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� _�` CITY OF DIAMOND BAR � DEPARTMENT OF COMMUNITY&,DEVELOPMENT SERVICES _ w 21660 E.Copley Drive Suite 190 PRESS \ �,,, (909)860-3195 Fax(909)861-3117 . BUILDI1mTG PER11%�IT APpLICATION _ _ _ . :, , , , '`;. . FIRMI.Y : : :,,.. ,. . t . y.„ Fa� .,t,,��k, . ,.,� � JOBSITE ,,,Y�.'�,� f_,.�x9� ���,� ��- ,y�� APPLICATION ��_ PERMIT�� P/C o ADDRESS "��� ,-fT_ DATE NUMBE # c� ISSUE TYPE OCC APN LOT TRACT � DATE CONST. GROUP p OWNER �` Y�!`"`f"� ADDRESS 'b�S7�✓`�r r �°-C1��°1 �� ZONING SETBACKS Z CITY�'_1r'i�e. �t IP�I�J'1.�!�TE . FRONT RW ❑ g APPLICAN-f �T TEL. REAR C SIDEfSIDE STREET RW C _ � CONTRACTOR SIDE C � ADDRESS_ '�"� � Q CITY ZIP TEL. PROPOSED USE t��u ARCWENG/ � DESIGNER NO.DWEL. NO. NO. a. ADDRESS UNITS STORIES BEDROOMS � CITY ZIP TEL. � DESCRIPTION SQ.FT. F CTOR PSF ADJ.AREANALUATION c� oOWNER-BUILDERDECLARATION , SFRlADD/REM � -� ' � ' �- ���`���� � � � Q I HER@BY AFFIRM UNDER PENA�TY DF PERJURV THA7 I AM IXEMPT FRQM THE CONTRACTORS LI- Cnyf8g0/C3fpOR W CENSELAWFORTHEFOLLOWINGREASOM(SEC.7097:58USINESSANDPP.OFESSIDNSCODEiANVCINOR (n U COUNi7WHICHHEIX11fiESAPERMITTOCONSTRUC7,ALTER,iMPRbVE,DEMOLISH,GRREPAIRANYS7RUq- (J,J pa(io/DbCk WTURE,PRIDq TO ITS S4VANCE,ASO REDUIRES THE APPLICANT FOA SUCH PERMiT TO FlLE A SIGNE� W g STATEMENT THAT HE Ofi SHE IS LICENSEO PUFiSUANT TO THE PROVISIONS OF THE CONTRACTpRS ll- � CENSE LAW(CHAV7EH 9(COMMENCINO WI7N SECTION�oao)OF prvISION a OF THE BUSINESS ANO PRO- �'�' POOVSpa FESSIONSCODE)ORTHATHEORSHEISEXEMPTTHEREfROMANOTHEBASiSFORTHEACLEGEDEXEMP- (� - V TION.ANYVIOLATIONOFSECTION7031.5BYANYAPPUCANTFORAPERMITSU&IEC4STHEAPPLIC,qNTTO Z RB-ROOP � ACIVIIPENALTYOFNOTMORETHANFIVEHUNDREDDOLLARS�SSUo;�.): � --� - � ❑t.A50WNEROFTHEPROPEHTV,ORMYEMPLOVEESWITHWAGESASiHEIHSOLECOMPENSATION, � Commercial - WILL DO TME WORK AND THE STRUCTUAE IS NOT INTEND�D OR OFFERED FOR-SALE'�SEC:�7Dd4,90S1- —I NESSANO PROFESSIONS CODE:THE CONTRACTORS UCENSE LAW DOES NOTAPPLv TO'AN�OWNER OF � PfiOPERTYWHOBULLDSORIMPROVESTHERWN,ANONMODOESSUCHWOHKHIMSELkORHEdSEI.�OR � OC THROUGHHISORHEROWNEMPLOYEES,PROVIDEDTHATSUCHIMPROVEMENTSARENOYINTENpEDOR � QOFFERE�WRSALEIFHOWEVER7MEBUItDINGORIMPFlOVEMENT'ISSOLDWITHWpNEYEAROFCdMPLE- � TION,TNE OWNEH-BUILDER WILL HME THE BURDEN OF PROVING THAT'HE OR SHE OIO NOT 6UIL�Ofl = IMP�VE FOR THE PURPOSE OF SAlE). � '��-�'�.'�'.'��'- '� O I.AS OWNER OF THE PROPERTY,PM EXCWSIVELY CON7RACTING WI7H LICENSED COMRACTORS � To CONSTRUCY�hiE PROJECT(SEC.70�4,BUSINESS AND PROFESSIONS CODE:Th1E CO,NTRAC70RS�LI- V1luetiofl ADJ.AREA � CENSEUWDOESNOTAPP�YTOANOVlNEROFpPROFERTVWHOBUILO50R!MPROVES7HEFIEOIJ,AND WHOCONTRACTSFDRSUCHPHOJECTSWITNACONTRACYOR�S)L�CENSEDPURSUANTTOTHECONTRAC. pNTiTY DESCRIPTION FEE � TOfiS UCENSE UW.). � _ � � ❑i AM D(EMPT UPoDER S�C. B.6 P.C.FOR TNIS PEASOiJ �a � � � �" � DA7E OWNER U 4� ,y� T � W C [A•.... t1 O LICENSED CONTRACTOPS DECLARATION W k* �;;�'�w; � � � IHEREBYAFFIFMUNOEPPENALttOFPERJURYTHATIAMLICENSEDUN�EFPROVISION50FGHAPTER . � D(COMMENCNO WITH SECTION 7000)OF�IVISION 3 OF THE BUSINESSAND PROFESSIONS CODE,AND MY UCENSE IS IN FULL FORCEAND EFFECT. m Q � � L�GENSE CIASS L�C.NO. ,J U DATE GONTRACTOR. ...'_. �.'��.' .-� a . . W � WORKERS'COMPENSATION DECLARATION � —� ¢ � IHEREBYAFFIRMUND6HPENAIT'OFPERlURYONEOFTHEFOLLDWINGDECLAR4710N5: �� - � � � Z Q O INAVEANDWILLMAINTAINACEFiT�ICATEOFCONSENTTOSELF�INSUREFOFWORKEFS' � _ � COMPENSATION.AS PiiOVIDE�BV SECTION 37000FTHE LABOR CODE,FOR THE PERFORMANCE W OFTHF_WORK FOR WNICHTHIS PERMIT IS ISSUED. � C] —' W _I HAVE ANO WILLMAINTAIN WORKERS'COMPENSATION INSURpNCE,AS REQUIRED BY SECTION � 3700 OF THE LABOR CODE,FOR THE PERWRMANCE OF THE WORK FOR WtIICH THIS FERMIT 15 ISSUED.MYYVOliKERS'COMPENSATIONINSUPANCECARFIERANDPOLICYNUMBERARE: CONSTNUCTION � CARRIER PLAN REVIEW ZPOLICYNUMBFFi _— CTRIC Q Q (IFIlSSECf%7NNE�NOTBE�LEIEDOFlFEPEMNTISWRIXJENUI�AREDWLLAFiS(5100)ORL�S). � UMBING W � 1 CEATIFY TFU1T IN THE PERFORMANCE OFTHE WOidK FOR WHICH THIS PFRMIT IS ISSl1ED,I MECHANICAL � SHALL NOT[MPLOV ANY PERSON INANY MANNEP SO AS TO BECOME SUBJ£CTTO THE �j WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF�SHOULD BECOME WSPECTlON FEE . SUBJECT TO Tl1E WORKERS'COMPENSATION PP.OVISIONS OF SECTION 37n0 OF THE LA80R -��- WOE,I SHALL FORTHWITH COMPLV WITH THOSE PftOVISIONS. � (SSUANCE � � SMIP p DATE: _ APPLICAN7: . � . W ENERGY P/C J WARNING:FAILURE TO SECUflE WORKERS'cOMPENSATION COVERAGE IS UNLAWFVL,AND SHALLBE � SUBJECTANEMPIOYERTOCRIMINALPENALTIESANDCIYILFINESUPTOONEFIUNDREOTHOUSAh'D ENERGVPERMIT OOLLA(iS(5100.000).IN ADDITION TOTHE COST OF COMPENSATION,DAMAGES AS PROVI�ED FOR IN � SECTION 37ae OF TFIE LABOR COOE.IMTEREST.ANDATTORNEI"5 FEES. RETENTION FEE: � CONSTRUCTION LENDING AGENCY PRE-ALT FEE: � I iiEREBV AFFIRM UNDER PENALTY OF PERJURY iHATTHERE IS A CONSTPUCTION LENDMG AGENCY � FORTHEFERFORMANCEOFiHEWORKF-0RWHICHTHISPERMITISI55VE�(SEC.30W,�CIV.C.).� - Z W — � LENDEF'S NAME ' F— LEN�ER'SADDRESS W I CERTIFYTHAT I HAVE READ iHIS APPLICATION hND STATE THATTHc A60VE INFORMATION IS CARRECT TOTAL FE ES ,�� � � p I AGHEE TO COMPLV WITH ALLCITY AND CAUNTY ORDINANCES AND STATE IAWS RELATING i0 6UItAING ��� . � CONSTR�CTION,AND HEREBYAUTHORIZE eEPRESENTATIVES OFTHIS COUNTV70 ENTEP UPON THE z ABOVE-AIENTIONEDGROPERTVFORINSPECTbNPURPOSES. COMMENTS � ,jg'����'t-�-a�� ���"i�'��� t� � m PERAIITTEE E(RINn �/y^�'"i Q �'�..@._r'^' ���~� �`1�Y�� � -� � � SiQNATURED�MI7TEE ���AT� �� = RECPT.NO. 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