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W ''-*-- CITY OF DIAMOND BAR
DEPARTMENT OF BUILDING AND SAFETY
BUILDING PERMIT
PRESS
FIRMLY
JOBSITE
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AD RESS ! 3? Lag g � _L
CATION
DATE UM
�� 80) NBER �_ CODE
ISSUE TYPE OCC.
DATE __1l CONST.S = GROUP
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�!APN LOT TRACT
! CROSS £ ET
I OWNER =L�
ADDRESSf_)A/ ' ✓�'' �''a' bid
ZONING SETBACKS akrrfeoiaEME--IM
FRONT- ❑
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SIDE,��TREET ^ RW ❑
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A—PP—LICANT r_ TEL-219,1k'
I CONTRACTOR�-
ADDR r;1CL
CITYe IIIA ZIP ��%G TEI��4'
—J SIDE ❑
SEWAGE ❑ PUBLIC PMT
DISPOSAL ❑ PRIVATE SO. FT./ 100 GAL
GRADING ❑ CU. YDS. EXC. CU YDS FILL
STATE J
NL'MgER �T�(%��
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TYPE
1
SQ FT FACTOR PSF ADJ. ARE LUATION
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I DESIGNER
ADDRESS—
LLL.
2
CITY ZIP TEL.
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3
4
PROPOSED USE f!5�_ �; c --
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GARAGE
NO. DWEL. NO. NO.
UNITS STORIES BEDROOMS
LOT DIMENSIONS
PORCH
VALUATION ADJ. AREA
QUANTITY
DESCRIPTION FEE
NO, OF BLDGS HOW
O�j,(N LOT USED
jY
ARATION 1 hereby affirm I am licensed junior provisions of Chapter 9 (commenciup
N. IED ..ONTRACTORS IEC'm Th
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�•• 41cn„c 70Mcl Fir-mo3 of the Rusmess and Prohss,ons Code. and my lass— is in full Irma a'd ahem
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V1. + RJILDER CFC.ARATION I he;eov alhrm !hat I am exempt from the Contractor's License Law for Mor Masa g
a,, .1 iSnr %".31 5 Bus anss and P:cf—tins fade Any city or county which requires a permit to coostruct,
:dtr• m,pmw :r,�rls^, or repair any structwe. Dna' to Itsissuance also requires the aplifitant far such permit
y ey 4a:e'n the he s cesion pursuant the to the provisions of the Conor th s Lienee Law !Chapter
r. r w m Secau 76.10) Division 3 of the Bdsmess and P1oless oTs Cpdm or that he is exempt themhom
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III, 1.4 5 'p' r"P a IMI re Ipso Ary Violation of Section 7031 5 by any appbcant Mr a permit suhlects
t al -art to a civ I reralty of not more than five hundred dollars (S5001;
4
i f �I as rnvnor Pt !^o. property, or my employees with wages as Ihmr sole compensation will do the work, and
il the sn ;:Iwo ,s cot worded or clleree for sale ISec 7044 Gammas and Professions Coca The Contrarte, s License
law 9 rx rm api:ly to BP owner o° property who builds or mproves thereon and who does such work himself,
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'hen to I Pr imp-I,meni .s sold withm one year of completion. The avn.r hwlder will have the burden of proving
i rn tl•m;nlr lis :,sur amplpyecs promded that such improvemenn are at mended n• edlered for sale If however
that hr 11 +I, Wr IA yr miprave car rhe purpose of sale I
JI, as owre, •:I !;:; ^rpm!y. am exclusively cantrachn5 with licensed contractors to construct the protect ISec
1144. Busrea3 dud nrofic �s Coale. The Contractor's License law does not apply to an owner of praperty who
wilds c onvo es 1L-oor. aro who njrla[[s for such prmeol5 with a [ontraclortsl licensed pursuant to the Cortracmr's
7:
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Law t
CONSTRUCTION
rr emmpt under Sec . B (r PC (Attach Certificate)
I
PLAN REVIEW
Gain Owner
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_
ELECTRIC _
PLUMBING
MECHANICAL
%VURKFRS' COMPENSATION DECLARATION I hereby affirm that I have a cerl[hcate of consent to Belt -insure or
' s crml•rme II Ph kers' Compersalion Inswanre, or a wiled copy thereofySat' 3800. Lab CI
I[L� cern+leu copy is erety furnished
1� Cmeiw1 I s'.led wdF the Bwtdmg Inspection Department or Department
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GRADING
t.\
i III AT' OF EXEMPTION FROM WORKERS COMPENSATION INSURANCE This section need not he. completed
ISSUANCE
i ,I the ;anon: Is for ane uondied i51G01 or less i rerbfy That m the performance at the work for which this
III s issued I hall .lot employ arty person in any, manner so as to me subtect to the III C persanon
I Laws If CI�' fem. Y
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DOTtApptica"
� NOTICE i0 APPLICANT If after making this Cprvin:ate of Exempnan, you should ratio sublttt to the Workers
U-
SM IP
PARK FEE
SCHOOL FEES
hmpensaI prawsom, at be Labor Code you must fathwith comply with such provisions In this permit shall
be occ r.,wl revoked
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DIVISION OF INDUSTRIAL SAFETY PERMIT CER7IFICATION
i
i . Ell hereby r.ertdv that na eacavatron Iwo (5) or more leer at depth into which a person is required to des[md,
t�
CITY ®F DIAMOND BAR
will be made it cornerson with work autha¢ed by this perch. and that Pro building structure. scaffolding. lalsewark.
n demoannn ar dismanthng thereof will he mare than thirty-six (30) feel high. (Chap 32 Grp 2• Art 2• See
341. CAM
BUILDING AND SAFETY
• l ❑As owner budder I will not employ, anyone to do wok which would require a permit from the Ducknotl of
Irclovna: Safety as noted above, unless such person has a permn to do such work from the diuniart
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❑DrmsmT: at loulcm al Safety Permit No
TOTAL FEES z 0
s CDNSTRUCTION LENDING AGENCY I hereby affirm that there ,s a construtnnn lending agency Ian the performerxe
of the wink far wh;rh this permit is issued (Sec 3097. Civ C I.
i Lenders Name
COMMENTS
jender', Address
• CERTIFICATE DF COMPLIANCE .AND AUTtI0R12ATo OF ENTRY 1 candy I have read this applicalam and state
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a that the nI or I un pwen i .matt I agree to comply with all state laws and city ordinances relating to buildup
rorsrrurnun. and authon p smentioe of the Department d Bunlding and Safety to en upon the poperry
fur winch I haW. art - oror t the p i mg ,nspttt s `
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RECPT NO. ______.._�_ PAID BY VALIDATION
Signature of Appl and j' Agem pa
WHITE—Department Copy, YELLOW—Finance Copy, PINK—Assessor Copy, GOLDENROD—File Copy, GREEN— Applicants Copy
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