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CITY OF DIAMOND BAR � ----�� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES _ 21660 E.Copley Drive Suite 190 PRESS ...�.. (909)860-3195 Fax(909)861-3117 ^��; BUTLDING PERMIT APPLICATiON FII�MLY „_ o� JOBSITE ��� �-y� ��� ���� DATEICATION PERMIT i��Q/� #!C ADDRESS Z/ _NUMBER �`�l o� ° 13SUE I ,_�) 1-� (''� TYPE OGC .- APN LOT, j ";T DATE �-► � ��J�-�� CONST. GROUP °C OWNEA � � ADD SS ' , � b' ; . ZONWG SETBACKS Z CITY � ZIP L. I REART RW ❑ g APPLICANT � TEL. ' SIDE/SIQE STREET RW ❑ � CONTRACT R , SIDE ❑ ¢ OITY I ° PROPOSED USE 0 ZI EL. - o ARCH/ENG/ • W NO.'DWEL. NO. NO'. ., z DESIGNER i n. „ADDRESS S BEDROQMS � CITY ZIP TEL. UNITS SSORIE � DESCRIPTION SQ.'FT. ' FACTOR PSF ADJ.AREANACUATION' � . ,�I��,,�, ,, �!YNER-BUILDER DECLARATION � SFFl/ADD/REM �� � �� � �� ��� O „Q : I HERE9YAFFIHM UNDEH P�NALTV OF PERIURY THAT I?M EXEMPT FROM THE CON7RACTOflS LI- G3f8JB/C3�WY �W ��CENSELAWFORh1EFOLLOWINGHEASON(SEC.7031.SBUSINES§ANDPROFESSIONSCO�E:ANVCIiYOR� � (J� _. �C.� 'COUNTYWHICHRC-0UIRESAPER�IITTOCONSTRUCT,ALTER,IMPROVE,DEMOLISH,ORREPAIRANVSTRUQ W . 'W' 'NRE,AR10N TO ITS ISSUANGE,Nl.50 RE�UIRES THE APPUC/WT FOR�SUCH PERMIT TO FILE A 516NED� �W P8flO/DBCK � � :'STATEMENT THAT HE Ofl SHE ISI��ENSEO�PURSUANT TO�THE PflOYISIONS OF THE CONTRACTORS'll• $ �.CENSELAWICHAPTERe(COMMENCINGWRHSECTION7DW)OF�IVISION30FTHEBUSINESSANDPRO-. �� POOUSPe �Tj ,FE5SIOMSC�OE)ORTHATHEOF�.SHEISE](EMPTTHEREFROMAN�THEBASISFONTHEALLEGEDEXEMP• (� - ,� 710N.ANYVIOIATIONOFSE�lON7031.58VANYAPPLICANTFORAPERMITSIJ&IEC75THEAPPLICANTTO� Z RE•ROOf ��� ' � "� `�A6MLPENALTVOFNO7MOREl}IANFIVEWUNDREDDOLLARS�f5no).j: � � ❑I,ASOWNEROFTHEPROPFAiY,ORMYEMPLOVEESWIiHWAGESASTHEIFSOLECAMPENSATION, 0. CORiff18�C18I ,,,�, ,,.WILI..00 TNE WORK,AND THE STRUCiURE IS NOT INTENOED OR OFFEFiED FOR$ALE(SEC.2a44,.BUSI- J , NE5E AI�PfiOFE5510N5 CODE:THE CANTRACNRS LlCENSE LAW DOES NOT APPLY TD AN OWNER OF � PROPERTYWHOBUILDSONIMPF{OVESTHEREON,ANDWHODOESSUCHWORKHIMSELFORHERSELFOR m� ' '�' THROOOHHISOHHEROWNEMPLOYEES,PROVID�THATSUCHiMPROVEMENTSAAENOTINTENDEDOR � � � � � �'W� OFFEqEbFORSALEIF,HOWEVEi�.IHEBUILDINGORIMPROVEMENTlSSO1DWITHINONEYEAROFCAMPLE-� ' .z �,�TION,TF�OWNER�BUILOER WILL HAVE THE BURDEN GF PROVWG TViAT HE OR SHE DID NOT BUILD OR . . _ ,,.IMPROYEFOHTHEPUHPOSEOFISALE). . - �. � i ���. ,,�W � ❑I,ASONMEROFTHEPROpERTY,AMEXCLUSIVaYCONTMCTINOWITFlLICENSEDCONTflACTORS '�,¢ '�_TO CONSTRUCT 7HE PR0.1EC7(SEC.7DW,'BUSINE55 AND PROFESSIONS CADE:THE CONTRACTORS Li- V81Uafiofi ADJ.AREA ',W '�,CENSEUIWDOESNOTAPPI.YTQANOWNEROFAPROPERTYWHOBUIIDSORIMPROVESTFIEREON,AND' . � �,_� �PY�FIOCONTRACTSFORSUCHPRWBCTSWITHACONTRACTOfl(S�LICENSEDPURSUANiTOTHECONTRAG � QUANTITY DESCRIPTION � ' � ��FEE :� �.��TORSLICENSELAWJ. �i . . . .. . . . I�'. � . B.8 P.C.FOR THIS PEASON ...¢.. '. . , . � DIAMIXEMPTUNp6R5EQ� U I �'i' UATE �� OWNER . U . � ��.. 'I W � � � LICErySEDCON7RACTORSDECLARATION � . W � ' �� . � � �1 HEAESY AFFIRM UNDER PENAL71"OF PERJUHV THAT i AM LICENSE�UNDEA PROV1510N5 oF CHAPTER� � �� ��� , � � '9�COMMENCINOWITHSECTIONYMO)OF��IVISION30FTHE6USINESSAN�PROFE6SIONSCO�E,AND �. � �'� MY LICENSE IS IN FULL FORCEA d EFFEGT. L�...Jj� m � � �� ENSE C� S �� . . 'LIC.N0. ���' -!�� �' � � � ' ' '. �a _ _ .� . J. � V �, ATE ��� CONTR4CT0 ' � , d . �y�` � . . �'.'. "" W, � WORI�EAS`COMPENSATION DECLARATION Q � �"' �� � � c�'i V � ' I HEREBV AFFIRUI UNDER PENAi.TVbFPEPJpRV ONE OfTHE FOLLOWING DECLARATIONS: Z a. , �• Q �'�., _IMAVEANDWILIMAINTINACERTIFICATEOFCA1d9ENTTOSELF-INSUREFORWOPKERS' = FY � '��S"- ��'�,y �"' COMPENSATION,ASPR VIDEDBYSECTION37000F7HELABORCOOE,FORTHEPERFORMANCE U C,.9 �a OFTHEWORKFORWHI HTHISPERAfITISISSUEO. , � � _ .! ° P. - „�' .,W', � � . ' 6P le' ,. , , ,. �,I.,_„ .�1 HAVEAND WILI MAIN7 IN WQRKERS'COMPENSATION INSUMNCE,AS REQUIRED BY SECTION � � ,Q'�� 37000FTHELABORCO Ei'FtlRTHEPERWRMANCEOFTHEWORKFORWHICHTHISPERM1T15 ISSUED.MYN!ORKEAS' �MPENSATION.INSU N ECARRIERANDPD�ICYNUMBERARE: CONSTRUCTION j, cnaaiEa PLAN REVIEW I,�I�. POucvNUMeER � � ELECTRIC , Q,� „ � .. : ... � (IHl55EC71alNE�N0T9ECOMR.ETEDOFTI#PERMfTISWR�NE}NNDREDpOIlAR5ry700)ORLESS} PLUMBING ��� I CEATIFV THAT INTHE �RFORMANCE OFTHE WORK FOR WHICH THIS PEHPAIT IS ISSUED,I MECHANICAL � � SHALL NOT EMPLOV AN�PERSON IN AP1V MANNER SO AS TO BECOME SU6JECTTOTHE d{� � WORKERS'COMPENSA�IXVLAWSOFCA�IFO ,ANDAGREETH IFISH BECOME INSPECTIONFEE �_Ca S''n ��..,� SU6JEGTTOTHEWOR R5'WMPENS PP VISIONS ,��a+7o H ' - `�J$' � �:��� ' �0..� I$SLIANCE '� �'@, � '�C'_g f���. E,1 S FORTNW 7H COMPLY T , � �-z . �p'.. DATE� � � PPLICA, . . . y .SMIP �cc=R �T".e {'�, �.�.i- ���k_���""b_."`�'' . W' - ENERGY P!C �,.h. �` h�;�`T;x '����,y'� WARNING FAILUFiE.TOSfiCURE RICERS'COMPENSATIIXd YERAGEISUNLPWFUL,0.NGSHALLBE - r��g��� , . '..^���;' SU&IECTAN EMPLOYER�TOCRI INA4PENALTIES ANO CIVIL FMES UP TO ONE HUNDRED THOUSAND ENERGY PERMIT �� OOLLARS(5700.D00).IN pQDiTI �70 iHE COSTOF COMPENSATION,DAMAGES AS PROVIDED FOR IN � J.;; SECTION3]oeOFlHELABOR ��E,,INTEREST,ANDATTOflNEY°SFEES. ' RETENTIONFEE: � . W''. . ; , . . . q,. C NSTRUCTION LENDING AGENCY pRE-ALT FEE: � O; �'.. 1 HERE9YAFFlRM 11NDEp�PENA TY O�PEAJLIFV THATTHEflE IS ACONSTflUCTION LENDING AGENCY '� FORTHE PERFOAMANCE OF TH�WORK WFi WHICH THIS PERMIT IS ISSU�(SEC.3097.CIV.C.). , � , . LLl�:�� � � . . ,. . `L,.T��I IEN�ER'S NAIAE i S F—�;�i LEN�Efl'3ADDRESS „ ���'�i ICERTiFYTHATINAVEREADTII�SAPPLICATIONANDSTATETHATIHEABOVEIKFORMAT10NiSCARHECT. TOTAL FEES ���,; '� ��,'� I AGRE'TO CAMPLV WITH ALL OIT'AND C6UNN ORDINANCES APID STATE L4WS REUITING T08UILDMG '� ' ���,�,,ili CONSTRVCTION,AN�HEpEBV, UTHqRIZE'�REPRESENTATIVESOFTHISCOUNNTOENiERUPONTHE , . . '� . . ,��, ABOVE�ME IONED RN Oft INSP TION PURPOSES. COMMENTS � - �I�� PE EE - � E �i � . ui�",I �" ��, SIGNATUHE E � '� TE ' � �,,, I... � .. REC?T.NO. PAIDBY � ���'��,VALIDATION� �'""' '� WHITE-0e arlment Cb YELLOW—Finance Co PINK—Assessor Co GOLDENROD—Fle Co GREEN— licant's Co '. P PY� PY� PX PY. APP PY ���� � �� � � _ ���� � �"� �� �� �� . '� €:�^s'. ;�5s� 3Y�.` . "L9 ��.�i ��tR � ._!� . 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