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f '"� � CITY OF DIAMOND BAR ` � , , �' ��
� PRESS�
. � .,, •�' DEPARTMENT OF BUILDING AND SAFETY FIRMLY��; , �,
�^� .� '� BUILDWG PERM�7 ,,
"` APPUCATION " PERMIT � .�~� USE
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ADDRESS'°�'"'�� � +�����'�' t"�~rt�t�fc. �+C� DA7E �` Nl.ffu�BER • �`�"'�' CODE'
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4 APN LOT TRACT DRTE +� �� �� ��` CONST. GROI�P
": '`� CROSS S�F�EET SETBA�KS �
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� ADDRESS ��Cr�"a :"u 3�e REAR „; ❑
„� CITY,��R���` '�fr�'^ ZIP ` .'� � �� ` SIi�E/SiDE STREET q�V ❑
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"' o ADDRES�I �� ��� ����`'�'���''"'� � SEWAGE ❑ PUBUC PMT# `
� DISPOSAL ❑ PRIVATE; SQf FT/100 GAL
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� F�DDRESS {�� 2
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� LOT DfMENSIONS m VALUATION ADJ.AREA
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~ LICENSE�COMRAC70RS DECLAPATION:I hereby atfirm that I am licensed undei pmvisions ot Chapler 9 Icommencing �'I"� . �`�
� with Sect�on 70U0)ot Division 3 of the Business and?mfessians Code,and mY license is in full force Bnd.eftict ,;�;�, ' _ • �
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� QWNER-BUIL�ER OECLARATpN:I heiebY alfirm that I am e�emp�Imm the Contractor's License Law lor ihe ldlowing -- �
Z reason�Sec.7031.5. Business aod Professians Code Any city ar coumy which requires 2 peimu lo construct. �-C'}�
o alter improve,demalish,or repair any siructure.prior lo I�s issuante,also requires the applicant lo�such permil z'
F- m file a signetl statemem that he is licensed pursuam to the pmvisions o1 the Conuactor's Lioense Law(Chapter (�� '�
� � 9 Icommencing with Section 700DI ol Oi�ision 3 of ihe 8usiness and Professians Code1 or ihat he is ewempt iherefrom �``
X and the 6asis for the alleged esemptian.Any violatian ot Seceon 70315 hy any applioant!or a permit su6jects ,
„, �.� Ihe applicant to a civil penalty of rot�ore lhan five hundred dollars IS50Q).P. � r
� ❑I,as owner of Ihe p�openy,or my employees with wages as iheir sole compensation,will da the work and , _
�he stru�ture is not intended or cifeieA for sale(Sea 1044.Business and P�dessians Code�The Cantracmr's License Q
� v Law does not apply m an owner of Droperty who builds or�mproves thaeon,and who das such work himself, (,) ' ,
' or thrsugA his o,vn employees,provided�hat such impmaement«are not intended or oNe�ed for sale.If,howevei. ��.�� '
- m the huilAing ar impravemem is solA within one year�u�completion:�he awner6uilder will have the�urden of pmvinp �
�- � iha�he did uot huilJ or impwve tor the purpose of sale.� -�
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�a ❑I,as owner ol ihe p�operly,am exlusrvely comra[tiny with licensed canlractors ta construct the p�oie[t ISeu ����
- o ?(144,Business and Protessions Code�.The Contracmr's license Law daes nat apply m an owner af praperly who �5�,,,
. 1 6u�lds o�I�nD�ova�therean,and who wniracis lor such pmjecis with a controctnr�s)iicensed pursuant�a Ihe Cnn��actor's
"` �'°�"s°�a"' CONSTRUCTION
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W ❑�am exempi under Sec ,e.B P.C.IAttxh certifioate� :�PLAN f;EV.,IEW
p Oate Owner , ^��-� �L�,�iTl;l��i:..,_..,� _.._.,__...__ ! _��.K1.��--., �., ,e.H�:
� WURKERS'COMPENSATION DECLAPATfIXJ�.I herehy affirm that I have a certificate of consent ta sNf�insure,ar
a cenficate_Vot Warkers'Compensation�nsurance,or a cerutied copv thereo�ISec.3804�ah.C.�. '�- PLUMBING
.• 6 ❑ce��sea,�oPY�:n�.ebY r��,anea f' . � MECHANICAI ... �• p ,
, c ❑Ce Irfied copy is Ided wrth the BuJdmg.InspecUo 0 pa tmem ar Depa tmen� <C. GRADING � �
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� CERTIFICFT�„OF EXEMPTION FflOM WOBNEHS COMPENSATIDM1I INSUAANCE Thii iection need no�6e'�ompleted ' �'�j`Cv`�JANCE � ,� ,r` �i�'�,.
y d the permt�is for one hunAred(5100)or less I ceraly thai in the perbrmance o�.ihe work r AhKh�this •- _ .� „. _,,,,_ „ —
" permh is iss�ed,I shall nat qmploy any perwn m arry manner sa as m b¢come su6ject lo IFr Ybrkers`�CoMpemalron - CJ`M'� � - /
� Laws of Califomia. "? � �� 4 " � � ��ur S
_ o • � : ``�. � RARK FEE � `•
0 0ate — Appllcant ' � �y.
� NOTICE APPLICANT�.�II,aher m�king thit Certificate of Exemption,you sMuW 6ecome subject M e WMkers M�� SCHOOL FEES
- � GomDensa�iSions ol Ihe Labor Code,you musi brlhwiM comply with sueh Drmisans a thit petlhit shal� . . .
� 6e deemed revaked. �
� ¢ DIYISION Of INDU5TPIAL SAFETY PERMIT CERTIFICATION� ' S ���h�
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� UI hereby certily ihat no excavaliqV.five(5�oi mYre teet In depth into which�persan is reQuired to descend, "�
- m will be made in conneciian with work amhw¢ed by thi3"permit,and Ihal ia WAdinp suutlure.scalfoldinA.f�isework, .
n- or demoleion or dismantling thereol,will be more than thirry-six(36)feet high.(Chap.32,Gry 2.Art 2,See
W� 341.Title A.C.A.CJ. . ..
2
3 ❑ps owner�6wlde�,I will not emplay anYone lo do work which wald require a permit imm Me avision of - '
� Industrial Saiety,as noted ahove,unle6s such person has a permit to da sucM1 work fmm the drvisbn. ' .
�
❑avision of Industrial SaFe F�rmit No. - _� ..h;d/y,,
. � ca�srnucrne�eNoinc ac�Ncv:i eg :YOTAL FEES "� '��' ( x.',.,
�y aNirm that ihere is a consUuction lendi�aperxy fa the perFo�anca "+ry ��*�Qv-�
- Z ol ine work lor which Mis permit is issued�Sec.3091,C'ra.C.�. g
� taider s eame' COMMENTS �
� m Lmder's Addiess � . .
'a CERTIFICATE Of COMPLIAHCE AND AUTFpPoZATqN DF ENTflY:I cmtify I hm road tliis applicnian aid�ste4 � -
er� �hat the infumatiaµgiven is carect I agree 10 comply wuh all state laws and ciry ordinanca rebtinp to 6uiNi�
� � cons�rur,tian,and autAoriie a rep2untative al 7he Oryar7menl 01 BuiNiap md Sakty ta mM opon tle praqerty
= tor wh¢h 1 have applie lor this permit tar iLe p se of makinp in�px�ions. ���;
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. ' � "Sig a�we ai Applicmt or nt r p�h RECPT NO.a PAID BY '�� VALIDItTION �
WHITE-Oepartment Copy,YECLOW—Fina�ce Copy,PINK--Assessor Copy,GOLDENROD—File Copy,GREEN—Applicants Copy '
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