE/C8f(MIT W CEN9EUWFORTHEFOLLOWINOPEASON(SEC.7oJ1.69USINE39ANDPHOPE3910N8CAdE;dHYCIYYOR C.) COUNTYWHICHRE�UIREBAPERMITTOCIXJB7RUCT,ALTER,IMPROVE,DEMOLIBH,OqHEPAIqANY'�1'RUC• W pa�lO/D9Ck wTUpH,PqIOH 70179 199UANGE,AL3O RE�UIRES THE APPLICANT POR SUCH PERMIT Tb FlLE A 516NED W � 3'fA7EAlEN?THAY HE OR 8NE IS UCENBED PURSUANT TO 7HE P%OVISION9�OF THE CONTRACTORB LI� . . CEN9ELAW(CHAPTERo(ClSMMENCIN4WItH9EC7tON7o�tl)OpbIV1910N30FTHEBU91NE89AND'PRO� u" POOVSp9 �FE8810NSCODE)ORTNATHEORSHE�BE%EMPTTHEREFROMANDTHEBASI9FORTHEALLE4�O�kEMP� U TION.ANYVIOUTIONOFBECTION7o31.eBYANVAPPLICANTfORAPERAl1T9U0JECT3TH�APPLI�ANTfO' Z RB-R00) ' � ACIVILPENALTYOFNQTMOHE7HANFIVEHUNtlRED�OLUIR5(Y600).�:�- '�� :; - � � ❑I,ASOWNEROFTHEPROPERtt,OFMVEMPLOVEESWITHWAOESA3THEIR80LECOMPEN5�A710N,� 0 CORII118fCffll z WILL DO THE WORK,AND THE STRUCTURE IS NOT WTENOED OR 6FFERED FOR SAIE(9EC.iO4(;BUSf• J NESS AND PROKES910N9 CADE:THE CONTHACTOqBIICENSE lAW DOES NOT APPIY TO�AN;ONlNEp OF� N PROPERTYWHOBUIL090RIMPROVESTHEREON,ANDWHODOESSUCHWORKHIMBELFORHER9ELFOq = CC THROUGHHISORHEROWNEMPLOVEES,PROVIDEDTNATSLICHIMPROVEMENT3ARENOTINTENdEDOR� � � . � OFFEREDFORSALE.IFHOWEVEFLTNEBUILO�NQORIMPROVEMENTISSOtDWITHINONEVEAf70KC0lAPL.E= Z TION,THE ON/NER�BUILtlER HJILL HAVE THE BUR�EN OF PROVINO THAT HE OR 5HE D�MS NOT 9UIL7 OR' � IMPROVEFOR7HEPURPO5EOFSAL�. � � ����.�� ❑I,AS oWNER OF THE PROPERTY,AM E%CLUSNEIYCONTRACTINO VJITH LICENSED CONTMCi'ORS� � TO CANSTRUCT THE PROJECT(SEC.7044,BUSWE55 ANO PROFESSIONS CADE:TNE CANTRXCTOR&Li= V8111fiSI0I1 ADJ.AREA W CENSELAWDOESNOTAPPLYTOANOWNEROFAPROPERTYWHO'BUILDSORIMPRDVE5THER�ON�,AND � WHOCONTRACTSFORSOCHPfiOJECTSWITHACAMRACYOR(S)UCENSEDPUFlSUANTTOTHECONTRKC- QUANTITY DESCRIPTION FEE Y TORSLICENSELAW.). � ' .. J � ❑I AM EXEMPT UNDER SEC. B.&P,0.FOR THtS REASON Q ' �O � � . � LL OATE OWNEP F' Z W � UCENSED CONTRACTORS DECLARATION W � I HEREBY AFFIRM UNDEfl PENAI.TY OF PERJURV THAT I AM LICENSED UNOER PROV�SIQNS OF CHAPTER � � � d 8(COMMENCING WITH SECTION 7000)OF DIVISION 30F THE BUSINESS AND PROFESSIONS CODE,AND Z �X MY LICENSE IS IN PUL�FOfiCEAND EFFECL m .,,,, , � UCENSE C S 4 � UC.NO. �"' � F— J V DATE�� C GONTRACTOR ' f . , a W _,. ., a� WORKERS'COMPENSATION DEC�ARA ON ¢ = U � 1 HEREBV AFFIPM UNDER PENALTY OF PERIURY ONE OF 7HE FOLLAWING DECLARATIONS: - � 4 . . .7 s-:.. . . ,. Z _IHAVEANDWILLMAMT/UNACEftTIFICATEOFCONSENTTOSEIF-INSUREFORN'ORKERS' _ CAMPENSATION,AS PROVIDED BY SECTION 37000F THE LABOR CODE,FOR THE PERFORMANCE U ¢ OFTHEWORKFORWHICHTHISPERMITISISSUE�. � �� � � W _IHAVEANDWILLMAMTAINWORKEFS'COMPENSATIONINSURANCE,ASREWIREDBYSECTION Q37000FTHE LABOR CODE.FOR THE PERFORMANCE OFTHE WORK FOR WHICHTHIS PERMIT IS _ ISSUED.MY WORKERS'COMPENSATION INSURPNCE CARR�ER AND POUCY NUAiBER ARE�-�"`� CONSTRUCTION � +�, CARRIER PU1N REVIEW Z POLICYNUMBER E�ECTRIC � � � Q � � (fHISSEC710NNEIDNOTBE�MRFTEDOFhIEPERMffISF�f10NEHUWRE�Wl1H(iS(S1W)ORIESS). UMBING ��"�'� �� r �' Z f CERTIFY THAT IN THE PEHFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS I ,1 MECHANICAL (3 SHALLNOTEMPLOYANYPEfi50NINANYMANNERSOASTOBECAMESUBJECTT THE � WORKEFS'COMPENSATIONLAWSOFCALIFORM0.ANDAGREETHATIFISHOUL BECG e INSPECTIONFEE = SU&IECTTOTHEWORKERS'COMPENSATIONPROVISIDNS FSECTION37oo THEyABOR � B, �s9.v„ cA0 SHAL ORiHWITHCAMPLYWITHT EPROVI NS. % ' , UAN�E� I "•�'+`•�' p �ATE: '} � APPLICANT: � � . . . SMIP J WARNIN :FAILURE TO SECURE WORKERS'COMPE SATION COVERAGE IS UNLAWFUL,AN�SHALI BE ENERGY P/C � SU&IECTANEMPLOYERTOCRIMINALPENAI.TIESAN�CMLFINESL'PTOONEHUNOREDTH6USAN� ENERC�YPERMIT DOLIARS(Sioo,000�,IN PDDITION TO7HE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN .r_I SEC710N 3708 OF THE LABOfl CDDE,MTEflEST,ANDATTORNEY'S FEES. RETENTION FEE: �. _ � � CONSTRUCTION LENDING AGENCY PRE-ALT FEE: � IHEREBYAFFIflMUNDERPENALTYOFPENURYTHATTNEi3EISACONSTRUCTIONLEN0INGAGENCY FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUEO(SEC,3D97,CIV.C.�, Z W � LEN�ER'SNAME 1— LENDER'SADDRESS � — —__' - ' ' �.. '-.�.a , "-....:' �.'�7+':.. � ICERTIFYTHATIHAVEREAD7HISAPPUCATIONANDSTATETHATTFIEABOVEINFORMATIONISCOPRECL TOTAL FE - W IAGREETOCOMPLYWITiiALLCITYANOCDUNTYOROINANCESANDSTATELAVJ§RELATIIVGT06U�f�.DING ' -�� � - ' - ��""'' '� � ' � " � CONSTRUCTION,AND HEREBV AUTHORIZE REPRES IVES OFTHiS CouNiY'ro 6NTER UPONTHE s � - Z ABOVE-MENiIONEDPFiOPERYYFORINSPECTION RP SES. COMMENTS � �� �T �� �� � �" ` `� — ... ¢ Efl EENAME(PRI / �� � , � Y�i�, � � / ra'L--,-.i i'�3 � O 7 EE ' D L „a � - �p ,.j �.�-• " � , = RECPT.NO. 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