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Home My WebLink About18242 ,, C1TY OF DIAMOND BAR t....��Y��''i;� - �'`�`` DEPf1ItTMENT 4F COMMUNI'I'Y&DEVEL4PMBNT SERVICES 21825 E=CQpley Drive �.�- �� (909)$60-3195 Fa�c(909)861-3117 PR�� BUILDING PERMIT APPLICATION FIRMi.Y � JOBSITE � i J APPLICATION \ PERMIT ��} P/C � ADDRESS� '`� # L�C�M'"1'��' S� DATE ��UMBER � J+ ��'k � ISSUE TYPE OCC APN l�QT TRAGT _ DATE CONSt_ GROUP p OWNER LtI G�+K :�OR . C>�`� ADDRESS '�..�t�C t t.-y"c�C,�t,T�� T ZONING SETBACKS � c�rv �'��aa-f z�� q i 7� T��_�f� 5�4�� aoNT _ Rw � APPUCANT �J'I-L 1�—L.�T3`�` TEL._ REAR � SIDEISIOE STREET RW C. m,q� CONTRAGTOR_ •�- � � � � "V G SIDE __ [- _ ADDRES6 �Z --�'k t � CITY N� 4 w.:s�(+ Z!P ET L�� _ ��_--�t Z�'�T PROPIJSED USE a ARCH/ENG/ _ z DESIGNER Np.DWEL. NQ. NO. a ADDRESS UNITS STDRtES BEDROOMS � CITY ZIP. TEL. �'`� DESGRIPTION SQ.FL FACTdR PSF ADJ.AREANAIUATtON cs � OWNER-BUILDER DEGLARATION SFRfADB/REM � � I HEREBV AFFIRM UNDER PENALTV OF P€RJURV THAI�I AM F%EMPT FR17M TNE CONTMCTpRS LI� � G8f8Q8/C2fp011 W GEVSEIAWFORTHEFOlI.C?WlNGPEASQN{SEG]031SBUSINESSANDPPOFESSIONSCO�E:ANYCITYOR _— G> COUNTVWH�CNREOUIitESAPERMiTT�C6tlSTRVCT,ALTER,�AAPROVE,OEMOLISM.ORREPAIRANYSiRUF W PBtiO/DBCI( � TURE,PRIOR TO 1181SSUANCE,AL50 REQUIRES THE FPPUCANT FOR SUGH PERMIT TO FILE A SIGNED � �� STATEMENT TNAT NE OR SHE IS liCEN5eD PURSUANT TO THE PROJI5IONS QF TNE CQYTRACTQRS U� � CENSE LAW(CHAPTEfi 9(COMMENCING WITH SEGI'IDN 7DOo7 OF DIVISION 3 OF THE BUSINESS ANb PRO- � PopUSpa � FESSIdNSC(}DE)ORTHATNEORSHEI5E%EMPTTHEREFf10MANpTHEBA5ISFORTHEALLEGEDENEMP� (�J � TKIN.RNYViOlAT70NOFSECTION1031S8YAMYAPPIiChNTF6RAPERMiTSUBJEC7STHEAPP�iC.AN7Tp Z Re-Roof r A CIVIL PENAI,TV OF NO7 MORE THAN FiVE HUNDRED DOLLARS(#500).)� � OI,ASOWNEROFTNEPROPERTY,ORMYEMPI.OYEESWITHWAGESAS7HEIflSOLECP44PEN&ATION, 0 �6lTiR18(C431 � � WIIL DO THE WOAK,AN6 THE STRUCTURE�S NOT MTENDED QR OFfERE6 Fqft SA4E(SEC.�644.BUS�� J NESS AN�PqOFESSIONS CODE:THE CqNTAACTOR&LICENSE LAW OOES NOT APPLY TO AN OWNER OF � PR6PERTYWHOBVIIDSORiMPRf?VESTHGFlE4N,ANDWHODOc55U:AiW4flt(HIM5filFOftHERSELFOfl m � THqOUGH HIS OR HER OWN EMP40YEES,PRC?VI�ED THAi SUCH IMPROVEMENTS ARE NOT MTENLIED Ofl � C]FFEFlEOF6fl5ALE.IF,HOWEVERT7EBUILDINGORIMPROVEMENTIS50LOWITHINONEVEAROFCOMPLF.- � TION,THE OWNEft�BUt[DER WR.1.HAYE THE BUF�EN OF QftOVitvG THAT HE OR SkiE DIO t�T BUItD OR � IMPFQVE FOp TME PURPOSE OF 5ALE). W IJI,A50WNEHOFTHEPROPERTY,AMEXCLUSNELVCQNTNACTINGWITHLICENSEDCONTRACTOR5 [[ fD CQNSTRUCT'�FIE PftOJECT j5EC.70db,BUSINESS AND PROFESS10N5 GOC1F�T}tE CANTRACTOR9 t�� V3IUdtio(i ADJ.AREA_ W CENSELAW�OESNOTAPPLVTpANOWNEROFAPflOPERTVwHOBl11I.pSORIlAPR4YE5TNEREON,AND F 4VHOC4NTRACTSFORSUCHPftOJECTSWITNACONTRACTOP(5)UCENSEDPURSUANi'TOTHEfANTRAC- QUANTITY DESCRIP716N FEE TOftS LICENSE LAW.}. � � p I AM EXEAd4�T UNOER SEC. 8.&P.C.FQR THlS REASON � � � � OATE OV.Rv'ER . _— ~ Z W � �IGENSED GONTRACTORS DECEARA7IGSN i j d LL` i HERFBY AFFIRM UNDER PENN.TY OF PEAJU�Y TNAT{AM I.ICENSED UN�Eft PPOVlSIONS OF C,4AP IER � �-�'� �f�h'r' �� (j,_ 9(COMMENCMG WiTH S6C�ION 7oao)iJF DIViSiON 3 OF THE BUSINESS AND PR6FESSONS CODE,AND Z �� X MV UCENSE IS IN FULL FOflCE AND EFFECT. m 4' CJ � � I,ICENSE CLASS-s ��+' LIC.NO.�� (' '"� � � 6ATE E3"2 d �L _ CONTRACTOR, A•L.R. • ,�SS�' d W � W�RKERS'G4MPENSATION DECIARATt6N -� u... a v� U � I HERE6YAFFiftM UNDER PENALTY OF PER,AIRY OhlE OF THE FOL�4WING DECIARATKK95: Z Q C] IHAVEAN[7WILLMAINTAINACEFTIFICATECFCONSENTTOSEIF-INSUREFORWORNERS' 2 � �COHiPENSATiON.AS PRQVIOED 6Y SECTION 376o OF TNE LA66R COpE,FO{i THE P£RFORMANCE W OF THE W4%N F4R WHICH THIS PERMIT IS lu"SUED. � � I MNVE AND WILI MAINTAIN WORKER6'COMpENSATION MSURANCE,AS REOUIRED BV SECTION � �37000FTHELABOHCODE.FORTHEPERFQPMANGEOFTHEWOAKFbRWHICHTHISPERMlTlS � — tSSUEO.AiV X�K�IR(K,EpR,.�S.'.,CQMPENSATIqN INSUjR^ANJ.',.,EI)CApfliER AN6 POt.iCY NUMBER ARE: CQNSTRUCTION �"�„ CARRIER_.Y�".l/...'G"O h'A... Ir%/%+p�` ...�/11.j�It.�vC�$" PI.AN flEYIEW ..... - � POLICV NUMBER 1N�Z^`�� . �.� 1.� �� ELECTRIC '� �� (n1IS5ECMINNEE6NOTBE��EDOFh1EPERMITISFi�RONEHUMREDDOLLARS(E100)ORLES5) PLIJMBING . � I CEflTiGY THAT IN THE PERFORiAANCE OF THE WOfiK FOR WHICHTHiS PERMiT IS ISSUED,I MECHANtCAL � _.._..._ __..... !,� SHA44 NOT EMPI.OY ANY PERSON IN ANV MANNEH SOAS TO BEGOME SUBJECT TO THE �J.JSPEGTION FEE _„ �j WCJ�KERS'CQMPENSAT!(�N UWS OF CAIIfOftNiA,AND AGREE 71iAT if I SMOULD 6EGOME ---��—��--- SUBJECT TO THE WORKERS'COMVENSATION PftOVI51ONS OF SECTION 310G OF 7 HE LABQH �� GObE,I SHALL FbflTHWII H GOMPLV WI7H THOSE PROVISiONS. � ISSUANCE �� pDATE:��'^ APPLICANt: ��--' / `T�-��-�� _.. SMIP . - � ENERGY PIC _ _ . J WARNING FAIU/AE TO SECllRE WORKERS'CQMPENSATION COVERAGE IS UNLAWFUi.,AND SHAIL BE LL SUBJECTANF.MPLOYERTOCRIMINALPENAI.TIESANDGIVI�.FINE5UPTOONEHUNOREDTHOUSAN� �NERGYPERMIT . OOlIAPS(Sico,ao0).IN AODITIbN TQ THE GOST OF CflMPEN6AT14N,QAMAGES AS PROVIJED F4R IN --�j�"'ti � SEGTIONJ�'JBOFTHELPBOFCO�E,MfEREST,ANDATTDRNEY'SfEE5. RETENTIONFEE: , _. _. �� CONSTRUCTIONIENDiNGl+GEi�7CV PRE-ALTFEE: __ .. . �- i HER£8Y AGFifttd VNDER PENA�T�`Of PER.lURY THAT TNERE iS AG4NSTP,UCTICN IENDMit3 AGENC;Y _ � FOP THE P[LiFOFMANCE OF THE WOFK FOP VJNICH THIS REflMIT I5155UE��9EC.}09I,GIV.C.). �� 2 — w � LENDER'S NAME .. � �--�� ___ __ _, F- IENDER'SAODflESS�..�^_ -- ..... - ['' � IGERTIfYTHATINAVEREACTNISAPP1.iCATpNANO5TA7ETH4TTHEA@QYEINfaftMRTlONiSGORR£CT. �QTAL I�E�� I ACREE TO COMP�_Y WITN ALL CITY AND COUNTY OPDINFNGES AND STATE LAWS RELATING TO BUILDING � CONSTRUCTIQN,AND HEREBY AUTHORIZE REPRESENTATNES OF THIS COUNTV TO F.NTEflUPON THE � ABOV@-MEM70NE0 PR6PERTY FDR INSPECi'iJN i'UftPOSES. COMMENTS .___,.__ � _�,/,�"t.�_..__—��.�i�,, — — PERMITf�PPINT), / � �— —� " c�_n �� r✓Ns2••.. f�'-��'d �--- _.— — � 51G/CATUftEOFPER ITTEE —�- Ob.TE y RECPt KO. �� PAID BY _. _ VALIDATION ~ WNITE—Dapartment Copy.YEILOW—Finance Copy,PINK—Assesso�Copy.GOLDENRQp--Pila Gopy,GREEN—ApplicaM's Copy � s� i � � �x e� �`�� ' P ��'��` � .�� a � m��i� � i�E �� i a, �^�� +�� _ � . ... . . .. .. . � � e�' ' ��. . ._ ..-� ' ? �,�„��..%�� _.. ... _. . .. � ... ... .. ... . . .. _ ��. .�.::�-+ -. . : ... _. . �. r, _ .., ` ,�,: "�w7 i i ��'�� . ... .. .. ... .... . - -; i� : w .a; ._ .. . . ... . . . ... . ..._ . �Z �: i �.;� F, ,f �. � �a� i .:("� .,.��y, �. .�', .... . . .... .. . ..... ... .. . ..... . . a„ .: id � � , ��. >, . ... . .. ___ .... .. ..._ _ _ ��.i �.,k — ' � ��... ' '. ! ` �.,�: � � . . . ... . . ..... . ... .... . .. .._.. .. ... . ._ . _ . ,e � s �" �—�r�i� . o . >� � s xi< � CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES 21825 E.Copley Drive (909)860-3195 Fax(909)861-3117 BUILDING PERMIT APPLICATION I, PRESS FIRMLY r5 yc 0!/t 2 14/ I L ADDR ESS APN LOT TRACT OWNER LA 6K :f&(t'I ADDRESS-L I t It t c:o nTW C ST CITY woIIL N"t'r ZIP°117-5 TEL.. 59h9 7- APPLICANT 1J1&C_TLvi,4 TTs4F TEL. CONTRACTOR A- L-.d--a c ADDRESS Z."- (� 1=f/,y CITY/'v 6 w..4 P zIP 91 t' �fy'?t L ARCH/ENG/ DESIGNER ADDRESS CITY ZIP TEL. OWNER-BUILDER DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI- CENSE LAW FOR THE FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE:ANY CITY OR COUNTY WHICH REQUIRES A PERMITTO CONSTRUCT,ALTER,IMPROVE, DEMOLISH,OR REPAIR ANY STRUC- TURE. PRIOR TO ITS ISSUANCE,ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI- CENSE LAW(CHAPTER 9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO- FESSIONS CODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP- TION.ANY VIOLATION OF SECTION 7031.5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS($500).): ^ I,AS OWNER OF THE PROPERTY,OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION, WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC 7044, BUSI. NESS AND PROFESSIONS CODE:THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF PROPERTY WHO BUILDS OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR OFFERED FOR SALE. IF,HOWEVER,THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF COMPLE- TION,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR IMPROVE FOR THE PURPOSE OF SALE). ^ I.AS OWNER OF THE PROPERTY,AM EXCLUSIVELY CONTRACTlNG WITH LICENSED CONTRACTORS TO CONSTRUCT THE PROJECT(SEC. 7044, BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI- CENSE LAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAC- TORS LICENSE LAW.). ^ I AM EXEMPT UNDER SEC. B. &P.C. FOR THIS REASON DATE OWNER LICENSED CONTRACTORS DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER 9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND MY LICENSE IS IN FULL FORCE AND EFFECT. 6-36 7?t CI c05 LICENSE CLASS LIC. N0. . S-5 C- DATE 6 �2-7-o L CONTRACTOR/J. L.A• •6 WORKERS'COMPENSATION DECLARATION I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS: I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS' COMPENSATION,AS PROVIDED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED 1 HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. MY WORKERS'COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE: CARRIER POLICY NUMBER Ht C--2- "f.- L-cS rl �i t (THIS SECTION NEED NOT BE COMPLETED OF THE PERMIT IS FOR ONE HUNDRED DOLLARS($100)OR LESS). I CERTIFY THAT IN THE PERFORMANCE OF THE WORN FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR CODE,I SHALL FORTHWITH COMPLY WITHTTHOSE PROVISIOONS.. L/4-( ! �TL- 6? DAT PLICANT E: I AP WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL BE SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS($100,000),IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3708 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES. CONSTRUCTlON LENDING AGENCY I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC. 3097,CIV.C.). LENDER'S NAME LENDER'S ADDRESS I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT. I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES (A f igJ/9N PERMITTE A(PRINT) SIGQ TURE OF PER ITTE� E DATE APPLI CATION(- P/C �\_g DATE UMB R/ ISSUE TYPE OCC DATE CONST GROUP ZONING SETBACKS FRONT RW^ REAR p SIDE/SIDE STREET RW^ SIDE^ PROPOSED USE N0. DWEL. N0. N0. UNITS STORIES BEDROOMS DESCRIPTION SQ. FT. FACTOR PSF ADJ.AREA/VALUATION SFR/ADD/REM U) Garage/Carport W Patio/Deck LL Poo)/Spa 0 Re-Roof Z 0 Commercial 5 m Valuation ADJ.AREA QUANTITY DESCRIPTION FEE J U !r 0 w W - Z V. 12 ffof LA 1. -S, 77 Z-/-z a U w CONSTRUCTION PLAN REVIEW ELECTRIC PLUMBING MECHANICAL INSPECTION FEE ISSUANCE SMIP ENERGY P/C ENERGY PERMIT RETENTION FEE: PRE-ALT FEE: TOTAL FEES 1 J U COMMENTS -N r-Tv- RECPT N0. PAID BY VALIDATION WHITE-Department Copy,YELLOW-Finance Copy, PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy