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--, CITY OF DIAMOND BAR � � � �'` — DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES I 21825 E.Copley Drive (909)560-3195 Fax(909)861-3117 PRESS "'-•��'� BUILDING PERMIT APPLICATION FIRMLY � JOBSITE y APPLICATION � �y� PERMIT f'�]'7'L�"'� P/C �, � o ADDRESS_ �'' I V p `I �C��� 1 �� DATE NUMBER�/ v� `."� o ISSUE TYPE OCC r° APN LOT��._ TRACT E'��" J �" DATE D �O � CONST. GROUP � p OWNER .3-!N �C'N zi � o ADDRESS '�/v i' '� � T� :v e�� �� ZONING SETBACKS Z CITY '17?��n s�k� G1rav ZIP��'j�lft TEL '+���!"'�� � FRONT RW ❑ p -� REAR ❑ o APPLICANT _T.Rf__�S_�___ TEL. SIDE/SIDESTREEf RW ❑ z 4 CONTRACTOR B'14) �� SIDE ❑ � ADDRESS a F$ � �.`' ` y � CITY > ZIP_�_�'Zuc:�TEL.:�--!� "���d°� PROPOSED USE �F�$P hT�G7�B'�-�. 7��'1 �C ��i?t"Y oARCHlENG/ ��~.� w DESIGNER NO.DWEL. NO. NO. a ADDRESS = CITY ZIP TEL. UNITS STORIES BEDROOMS � cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION � OWNER-BUILDER DECLARATION SFR/ADD/REM O I HEREBY AFFIRM UNDEFi PENALTV OF PENURY THAT 1 AM EXEMPT FROM THE CONTqACTORS LI- G8f89B/C2f�101'l W CENSELAWFOflTHEFOLLOWINGREASON(SEC.�o31.58USINE55AND?ROFESSIONSCO�E:ANVCI7YOR (f� U COl1NTYWHICHREOUIRESAPERMITTOCONSTRUCT,ALTER,IMPROVE,DEMOLISH,ORREPAIFANYSTRUC- W patio/Deck w TURE,PRIOR TO ITS ISSUANCE,AL50 RE�UIRES THE APPLICANT FOR SUCM PERMIT TO FlLE A SIGNEO W STATEMENT THAT HE OR SHE IS LICENSEO PURSUANT TO THE PROVISIDNS OF THE CONTRACTORS LI� � CENSE LAW(CHAPTER 9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF 7HE BUSINESSAND PRO� V' Pool/Spa FESSIONS CODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP� � TION.ANVVIOLATIONOFSECTION7031.SBVANYAPPLICANTFORAPERMITSUBJECTSTHEAPPLICANT'O z Re-ROOf A CIVIL PENALTY OF NOT MORE THAN FNE Hl1NDRED DOLLARS(5500).)� Z ❑I,ASOWNEROFTHEPROPERN,ORMVEMPLOYEESWITHWAGESASTHEIRSOI.ECAMPENSATION, Q COfi1RIBfCiBI WIIL DO THE WORK,ANO THE STRUCTURE IS NOT INTEN�ED Ofl OFFERED FOR SP.�E(SLC.7044,BUSI� J � NESS AND 7ROFESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES NOT APPLV TO AN OWNEfl OF = PROPERN WHO BUIL�S Oft IMPROVES THERcON.AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR CC THflOUGH HIS Ofl HER OWN EMPLOVEES,PROVIDE�THAT SUCH IMPROVEMENTS AFE NOT INTENDED OR m � OFFEHEDFORSALE.IF,HOWEVER,THEBI,'ILDIYGORIMPFOVEMENTISSOLDWILHINONEYEAROFCOMPLE� Z TION.THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVWG THA7 HE OR SHE DtD NOT BUILD OR � IMPROVEFOATHEPURPOSEOFSALE). W ❑I,ASOKTIEROFTHEPROPERTY,AMEXCLUSIVELI'CONTPACTI�'GWIhILICENSEDCONTRACTORS [C TO CONSTRUCT THE PROJECT(SEC.7o44,Bl1SINESS ANO PROFESSIONS COCE THE COMRACTORS LI� V3IU�fI0f1 ADJ.AREA W CENSELAWDOESNOTAPPLVTOANOWNEROFAPROPERTVWHOBUI�.DSORIMPPOVESTHEREON,ANO F WHOCONTRACTSFORSUCHPROJECTSWITHACONTRACTOR(S)LICENSEDPURSUANTTOTHECONTRAC- QUANTITY DESCRIPTION FEE � TORS LICENSE LAW.). � LJ I AM EXEMPT UNOER SEC. B.&P.C.FOR TMIS FEASON Q � � ll.. � DATE OWNER �" Z W � LICENSED CONTRACTORS DECLARATION W ¢ � I HEREBYAFFIRM UNDER PENPLTV OF PERJURY THAT IAM IICENSED UNDER PROVISIONS OF CHAPTER � � 9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THG BUSINESS AND PROFESSIONS CADE,AND Z X MV IICENSE IS IN FULL FORCE AND EFFECT. � LICENSE CLASS C Y� LIC.NO._��!��+ � j ~ �� J V DATE CONTRACTOR ��,1 :�1"y d W � WORKERS'COMPENSATION DECLARATION Q � I HEfiEBV AFFIRM UNOEfi PENALTY OF PERIURV ONE OFTHE FOLLOWING DECLARATIONS: Z � _I HAVE AND WILLMAIN7AINACERTIFICATE OF CONSENTTO SELF-INSURE FOR WORKERS' 2 COMPENSATION,ASPROVI�E�BYSECTION370aOFTHEL4BORCODE,FORTHEPEFWRMANCE U Q OFTHE WORH FOR WFIICHTHIS PER611T IS ISSUE�. � � w _IHAVEANOWILLMAINTAINWORKERS'COMPENSATIONINSURANCE,ASREaUIREDBYSECTION Q 370o OF THE LABOR CODE,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUEO.MYWORKERS'COMPENSA71041MSURANCECaRRIERAN�POLI$YNUMBERARE: CONSTRUCTION � ��� � CARRIER ���G T"� �-'I�IFG7 y� PLAN REVIEW `, Z POLICY NUM9ER � f�����.Z CI ,�Li!��Y ELECTRIC Q 0 (1}iIS5ECT10NNEmNOTBEOJMPLEf�OFiHEPERh9TISFORIXJEHUWRED�OI.LAR5�S700)ORLE55). PLUMBING Z 1 CERTIFY THAT IN THE PERFORMANCE OFTNE NJORK FOR WHICH THIS PERMIT IS ISSUED,I MECHANICAL �J SHALLNOTEMPIOYANYPERSONINANYMANNER50AS70BECAMESUBJECTTOTHE V] WORKERS'COMPEfISAT10N IAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME INSPECTION FEE SUB�ECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTIDN 370o OF THE UBOR ,/� 1 � CODE,I SHALL FORTHWITM COMPLV WITH THOSE PROVISIONS. ISS�IANCE �C:/ � � � i c p DATE: '�I�1"'�✓ � APPLICANT ______ ��'�. . – SMIP ! '� a � J WARNING:FAILURETOSECUREWORKERS'COMPENSAT���NCOVE9AGEISUNLAWFUL,AN�SHALLBE ENERGYP/C LL SV&IECTANEMPLOYERTOCftIMINALPENALTIESANDqVILFINESUPTOONEHUNDREOTHOUSANO ENERGYPEFMIT DOLLARS�E100,OOC),IN A.�OITION TOTHE CQSTOFCOMPENSATION,DAMAGESAS PROVIDED FOR IN • Q � SECTION 3�09 OF THE LABOfl CODE,INTEflEST,AND ATTOflNEV'S FEES. RETENTION FEE: � a CONSTRUCTION I�EN�ING AGENCY PRE-ALT FEE: O � i HEREBYAFFIRM UN�ER PE4ALTY OF PERJURV THATTH[RE IS ACONSTRUC710N LENDING AGENCY FOP THE PEflFOiiMANCE OF THE WOflK FOP WHICH THIS PERM IT:S ISSUED(SEC.3091,CIV.C.), . Z W S LENDEfi'S NAME � F_– IENDEF'S A�DRESS � � ICERTIFVTHATIHAVEREADTHISAPPLICATIONANOSTATETHATTHEABOVEINFORMATIONISCOqRECT. TOTAL FEES � Z �� W I AGREE TO COMPLV WITH ALL CITV AND COUNTV ORDINANCES AND STATE IAWS RELATING TO BUIIDING � CONSTRUCTION,ANDHEREOVAUTHORIZEREPRESENTATNESOFTHISCOU�yTVTOENTERUPONTHE � ABOVE-MENTIONE�PROPERTV FOR INSPECTION Pllfl?OSES. � �..�„��I'�� � COMMENTS J � � � 1 ITTEENAME RI T) Cl C SIGN OF PERMITTE - DAT RECPT.NO. 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