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�� CITY OF DIAMOND BAR DEPARTMENT OF COMMUNITY dt DEVELOPMENT SERVICES � 21660 E.Copley Ihive 5uiu 190 (909)860-3195 Fax(909)861-3117 . PRES$ '�'� BUII.DING PERMIT APPLICATION FlRMLY o� JOBSITE /�,," t��� gl�tS3 APPLICATION�p Jf� PERMR / C� P/Q� ADDRESS �6Zq �f:�x TKAIL. [.�'S'HGl\1(�f3A�_U DATE " " NUMBER ` S` it "" ��, � APN��f 3 LOT�/� TRACT .3�5��' � �SSUE TYPE OCC DATE CONST. GROUP � OWNER o ADDRESS3t43 ��T� Fb�2TDF/ O ZONING SETBACKS �"' cmrNE���e7 BEhcFi ZIPG't`�a66o TEL REART RW Op APPUCANT S//y0 1 sH 1M TEL �i�R-S�o SIOE/SIDE STREEf RW ❑ � CONTRACTOR S I MON SNt 1 M ' SIDE ❑ ADDRESS � CITY k�AilLfT ZIP��TEL - pp PROPOSEDUSE.� � IC. I��IJC�. � ARCWENG/ • ��MDL�F�L --- L 1 ��Ih�/si� DESIGNER NO.DWEL. NO. NO. ADOFESS UNITS (� STORIES � BEDROOMS�, � CITY ZIP TEL. � tn DESCRIPTION Sa.FT. FACTOR PSF ADJ.AREANALUATION p� OWNER-BUILDER DECUIRATION SFR/ADDrREM 2 O " 1 NEAEBY AFFlRM UNDER PENILLTY OF FEiVJRY TUT 1 MI E%EMPT FROM TNE CON'TMCTORS ll- GflfdgO/CflfpOfl CENSEUWFORTHEFd10WMOREASON(SEG70.77.66USiNE55AN0iROFES510N5CODE:ANYLITYOR (n COIA(TYYMI1GIRfOUWESAiERMRTOCONSTRUCT,ILTER�MFROVE.DEMOLISM,OqftEPA1RMlYSTRUC• W PflSi01D6Ck 3 � NRE PNON TO R9 tSSUANCE,PLSO NEW IHES TME AVPIICANT FOR SUCFI VEfUlIT TO FILE A SIGNED W � ETATEMENT THAT HE OR SHE 6 UCENSE�RIRSUMT TO THE PROYISIONS OF hiE CONTMCTORS ll- . CENSE tAW(CHAPT£R O(COMIAENCWO WIiN 5ECT10N 70aa)Of OMSION]OF TH[BUSINESS AN�VRO. � � PoollSpa � iESSqN4COO�ORiMATHEOR5HE13E%E/APTT7IEREFROMANDTIEBASISiORTkEILLEGEDE%EMP- (� TqN.AHYVIOLATIDNOFSECT10N7IXi1.68VAHVMPIICANTFORAPERMITSU&'ECTSTNEAPPLICANTTO Z Re-Roof � ' ' � � ACIVIIPEHALttOfNOT►qREhWlFIVENUNDREDDOLUR5�15o0).): � � � O�ASOWNEHOF7HEPROPERTY,Oi1MYEMPL01'EESWITHWAGESASTHEIRSOLECOMPENSAiqN, � (,`pmmBfCl81 � � � ��• - YYILL 00 TME YYOFiK,/WD iHE STRUCTURE IS NO7 1NTENOEO OR OFiEREO FOR SILE(SEG 70N,BU51- J N NESS AMD iROFE5570N5 COOE THE COHTMCTORSLICENSE UW DDES NO7APPLYTO AN OWNEROF ? - - ,. � PROPEHfY YRiO BULDS OR M7ROVE5 7MEREON,AND K'F1000E5 SUCH ri'ORK NIIA�ELF OR HERSEIF OR � � 2 THROUGH HIS OR HEF OriN EMVLOYEE3,GROVIDED TW�T 3Utl1 I4PROVEMENTS ARE NOT q1TENDED OR LL� � .OfFE(�DiORSKE1F11ON�EVERTMEBU0.dNQORIMPROVEMINTI55dDWITHINO4EVEAROFCOAIP�E- �TqN,THE GwNER��BUItDER N7LL HAVE TME BUftDEN OF PROVNa TNAT HE OR SHE DiD NOT BUIID OR MPi10V[FOi1THE PURP0.SE Of SALEI. , W Otti^ON�NEROFTHEPROPERTI;AA/EXCLUSNELYCOMMCTWGYrtfHUCEKSEDCONTMCTORS � TO CONSTRUCT TNE YROJECT ISEG 70N,BUSIt1E55 AHD PFiOFE5510N5 COD[:TME CONTMCTORS tl• V8IU8IIOf1 � ��ADJ.AREA CEN6E UW DOES NOTMVIt TOAN OMIER OF A VqOVERiY WH0 BULDS OH IYPROVES THEHEON.FND C"" � WHOCONTMCTSFORSUpIPHWfCTSWITHACONfRACTOR(S�IK;ENSEDVURSUAtRTOTHEODHTMG QUANTITY OESCRIPTION F�E � TORS UC915E UW.} .. . O IIM EXEMaT U1tlER SEC. B.t P.C.FOR TMiS REASON ¢ U LL. ¢ . DATE OWNER --- V � UCENSED CONTRACTORS DECLARATION . W - , J � w '" IHEREBVAFFWIAUNDERVEN.LLTVOFOE0.ri1RVTHATIA4LICENSEDUN7ERCROVI5iON50�CWPTER U. 2,C �(COw1ENCVN3 VIrtH SECTION 7000)OF DI�nSqN 9 CF TN[BUSINESS IJ�ID PROFESSIONS CODE,ANO Z X W IICENSE R N FULI FORCE AND EFFECT. � ' m . . . UJ �yf� L � LICENSE CUSS ✓ LIC.NO. V ��D I� j � ' ; �,� 6��/oa CONTMCTOR siMo� s J = WOiiKERS'COMPENSATION DECLARATIO" 3 Q � IHEREBYAFFW.IUNOERPEtULTTOFiE0.1UNYONEOFTHEFOLLOwINa CUM 'S�, Z � �IHAVEMAWILLI�MNTAINACERTIFIUTEOFCONSENTTOEELFaNS = ' ��� COMPENSATICN,AS PROVIO[D BY SECTON To0 OF iME UE70R COOE,FOR THE �iIAANCE w OF lNE M/ORK FOR WNICH iH15 iERMIT IS ISSUEO. . � 0 Q _I HAYE MIO N"LLIWMAW WCPo(ERS COM�ENSATION MSUMNCE.AS REOUIRED BY SECTqN /� a7oo OFiNE LA40R COOE.FOR THE DERFOivAANCE OF iHE WORN iOF WNICHTH�S 7ERMIT IS (J � LSSUm.A1YNOFi1(ERS'COMPENSATIONINSUFUNCECAFNERA.WMJLICYNUMBERARE, CONSTRUCTION - `� '~ 7 CARRIER UL ,�I F�EiLE l/�JS(/ PLANREVIEW 1 � � va�„n,,,eEA N W G4�4��3 90 � e� TR�c . 0 (�1lS5EciaNu[muoTBEQY.fLFtIDOcnEvfpwrsroaa+E 'L,(S� J� I PLU BING Z 1 CER'IF'/THAT MiNE VERFIXU/ANCE OF THE WORK FOR NNIp17H15 P 455 � HANICAL :JU1L NOL EMPLOV/J!'/VERSON IN ANY MANNEF 50 AS TO BEGCME SU0.IEGT YQ'M TS, ( � WDR!(ERSGOMPENSATIONU�'/SOFCAL�fORNtA,AND�GREETMATIFI5/qULDBE INSPECTIONFEE 7�a/"��'�*� S SUBJECTTOTHEWORI(ERS'Cp.�7ENSA7qNPROVIS10N50FSECTION770oOFTHE R �. Li.I.Y.J` cooE,�sww.�oanrvnn�couv�r wm+r�a. aov�si r+s. ISSUnNCE O p DnTE:��OQ_ APaLK+�NT. SMIP W ENERGY PIC C�P � WARNING:FAQURE TO SECURE WORKERS'COIAPENSAT COVERAGE IS UNLAWFUL AND SHALL BE ���—_ . ('�y SUBJECTANE11PlOVERTOCAlA1PlALPENALTIESANDCMLFWESUPT�ONEHUN�RE0T/KK1SAN0 ENERGYPERMIT � DOLLARS(itao,Doo),W ADDITION TO THE COST OF C06�aENSAT�ON,DAUAGES AS PAOVIDED FOR IN ��� J SECT10N77000FiH[IAHORCOOE,MTEREST,ANDATTORNEY'SFEES. � � f' L! 711+1 •� ' RETENTION FEE: � d CONSTRUCTION LENDING AGENCY P 6 L7 FE : IJ/ � i• �J t1�"\` Jr�1 � � sr � INEREBVAFFIRAIUNDERPFNALTYOFGERNHY7F�ATTMEREISACONSTRUCTiONLfNDIN6AGENCY FOR iHE P[RFOiYAANCE OF hIE WORK FOR WHICH THIS PERMITIS ISSU[D(SEC.]09�,CIV.C�. Z �/ W � LENDEF'SNAME � LENDER'SPD�RESS � ICERTIiYTHATIHAYEREADTH15APPLICATIONANDSTATETHATTMEIIBOVENFp{3MATqNISCORRECT. 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