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� CITY OF DIAMOND BAR � �
--1��— DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES ��
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, 21660 E.Copley Drive Suite 190 .
� (909)860-3195 Fax(909)861-3117 �, PRESS
/ ��'�^'f�w BUILDING PERMTl'APPLICATION _ .� FIRMLY
� � JOBSITE J�'n/ �G�/� /��iE APPLICATION p PERMIT /[�� P!C �l_/j��
o AODRESS �-��� �/ /�/q'+�V DATE �� �7 / NUMBER 7 # ( �I
� � 'ISSUE TYPE OCC
APN LO TRACT DATE CONST. GROUP
p OWNER '
p ADDRE S ZONING SEfBACKS
� CITY ZI TEL. - REART RW ❑
APPLICANT ,��� TEL. SIDE/SIDE STREET FiW ❑
� CONTRACT SIDE ❑
q� ADDRE ~ PROPOSED USE GYf B S
� CITY ZIP TEL. I
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� DESIG E NO.DWEL. NO. NO.
ADDRE S UNITS STORIES BEDROOMS
� CITY ZIP TEL.
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� cn DESCRIPTION SQ.Ff. FACTOR PSF ADJ.AREANALUATION
� OWNER-BUILDER DECLARATION SFWADD/REM
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I HEREBV AFFlRM UNDER FEN/�LiV OF PERIURV THAT I AM EXEMPT FROM THE CONTRACTORS LI- G8296/C8f�10ff
W CENSELAWFORTHEFOILOWINOREASON(SEC.7031.5BUSINESSANDPROFESSIONSCODE:ANVCITYOq (n
U COUHfYNMICHREWIRESAPERMRTOCONSTRUCT,ALTER�MPROVE,DEMOLISH,ORREPAIRANVSTRUG
W NRE,PRIOR TO ITS ISSUANCE,/�LSO REOUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED w Patio/Deck �
STATEMEHf THAT HE OR SHE IS LICENSE�PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI�
� CENSE UW(CHAPTER i(COMMENCINO WITH SECTION 7o00)OF DIVISION]OF THE BUSINESS AND PRO- LL' PooUSpa .
FESSIONS CODE)OR THAT HE OR SHE IS E%EMPT THEREFROM AND THE BA515 FOP THE ALLEGED EXEMP-
TION.ANYVIOLATIONOFSECTION7031.SBVANVAPPLICANTFORAPERMITSU&IECTSTHEAPPLICANTTO Z Re-Root �
� ACML PENALTY OF NOT MORE 7HAN FNE HUNORED DOLURS(i500).):
� ❑I,ASONMEROfTHEPROPERTV,ORMVEMPLOVEESWITHWAGESASTHEIRSOLECOMPENSATION, ❑ Commercial . –
WILL DO THE WORI(AND THE STRUCTURE IS NOT INTENDED OF OFFERED FOR SALE(SEC.701I,BUSI� J
� N NE55 M1D PqOFESSIONS CODE:THE CONTMCTORS IICENSE UW DOES NOT APPLY TO AN OWNEH OF �
PROPEHTY M?f0 BUILDS OR IMPROVES THEREON,AND NMO OOES SUCH WORK HIMSELF OR HERSELF OR
Q THROUGH HIS OR HER ONM EMPLOVEES.PROVIDED TNAT SUCH IMPROVEMENTS ARE NOT INTEN�EO OR m
� OFFEREDFORSALEIF,HOWEVER7HEBUILOINOORIMPROVEMENTISSOLDWITHINONEYEAROFCOMPLE�
Z �`TION,THE OWNER�BUItDER WILL HAVE TME BURDEN OF PROVINO THAT HE OR SHE DID NOT BUItD OR
� IMPf1OVE FOR THE PURPOSE OF SAL�.
w ❑1,tiSOWNEROF THE PROPEHTI',AA1 EXCLUSIVELY CONTRACTINO WfTH LICENSED CONTRAC70RS
� TO CONSTflUCT THE PRQIECT(SEC.70a�,BUSINESS AND PROFESSIONS CODE:THE CONTRACTORS LI- VelUei1011 ADJ.AREA
� CENSEUWDOESNOTAPPLYTOANOWNEROFAPROPERTVNM1iOBUILDSORIMFROVESTHEREON,AND
WFIOCOHfRACTSFORSUCHPR0.JECTSWI7HACONTMCTOR(5)LICENSEDPURSUMIT70THECONTRAG QUANTITY DESCRIPTION FEE �
70RS LICENSE UW.).
❑I AM EXEMPT UNDER SEC. B.8 P.C.FOR THIS REASON Q U
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� �
DATE OWNER U
Z W
F LICENSED CONTRACTORS DECLARATION W
� 1 HEREBV AFFIRM UNDER PEN/�LTY OF PERIURY THAT I AM L�CENSED UNDER PHOVISIONS OF CHAPTER Z �
� 0(COMMENCWO N7TH SECTION 70a0)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CADE.AND
�� MY LICEHSE IS IN FULL FORCE M!D EFFECT. • `, m C
� LICENSE CL.� LIC.NO. _/ � j
� / J
� - V DATE // CONTRACTO a
W
� WORKERS'COMPENSATION DECLAAA I –� � f
� 1 HEREBV AFFlRAI UNOER PENALTV OF PERIUHY ONE OF THE FOLLOWING DECUMTIONS: � �
�
� _IHAVEANDWILLMAINTAINACEFifIFICATEOFCON5EN770SELF-INSUREFORWORKE S' _
COMPENSATION,AS PROVIDED BY SEC710N 370o OF THE L/�BOR CODE,FOR THE PERFORMANCE U
Q �dFTHE WORK FORNM1iICH THIS VERMIT IS ISSUED. � .
W �
_I HAVE AHD WILL MAIMAIN WORNERS'COMPENSATION INSURANCE,AS REOUIqED BV SE r�,
Q 37000F TME LABOR CODE,FOF THE PERFORMANCE OF THE WORK FOR WHICH 7HI5 PERMI ��4 X/)
0 ISSUED.MY WORK 5'COMPENSATIOfJ I�y URANCE CARRIEH AND POLICY NUMBER ARE: � CONSTRUCTION ��I '�//, � V `��
� CARRIER • �'v PLAN REVIEW � v��Cf'�
Z paicr NUMeEa � � � ELECTRIC '. +r1. �/� _ �
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� (iWssECt10NHE�No78Em.PlElEoOFhEPEWXf5Wa0NEVAA�DREODa1/�asfttoo)oaLFss� PLUMBING . 8.�. n. V ' 9ie({�
Z I CERTIFV THAT IN THE PERPORMANCE OF THE WORK FOR WHICH T reaMir is issueo,i MECHANICAL vv�nvr�!w. /�VJ`
('} SNALL NOT EMPLOY ANV PERSON IN ANY MANNER SOAS TO THE `1(ef ��I�'
� WORKERS'COMPENSATIONUWSOFCALIFORNItiAND EE IFI OU�DB INSPECTIONFEE CA� OAI�.
S SU&IECT TO THE NfORKERS'COMPENSA7 VIS a70o OF THE O �N ''Vl
CAP ISH FORTHWITHCOMPLV WI i o . ISSUANCE �•�n� `�.��
0 / •��� •
p DATE: / I APPLICANT: SMIP ar
J WARNINO:FAILU 70 SECURE WORKERS'COMPENSATION VEFAGE IS UNUWFUL,AND SHALL BE ENERGY P/C '
� SUaIECT M!EMPLOVER TO CRIMINAL PENALTIES AND CIVIL FINES UP 70 ONE HUNDRED 7HOUSAND ENERGY PERMIT
DOLURS(S10o,000),IN ADDI710N TO THE COST OF CAMPENSATION,DAMAGES AS PHOVIDED FOR IN „ �,
� SECTION 3708 OF THE LABOR CODE,INTEREST,AND ATTORNEV'S FEES. RETENTION FEE: , � �U �
d CONSTRUCTION LENDING AGENCY PRE-ALT FEE:
O
� I HEREBV AFFIHM UNDER PENALTV OF PERJURV THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF 7HE WORK FOR WHICH 7HI5 PERMIT IS ISSUED(SEC.3oY7,CIV.C.). .
Z
W
� LENDER'S NAME
F_ IENDER'SADDRE55 � /f
� I CEFTIFY THAT I HAVE READ THIS APPUCATION NID STATE THAT THE ABOVE INFORMATqN IS CARRECT. TOTAL FE ES �/ //')�'���
� I AGREE TO COMPLV WITH/�LL CIT'AND COUNTY ORDINANCES AND STATE UWS REIATING TO BUILDING �� y A/���/Sn `�Y
CANSTRUCTION,AND HEREBV AUTFiORIZE REPRESEN7A71VE5 OF THIS COUN7Y 70 ENTER UPON 7HE [/I/A Y' I
� ABOVE�M TIONED PR07ERTV FOR INSPECTION PURPOSES. I V •
Z � 1 �� �� COMMENTS I �
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� IGN DATE
= RECPT.NO. PAID BY VALIDATION__ �
~ WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assesso�Copy,GOLDENROD--File Copy,GREEN—Appticant's Copy
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