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_ _._ . _. __ _ _ __1�_ CITY OF DIAMOND BAR ..�''',� DEPARTMENT OF COMMUNITY&DEVELOPMENT 5ERVICE5 ��� � 21660 E.Copiey Drive Suite 190 . ,^..,,,,. (909)860-3195 Fax(909)861-3117 PRE$$ �•�9� BUII.DING PERMIT APPLICATION � FIRMLY � JOBSITE APPIICATION c Q PERMIT P/C � o ADDRESS -Z�'rJ �N�tA� C'.�"F� R� DATE ��7 �/� NUMBER ����� # c� ISSUE ��-S_Q� TYPE OCC APN LOT TRACT` DATE � CONST. GR�UP p OWNER ADDRESS� 1I�� lIA'�C7 � ZONING SETBACKS z CITY �37lIT�i�I?i Q ZIP I' TEL g,���� ' � FRONT RW ❑ g APPIICAN'f TEL. REAR ❑ SIDEISIDE STREET , RW ❑ � � �1 ��� c� .,.,s : a � CONTRACTOR� ✓ SIDE ' ' ❑ p� ADDRESS q � " PROPOSED USE ^ � � cmr _�_l-�A�R�� ZIP�' TEL :s � � /C� o ARCH/ENG/ W DESIGNER NO.DWEL. NO. NO. n. ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � DESCRIPTiON SQ.FT. FACTOR PSF ADJ.AREANALUATION � � OWNER-BUILDER DECLARATION SFRIADOlREM � O p I HERE6V AFFCiM UNDEH PENN.TY OF PERJURY THAT I AM E%EMPT FROM THE CONfRACTOPS LI- � Garage/Carport W CENSELAWFORTHEFOLLOWiNOREASON(SEQ7031.58USINESSANDPROFE551�NSCODE:IUJYCITYOFl U pDUNTYWHICHRECU�RESAPERMITTOCONSTRUCT,ALTER,�MPROVE,DEMOUSH,ORHEPAIRAN�STRUC� W P8ti0/OBGk W NNE,PRIOR TO ITS�SSUANCE,AL50 HEQUIRES THE APPI.ICANT FOR SUCN PERM�T TO FILE A SIGNE� � � STATEMENT h!AT HE OR SHE IS LICENSED WRSUANT TO THE PROVISIONS OF THE CONTqACTORS U� � CENSE LAW�CHAVTER 91�MMENCINO wITH SECTION 7000)OF DIVISION 30F THE BUSINE55 AND PPO- V' P�oUSpO FESSIONSCOOE�OATHATHEORSHEISE%EMPTTHEREFROA7ANDTHEBASISFORTHEALLEGEDEXEMP- (�J TpN.ANYVIOIATIONOFSECTION7031.5BVqNYAPPLICFNTFORAPERMIT5U8)ECTSTHEAPPL,ICANTTO Z fle-Roof `„� ACINLPENALT'OFNOTMORETUNFlVEHUNDREDDOLLARS�S5o0).): � �I,ASOVMEROF7HEPqOPEPT'.ORMVEMPLOYEESWITHWAGESASTHEIRSOLECAMPENSATION, � COR1rtIBlCl81 - VALL DO THE WORN,M1D THE STRUC7URE IS NOT IN7ENDED OR OPFERE�FOP SALE(SEC.7o4a,BUSI- J � NESS AND PROFESSIONS COOE:iHE CONTRAC70RS LICENSE LAW DOES NOT APPLV TO AN OWNER OF = Vi�PERTV VhlO BUILDS OR IIAPqOVES THEREON.AN�MMO DOES SUCH WORK HIMSELF OR HEiiSELF OR � THflIXI(iHH150RHERONTlEMPLOYEES,PROVIDEDTHATSUCHIMPROVEMENTSARENOTINTENDEOOP m � OFFEREDFOHSALE�F,HOWEVERTME8l11L01NGORIMPROVFAIENTI550LOWfI'HI40NEYEAROFCOMPLE- Z TION,THE OWNER-BUILDER WILL HAYE THE BURDEN OF PROVMG THAT HE OR SHE OIO NOT 9UIL0 OR = IMPiiOVEF011THEPUHPO5EOF5ALE). ❑I,AS ON7dER OF THE PROPEFTiY.AM E%CLUSIVELY CAMRACTING WffH LICENSED CONTRACTORS � TO CONSTRUCT THE PROJECT(SEC.70�4,BUSINE55 AND PHOFESSIONS CODE:THE CONTRACTORS U- VflWBIlOf1 ADJ.AREA W CENSELAWDOESNOTAPPLVTOANOWNEROFAPROPERTVWHOBULDSOpIkPRDVESTHEREON,AND � WIIOCONTMCTSFORSU�IPROJEGTSWIh!ACONTRACTOR�S)LICENSEDPURSUMfTTOTHEGONTM6 QUANTITY DESCRIPTION FEE � TORS LICENSE LAW.). �J� o ❑IANEXEMPTUNDERS�C. 6.6PC.FOfiTHISREASON Q e7� O 'C� � �� 3 � � LL OA7E OYJNER _ .__ f' Z W � LICENSEDCONTRACTORSOECLARATION -� � " � ` ""'- ''- " �'� � W IHEREBVAFFIRMUNDERPENALTYOfPERJURYTHATIhlALICENSEDUNOEFPNOVISIONSOFCHAPTER � Q_ 9(COMMENCING W�TH SECTION 7000�OF DWISION 30F hiE BUSINE55 AND PFOFESSIONS COOE,ANO Z MY LICENSE IS IN FULL FORCE AND EFFECT. m o UCENSE CLASS C\i�"'I C, LIC.NO. ��p`�� /� � U DATE i i I��% CONTPACTOR '�����/��1, d YL � WORKERS'COMPENSATION DECLARATION Q � U N 1 HEREBV AFFIRM UNDER PENALTY OF PERJURV ONE OF THE WLLAWING DECLARATIONS: � Z Q 0 �HAVEAN�WILLMAINTAINACERTIFICATEOFCONSENTTOSELFJNSl1REFORWORNERS' _ � �COMPENSATION,AS PROVIDEO BY SECTION 37ooOF THE LABOR CODE,FOF TME PERFOflMANCE �U OF THE WORK FOR WHICH TNIS PEflMIT IS ISSUED. � B w ^I HAVE ANO WILI MAIMAIN WOflKERS'COMPENSATION INSURANCE;AS REOUIRED BV SECTION Q 3700 OFTHE LA80R CODE,FOq THE PERFORMANCE OF THE WORK FOR WH�CH THIS PERMIT IS ISSUE�.MV WDFKERS'COMPENSATION INSURANGE GARRIERAND PDLICY NUMBER ARE'� CONSTRUCTION J j cARRiEq PLAN REVIEW � POLICVNUMBER ELECTRIC /�� 0 (rr+asEcrroNNe�rioraEar�r��ooFn-e�aHu*�sFoaonEriuwaEooat.ntu�5ia)oniEss). PWMBING Z I CEHTIFY THAT IN TXE PERFORMANGE OF THE N^DRK FOR WHIGH THIS PERMIT t51S5UED,I MECHANICAL �j SHAI.LNOTEMPLOYANYPERSONINANVMANNERSOASTOBECOMESl1BJECTT07HE �NS ONFEE [%� WORKERS'CqMPENSATION LAWS OF CALIFORNIA.AN�AOflEE THA71F I SHOU.D BECOME � SU&JECTTO THE WORNF_RS'COMPENSATION PROVISIONS OF SECTION 37060F THE 1A80R �] � CODE.�SHALL FORTHWITN COMPLY WITHTHOSE PROVISIONS. SSUANCE �O`� 0 SMIP p DATE:___. APPLICANE _ . J ENERGY P/C WARNING:FAILURE TO SECURE WORNERS'COAiPENSATION COVERAGE IS UNLAWFUL,AND SHALL BE LL SU&IECTANEMP�OYERTOCRIMINALPENALTIESANDCIVILFINESUPTOONEHUNDREDTHOUSAND ENERGYPERMIT �IXLARS(Sioo,00al.IN RDDITION TO THE COST OF COMPENSATION,DAMAGE9 A9 PFOVIOED FOR IN J SECTpN37080F'HELABOflCO�E,INTEREST,ANDATfORNEYSFEES. FETENTION FEE: TTV!1T T7 A s D Ai) o� �z az�r-a�az�zi'�$P��B�nru�- O CONSTRUCTION LENDING AGENCY PRE-ALT FEE: '83TitY r�rnr�. m ♦i �+cr aJ17�i.iZ7IIV'CT�-�J"ZIt�1 ]r-------- � IHEPEBYAfFIRMUNDEFPENALTYOFPERJURYTHATTHEREISACONSTRUCTIONLEN0INGAG6NCV � FOR THE PERW FEIANCE OF iHE WORK WF WHICH THIS PERMIT IS ISSUED(SEC.3ae7,GV.G.�. Z W � LENDER'SNM/E__ F— LENDER'SADDRE55 — W ICERTIFYTHATIHAVEREADTHISAPPLICATIONANDSTATETHATTHEABOVEMFORMATIONISCARRECT. TOTAL FEES I � IAGREETOCAMPLYWITHALlC1TYANDCOUNTYORDINANCE5AND5TATELAWSREUTINGTOBUIIDING � / / �O CONSTRUCTKKJ,ANO HEREBY AUTH�FIZE REPRESEN7ATIVES OF THIS COUNN 70 ENTER 11PON THE �--r� � ABOVE�MENTIONEO PROPERTY FOR INSPECTION PURPOSES. � Z COMMENTS r � o �S"t����-9 ��°�i m PERMITTEE NAME(P (n �."�.�t,.0 _� y SIONATUREOFPERMITTEE ATE = RECPT.NO. 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