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�'` CITY OF DIAMOND BAR ' �'r pRESS
�� '- ",. '+� DEPARTMENT OF BUILDING AND SAFETY FIRMLY
` � BUILDING PERMIT
JOBSITE _ - APPLJCATION Cr� PERMIT � USE
ADDRESS 1'� r. � DA7E �.��+,�NUMBER � � CODE
` APN � LOT TFiACT A EE ��'�'- 1��� CO ST. � � GR�OUP
o CRO STREET Z���N� SETBACKS "P"r"�""E""5
°= OWNER -�-- � ''� r--I FRONT RW ❑
o ADD ES `- ��- ���'� �`�'h � REAR ❑
„� CIT�• ZIP' TEL�. l SIDElSIDE STREET FiW ❑
g APPLICANT � `�� TEL�^i��� SIDE ❑
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Q CONTRAC70R � ��� �'-�-' SEWAGE
o AD ESS 1,� �- `� C DISPOSA,L � PUBLIC PMT�
❑ PRIVATE SQ.FT/100 GAL
,� CIT �,����'� ZI1�11�TEL��i�
= STAT[
u, ' �— .. � -� GRADING � CU.YDS.EXC. CU YDS FILL
y LIC.NUMBER< .
y ARCH/ENG �� ' � �pE SQ � ���� � ApJ. AREAIVaLUA7101V
=' DESIGNER ��`Sl,��-�+��; W 1 -'e_ �
� ADDF3,ES�� C. (,��, 2
��CITI��' �� ZI r� ���TEL��,�- C� 3
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C:s� Z
� PROP05ED USE �` ' 4
� �.C'� d GARAGE
o NO.DWEL. NO. NO. � PORCH
y UNITS STORIES BEDROOMS ,
� LOT DIMENSIONS m VALUATIO ` ADJ.AREA
o NO.OF BLDGS HOW QuaN7�Y DE CRI ION " FEE
� ON LO USED Q -� �y
oc U �
~ LI�:ENSEII LUNTRACTORS OECLAflATqN:I�erehy a�firm that I am 6censed wder O�n�i�ions o1 Chapter 9lmmmeMmg � � �� �����
Y rrvr,h Sectior 70UOi cl Oiwsian 3 nf rhe B�isiness anA Prolessions Code.and my�¢ense�s in full lorce and elfect �
3 � �
u- fNJNER�BNI�ER JECLARATION I herehy afhrm that I am exempt from ihe Comracloi s Lrtense Law lar the lollowing �...�
Z�reasan�Sec i0315 8uaress and P:alessions CoAe Any nly af county whith repwres a permh ta tunslruc[ (7 ���, J`,�(..�/
O nlier,impmve,Jenm�:sn or repair arry stmcture,prior to its issuance,also repmres Ihe applieant for such permtl Z `
� io Ide a sm,ned stalerent iha;he is!icensed pursuant�o the pravisions at the Contracmr"s L¢ense Law!Chapter � �� l�'�'�.! �j� J �t'�',�,��
p� 91cor.mencmq roth$ecnon 1QOD;ol Omsron 3 0l�he Business aml Pmfessons Cadei��Ihet he is t�em0��hemtrom
a, and�hz hasi�lo� i!�e alleqed sxempuon 4r.y vmlation of Secuon 70315 6y any applKanl!or a permil su��etls � R ''�(� r ����'�!) �
W the alpncam m a ervil Genal�v of r.ot nare t�ar.Irve hundied dollars 135001? a
� ❑!.ae owr.e�af[he pr�perh,or my einployees with wages as tAeu sole compensaUon,will do the work,and
~ the stvcmre is nm mrended or ollered lor sale�Sec T044.Busmess and Prolesvom Cade The Conttu�or's License e( � R � � �,�(~i�
�,~j �aw does mi aOCly to ar mvner o�pmpe�N who uuilds m improves ihercon.and who dces such work himull CJ
W m ihrouyh hu owr employees.prowtled Ihal wth imprwemenR are nat imended ai ofle�ed for sale If,howevec �
= the hmld�rr,cr impreuemenl¢sold w:thm are yex ol.an0letion,Ihe owreo-6utlde�will nave ihe burden of praving Q
y Ina[ne diG nat bwld rn imp+ove�or Ihe purDase at sale� x J
�/1 ^I as owne'ot Ihe "
J Vr00e!�y dm eyCluSi`rely[DniraCllny wnk hrenseC conlractars to co�strucl the O�ol���$e[ 111
7044,9usiness antl Pro�essions Code The Contracmr's License law does no�apply to an avner ol properry wha �
6 ^_udns or,mprcoes;herean,and wha contracts Im such pra�ec�s wnh a contracmr�sl��censed pwsuam ro the Contractar'S -� '-�-----. n
��cense�aw; CONSTRUCTION./ �4 � f�^��
W '''��� ���yyy��� ' `� 1 /�y�
r ❑I am eeemp;under Sec .0 6 PC!Attac�Certihntel PL V�Ew��� �"'f"'t.Q j 'K�"
� �,� °ixne1 ELECT �d�
� NARKERS'COMPENSATIq4 OECLABATIIXJ.I hereW alhrm�hai I have a ceraficau of consent m self-insurt,ar "'"'"� G`' .+]+!,��y�'�
a�enificate ef Nbrkers'Compensahon Inswance,or e ce��ified copy theieol(Sec 3800,Lah C 1 ,�}e-� --- "�1�
¢ ❑Cemtie ropy is here6Y����shed IVIG.ri�.�/0.L + ��
W � nl�eA copy is'detl wiih tAe Buiiding Inspeeuon Oepatmem or Departmem � GRAD�N�.7
Z C_'�
� f,ERTIFICATE OF EXEMPTION FROM WORKERS'COMPENSATION INSUBANCE This section need nM 6e completed � S`�A(�G` � �:
y d�he permn¢for one hunAred IS1001 ar less I cemlV that m the perinrmance of Ihe wak For wAkh Mrt ry�•y`
r Uermn is issueC I shall not emp�oy arry person in any r so as W ame su6�a1 lo ihe Nbrkers'Canpensabon ���P`�� � J�
o �awr o�Cahkrma � �- PARK FEE
� o°1e���q`' "D��` � LL- SCHOOL FEES
W NOTICE APPLICANT H alter making th�s Certilkate xemp y he sub�ect m the Worker's
� Cumpensatmn provismns al ihe Lahar Cotle,yau must imthw comp th rav ions a this pe�mil shall ,
6e deemed revoked ry .�} ,n +�
� qVIS10N Of INp15fRIAL SAFETY PEHMIT CEHTIFICATION� T : ��1}6'�O.'-ij "' � �L�—j ° 7� �✓rJ
W 4
n- ❑I hereUVi cenify mae nn eycava�ian(rve 15)or mwe(eet m dep�h�nto wA�ch'S'pe[sm is nqmred m descend,
� will 6e made m connectwn wnh work auMpr¢ed hy 1Ais permn;•and ihat no huilding slructwe,staffdding,fduwork,
n- ar demairtion or d�smanlling ihereof.wtll ne more tlwn thirry:sn�13.6)�eet high (Chap 3.2,Gry 2.An 2.Sec , .,
W 341.Title 8.C A C 1 • .. � .
s �
3 ❑ps uwner0ud0er.I will no�empby anyane la da wark whuh wouM reqwre a pw�nit From thc Div�san of
f-- Indusvwl Sahty,as nomd ahore,udess such permn has a pwmp�a do,�u�h worY Gom Ihe Qrvaion.
� '::,� : ; s i+.i^t�w '.,.
W ❑a.,=�o�m��a�=���a�S�,e�Y��m,�No TOTAL FEES �
� CONSfflUCTqN�ENOING AGENCY�I herehy afhrm�hat there�s a ronshuaian bndirg apncy lo�;tlu performan�e
Z nf ihe wark far wnmM1 this perml is isweU ISK.3097:Cin.CA .. � . ' ' ' � ' 1 �
� �enders N+�e COMMENTS C�1 �—' `� (D '� � .-�..�. �n.. �?•
� Lmaer'sl+d6ess �� �
Q CERTIFCA7E Of COMVLIANCE AND AUTNp111ZAi1W OF ENTRY I certify I have read Mu appliulion eM sute �
w [hat Ihe�Mamatmn grven is cwrect i agree ta�amply wnh all staoe laws ard ciry ordiiw¢a relatip to huiFdi�p
yconstrucuon,and a�thona repramntative of the Department o�Buildi�q aid Sahry Oe mtrr tpon tle properly
s fu rth I haw lied forl ^ eimrt Inr ihe OWou o�me4ing inspeclions.
r �
sqn e m m !_'�` ' �n,�� RECPT N7.��PAID BY � � VALIDATION
� p LIAW—Finance Copy,PINK—Assessor Copy,GOLDENROD—Fila Copy.GREEN—Applicants Copy �
BS106-71l89 �_ �--`��O\��� '---.`
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