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CITY OF DIAMOND BAR COMMUNITY DEVELOPMENT DEPARTMENT 21660 E. Copley Drive Suite 190 (909) 860-3195 Fax (909) 861-3117 10. BUILDING PERMIT APPLICATION JOBSITE ISSUE TYPE OCC ADDRE3 �1— FRONT RW ❑ REAR ❑ APN IIOT TRA OWNER ADDRES CITY QIP TEL. - APPLICANT i C,n C. t TEL. CONTRACTOR ADDRESS CITY ZIP TEL.? -2 �s ARCH/EN + DESIGNE % n ADDRE r CITY ZI T L) OWNER -BUILDER DECLARATION 1 HEREBYAFFIRM UNDER PENALTY OF PERJURY THAT 1 AM EXEMPT FROM THE CONTRACTORS LF CENSE LAW FOR THE FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE: ANY CITY OR COUNTY WHICH REOU IRESA PERMIT TO CONSTRUCT, ALTER IMPROVE, DEMOUSH, OR REPAIR ANY ST"M TYRE, PRIOR TO ITS ISSUANCE, ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS L4 CENSE LAW (CHAPTER 0 (COMMENCING WITH SECTION 70001 OF DIVISION I OF THE BUSINESS AND PRO' FESSIONS COO THAT HE OR SHE IS E% EMPT THE REFROM AND THE DA5IS FOR THE ALLEGED E%EMP• TION. ANY VIORA OF SECTION 7071.6 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO ACNIL PENALTY OF TMORE THAN FIVE HUNDRED DOLLARS 111500)): OLASOWNERO 4E PROPERTY. OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION, WILL DO THE WOW( E STRUCTURE KNOT INTENDED OR OFFERED FOR SALE (SEC. 7044, BUSI. NESS AND PROFESSIONS :THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF PROPERTY IM40 BUILDS ORIM ES THEREON. AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR THROUGH HIS OR HER dIrH EMIL S, PRDVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR OFFERED FOR SALE IF, HOWEVER THE DWGORMIPROVEMENT IS SOLD WITHIN ONE YEAR OFOOMPLE- TION. THE OWNER -BU LDER WILL HAVE BURDEN OF PROVWG THAT HE OR SHE DE) NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALEJ. ❑ I, AS OWNER OF THE PROPERTY. AIA E% IVELY CONTRACTY40 WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT (SEC. 7044. BURIN AND PROFESSIONS CODE: THE CONTRACTORS LI. CE NSE LAW DOES NOTAPPLY TORN OWNER OFAPn RTY WHO BUILDS OR IMPROVES THE REON,AND WHO CONTRACTS FOR SUCH PROJECTS WITHACON7RA (S)LICENSED PURSUANTTOTHE CONTRAC- ONTRAGTORS TORSLICENSE LAW} O 1 AM EXEMPT UNDER SEC. B. A P.C. FOR THIS REASCN DATE OWNER LICENSED CONTRACTORS DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT IAM LICENSED UNDER PROVISIONS OF CHAPTER 0 (COMMENCING WITH BECTON 7000) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE, AND MY LICENSE IS IN L FOACE ANO EFFECT. LICENSE DATE CONTRACTOR ©� WORKERS' COMPENSATION DECLARATION , I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS: —I 14AVE AND WILL MANTAIN A CERTIFICA7E OF CONSENT TO SELF -INSURE FOR WORKERS' COMPENSATION. AS PROVIDED BY SECTION 7700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 11 ISSUED, I HAVE AND WILL MAINTAIN WORKERS' COMPENSATION INSURANCE, AS REOUIRED BY SECTION 3700 OF THE LABOR CODE. FOR THE PERFORMANCE OF TME WORK FOR WHICH THIS PERMIT S ISSUED. MCOA NSATCE CAR RAND POKY' NUMBER ARE: CARRIER, I � i l POLICY NUMBER1 � I y (MS SECTION NEED NOT BE IXI.OiETED OF THE PERMIT B FOR ONE HUNDRED DOLLARS wm OR Lm I CERTIFY THAT W THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE WORKERS' COMPENSATION LAWS OF CALIFORNIA AND AGREE THAT IF 1 SHOULD BECOME S ECT O THE W(%IKERS'COMPEN TION PRO IONS OF SECT THE LABOR E, I FOttHAMTH COMPLY WI TH E VISIONS. DATE: APPLICANT COVERAGE IS UNLAWFUL. AND SHALL BE WARRING. AILU TO SECURE WORKERS'SIE SUBJECTAN EMPLOYER TOCRIMIAL PENALFWES UPTOONE HUNDRED THOUSAND Dd.UAS(f1m00o),INADDITION70THECSATXkI. DAMAGES AS PROVIDED FOR IN SECTION 3700 OF THE LABOR CODE, INTEREMFEES. CONSTRUCTION LERbING AGENCY I HEREBYAFFIIRAN UNDEnP ALTYOF PERJURVTHAT THERE IS A CONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE OF WOIRKFOR WHICH THIS PERMIT IS ISSUED (SEC. 3007, CIV C.). LENDER'S NAME LENDERSADDRESS I CERTIFY THAT 1 HAVE READ THIS APPLICA71ON AND STATE THAT THE ABOVE INFORMATION IS CORRECT. 1 AGREE TO COMPLY WITH ALL CRY AND COUNTY ORDINANCES AND STATE LAWS RELATING 70 BUILDING CONSTRUCTION, AND HEREBY AUTHOR REPRESENTATIVES OFTHIS COUNTY TO ENTER UPON THE ABOVE NTPROPERTY FOR IN P ION PURPOSES. 4 arx c_ PERMITTEE W 9, ^1—) �'// SIGNA7UREOF O IT E PRESS FIRMLY DATE 'O O 1p NUMB RAO7 9-11; ` . ISSUE TYPE OCC DATE CONST.GROUP ZONING SETBACKS FRONT RW ❑ REAR ❑ SIDEISIDE STREET RW ❑ SIDE ❑ PROPOSED USE 1 NO. DWEL NO. NO. UNITS STORIES BEDROOMS DESCRIPTION SO. FT. FACTOR PSF ADJ. AREAIVALUATION SFF/ADDIREM Garaps/Carporl WPatio/Deck LL Pool/Spa O� ZRe -Roof 0 Commercial In Valuation ADJ.AREA QUANTITY DESCRIPTION FEE � c�� s � a.•U of yr U !r U W J W 3 /✓>/R- S S Ta. a 2 Z 4 S U W ONSTRUCTI N �I PLAN REVIEW IC �Z6 MECHAN • U I ECTION FEE SSUAN 1 (O� • '� SMTP ENERGY P/C ENERGY PERMIT RETENTION FEE: PRE -ALT FEE: TOTAL FEES I r 3 y? S COMMENTS RECPT. NO. 5.7 PAID BY l VALIDATION WHITE-0sponment Copy, YELLOW -(-Finance Copy, PINK—Aswasot Copy, GOLDENROD—File Copy, GREEN—ApplioaM's Copy V CITY01- DItj, ro INSPE=0710H �SET BACK, FLO-OP-101ST �01 FTGS/FORMSISTEEL rLu"Q IS ELECTRIC,A jQ-W�.W]DER FLOOR DUCT GROUND PLUMBING U FJDFR FLOOR CONDUI F -;.Tim SLAB GRADE FIRFPLAd :r- ,�:rj TEMIP POWERI FIR -PLACE B C, ND E; E A M V. ,TER SERVICE-----. fl