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11046 (5)
_�_ ���1�'l,�'� ��� CITY OF DIAMOND BAR nS�� � � COMMUNTTY DBVII,OPMENT DBPARTMENT �o 21660 E.Copley Drive Suite 190 � ��- � PRE�J• (909)860-3195 Fax(909)861-3117 � � �'""°y�� BUIL.DINGPERMTTAPPLICATION � FIRMLY � JOBSITE ����� ���� �I�� �JV DATEIGA 1 ���� Ty } ERMfT ���� P/C o pDDF1ESS UMBER # � ISSUE r" PE OCC APN LOT TR CT DATE CONST. GROUP p OWNER .��.fJ��A��. "- ADDRESS .:�� ZONING SETBACKS z CITY� ZIP ,�� TEL. � FRONT RW ❑___ p APPLICANT-� ��a��r?��'� TEL.� S�E/S1DE S7REET RW ❑ � CONTRACTOR ' ��� � � !s"A / SIDE ❑ � ADDRESS � � c, PROPOSED USE o CITY �0�_0./��G'P� ZIP +� j%'' TEL. ������ ' o ARCH/ENG/ iz DESlGNER NQ.DWEL. NO. NO. a AD�RESS UNITS STORIES BEDROaMS �' CITY ZIP TEL. cn, cn DESCRIPTION SQ.FT. FqCTOR PSF ADJ.AREANALUATfON p�� OWNER-OUILDER OECI.P.RATION � � � SFR/ADDlREM � � � � � � O I HEREBY AFFIFM UNDEfl PENALiY OF PEflJUR1'THAT I AM EXEMPT FROM iHE CONiPAC70fl5 LI� Gfl18g0/CSfp01i W �CENSELAWFORTHEPoLLOLYINOREASON(SEC.1031.5BUSWESSAN�PROFESSIONSCODE:ANYCITYOR (() ' ' G3. COUNiYWHICHREQUIR[SAPERMI7TOCONSTRUCi,ALTEH,IMPROVE,OEMOLISH,ORRcPAIRANVSTRUC- � �. � �'� TUflE.PRIOR TO ITE ISSUANCE,AL50'REQUIRES THE APPLICANT FOR-SUCH PENMIT i0 FILE A'SIGNE� ' w 'P8t10/DZCIC ' ' STATEMENT 7HA7 NE OR SHE IS LICENSED PURSUANT i0 iHE PROVISIONS OF THE COfViRACTORS LI- �-��.�CENSELAW(CHPPTERB(COMMENCINGWITHSECTION7ooc)OFDIVISION3OFTHE6USINea'SANDpRO- � POaVS � ' '�FESSIONSCO�E)ORTHATHEORSHEISEXEIAPTTHEREFROMANDTHEBASISFOR7HEALLEGEOE%EMP- �-+p o �TION.ANYVIOLATIONOFSECTION]o31.5BYANYAPPLICANiFDfiAPERMITSUBJEC75THF.�APPLICANTTO Re-Roof d,+ ��.��2 - 2 A CIVIL PENAL7Y OF NOi MORE THAN FNE HUNDRE�DOLLARS�S5o0).j: � '- ` ' ' o . ❑I,ASOWNEROFiHEPqOPERN.ORMYEMPLOYEESWITH'NAGESASiHEIRSOLECOMPENSAiION,� � CO�fIf110fC1&I � � � . '� Z� 'WILL DO THE WORfC,AND THE 3T�3UCTURE�IS NOT INiENDE�OR OFFERED FOR SALE(SEC.7044,BUSI- J � NESS AND PPOFESSIONS CODE:THE CONTRACTORS UCEN3E LAW DOE5 NOTAPPLV?O AN OWNEF�OF j �, � ,,,PROPERTV WHO BUIL�S OR IMPROVES THEf7EOW,AND WHO DOES SUCH WORK HIMSFI�OR HEflSELF'OR (r'�� THROUGHHISORHEFlOWNEMPLOYEES,PROVIDEOTHATSUCF'IMPROVEMENTSARENOYINTENDEO�OR .m ' �� OFFERE�FORSALE.IFHOWEVER,THEBUILDINGORIMPpOVEMENT�S50LDWITHINONEYEAROFCOMPLE - � � � � '�,'TIOM.THE OWNEq-BUILDER WILL HA�E THE BURDEN OF PROVING THAT HE Oft SHE�ID NDT BUILD OP � � �",IMPPOVEFORiHEPURPOSEOFSAIEf. , ' W,', ❑I,ASOWNEROFTHEPqOPERTY.AMEXGW5IVELVCONTRACiINGWIiHLICENSE�C.�M1TRACTORS� , � � �YO CONSTRUCTTHE PROJECT(SEC.7044.6USINESSAND PROFESSIONS CODe:iHE CON7RAG70R5 LI� V8II18IIOf1 ADJ.AREA � W= 'CENSELAW�OESNOTAPPLYTOANOWNEROFAPFOPERiYWHOBUILD50RI.NPRO�ESTHEREON,AN�� �"WHOCON7RAGTSFORSUCHPROJECiSWITHACONTRACTOR(S]LICENSEOPUFSUANTTOTH�GONTRAG QUANTITV DESCRIPTION FEE � Y TORS LICENSc LAW.�. � �IAM EXEMPT UNDER SEC. B.&P.C.FORTHI6 FEASON J O V � � � � � LL �A'fE OWNEft_,__' F . O —_--_ W . . , Fd LICENSED CONTRACTORS DECLARATION - � . � W �`'��' ����� CC IHEqEBYAFFIRIAUNOERPENALTVOF�ERJURYTHATIAMLICENSEDl1NDERPROWSION50FCHAPTEfi �'� � d '� 9(COMMENCINGWIiNSEC�ION'�o0o)OFONISION30FTHEBUSINESSANDPROFESS'.ONSCODE,lJ�D z - �X � MV LICENSE IS IN FULL FORCE AND EFFECT. � � ,� e � c y°�� � 1J �Ay �-7�+yy� � � LICENSE CLASryS ��� & UC.NQ. ��4,�✓ ✓ � U DATE /��^`f�'��� CONTRACTOR- `��� � „ � ��d .. �.� ,o O n�� � L1J . . ' ' � - r� svi^a � WORKERS'COMPENSATION DECLARA710N Q � IHEftEBYqFFIRMUNDERPENqLTYOF?ERIURYONEOFTHEFOLLOWINGDECLAPATIONS: Z � � IHAVEANDWILLMAINTqINACERTIFICAiEOFCONSENTTOSELF�INSUREFOqWORKEftS' ay Q iCAMPENSATIdN,ASPqOVI�EDBY5ECTiON37oaOFTHELFBORCO�E,FOqiHEPEfiFORMANCE U �. Q OF THE WORK FOR WHICH iHIS PERMIi I5155UE0. � ' W __IHAVEAN�WILLMAIN7AINWORKERS'COMPENSATIONINSURANCE,ASREOUIRE�BVSECiICN '�� Q 37a00FTHE LABOR CODE,fOR THE PERFORMANCE OFiHE WOqK fOR`h'HICH THIS PERMIT IS �� �� ' ISSUED.MVWORKERS'COMPENSATIONINSURANCECAqRIERANCPOUCYNUMBEflARE CONSTRUCTION J , j caaaiEa PLAN REVIEW - �' Z POLICYNUMBER ELECTRIC Q '� � (fH;55ECTpNNEmNOTBEGOMPLEiEDOFTh'EPERMfrISFORONEHUNUimD01.fAF5(510o)ORLESS�. PLUMBING Z ICERiIFYTHATINTHEPERFORMANCEO'=THEWORKFURWHIGHTHISPEFiMITI5155UED,l MECHANICAL � SHALL NOT EMPLOY ANY PERSON IN ANY MANNEF SOAS TO BECOME SIIBJECT T07HE � WORKERS'COMPENSATIONLAWSOFCAUFOPNIA,ANJAGREETHAT;FISHOULDB OME INSPECTIONFEE __ I� Fr�� = SUBJECTTO THE WORKEflS'COMPENSATION Pfl,ISION F SECTION o OF i L4BOR ' ' CO�E,I SHALL fORTHWITH COMPLY WITH i O��FOV I N5. ISSUANCE � � ��� � 3 '� p- DATE:_ � APPLICANT: � � SMIP ��6, r _ li J� � � ENERGY P/C - �!'���J� �� WARNING FAILt1RE TO SECU�9E WOflKEfiS'COMPENSAiION GOVEPAGE IS UNLAWFUL,AND SHALL Be --� ' � SUBJEGTANEMPLOYEF?OGRININALPENA�TIESANDCIVILFINESUPTOONEHUNDREDTNOUSAN� ENERGVPERMIT ' ODLLARS(y1a0,oC0),INADDITIONTO7HECOSTOFCOMPENSATION.DAMAGESASP�90VIDEDFORIN � SECTION 37oe OFTHE LA60R CODE.INTEREST,AN0 A7TORNEY'S FEES. RETENTiON FEE: � � -Q CONSTRUCTION LENDING AGENCY PREALT FEE � ' ' � IHEREBYAFFIRMUN�ERPENALTYOFPERJURVTHAITHEREISACONSiPUCTIONLEN�MGAGENCY ____ - � FOR iHE PERrORWANCE OF iHE WORK FOR WHICH TtilS PERMIT IS ISSUED(SEC.3097.GN.C.). - Z W � � LENDER'SNAME __ �� � F— LENOER'SAODFiE55 ' - � �� { �.� ICEFTIFYTHqTIHAVEREADTHISAPPUCATiONAN�SiATETHATTHEABOVEIA'FORMATIONISGORRECi TOTAL FEES - . � � � I AGREE iO COMPLY WITH A'_L CITY AND COUN7Y ORDINANCES AND STATE LAWS RELA'f1NG TO BU1L01NG �� � CONSiRl1CTION:AN'J HERE9V AUTHORIZE REPRESENiAiIVES OF THIS COUNTY TO ENTER UPON iHE '- � � PBJYE-MENTIONED PROPERiY FOR INSPECIION PURPOSES �COMMENTS__ i, _ ��� ��A� gPEftMITTEENAME P � � ���� �� � - ' CfJ '�. Uj SIQNATUFiEOFPERMITrEE ' DA7E : .� � = RECP7.NO. PAID BY �'' - � VACIDATION � � - WHI7E—Department Copy.YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—ApplicanE's Copy � � ����� �° i � .�� �� �. ������ �� �� &� .pp �, y . 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