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_�� CITY OF DIAMOND BAR' �- DEPARTMENT QF COMMUNITY&DEVELQPMENT SERVICES ' 21660 E.Copley Driae Suite 190 � ,,,,� (909)860-3195Fax(909)861-3117 PRESS A�', BUILDING PERMIT APPLICATION ---, FIF�ML.Y N JOBSITE p c ' APPLICATION PERMIT � `�2/„�P/C o ADDRESS ��� C3� "JI Iv� `L.1�✓F.IE DATE NUMBER ✓ K� # � D TEE � ONST. GR OCC -- APN LOT� TRACT .3��"-I t!C% !��~`��' OUP p OWNER � �.'C . �` ADDRESS ^''i ' . M ZONING SETBACKS QCITY � �--�..A�I� ZIP��OTEL. . � ~ j FRONT RW ❑ � APPGCANT I TEL. REAR ❑ SIDE/SIDE STREET RW ❑ � CONTRACTOR .L� SIDE ❑ Q ADDRES � CITI° � � ZI TEL.'`^'��[.�'j��J PROPOSED USE � ARCH/ENG/ ' z DESIGNER, . , 0.; ADDRESS NO.DWEL. NO.', NO. UNITS STORIES BEDROOMS �', CITY � ZIP TEL. cn, DESCRIPTION SQ.FT. FACTOR PSF AW.AREANALUA'iION �, �. .,,, _, _ WNER•BUILDER DECLAA,4TION SFR/ADD/REM � �' � � " � � O d�, I HEREBY AFFlRM UNDER EASCN(SEC.7m7.5B11S I AM EXEMPT FROM THE CONTRACTORS LI-� Gdfflge/CAfPoR � � � ����, � �, qENALTY OF PERJURY THA W CENSELAWFORTHEFOLLOWIN�R MESSANOPROFESSIONSCO�E:ANVCIiVOR (n - - �U. COUNiYMMICHRC-0UIRESAPER�.9ITTOCONSTRUCf,ALTEF�,IMPROVE,DEMOLISH,ORREPAIRANYSTRUC- W P8fi0/�BCK � � '�'' TURE;PRIOR TO ITSiSSUANCE,yL50'REQUIHES THE APPLICANT FOR SUCH PERMIT TO HLE A SIGNED - - w STIITEMENT THAT HE OR 9HE I I LICENSED PURSUANT TO'�THE PflOVISIONS OF THE CONiflACTORS U• � W � �, CENSE L1 W(CHAPTER B(COMM�NCING YdITH SECTION 7000)OF OIVISION 3 OFTHE BUSINESS AND PR0- � POOVSP9 '� ,� FESSIONS CODE)OflTHAT HE Of{SHE IS EXEMPTTHEREFRDM ANDTHE BASIS FOR TNE nLLEGE�EXEMP- ' TION.ANYVIOLATIONOFSECTIO�d70315BYANYAPPUCANTf-0RAPERMITSUBJECTSTHEAPPCICANTTO� Z RB-RDof . . �� ACIVILPENALNOFNOTMORETIHANFIVEHUNDRE�OOLLARS(5500).�: ��, � ❑I,ASOWNEROFTHEPHOpEii7tlORMVEM�OVEESWITHWAGESA5THE1R50LECAMPENSATION,��� � COrtIrt18PCIdI �' '' . WILL DO THE WORK,AND THE 5 RUCNRE IS NO7.INTENOED OR OFFEPED FOR SALE(SEC.704/,BUSI- J . , ��. NES$AND PROFESSIMJS CO�E:THE CONTRACTOflS LICEMSE LAW DOES NOT APPLY TO AN OWNER OF � � � PqOPERTYVMOBUIlD50RIMP OVESTHEREON,ANDWHODOESSUCHWORKHIMSELFOR�HERSELFOH'� �. � � qC'.�. TMRIX1GHIi15DRHEROWNEM UVEES,PROVI�EDTHATSUCHINWfiOVEMENTSARENOTINTEN�EDOR� m -� ' ' ' � , � �W. OFFEREDFORSQEIF,HOWEVE iHEBUILDINGORIMPROVEMENTiS50LDWITHINONEYEAROFCOMPLE-,. 0'.I.' �I ..... ,,. �,Z„ TION,THE OWNER-BUIIAER WI HAVE THE BURDEN 6F PROVMG THAT HE OR SHE DID NOT BUIID OR IMPHOVEFOqTHEPl1RPOSEOFSALEj. �� � � ,W'., '. ❑I,ASOWNEROFTHEPR PERTY,ANEXCLUSIVE�YCANTRACTINGWITHLICENSEDCONTRACTORS � '�, ��'� TO'.CONSTRUCTTHE PqOJECT(SEC.7044,6USINESS AND PROFESSIONS CODE:THE CONTRACTORS LI- V8IU0210f1 I ADJ.qREA ��� �� �W�� CENSELAWDOESNOTMPLYTOANOWNEROFAPROPER�YWHOBUILDSORIMPRWESTHEflEON,AND �� � "��''�. W11000NTRACTSFORSUCHPRP.IECTSWRNACONTRACTOR�S)LICENSEDPURSUANTTOTHECANTRAG qUANTITY DESCRIPTION �' . '� FEE ' � � �]C,�, TORSLICENSELAW.�. , ,. .. �, � ❑IAM EXEMPYUNDERSE�.'� 8.&P.C.FORYHIS REASON Q � � � � i U I W � . DATE I � OWNER � V �' J �. �, � LECE.9ED CONTflACTORS DECLARATION W � �, .. , �� ', ��i I HEflEBYAFFiRM UNDEH PENAL .OF PERJURY TNAT IAM LICENSED UN�ER PROVI510NS OF CHAPTER � '. � '. ��,�'�. 9�COMMENCINGWITHSECTION''�OOOJOFDIVISION30FTFiE8U51NESSANDPROFES510NSCODE,AND Z ' ' ' iL� A1Y UCENSE IS IN FULL FORCE q EFFECT. , m ' �o�' 41C�NSE CIASS '� LIC.NO.i ..1.� �v � ' H _ �J ��}��} � � ATE�� �� � CONTRACTOR ��U fX{14—+ d L�l,!''�'� '1I . � � ���. WORryERS'COAAPENSATION DECLARATION � a . . ..,u--,. �� I HEREBY AFFIRM UN�ER PENAL7Y OF RERIURY�NE OFTHE f-0LLOWING DECLARATIONS: Z � - • ^ �..� � 0,'�, _IHAVEANDWILLMAINTqI1NACERTIFICATEOFCONSENTTOSELF-0NSUREFORWORKERS' _ ^ P^ � CAMPEN$kTIOM,AS Pfl<jVIDEp BYSECTION 3]0o OFTHE LA6CR CODE,FOR THE PERFORMANCE' U � Z` S p�•�� l�W � OFTF9E WORK FOR WHI�F1 THIS PERMIT IS ISSUED. � u r�"' � �W �I HAVEAN�WILL MAINTd�IN WGRKERS'COMPENSATION INSURANCE,AS FE�UIRED BY SECTIDN � �'. Q37o00FTHEL4BORCODE,FORTHEPERFORMANCEOFTHEWORKFORWHICHYHISPERMRIS � J, ISSUED.MY WORK1ERS' MPEP6�A7TION INSURANCE CARR1IER,�AND POLICY NUMBE1flARE: CONSTRUCTION ',. '�y�� cAaRieR � .L.�:�.�����c ,T�� vii—��l- PLAN REVIEW ', .Z, POLIGYNUMBER ELECTFIC, , . Qi ^ � '� �� (hiISSECTIONN�NOT�E�OORFPLETmOF7FiEPEFihYTISFORONEHUtJ�REDWI+ARS(510o)OHLESS). PLUMBING � ' � I CERTIFYTHAT INTHE ERFORMANCE OFTHE WORK FOR WHICH THIS PERMIT IS ISSUED,I -MECHANICAL � � C'S SHALLNOTEMPLOYAN PER$ONINANYMANNERS TOBECAMESUBJECTTOTHE � �/j WORKERS'COMPENSATONLAWSOFCALIFO NDA REETH ISHOULDBECOME INSPECTIONFEE ��� _ � � SU&IECT TO THE',WORK RS'COMPENSA P VI510 N 3j�o,OF THE LA60R �� - � pE,I SHALL FORTHVJITN COMPLY H THOS ' i , ,j�j���/��? ,� ISSUANCE �Y ���y..�t -.CY. LI� "' �j l T��/S..J SMIP .p.. DATE:`�� I PPLICAN: - . '� . °"�� WARMNG FAlLt1RE TO SECURE' RKEHS'COMPENS IaN COVERAG IS UNL4WFUL,AN�SHALL BE� ENERGY P/C � � �'�`.%� r��'� - �J. "'__'-- _ " SU&IECTAN EMPLOYERTO CRI INALPENALTIES AND CNIL FlNES UP TOONE HUNDRED THOUSAND a� " -- �aJ � �} DDLLARS(StOD.000),INADDITIO.YOTHECOSTOPCOMPENSATION,DAMAGESASPfiOVIOEDFORIN ENERGYPERMIT ''�"' S ��� ' J SECTI�N 37a80f THE LA60fl �OE,INTEREST,AND ATTOHNEY'S FEES. � �' � ' p[ '�� RETENTiON FEE: .."'a�. '�Y .o� COINSTRUGTION LENDING AGENCY PRE-ALT FEE: ��,{��' �'�r ��� IHEREBYAFFIRM-UN�ERPENAL�;I'OFPERJURYTHATiHEREISACONSTRUCTiON�ENDINGAGENCY � qJ '' - FORTHEPERWFiMANCEOFTNI WOflKWRWHICHTMISPERMITI5155UE�(SEC.3097,QV.C.). a,yJ W , '� ' . . . .. ',�' LENDER'SNAME � �' - � F-�. LENOER'SAODRESS � ���, ICERTIFYTHATIHAVEREADTHISAPPUCATIONANDSTATElHATTHEABOYEINFORMATIONISCARNECT. TOTAL FEES �� �71`�t�:(nD, � IAGFiE'TOCOMPLYWITHAILdiYANDCAUNTYORDINANCESANDSTATELAWSRELATINGTOBUILDING `L� �� CONSTRUCT{ON.ANDHEREBV�THORIZEREPRESENPATNESOFTHISAOUN7VTOEN7ERUPONYHE . � , , - � � ABOVE-MENTIONED PROPERTY dR INSPECTION PURPOSES. COMMENTS - � J� � , � ' m'', pERA6TT NAME . . " a, � � �� � ��(%j�. SiONATUiiEOF EF E ', DAT ' ' � ���' li . RECPT.NO. PAID BV YALI�ATION ��, WHITE-0eparlment Copy,YELLOW—Finance Copy,PINK—Assessor Copg GOLDENROD—Fila Copy,GREEN—Applicant's Copy �� . ���� �� ��� � ,� � � � ����� � � � r� �::: � �:� � � , � =; �.;� � � � .� � � � , � ' ��""s��?�:;�;� � , � � � E �.�.�'��:,3�t��" ��, i... ____-�--- � — � �_. - _._. g�� .�_� �� �,: �: p� �° "�� " �° `�(�"�iY'�j�:y�" s ��� � �� ' I . � , ,' E, ?°'¢i1i��L+�:Fi?�ii . . � . i . . . '� , �� t __„. 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