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/ ----�`�---- CTI'Y OF DIAMOND BAR � COMMUNITY DEVELOPMENT DEPARTMENT -...w • 21660 E.Copley Drive Suite 190 (909)860-3195 Fax(909)861-3117 PRESS ���"""�� BUILDING PERMIT APPLICATION FI R M LY o� JOBSITE / NUMBER ' S �� �'1� T I�.�. ADDRESS 26f7S ��y�_Cll_1Q,�C �� DATEICATION 4�3/�� PERMIT —i -- �/C � ISSUE ' TYPE L OCC APN LOT TRACT �"2` –�{g' °C OWNER I 0� .�� DATE CONST. GROUP O ADDRESS � 20NING SEf6ACKS RW ❑ Z CITY��_ ZIP TEL. FRONT o APPLICANT _ TEL. REAR n z SIDEJSIDE STREET RW ❑ Q CONTRACTOR� ' � '+�,jSJ' cc� �l�C,._ SIDE ❑ Q ADDRESS--� t ` i � CITY ��.�, �'j'�_ ZIP (2.4� TEL L�� PROPOSED USE 1r�� -►ti.-�a.�-E.-`�°�i�� w ARCH/ENG/ J�� Z DESIGNER SSO. �-N�____ w NO.DWEL. NO. NO. = CITY 5 ZIP TE 2 UNITS STORIES BEDROOMS � cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BCILDER DECLARATION SFFl/ADD�REM � O � I HEREBY AFFIRM UN�=R 7ENALTY OF PERJUFY THAT I AM E%EMPT FROM THE CONTRACTORS LI- G2f290/Cd�pOfl W CENSELAWFORTHEFOILOWINGREASON(SECJ031.5BUSINESSANCPROFESSIONSCO�E;ANVqTYOa (n U COUNTYWHICHREQUIRESAPERMITTOCONSTRUCT,ALTER.IMPROVE.DEMOLISH,ORREPAIRANVSTRUC• W PdliO/DECk w TURE,PRIOR TO ITc ISSUANCe,ALSO REOUIfiES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED W STATEMENT THAY HE OR SHE IS LICENSED PURSJANT TO THE PROVISIONS OF THE CON7RACTORS LI- � CENSE lAW(CHAPTER 9(COMMENCING WITH SECTION 7000)OF DIVISION 30F THE BUSINESS AND PRO� � POOVSpd O FESSIONSCO�E)ORTHATHEOFlSHEIS[%EMPTTf{EHEFROMAN�THEBASISFOFTHEALLEGEDEXE�AP- (� � TION.ANYVIOLATIO�OFSECTIONJ031.SBYANYAPPL�.CANTFORAPERMITSUB.;EGTSTHEAPPLICANTTO Z Re-Roof � AdVILPENALTYO=NOTMORETHANFIVEHUNDFEDDOLIARS�85a0).): � LiI,ASOWNEROFTHEPROPERTYOHMVEMPLOYEESWITHWAG=5A5THEIRSOLECOMPENSATION, 0 COlf1RIBfCiB! Z WILL DO THE WORK,AND THE STRUC7t1RE IS NOT IN7ENDED OR OFFEiiED FOR SALE(SEC.7044,BUSI- J � NESS AND PROFESSIONS CO�E:THE CONiRACTORS LICENSE LAW DOES NOT APPLV TO AN OWNER OF = PROPERTV WHO BUIIDS OR IMPROVFS THEREON,ANO W HO DOES SJCH WORK H IMSELF OR HERSELF OR � THROUGHHISORHEROWN'cMPLOVEES,PROVIDEOTHATSUCHIMPROVEMENTSARENOTINTENDEAOR m - Q OFFEREDFOaSALE.IF,HOWEVER,THEBUILDINGORIMPROVEMENTISSOLDWITHIN04EVEAROFCOMPLE z TION,THE OWNEF-BUIL�ER WILL HAVE THE BURO[V OF PFlOVING THAT NE OR SHE DID NOT BUIL�OR = IMPROVEFORTHEPURPOSEOFShLE). W ❑I,ASOWNEROFTHEPROPERTY,AME%CLUSNELVCONTRACTINGWITHLICENSEDCONTRACTORS [[ TO GONSTftUCT THE PR0.IECT(SEC,)044.6USINE55 ANO PROFESSIONS CO�E:THE CONTFACTORS L'- VdludfiOn 4 ADJ.AREA W CENSELAWOOESNO7APPLYTOANOWNERGFA:�ROPERTYWHOBUILDSORIMPROVESTHEREON,AND � WHOCONTFACTSFORSUCHPROJECTSWITHACON7RACTOR�SJLICeNSEDPURSUANTTOTHECONTR0.G QUANTITY DESCRIPTION FEE Y TORSUCENSELAW.), Q ❑i AM EXEMPT UNDER SEC. B.8 P,C.FOR THIS REASON Q 2 �Q U � OATE OWNER f` � o --- W . � �, ¢ LICENSED CONTRACTORS DECLARATION W CL IHEfiEBYAFFIRMUNOERPENALTYOFPERJURYTHA7IAMLICENSEDUNDERPFOVI510NSOFCHAPTE9 � � s(COMMENCING WITH SECTIDN 7000j Of 01VISION aOF THEBUSINESS ANO PROFESSIONS CODE,AND Z X MY LICENSE IS IN FULL FORCE AND EFFECT. � � LICENSE�C.L`A/S$ � LIC.NO. L�� � � V �ATE�/'Z � � CONTRAC70R��_ CL �� � � WORKERS'COMPENSATION DECLAFfA�10N��''��C• Q � � . �,y .4 � 3 C9� f � IHEREBYAFFlRMUNDERPENALTYOFPENURYONEOFTHEFOLLO'NINGDECLARATIONS: Z �'�"' q Sl/ Z _I HAVE AND WILL MAIN7AIN ACERTIFICATE OF CONSEN7 TO SELF-INSURE FOR WORKERS' _ �q Q COMPENSATION,ASPROVI�EOBVSECTION37000FTHELABORCOOE,FORTHEPERFOfiMANCE C� r� t di� .S g �lf OFTHE WOHK FOR WHICHTHIS PERb11T'.S ISSUED. W 0 � w _I HAVE AND WILL MAINTAIN WORKEFS'COMPENSATION INSURANCE,AS REOt11iiED BY SECTION Q 37ao OF 7HE LABOR CODE,FOR 7HE P' FORNANCE OF THE WORK FOR WHICH THIS PERMIT IS - ' � ISSl1EC.MY W RKE S'COMP,E�JSATIOI I'�NSl1RANCF CARRIER AN�PO'JCV h'UMBER ARE: CONSTRUCTION � �O J ,y� � CARRIER � � PLAN REVIEW _ �71'�-I.7 Z POLIf,V NUEI6ER ELECTRIC �./L/,'; `�]�� �S 4 - '7 �r, � (iH55ECT10NN�mNOTBEOJMPLETEDOF7FiEPERMITISFORIXJEHU�RE�DOLLAAS(E1W)ORIESS). PLUMBING S/�.�'G � / j �✓S W �' �y� //� Z 1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WH'CH THIS PERMIT IS ISSUEO,I MECHANICAL S�. li'-/ � � � 1(J C'3 SHALL NOT EMPLOY A�'Y PERSON W ANY MANNER 50 AS TO BECOME SV&IECT TO THE (�j WORKEflS'COMPENSATION LAWS OF CA'JFORNIA,AND AGREETHAT IF I SHCULO BECOME INSPECTION FEE SUB.IECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR j {�� � CODE,1 SHALL FORTHWITH GOMPLY'NITH THOSE PROV�$, ISSUANCE 1.��-✓y I� O O p DATE:����'_J_�1�/_ APPLICANT: �r __� SMIP •� ! Y S Ce7 J WARNIN :FAILURETO SECUPE WORKLRS'COMPENSATIDN COVERAG_ UNLAWFl1L,AND SHALLeE ENERGY P/C �� � SUBJECTAN EMPLOYER'O CR'�MINAL PENALTIES AND CIVIL FINES UP TOONE HUNDREDTHOUSAN� ENERGY PERMIT } DOLLARS(E1o0,0ooj,INAD�ITIONTOTHECOSTCFCOMPENSATION,DAMAGE5A5PROVIDEDFORIN (7 � �/q�/q � SECTION 3708OF THE LABOR CODE,INTEREST,ANDATTORNEY'S FEES. RETENTION FEE: ,$� {„/l! d CONSTRUCTION LENDING AGENCY PRE-ALT FEE � O —� � I HEREBYAFFlRM UNOER PENALTV OF PERJURY THAT THERE IS A CONSTRUCT'ON LENDING AGENCY � � � FOR THE PERFOFMANCE OFTHE WORK FOR WHICH THIS PERMIT IS ISSVED(ScC.3097,CIV.C.�. — Z �W � LENDER'S NAME F-- LENDEfl'SADDRE55 � i CERTIFY THAT I NAVE READ iH15 APPUCA'IO�AND STATETHATTHEABOVE INFORMATION IS CORRECT. TUTAL FEES � � � �L,.`•J� I AGREE TO COMPLY WITH AL�qTV AND COUNTV OflDINANCESAND 5T0.TE UWS RELATING TO BUIL�ING CO 4 � CONSTRUC710N,ANDHERE9YAUTHORIZEREPRESENTATIVESOf-HISCOUNTVTOENTEFUPONTME . �y z ABOVE-MENT�:ONEO PROPERTY FOR INSPEGTION PURPOSES. COMMENTS // � J � M m PERMITTEE NAME(PRINT V� �f 'Z� � SIGNATUREOFPER TE -7� � � RECPT.NO. PAID BY I 2 VALIDATION___1...�� WHITE—Depadment Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—ApplicanYs Copy .,.. ._ .._...... , -1_...._ �. .. �.,... . ...,..., . .�.. . ; E t3� �i � � _ _ , �� �� � .: _ a: x. .. . z.,__ ,, � � � ;tt , _ , � � , � � � , ,ya � � , ;�. �. � , � �£ F. , ; ������� �_ _ ` . � j ��.���.��,��r ^ � .. . . _.� __ � __.._... ._._ ���.���,���r����t� ; 3�� i " °���€������� � -�--__,_ . __ �_ _ __ ___ _.__ , E�..�� �.r•;-��3C��J��I�J ' __ � �_t��C��R t=�,�iC�i?�1.��,T �?— ___..A��_ _:'_ -_�__ � � �". �'E��°dC}``� v1�; �....�..�._.. _ .____.._. .�r.,r .� i�p �$ ,��r� __ _---i-�..��i'7.�F{�'�C3f3�C�CJ9�1�1�d€`f' �_ __ �L:���F?r��'� Gr� ; �`�}��?'��C��F�3�Nr'�Aii��d � ,. . 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