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�-� � CITY OF DIAMOND BAR ----�'t`' -- DEPARTMENT OF COMMUNTI'Y&DEVELOPMENT SEItVICES I � „ � 21825 E.Copley Drive -' (909)860-3195 Fax(909)861-3117 PRE$$ ``'%v�^� BUILDING PERMIT APPLICATION FIRMLY JOBSITE �r 1� APPLICATION �/y,� PERMIT � P/C ¢ ADDRESS�-��°�.�6 tG�� �d� e-�� DATE r!✓ls° NUMBER # o ISSUE TYPE OCC °-° APN LOT TRACT DATE CONST. GROUP °C OWNER �� O �` ADDRESS ZONING SETBACKS Z CITY ZIP TEL. FRONT RW O g APPLICANT ' TEL. REAR � z SIDE/SIQE STREET RW ❑ ¢ CONTRAC70R G °""' SIDE ❑ � ADDRESS ! � � �^'�.� �7 � CITY �.`G�rr�--I ZIP�TEL. 23G"�b PROPOSED USE � ARCH/ENG! I w DESIGNER N0.DWEL. NO. NO. � ADDRESS UNITS STORIES BEpROOMS � CITY ZIP TEL. � DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION cn ' � O�/NER-BUILDER DECLARATION SFR/ADD/REM � O i p I HEREBY AFFIRM UNPER PENAL7Y O�PERIURY THAT i AM EXEMPT FROM THE CONTRACTORS U- (`jg�y9e/C8fp017 Ll,,.� CENSELP.WFORTHEFOLLOWINGIREASON(SEC.7a3158USINESSANOPROFESSIONSCO�E:ANVCITVOR (n U��. � COUNIVWHICHflEQUIflESAPEFry11TTOCONSTRUGT,ALTER,IMPROVE.DEMOLISH,ORREPAIRANYSTRUC- W patio/Oeck w� TURE,PRIOR TO ITS ISSUANCE,A`LSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FlLE A SIGNED � ��, STATEMENT 7HqT HE OR SHE IS FICEN$EO Pt1R5UANT TO THE PROVISIONS OF THE CONTRACTORS LI- �'., CENSE lAW(CHAPTER B(COMME CING WITH SECiION�aoo)OF�IVISION 3 OF THE BUSINESS AND PRO- � POOUSp2 � FESSIONSCO�E)ORiHATHEOR�HEISEXEMPTTMEREFPOMIANDTHEBA515FORTHEALLEGEDEX'cMP- (� QTION.ANYVIOLATIONOFS6CTIOry7o37.68YANYAPPL!CANiFORAPERM1iSU8JECTSTHEAPPLICANTTO z Re-Roof � A CIVIL PENALTY OF NOT MORE TIiAN FNE HUNDRED DOLIARS(ESoo�.): �' ❑I,ASONlNEROFTHEPROP��ERTV.kIPMVEMpLOVEESW1iHY✓AGESASTHEIRSOLECOlAPENSATIOPI, 0 COI71rt1BrCIflI Z WIllOD THE WORK,ANO THE ST�IUCTl1FE IS NOi MTENOE�OP OFFERED FOF SALE(SEC.7o44,BUSI- J � . NESS AN�PFiOFESS�ONS CODE:'�1�E CONTRACTOR&LICENSE LAW DOES NOT APPLY 70 AN OWNER OF � � PROPERfYWHOBUILD50RIMPRpVESTHEftEON.AN�WHO00E55UCHWORKHIMSELFORHERSELFOR m - �� THROUGHHISOftHEROWNEMP�IOYEES,PftOVIDEDTHATSUCHIMPROyEMENTSARENOTINTENDEDOF � WQ DFFERE�FORSALE.IF,HOWEVEp,ITHEBUIL�INGOflIMPROYEMENTI550LDW;THINONEYEAROFCOMPIE- ' Z '� TION,THE OWNER-BUILDEp WILL HAVETHE BURDEN OF PROVING THAi HE OR SHE DID NOT BUILD Ofl � �, IMPfiOVEFOqTHEPl1PPO5EOF ALE):� . UI,ASOWNEROFTHEPRO ERTY,:AME%CLUSIVELYCONTRACTINGWITHLICENSEOCONTRACTORS �,.'� �TO CANSTRUCT TNE PROJECT(S C.�044,B1151NESS ANO PROFESSIONS CODE:iHE CONTRACTORS LI� VflIt18IlOf1 ADJ.AREA W'� CENSELAW90ESNOTAPPLYTO NOWNEROFAPROPFANWHOBUILDSORIMPROVESTHEREON,AN� �� WHOCONTRACTSFORSUCHPRO ECTSWITHACONiRACTOR�S)LICENSEDPURSUANiTOTHECONTRAG QUANTITY DESCRIPTION � FEE � TOflSLICENSELAW.). � , J /��q��g� j� � � p I AM EXEMPTUNDEfl SEC.��, B.8 P.C.FOR THIS REASON Q 'F'O"�-w°`�t� �-1.as" ��� Q J✓Z ��1 �-� �� � �AiE �. OWNER �y�� � W 4 � LICEN�ED CONTRACTORS DECLARATION �j � I HEREBYAFFlRM UNDER PENALTY OF PERJURY THAT IAM LICENSED UNDER PROVISIONS OFCHAP7EP � � 9(CqMMENCINGWITHSECilON7600jOfDIVISION30FTHEBU5INESSANOPROFESSIONSCODE,ANU z X MYLICENSEISINFULLWRCEAN EFFECT. �7 � LIGENSE CL*A.S�S ��_LIC.NO. ld�J G,L}�'�. �.� U �ATE !'� �-�'I�� CONTRACTOR �'�it. �- LLt � . WOFKERS'COMPENSATION DECLARATION � = U � I HERE6YAFFIRM UN�ER PENALTYOF PER.RJRY IXJE DFTHE FOLLOWING DECLARATIONS: � Z � __IHAVEANOWILLMAINTAIMACEATIFICATEOFCONSENTTOSELFANSUREFORWOPoCERS' _ Z COMPENSATION.ASPROI{IDEDQYSECTION3�ooOFTHELABORCODE,FORTMEPERFORMANCE U Q OF"fHE WOflK FOR WHICt�THIS PERMIT I51S5UED. � � ' � W _I HAVE AND WILL MAINTAIN WORICERS'COMPENSA710N INSURANCE,q5 REOUIHE�BY SECTION � Q 37000FTHELABOp COD�1,FORTHE PERFORMANCE OFTHE WOftK FOF WHICHTHIS PERMIiIS —�s � ISSUED.MV WORKERS'C��PEIJSATION MSLIPANCE CA RIEfl AND POLICY NUMBER ARE GONSTRUCTION � CARRIEp �r�_ 7C� x� PLAN flEVIEW z Poucvnnimeen_T J `�e �� �'�t � ELECTRIC � (IHISSEC'f10NNE�NOiBE�CQNPLETEDOF1HEPeRMfTISWRONEHU�REDOJLL4RS(b100)ORLE55). PLUMBING W ICEHTIFYTHATINTHEPE�ZFORMANCEOFTHEWORKFORWHICHTHISPEftMIiI51S5UE�,l MECHANICAL Z � SHALL NOT EMPLOY ANY pERSON IN ANY MANNEP 50 AS TO BEGOME SUBJECTTO THE � WORKERS'COMPENSATION IAWS OF CALIFORNIA,ANO AGREE THAT IF I SHOULD BECOME INSPECTION FEE -u-�.A�;.— Sl1HJECTTOTHEWORKE�S'COMPENSATIONPROVIS �SOFSECilON37000FTHELA60R IN f��,,, ;;�;'� ✓l�4, i�"�"°°°" " , i --^'-�^ ' , ENERGY P/C °� ' .^,�a P ... ',.. . ��� ��� CODE,ISHALLFORTgHWITI COMPLYWITHTHO n VI IDNS. �SSUANCE i t /'==++s- E tl �'1 '� O �ATE: �"Z.P�"�l y ' _ � P� A�PLICANT. - , W J WARNING:FAILURE TO SECURE W RKEf7S'COMP=NSATION COVERAGE IS UN.AWFl1L,ANO SHALL BE : - �—y SUBJECTANEMPLOYEflTOCRIMIPJALPENALTIESANDCMLFINESUPTOONEHUNDREDTHOlJSAND ENERGYPERMIT z I 7 �OLLARS(S1 W,oW),IN ADDIiIDN OTH€COST OF COMPENSATION,�AMAGES AS PROVIDE�FOF IN � � SECTION370BOFTHELA60flC0[T�E.MTEREST,AN�ATTORNEY'SFEES. RETENTIONFEE: `�"�� �� COMSTFIUCTION LENDWG AGENCY � PREALT FEE: i,..�;,:,,<..a....`�`�...Wp,_,__.._.._»_.�----r ' � IHEREBYAFFIRMUNDEflPENALT�'OFPERJUPYTHATTHEPEISACONSTRUCiIONLENDINGAGENCV a- FORTHEPEFFORMANCEOFTMEWOFK';FOflWHICHTHISPERMIiISISSllEO(SEC.30W,CIKCJ. � Z I W � LEN�ER'SNAME __ I F_ LENOER'SADDRESS �'� � TOTAL FEES � '��,�� � I CERTIFY THAT I FWVE FEA�TMIS pPPLICATiON AND S�ATE iHAT THEABOVE INrOftMATION IS CORRECT. � IAGREETOCOVAPLVWITHALICITYAN�'�COUNTVOflOMAPICESANOSTATELAWSRELATINGTOBl11L�ING CONSTRUCTION,AND HEREBY AU'�FiORIYE REPRESENTATIVES OF THIS COUN7Y TO ENTER UPON THE zABOVE-MENTIONEDPROPERTYFQRINSIECTIONPUlPOSES. COMMENTS -' J � `'/ i � m PE0.MITTE A (PRI Q � I � � SIGNATUqE F PEFIMI EE � '�, e�/DAT ' _ �. �� /"" �'J�Q� RECPT.NO. 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