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�` CITY OF DIAMOND BAR �
DEPAI2TMENT OF COMMUNITY&DEVELOPMENT SERVICES �
� 2166t}E.Coptey I?rive Suite 190
(909)860-3195 Fa�c(909)861-3117 � � RESS
��� BUILDING PERMTI'APPLICATION �%%�f�� FIRMLY
� J08SITE �.3�_�G y� ! �,�.. APPLICATION `�-�\ �- �\
� ADDRESS *�"� fK:'.f,�E;.a'C�� � t�. t-t DATE J !� � �NUMBER �lJ �/C
` 18SUE TYPE OCG
� APN !OT��Q TRACT �c+���7 DATE i CONST. GROUP
p OWNER _,.,�;LG J"� I�C j2j,�j --�—
� ZONING SETBACKS
� ADDRESS�.-�i"+/` tLl1 �yj t,�¢'�r'!'!�_��� ��C?i�
� GlTY__��"�La�'7-G� ZIP��,�j�jfEC..`f4r/-7�'J-tfjf6� REAR� RW �
APPLICANT _ TEL gIDElStQE STREET RW (�
� CONTAACTQR� � S�QE U
� ADORESS �-C�i YZ'1 fi'
GITY Z!P_� TEI. PROPf?SED USE ti�. C �"r,
w ARCH/ENG/ (��
��„ DESIGNER��,��-�.��`-�+^���1'"f,t.2�Y.2�_ NO.DWEL NO. NO.
'� ADDRESS i� �2. t1NtTS STORIES BEpROC3MS
� CITY . _ ZIP(1 -�,}'�TEL.`7l�i tii1 `l��j
� DESCRiPTION SQ.FT FACTOR PSF ADJ.AREANALUATIQN
� OWNEA•BUIL�ER DECLARATION 8FR1AQDIREM
O
I HENEBY AFFIRM UMOER PENAI.TV OF PERJURV THAT I MI EXEMPT FROM THE CON7RACTORS U� G8f890/C5(POR
� CENSElA1NF(7R7HEFq.LOWINC3RFASLIM(SEG.7tlDt.56U51NESSANDPROFE5SlON5GOGE:ANYCITY6R (j,}
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TUFE,VRqR 70 IT$ISSUANCE,ALSQ REQUIRES TME APPLICMIT FOR SUCH PERMIT TO FILE A SIGNED �
� STATEMENT T}GT HE 4R:itfE t$llGEMSED PURSUMF TO THE PftOViSI�ttS OF TNE C�NTRACTQiiS lF
CENSE LAW(qi�PTER 9(IxM1MENCINf3 WIiN SEC710N 19oa)OF�IVISION 3 OF THE BUSINF.SS ANO PR4• u' POOUSpB
FESSIONS CpDE)OR TMAT ME Ofl SHE IS E%EMPT THEREFHOM AND THE BASIS FOR THE A4LEGE0£%EMP-
TKKi.MTYN;Hl4TIONOFSECTtIXi7031.58YMlYAPPLICANTF6R�iPEAMiTSU&/ECTShiEAPf�IiCANTTO Z �}p.Fjpp�
� A CMl VENAI.TV OF NOT MORE THAN FNE HUNDRED DOI_LP.RS(1500).)�
� ❑I,A54WNEROFIHEPHbPEPTV,�f34YEMPlOYEESWfTHWP.�GSASTl1EIRSOIECOMPEN5ATiOM, 0 �pmrt56tGiaE
WIt1 DO THE W6RK.AND 7HE S7qUCTURE i5 NOT iNiEND£D OR OiFEPED FOfl SALE(SCG.�D44,BUSI- J
� NESS N!D PqOFE$51qJS�X1DE;THE GONTMC70R5 LICENSE lAW DOES NUT APPLV TO AN OWNER OF �
RppPEHTY WHD 9ULL.D60N 1biPROYES hiEREON,ANO WMR OOES SUGt[WORN HIMSELFdR HERSEIF OH
CC T1iRf7UaNMSORHERpNMEMP�ovEES,PPqV1DEDTHATSUCFIIMPROVEMENTSARENO7INTENDEDOR m
� OFFEREOFORSN.EIF,HOWEVER117EBUILDINGORIMPROVEMENTISSULDWITHINONEYEAROFCf1AAPLE�
Z TqN,THE Q4VNEH-8i1�pER WIiL HAVE IHE BtfflDEN 4F PROVtNG 7NAT HE bfl SNF Di�tN�7 9Ut10 Op
� NAPM?VE iqR TME PURVf7�iE OF SALE�.
0 I,A5 OYVNEfl OF THc GROPERTY,AM E%CLUSIYELV CON7MC71Nf;W17H LICENSED CDN i RACToqS
('t TQ CONSTflUCT TFiE PROJECT(SEC.7tl44.BUSINE55 AND PROF�SSI�S COOE:THE CQNTMCTORS ti- V81U8110I1 A�J.AREA__
UJ CENSEUWpOESNOTAPFLVTOANOWNEFlOFAPROPERTYWHOBU14�50RIMPR17VE9THERE4N,AND
� lYHOf`ANT1iACT5FpRSUC}lPRQJECTSWlT}1AC0l�ITR�CTOR(5)l{CENSEQPURSV/dVTTOT.iEGONTRiC- QUANTITY DESCRIPT}OtV FEE
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CI fAM E%EMPTllNDERSEC. 8.d P.C,FQftTHiS REASON Q
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IICENSED C6NTRACTORS DECLARATiON �
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IHEREBYlFFIpNUNDERPeNAt,IYOfPER1URYTH4TiAMLiCEN$EDUNDEflPROYiSK1N50fiCHAPTER � r �
� 4i��ENCIN(iWITHSECTpN'7o0o�6FDIVISION90F?HEHUSINESSANDPflOFE5S�CN5CA0E,AND Z
�{ MV LICENSE IS IN FULl F4PCE AND EFFEC7.
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� UCENSE CLASS��,,,,,_____ LIC.NO. �7 I ������ j
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�+� COMVB�SKTION.A£GROVI6Eb BV SECTI6N 3�06 pF TYtE UBOR COC7E,FOR THE PERiORMANCE `U
� THE WOHK FOR WHICH THIu PERMIT IS ISSVEp. �
�
� I HAVE AND WiLL MAINT0.IN WORNFR5 COMPENSATION MSUFiANCE.AS RFQIJIRED 6V SECTION ///•�� �.-n
� 37000FTNELAH4RCCIDE.FOflTHEPERFONlAANCEOF7HFWORKFqAWHICHTNI&PERMI IS � ���/�,��t .
tSSUED.MY �//,�E�RS'CAMPENSATION itJSURANC/E/chRRiE/R�AND PqU�CYq N� (B�"t AAE: CONSTRUCTION ��'� s�✓
jCAARIER__��'I � `� '+' -p,,l,.�����" "� PLANREVIEW � . . ... _
d POIICVNUM6ER / .„�_x���.�. ELECTRIC � ��
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� I CfRTIiYTNAT M TtiF PERR'ORMANCE OG 7NE WORK FOfi WHICItTHiS PERMIT�S ISSUEO,i MECHANIGAL ____._,,,. _�.,,_. ,
(,� SHALL NOT EMPLOY ANY VEPSON IN ANV MANNER 50 AS TO BEGOME SVBJEGT i O'fME
� YKJRKERS'(:OMPENSATIONLAWSOFCAIifOR48A.RNDAGREETMATIFiSMOVLGBECAME INSPEC�IONFEE .
� SU&fECTTOTHEIWSRKERS'CUMPENSATIpNPROV1510M50fSECTKNJJ7otlOFTHEUBOR — \
COOE.I SHALL FOfllHW1TH COMPLY WITHTHOSE PROVIS�ONSy �SSUANCE ��.0-��.�J
p �� [�. SMIP
p QATE:`_�'_' � _ i�� APPLICANT: �L��-rL ,. _....._._ ..
� ENERGY PtC ,--
� WRRNING:fAILURE TO SECUFE 4JC RKERS'CqMPENSATIpJ COYERAGE IS UN4AWFVL,AND SHALL BE
� SU&IECT AN EMPlR7YER TO�RIMINAL PENALTIES pND CIVII FINES UP TC7 ONE NUN�PED THOUSAND ��.JERGY PERMIT
OOiIARS(ii W,W6j.iN ADOITtON T�SME C65T OF COMPENSATIOH,DAMAGES AS PfiOYl0E0 FOft(P1 --��- -----------
� SECTION]IOb OF TME LA6oN CC?OE,MTEREST.ANpATTORNEY'S KEES. RETENTION FEE: „__.
� CONSTRUCTiON LENOING AGENCY PRF-ALT FEE: ,,,,_.__
� i HEREBY AfFiRM UNDEFi PENN.TY Oi'PEfl.tUftY TNAT TtFERE IS ACANSTft4tCTiON L.ENDtNG AGENCY ��_��,__�i _
FORTHEFERfORAAANCEOFTNEWOflKfOq ICMTMISPERMIt151 UED(SEC.3tl97,CIV.C.).
� �,fL�•{1 �l{ �
� .—_ — � — - _
LENDER'S NAME_
F- 4Etk3EtY5ADORE55� _
� i GER71fY THAF t H4VE R6AD THIS APPt,iCATibN AND STRiE IHAT TME ABQYE INFOPMRTpN FS COIiftEC7. TO t AL�E 4.� � � �� �
� i AGREE l0 COMPLV WITH ALl CITY AND COVNTY ORDINANCES AND STAfE lAWS RELATING TO BUILDING
GONLTRUCtION,AND HEREPY AUTFqRIZE REPRESENTATIYES OF THIS CAUNTY TO ENTER UPON 7XE
�. ABOY£-MENTpNEO Rli�PEftTY F6A iNSA- iKJN AURP0.SE5. COMMENTS„_„
� ��'��-�3 !'s.�'.l � —
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� s�crw E oF psAM�rr[€ on7E �- pq�D BY VAI.IDATION_,�_
� RECPT.NO.
WHITE—Department Copy,YEt14W—Finar�ce Copy,PINK—AsssssOr Copy.�OI.QENRflD—Fiie Copy,GREEN—Appiicant's Gapy
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CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVE�OPMENT SERVICES
21660 E.Copiey Drive Suite 190
09)860-3195
PERMIT Fax(909)861-3117
BUI�DING in .7�1 ' A
BUILDINGG PERAPP�ICATION rf7 L�(r
JOBSITE d�7�L
ADDRESS
APN LOTi'TRACT S d 4(� 1
OWNER
ADDRESS//I NN_'•{!}N7�
CITY r ZIP c EL.�i-1%-777-44'60
APPLICANT TE�.
CONTRACTOR_C
ADDRESS 7'1'1
CITY ZIP TE�.
ARCH/ENG/
DESIGNER 6 C,i-,a < -
ADDRESS 1-NA
CITY. ^ZIP c�+TE�.-7/4-5r- 1/77,7
OWNER-BUI�DER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE�P,W FOR THE FOL�OWING REASON(SEC.7031.5 BUSINESS AND PROFESSIONS CODE: ANY CITY OR
COUNTY WHICH REOUIRESA PERMIT TO CONSTRUCT,A�TER,IMPROVE,DEMOLISH,OR REPAIRANY STRUC.
TURE. PRIOR TO ITS ISSUANCE,ALSO REQUIRES THE APP�ICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI-
CENSE IAW(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 A�LEGED EXEMP-
TION.ANY VIOLATION OF SECTION 7031.5 BY ANY APP�ICANT FOR A PERMIT SUBJECTS THE APP�ICANT TO
A CIVIL PENA�TY OF NOT MORE THAN FIVE HUNDRED DOL�ARS($500).):
^ I,AS OWNER OF THE PROPERTY,OR MY EMP�OYEES WITH WAGES AS THEIR SOLE COMPENSATION.
WI�L DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SA�E(SEC. 7044, BUSI-
NESS AND PROFESSIONS(MOE:THE CONTRACTORS�ICENSE lAW DOES NOT APP�Y TO AN OWNER OF
PROPERTY WHO BUI�DS 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 BUI�DING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF COMPLE-
TION,THE OWNER-BUI�DER WIL�HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUI�D OR
IMPROVE FOR THE PURPOSE OF SALE).
^I,AS OWNER OF THE PROPERTY,AM EXC�USIVE�Y CONTRACTING WITH �ICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC. 7044,BUSINESS AND PROFESSIONS CODE:THE CONTRP,CTORS LI.
CENSE t_AW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUI�DS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PRO)ECTS WITH A CONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAC-
TORS UCENSE�AW.).
^ $AM EXEMPT UNDER SEC. B. &P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DEC�ARATION
I HEREBY AFFIRM UNDER PENA�TY OF PER7URY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE.AND
MY�ICENSE IS IN FUL�FORCE AND EFFECT.
LICENSE CLASS�IC. NO.
DATE e(h . 6i-_:09C7 CONTRACTOR 1'�I !_T F�F(��,_11,9f j
T"
WORKERS'COMPENSATION DECLARATION
II HE E FFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS
I HAVE AND WIL�MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'
COMPENSATION,AS PROVIDED BY SECTION 3700 OF THE IABOR CODE, FOR THE PERFORMANCE
THE WORK FOR WHICH THIS PERMIT IS ISSUED.
I HAVE AND WIL�MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION
3700 OF THE�ABOR CODE,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY ERS'COMPENSATION INSURANCEf:APRIER RND POI.ICY N BEfl
40IS/
G
Jt
CARRIER
POLICY NUMBER
^'j[
•4 t9(T}RSS NEOO KI/T EECOkAPLEIEDOFTV-E PERMIT IS FOHONE HUNDRED DO�LARS($100)OR LESS).
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
SHAL�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�ABOR
CODE.I SHALL FORTHWITH COMPLY WITH THOSE P
OVISION.
R
DATE: -I/APPLICANT:
WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERP,GE IS UN�AWFUL,AND SHAL�BE
SUBJECT AN EMPLOYER TO CRIMINA�PENALTIES AND CIVI�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 ATfORNEY'S FEES.
CONSTRUCTION LENDING AGENCY
I HEREBY AFFIRM UNDER PENA�TY OF PER]URY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR ICR THIS PERMIT IS I UED(SEC. 3097,CIV.C.).
LENDER'S NAME(sue/Lami
LENDER'S ADDRESS
1 CERTIFY THAT I HAVE READ THIS APP�ICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT
AGREE TO COMPLY WITH AL�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 INSP TION PURPOSES.
PERMITf AME(PRINT)
SIGNA E OF PERMITfEE DATE
APP�I
CATION--PERMIT
/C
DATE
#
ISSUE TYPE OCC
DATE CONST GROUP
ZONING SETBACKS
FRONT RW^
REAR^
SIDE/SIDE STREET RW^
SIDE^
PROPOSED USE C y'^
N0. DWE�. N0. NO.
UNITS STORIES BEDROOMS
DESCRIPTION SQ. Ff. FACTOR PSF AD).AREA/VALUATION
SFR/ADD/REM
U) Garage/Carport
W Patio/Deck
L
L.I
LL PoolJSpa
Z Re-Root
Commercial
Valuation AD.I.AREA
QUANTITY DESCRIPTION FEE
U
U
w
W
Z
a-
Z
S 1•�L��/
CONSTRUCTION
I Lei/v
PLAN REVIEW
ELECTRIC
P�UMBING
MECHANICAL
INSPECTION FEE
ISSUANCE r.V.
SMIP
ENERGY P/C
ENER6Y PERMIT
RETENTION FEE:
PRE-ALT FEE:
TOTAL FEES v1 �'
COMMENTS
RECPT. NO. PAID BY VA�IDATION i- -
WHITE--Department Copy,YE��OW-Finance Copy, PINK-Assessor Copy,GOLDENROD-File Copy,GREEN-Applicant's Copy