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CITY OF DIAMOND BAR � "rt� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES �► � ,> 21660 E.Copley Drive Suite 190 (909)86Q3295 Fax(909)861-3117 PRESS '°�' BUILDING PERMIT APPLICATION FIRM Y QJOBSITE ��;�f�� � `��� DATE CATION y y� , o `l� PERMIT i,� /� ADDRESS `�'" a/ 6 g� NUMBER � # � APN LOT_;., TR T �SSUE _ ���, ,�� T+/pE OCC p OWNER �B%�� �� � DATE__��'�—�=CONST. GROUP p ADDRESS� LLl�., • ZONING SEfBACKS � CITY IP f TEL. FRONT _ RW � APPUCANT`,, tr" 1��-- TEL. REAR � � SIDE/SIDE STREET pyy 7 aa CONTRACTOR�f SIDE _ � g ���5 ¢ � Z!P TEL. J �7 - PRGPOSED USE ' �� � o ARCHJENG/ ' � DESIGNER — NO.DWEL. Np, N� ADDRESS � CITY _ __ ZIP_ TEL._ UNI�"S STORIES BEDROOMS � '— DESCRIPTION SQ,FT. FACTOR PSF ADJ.AREANALUATION O OWNER-BUILDER DECLARA710N SFFl/hOD/REM d I HERE9Y AFFlRM UNDER PENPLTY�PEPJURY THAT I AM EXFMPT FqOM TH'c CANTRACTORS U� G2f89B/C8Ip01'f L_iil CENSELAWWHTHEFIX.LOWINGflEA50N(SEC.703i.58u51NESSANDPROFE5510N5CODE:ANVCiT'OR (n 5•� COUNTYNMICHf$pU1RE5APERMITTOCONSTRUCT,ALTER,IMPqOVcOEMOUSH,OpREPAIRANYgTRUC. W pa9ioNack W NRE,VRIOR TO ITS ISSUANCE.dLSO REOUIRES THE APPLICANT FOR SUCH PERMIT TO FILE 0.SIGNEJ � STATEMENT THAT HE Ofi SNE IS LICENSEG PURSUPNT Ta 7HE PROVISIONS OF THE COMFACTORS LI� CENSE UW(CHAPTEq 9(COMMENCINO WITH SECTION 7o0e)OF DIVISION's OF?HE BUSINESS AND PRO- � PooUSpa FE93qNS CODEJ qi THAT HE OR 5HE I5 EXEMPT THEREFAOM AN�THF BASIS FOR T4E/�1;E�ED E%EMP. (� V TION.ANVYIOLATIONOFSECTION7031�BYqNYAPPLICANTFORAPFAFriITSUBJECTSTHEAPPLICANTTO Z Re-Roo1 � ACINL PENALTY OF rypT MORE iHAN FIVE HI;NORED OOLLARS(f5aa).�: " � "I.AS015NEROFTHEPROPER'Y,ORMVEMPLOYEESWITNWAGESASiME1R50LECOMPENSATiON, CO�i1RIQfCl81 VALL 00 THE WORK,AND THE STRUCTURE IS NOT IkTENDSD OR OFFERE7 POR SALE(SEC 7Ca4,BUSI- � � NE55 AND PqOFE5510N5 CODE:THE CONTRACTORS LICENSE UW�OES N0T APPLY 70 pN OWNER OF � PROP6qTY VYFp BURDS OR IMVROVES TMEREON.AND WHO DOFS SUCH WORN HiMSFLF OR HERSELF OR [C hIROUGI/HIS Oft HER DMM EMPLOVEES.PPOVIDEO THATSUCH IMPROVEMENTS AqE NOT INTENOED OR � — '�' Q OFFEREDPoRSII�E.IF,HOWEVERTNE9UILDINGORIMPROVEMENT15SOLDWRHINONEVE/{qOFCOMPIE� y TION,THE OWNER�BNL�EFi WILL NAVE THE BUROEN OF PROVING THpT HE OR SHE D�D NO?BUILO Oq �— = IMPROVE FDR THE PUflPOSE OF SALE�. � � � ❑I,AS OYlNER OF THE PROPER'Y,AM EXCLUSIV:LY COMAfMTNC WITH�.ICF.IiSED CONiRACTOpS � TO CONSTRUCT THE PRQ1E�(SEC.7D14,BUSINESS AWC PROFESSIONS cCDE�TFIE COkTRACTORS U� `Jg1118ti0Y1 _ADJ.AREA � CENSEU�WDOESNOTAPPLY70ANONMERaFAPROPERTYWHODUilD50FlIMP310VE57HEREON,AN7 ---- W}IOOOMRACTSFpqSUCHPibOJECTSWITHACpNTiiACTOR(5)LICENSEOPURSUM!!TOTHEOONTRAG QUANTIIY DESCRIr�TlON Y mRsuc�sE�aw.�. _ FEE � U I M1 E%EMPT UNDER SEC.___ ______6.R P,C FOti THIS REASGN Q 3 � —.� � DATE _. ` O1Y1ER` —__"�___ '_____ Q '______ Q � _____—_""_" U —� �d IICERSF�CONTqAC?Qp5 DECLARAT!Oti �r--" OC W -- --- IHEREBYAFF(qMUNOERPENPITVO'r�ER�UflVTHhTI,W,.IC:'flSEOU4DEQPROVISIONSOFCHIJTER � S 91�MENCINGWITHSECT!qV'laoDlQFOfVI510N�OFTHEBUS:NESSAND?ROFESSIONSCADE,ANO Z� O MY IICENSE IS ik FUI.L FOPCE AN�EFFEC7. � � ry� � m —4-- -- / LICENSECLASS LIC.NO "� '�� 1-1-- _ �'__'_'_ ._ "_ . � � �ATs =�!_� CONTHAC70 _.__ L � _ —"— W � � WORKERS'COMPENSATIOR CI_ARATIJN 1 ��'-- � � � ,�, 3! �2 ��---� � 1 NEREBV AFFIRM UN�ER PEN,U,TV OF 9ERIUW ONC-CF i Ni:F'J!LOW.NG OECiAFlh� � z � , � __I MAVE AND W1Li MNNT�tN A CER i tfICATE O�GY:NSENT TO SELF-!NSl!Rc fpq LVORKFRS' _ -` � C051PENSATION.AS�ROVIOEJ BY SECTION 3]:A OF T7iE LA90R COD£,Ff.R T*tF PERFORMANCE U� OF TME WORK FOR WNICH?HIS PERMIT IS!SSUED. W � � � � __I HAVE AND IY:LL MhINT0.1N WORKERS'CAMPENSATiON IhSUHA�CF_..t5 REnU:RE�H"S�CTION � 3�OOOFiyEu160R�.17DE.���RTHEPERFOFtMM'CFOFTHEWORX�ORWNI(':�THISPEFMR�S J I$SUrD.ldY640R!( WM?NSAT�ONINSURANr=^anF1'tRAvpp. . NllM6F.RAFE: CONSTRUCTION ______,_ ___ � Cd.RFIEA,__'_�, �•. � 6 PLANREVIFW -- -- i' � oouCYnUMBER_�_ ' ��_"t.' ELECTRIC _ � fiHl45E(:IIChNE.�NOT0EC�17LEiEDOFT}+EPEPfMU'�"OFiONEMJPI'hiED C is+ io�} PLUMBING __ ^ w L � z 1 CEqTIFV THAT IN THE PFRFORMANCE Of TH'c WORK FOR WNICH'HIS PES41715 ISSUFD.I MECHANICAL C7 � SIfALL NC1T EMPIAV ANv PERSON IN ANY MqNNER SO AS i0 BECOME$U9JECT TO THE ((ii � � N1 (/) WORKE"j5'COMPENSA710NLAWSOFCALI�ORNIA,ANOAGREETNATIFISHOULD9cCOME iNSPECTtONFEFy� � SUBJECTTOTHEYlORKERS'CA4PEk&ATIO�pAOVI 1 SOF CTIOM ooOK'HELAAOH ��� + U � CADE,tSNp1,4FGR_'�1 I�HGDMPLYWIT'iTHD 510 ISSUANCE''�a �rV1J O j ��] ��`pp,, � - — p DAT'e�(����M.s�(ppLiCANT _ _ • �_ �__ SMIP � �1J'1'�py � WqRNINO:FAILUH�7'O SECI:flE WORKE 'CCMP� SATICK COVERAGE 15 LN�P.w'FUL,aN0 SHAL�BE ENERGY P!C �'�'�1�V�'��T a� _ � SU&IECTAN EMPLOVER TO GR!MINAL P AND qViL FINES VP TOONE MUNDFlE�THOUSAND ENERGY PERMIT JOOlLARS(f100,000�,IN AODITIqV TO7NE COST QF COMPENSATqN,�AMAGES AS Pf70V:OED FOR!N SECTqN 9708 OF THE U130R CODE,INTEREST,ANp ATTORN[YS FEES. RETENTION FEE: _ ____ __ _ � sz �Q CONSTRUCTIONLENDINGAGENCY PRE•ALfFEE: _ ___.____.._ � IHEREBYAFFIflMUNDERPENAL�1laFPERJUFNTI!qT?HERF.ISACONS7RVCTIONLENDI4GAGENCV ____ Z FOR THE PERFORMANCE OF THE WORK FOR WHICIi THIS PERMIT IS ISSUED�SEC.3067,CIV.C.�. --'- -- - � _'—_"__—._'_—____'___'—'_ _-'�""'—__'—_'_-_ .. . . . ,_,.. LEN�ER'S NAME F- LENOER'SAODRESS___, 7- ...�\ W ICERTIFY'HATIHAVENEdD7HISAPPUCA7!ONANOS'AiETHAT'HEABOVEIIvFORMATIONI500RRECT. IOTAL FEES ` � d 1 AGREE TO CdAAPLY WITii ALLc:IP.'Af.O COUNN OR�INAYCe$pND STATE LAWS RF.UTING 70 BULL.DING � CONSTqUC710N,ANDHEREBVAUTHDR12EqEPRESEMATIVESOF7H15CD'JNTYTOENTERUPONTHE Z ABOYEMENiIONED PROPERTV FOR INSPECTION P11E1 OSES. 0 � / VCMMENTS ______ J �� � /i �� " ' . ... m — . . . . . . _ . . . . � PERMITTE' I.NT) � __— �� _ n✓� . � d y -- �- , .. � IG PEe7Y.ITT � pATE �--'- '-- — SiECPT.NO. 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