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�: ..,..,,.._, . , , . ,.�,.:.,.,-,.m,�,. .. _..�..w.�»..__.•�.,�.�e<�:,-��'-�a�� -����.,,. �� . �.��:.� . �,.�.,_ .u..t...: �. -----��``k— CTTY OF DiAMOND BAR �:� � � COMMUNITY DEVELOPIVIENT`T)EPARTM�N'I' �/� . , _>„� . 21660 E.Copley Drive Suite 190 PRES+fj+ (909)860-3195 Fa�c(909)86]-3117 ��� �'�M"� BUiLDING PERMIT APPLICATION FIRMLY a� JOBSITE I ���, S ���a �� ,;;. APPLICATION` " �� ,^ `PERMIT � � I 8 P!C ADDRESS DATE � NUMB�R # �, ISSUE TYPE OCC ^° APN LOT TRACT DATE � � CONST. GROUP q OWNER r�1 � �-3'� ADDR S � <% �° t���'1—e�t>��--n-��/— ZONING SETBACKS z CITY��G'✓na-n1,�2 Z� ZIP I��� TEN ' FRONT RW ❑ � APPLICANT TEL. REAR ❑ Z SIDEISIDE STREET RW ❑ Q CONTRACTOR �P 'Ct,w�-f.i �a SIDE ❑ ADDR SS C- , ° -h- ��1, � CITY °1` � ZIP TEL. PROPOSED USE__ w� ARCH/ENG/ z DESIGNER NO.DWEL. NO. NO. � ADDRESS UNIT'S STORIES BEDROOMS = CITY ZIP TEL. � DESCRIPTION SQ.Ff FACTOR PSF ADJ.AREANALUATION � OWNER-BI;IL�ER DECLARATION SFR/ADO/REM O p I HEREBY AFFIRM UNOER PENALTY OF PEftJURY THAT I AM EXEMPT FROM THE CONTRACTOqS LI� GefB J8/C2�OfI W CEN5ELAWFORTHEFOIION'INGflEASON(SEC.7031.SBUSINESSA�Y�PROFESSIONSCOOE:ANVC�TYOR (f� � COUNTYWHICHREOUIRESAPEFMITTOCONSTRUCT.AITER.IMPftOVE.DEMOLISM,O%REPAIRANYS"RUG- W POtio/DeCk W TURE,PFiIOR TO ITS'ISSUANCE,ALSa REOUiRES THE APPLICANT FOR 5UCH PERMITTO FILEA'SIGNED w STATEMENT THAY HE OR SHE IS UCENSED 7UFSl1ANT 70 THE PROVISIONS OF 7HE CONTqACTOFiS LI- � CENSE LAW(CHAPTER 9(COMMENCING WITH SECTION�000)OF DIVISION 3 OF THE 6USINESS AND'PpO- �'�"� PDOVSP9 � FESSIONSCODE�ORTHATHEORSHEISE%EMPTTHEREFROMANOiHE0A51SFOPiHEqLLEGEDEXEMP- (�, AICIVILPENA�LTYO�FNOTMORE HANFIVEHUNDREDDOLrLARO$5�"MITSUOJEC7STHEAPPLICAIJTTO Z Re-Roof U � ..._. . .. ..,.. ... Q ❑I,ASOWNEROFTHEPROPER'R',ORMYEMPLOYEESN'ITHWAGESASTHEIRSOLECOMP'cNSATON, L�j COtllttlBfC181 Z WILl00 THE WOPK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SF.C.70dd,B1J51- J NESS AND PROFESSIONS CO�E:THE CONTRPCTOflS LICENSE LAW�OES NOT APPLY TO"AN OWNER OF � PROPERTVW408UILDSORIMPROVESTHEREON,ANDWHODOESSUCHWORKHIMSELFOqf1ERSELFOR = � THROl1GH HIS OR HEF OWN EMPLOVEES.PROVIDED THAT SUCH IMPROYEMENTS ARE NOT IN1'ENDED OR m w OFFEREDFORSALEIF,HOWEVCR,THEBUIL�INGORIMPFOVEMENTiSSOLDWITHINONEYE4ROFCOdAPLE- - � TION,THE OWNER-eUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OP.SHE DID Nb7�BUICD OR Z IMPROVEFOR'HEPURPOSEOFSAI.E} � = OI,ASOWNEROFTHFPROPER'n',AMEXCWSIVELYCONTRACTINGWITHLICENSEDCON7RACT075 W Q TO CONSTRUCT THE PROJECT(SEC.7044,BUSMESS AND PROFESSIONS CODE:THE COVTRACTOl75 L'- VdIUBflOf1 ADJ.AREA W CENSEL4WDOESNOTAPPLYTOANOWNERDFAPFOPEPTYWHOBUILDSORIMPRO�ESTHEREON,:ANO � WHOCONTRACTSFOflSUCHPROJECTSW(THACONTRACTOR(5�410ENSEDPURSUANTTOTHECONTRAG QUANTITY DESCRIPTION FEE � TORSLICENSELAW.). � J � ❑I AM EXEMPT UNDER SEC. B.8 P.C.FOR T41S flEASON � � � V'" OATE OWNER .. .... . U Z �yA � LICENSE�CONTRACTORS DEGLARATION , W ¢ � IHEREBYAFFIRMUNDERPENALTVO=PERJURVTHATIAMUCENSEDUNDERPROVISIONSOFCHAPTER � d 9(COMMENCMG WITH SECTION 70CD)OF DNIS�ON 3 0F THE BUSINESS AND PROFESSlONS CODE,AIV� z `X MY UCENSE IS W FULL F RCE A EFFECT r� � LICENSE CLASS � ��� _LIC.NO. "'�p�q� l��L L � j U DATE ��_� CONTRACTOFi 1°'�� �+–'1��_ 0. � LlJ .., ..... .� � WORKERS'COMPENSATION�ECLARA710N � �j l�-.� F,•nQ� � � I HEREBYAFFIRM UNOEH PENAITY OF PERJURV ONE OF THE FOLLOWING DECLARATIONS: C� Q � IHAVEANDWILLMAIN'AINACERTIFICATEOFCONSENTTOSELF-INSUREFORWORKEAS' S Z COMPENSATION,AS PflOVIDED 8Y SECTION 370o OFTHE LABOft CODE,FOR THE PERFORMANCE U Q OFTHE WORK FOF Wh'ICH THIS PERMIT IS ISSUED. � � W I HAVEAND WILL MAINTAIN WORKERS'CAMPENSATION INSURANCE,AS REQUIRED BY 5��� B 370o O�THE LABOR COOE,FORTHE PcRFORMANCE OFTHE WORN FOR WHICHTHIS�E T I � ISSUED.MV WOR RS'COMPENSAiION INSURANCE CARflIERAND POLICYN �A CONSTRUCTION J �u ^�7� ,,, � CARPIER `' � ( �t'�.�-n�' �,� � _ , PLAN REVIEW . .::: ..... .. .... Z , . POLICYNUMBER -„-..�--'7�AJ � . . . ... . .._,_... . ....,..r,:�. . �... . . . ��-- ELECTFIC ¢ � (fHISSECTKYJ�'EmNOTBE�IPLEIEDOFTHEPERMrt'ISFORONEHUNDREDDOLLARS(5100)Q�E�, W 'i � ICERTIFYTHA?INTHEPERFORMANCEOFiHEWORKFORWHICHTHIS^EFMITIS S ,� ECHANICRL SHALL NOT EMpLOV ANV PERSON IN ANV MANVER SOAS TO BECOM'e SUBJECT � WORKERS'COMPENSATIOM1LAWSOFCALIFORNIA,ANDAGREETHATIFISHOUL� OME FEE SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF A4E L ABOR = CA�E.ISHALLFOqTHW;111COMPLYWITHTHOSEPROVI510N5. _P�NCE � 0 p DATE: APPLICANT: � ENERGY PiC � WARNINO:FAIIUflE TO SECURE WOqK[RS'COMPENSATION CAVERAGE IS UNLAWFUL,ANO�SHALL BE� � SUBJECT.ANEMPLOVERTOCFlIlAINA_PENALTIESAN�CIVILFINESl1PTOIXJEHUN�REDTHOUSANO ENERGYPERMIT DOIIARS(5100,000�,IN A��ITION TO THE COST OF COMPENSATION,�AMAGES AS PROVIOED FOR IN J SECTION 37oe OF TNE LABOF CODE,MTEREST,ANO A'fTORNEV'S FEES. � RETENTION FEE: � d CONS7RUCTION LENDING AGENCY PRE•ALT FEE: O � IHEREBYAFFIRMt1NDERPENAITVOFPERJURYTHATTHEREISACANSTRUCTIONLENDINGAGENCY � FOR THE PEP.FORMANCE OF THE WOPK FOR WHICH THIS PERMIT IS ISSUE�(SEC.3097,CIV C.). � - .. . Z w _-- — � lENOER'S NAME _ � � ' F— LENDER'SADDRESS � ICERTIFVTHATIHAVEREADTHISAP7LICA?IONANDSTA7ETHATTHEABOVEINFOR�AATIONISCORRFCT TOTAL FEES . J , . . - ' ' � fAGREETOCOMP4YWITHALLqTYANOCOUNTYORDINANCESANDSTATELAWSRELATINGT08U1LDIIJG � CONSTRVCTION,ANDHEREBVAUTHORIZ'cFEPRESENTA71VE5OFTHISCOUNTVTOENTERUPONTHE �. + +• - � � ABOVE-MENTIONED PROPERTY FOR INSPECTION PUR?OSES. COMMENTS � �4iC �.�.Y�."C° �G�YLC.� � ..._ , �. � ' ' ��� � � > --------- � +� �'';i����;ll I, . ¢ PERMITTEENAM (PRI T; �'� �+!'� C!� Q j � SIGNHTUR OFPERMITTEE � - DATE RECPT.NO. 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