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Home My WebLink About12952 �� CTTY OF DIAMOND BAR �� DEPARTMENT OF CCIMMUNITY&DEVELOPMENT SERVICES IQ"� 21660 E.Copley Drive Suitc 190 PRESS w (909)860-3195 Fax(909)861 3117 a�°,.. BUILDING PERMIT APl'LICATYON _ ,.,. , . .,, , , FIRMLY . _ : _, ,. � JOBSITE p � �� APPLICATION �1 .-�`q PERMIT J � P/C o ADDRESS !��I �-�� -fI H� DATE I.�� t ` NUMBER "" --��# c� ISSUE TYPE OCC APN LOT TRACT '�1��•� DATE CONST. GROUP p OWNER U T'G k ��.�✓� p ADDRESS I'=I�S `T/FIL.I, L��=�� ZONING SETBACKS � CITY F�.�M✓7 ZIP �r�TEL.�` �-�'-�'I��'' FRONT RW ❑ APPLICANT TEL. REAR O � SIDE/SIDE STREET RW ❑ CONTRACTOR (��fJ�'�� SIDE C� � ADDRESS CITY ZIP TEL. PROPOSED USE �.�NTGn�oh �fC,/t �C..�i-Tt u✓ 0 ARCH/ENG! � DESIGNER NO.DWEL. NO. NO. ADDRESS UNITS �� STORIES BEDROOMS � CITY ZIP TEL. N DESCRIPTION SQ.FT. FAC70R PSF ADJ.AREANALUATION N � OWNER-BUILDER DECLARATION SFFUADD/REM � 1 HEAEBV AFFlRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTOqS L6 G3fdgB/CBfPOR � GENSEUWFORTFIEFU.LOWINGREASON(SEC.7a3t.5BU51NE55ANDFFaFE5510N3CODE:ANYCITVOR (n C� COUNTYNMICHREOUIRESAPERMYfTOCONSTAUCT,ALTER,IMPROVE,DEMOLISH,ORFiEPA1RANY5TRUG LL) pytio/DBCk � NRE,PRIOR TO ITS ISSUANCE.ALSO REQUIRES THE APPLICAN7 FOR SUCH PERMIT TO FILE A SIGNED W � STATEMENT THAT HE OR SHE IS LICENSED PURSUANT To 7NE PROVISIONS OF 7ME CONTRACTORS LI- � CBiSE lwW(CHAPTER B(CAMMENCINQ N7TH SECTION 7000)OF DINSION 3 OF THE BUSINESS AND 7R0. � PooUSpa FESSIONS COOE)OR iHAT ME OR SHE IS E%EMPT 7HEREFROM AND THE BA515 FOR iME ALLEOED E%EMP- TION.ANVVKKATIDNOFSECTION7031.68YANYAPPLICANTFORAOERMITSUBJECTSTHEAPPUCANT70 Z Ra-Roof � ACML VENALT'OF NOT MORE THAN PIVE HIINDRED DOLLAR3(S50JJ.): � ❑I,ASOVfNEROFTHEPROPERTV,ORMVEMPLOYEESWIiHWAGESASTHEIRSOLECAMPENSAiION, � CoRImBfCI21 VfILL DO TiE WOHN,M1D THE 3TRUCTURE IS NOT IN7ENDE0 OH OFfERED FOR SALE(SEC.7oda,BUSF J NESS MID PROFESSIONS CODE:TNE CONTRACTORS LICENSE LAW OOES NOT APPLY 70 AN OWNER OF � PFOPEFiT'N'FiOBUMD50RIMPRDVESTHEREON,AN�WHOD0E5SUCHWORKNIMSELFORHERSE1.fOR � (r iHHdIOHHI50RFEHOWNEMPLOYEES.PROVIOEDTMATSUCli1MPHOVEMEN75ARENOTINTEN�E00R m QOFFEREDFORSALEIF,HOWEVER,IHEBU�IDIMGORIMPROVEMENTISSOLAWITHINONEVEAROFCOMPLE- z �TION.THE OWNER-BUILAER WILL HAVE 7TSE BURDEN OF PROVING THAT HE OR SHE OID NOT BUIL�OR � IMPROVEFORhiEPUHPOSEOFSALE�. w ❑I,ASOWNEHOFTHEPROPERTY.AME%CLUSIVELYCONTRACTINGWITHLICENSEDCONTRACTORS (Y TO CONSTRUCT THE FPQIECT(SEC.70N.BUSINE55 AND PROFESSIONS CODE:THE CON7RACTORS LI- V21118I1011 ADJ.AREA W CENSEIJ�W�OESNOTAPPLVTDANOMMEROFAPROPERTVWHOBUILOSORIAAPqOVESTHEREON,AND � WFIOCONTMGTSFORSUGHPR0.IECTSWITHAC9NTflAGTOP.(SjLICENSEDPUflSUANT707HECONTM4 QUANTIN ESCRIPTION FEE � TORS IJCENSE UW.). � ❑I AM EXEM7T UNDER SEC. B.d P.C.FOR THIS REASON 3 � � OATE OWNER U ? • W � LICENSED CONTRACTORS DECLA TION W � IHEREBYAFFIRMUNDERPENALTYOFPERJURVTHAT�AMLICENSEDUNDERPROVISIONSOFCHAPTER �, � 9�COMMENCWOWITHSECTKKJ7000JOF�IVISION30FiHE8U51NE5SANOPROFES510N5CODE.ANO Z X MY LICENSE IS IN FULI FORCE AND EFFECT. m u� 0 LICENSE CLASS LIC.NQ � V pATE CONTRACTOR 0- W � WORKERS'COMPENSATION DECLARATION ¢ � I HEREBYAFFIRM UN�ER PENALTY OF PERIURV ONEOFTHE FOLLOWING DECLARATIONS: U � Z Q O I MAYE AND WILI MAINTAIN A CERTIFICATE OF CONSENT TO SELFINSURE FOq WOFKERS' S � COMPENSATION.ASPROVIOEDBVSECTON370DOFhIE1�1BORCODE,FORTHEPEPFORMANCE `U OF THE WORK FOR WMICH TIiIS PERMIT IS ISSUED. � � I HAVE ANO WILL MAINTAIN WORNERS'LOMPENSATION INSURANCE,AS RE�UIRED BV 3ECTION Q 37000F THE LABOR CODE,FOR THE PERFORMANCE OF THE WOPK FOR WHICHTHIS PEPMIT IS ��'� ISSUEO.MY WORNERS'COMPENSATION INSURANCE CARRIEF AND POIICY NUMBER ARE: CONSTRUCTION `6� � 7 CARRIER PLAN REVIEW � voucvNUMSEa - ELECTRIC � (IHISSECfiqdt�ND7BECOMPL.E1'FDaFTVEPEM�Rl6f-0RON�FRNJDREDDIXLAHS(51oo�ORLESS� PLUMBING W ICERTIFYTHATINhIEPERFORMANCEOFTHEWORKFORWH�CHTHISPERMITI515SUED,I MECHANICAL Z - (!f SHAIL NOT EMPL�Y ANY PERSON IN ANY MANNEF 50 AS TO BECOME SUBJECTTO THE � WbRKERS'COMPENSATIONI,AWSOFCALIFORNIA,ANOAGREETHATIFISHOULDBECOME INSPECTIONFEE SU&IECTTO THE WOPoCERS'COMPENSATION PROVISIONS OF SEC7�ON 3�0o OF THE LABOR �SSUANCE + s CADE,I SHALL FOqTHWITH COMPLV WITH THOSE PROVISIONS. � SMIP -�A��,-,��999 a p OATE: APPLICANT: . . � ENERGV P/C WARNING:FAILURE TO SEWRE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,ANO SHALL BE � SUBJECTRNEMPLOYERTOCRIMINALPENAL7IESANDCIYILFINESUPTOONEHUN�REDTMWSANO ENERGVPERMIT WLURS(S1oa,aoo),IN ADDITION i0 THE COSTOF COMPENSATION,DAMAGES AS PROVIDED FOR IN � � SECTpN37080FTHElABORCO�E,INTEREST,ANDA7TOFNEYSFEES. RETENTIONFEE: RTTL��,��M_��'�� d CONSTRUCTION LENDING AGENCY PHE•ALT FEE: _ LC IHEREB�AFFIHMUNOERPENAITYOFPERIURYTHATTHEREISACONSTRUCTIONLENDINGAGENGY � FOR THE PERFOPMANCE OFTHE WORK FOR WHICH THIS PERMIT IS ISSUE�(SEC.30B7,CN.C.). Z W � LENDER'SNPME � LENDER'SADDRESS — �!'�Q� � � ICERTIFYTHATIHAVEHEAOTNISAPPLICATIONPNDSTATETNAThIEABOVEINFORMATIONISCORRECT. TOTAL FEES D � I AOREE TO COMPLY WITH ALL CITV AN�CAUNTV ORDINANCES ArID STATE LAWS REUTING TO BUILD�NG CONSTRUCTIIXJ,AND HEREBY AUTFIOR�ZE REPRESEMATIVES OF TNIS CAUNTY TO ENTEii UCON THE .. ZABOVE-MENTIONED PRDPERTY FOR MSPECTION PURPOSES. COMMENTS � -�c.o�, C�f1i�1 /�tr;32�-� s PE^RMITTE NAAIE(PRINT) � //�� •`."��—�� ^ / . ��. '� � S16NANRE OF PEflMITTEE l OATE `�� " � RECPT.NO. 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