HomeMy WebLinkAbout16268 (225) CITY OF DIAMOND BAR �~ '
---��' DEPARTMENT OF COMMUNITY 8c DEVELOPMENT SERVICES �
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WASTEWATER
RECLAMATION
sa��o WqSTE MANAGEMENT C O U N T Y S A N I TAT I O N D I S T R I C T S
OF LOS ANGELES COUNTY
1955 Workman Mill Road,Whittier, CA 90601-1400 �
Mailing Address: P.O. Box 4998,Whittier,CA 90607-4998 CHARLES W. CARRY
Telephone: (562) 699-741 1, FAX: (562)699-5422 Chief Engineer and General Manager
Go tee7�ou°cs�: 7:00 a.m.- 4:00 p.m.Mon.-Thurs.
7:00 a.m.- 3:00 p.m.Fri.
Account No.: 114011926
� District No.: 21
SEWERAGE SYSTEM CONNECTION FEE L __ __ _ _ �
Date: December 07, 1999
Properky Owner: PEICHIN L CHENG
Address of Property: 2856 VJAGON TRAIN LANE
DIAMOND BAR, CA 91765
Thomas Guide Page:
Contact: TONY TANG
Phone: 626-444-3338
Mailing Address: 10926 RUSH ST. #B168
SOUTH EL MQNTE, CA 91733
County Assessor Map Book,Page,and Parcel Number: 8713-025-002
Structure is Proposed.
User Category and Units of Usage:
Category: OlA
Number of Units:
Square Footage:
CONNECTION FEE CALCULATION
1.00 X $1,290.00 = $],290.00
Num6er of Units of Usage Connectian Fee Per Unit af Usage Connection Fee
COMMENTS: '
$1,290.00
Connection Fee Due
IFee Paym�nt Rzceived Frum: Procetiszd by: LC;H • .
PsrcHiti i.. cHi,�c nr�, � n .
Amuunt: 51,290.Q0 C'k. No.:01939
I).('.: Datz: D�ceml>�r b7. 19�9
I — —•- -- --- — -
BUILDIN<i DGPT COI+Y VALID ONLY WHEN STAMPED
�a Recycled Paper ,
� WALNUf VALLEY UNIl�IED SCAOOL DISTRICT
880 SOUTH LEMON AVENLTE WALNUT CA 91'789
CERTIFICATE OF COMPLIANCE
With Fee Provisions of
Govemment Code Section 65996 '
DEVELOPER/OWNER C G �/� / '
ADDRESS 2 �.,5�/ j� Signa e of Apphcant
CITY/ZIP / • The person signing represeats that he/she is authorized
TELEPHONE Z, to sign on behalf of the owner/developer and that che
. information provided is true and accurate to the best ot
his/her knowledge.
NEW LOT ADDRE S USE O UILDING T�Tj`�L,S .
a� ��� �����., � ��'1i . - ,—�_ f ���
�/%�iln.--,� /3f 2 sidendal/ o i Ind i
City � � �
�
i �
HOME IMPROVEMENT OR REMODELING PROJECT �
ADDRESS DESC ION TOTAL SQ. FT.
.
Diamond Baz Walnut Bedroo , ., Kitchen, etc.)
Signature of Superintendent of Buildings Date� � l
TO BE COMPLETED BY SCHOOL DISTRICT
FEE SCHEDULE: The development fees levied by the Walnut Vailey Unified TOTAL FEES DUE q
School District under provision of Government Code§65995 $ ,��, 4�.�7• / �
are: (EFF. 8/17/98) Residential Development $1.93/sq. ft. Receipt# �" 5
Commercial/Industrial $0.31Jsq. ft. Date �
Fees are assessed on TOTAL square footage "living space" of ALL new or remodeling constructi n pr jects OVER 500 sq. feet
(eliminating gazage or uncovered patio).
�This is to certify that all fees due to the Walnut Valley Unified 5chool District under provision of Government Code Section
65995 have been received and a building pemut may be issued.
This is to certify that the above described development has been determined to be EXEMPT from the development fees of
Government Code Section 65995 and a building permit may be issued.
Exempdon Justification: PROJECT IS 500 OR LESS SQUARE FEET
OTHER
d �
�T�-n� Gr, �o �sr�►�f�--
Assistant Superintendent
Fiscal and Facilities Management
1/87 Rev. 2/88; 6/88; 8/89; 1/90; 8/90; 10/90; 8/92; 6/93; 11/93; 8/94; 6/96; 1/97; 8l98
PLEASE SEE NOTICE OF 90-DAY PERIOD FOR PROTEST OF FEES ON REVERSE SIDE
NOTICE OF 90-DAY PERIOD FOR PROTEST OF FEES
Secti�n 66020 of the Govemment Code enacted as.Assembly Bi11.�Q91,se�fprth as Chapter 5�9,
Statutes of the State of:California, 1996 effective'J�tar}c 1; P�97, requires that th�s schoc�l
district provide a written notice to the project applicanf�t 'the time�o€�paycrient�bf��chool fees,
mitigation payments or other exactions. This notice is to advise;j�rou that`�y ptofest 'uy fegard
to such amounts or the validity thereof in accordance with Sectioir6�02Q'of the�(�overnment
Code and other applicable law,�comr�ences with such payment or performance of any other
requirement as described in Section 66020 of the Government Code. Additionally, this notice
advises that the protest thereof must occur within 90 calendar days thereafter.
� CITY OF DIAMOND BAR ����� .. c_n�� -��
- �?j DEPARTMENT OF COMMUNITY 8c DEVELOPMENT SERVICES
21825 E.Copley Drive
(909)860-3195 Faac(909)861-3117 E$$
y����°�� BUILDING PERMIT APPLICATION FIRMLY
o� JOBSITE 1 � APPLICATION ��`��-��"�,PERMIT I�� �� P/C
ADDRESS_ �� DATE P'� Nl1MBER #
� ISSUE TYPE OCC
`�° APN LOT TRACT DATE CONST. GROUP
p OWNER
p ADDRESS ZONING SE76ACKS
z CITY ZIP TEL. FRONT RW ❑
Q APPLICANT TEL. REAR ❑
z SIDE/SIDE STREET RW ❑
Q CONTRACTOR �' � SIDE ❑
ADDR
� CITY ZIP TEL. PROPOSED USE -
o ARCH/ NG/
�z DESIGNER NO.DWEL. NO. NO.
a ADDRE55
� CI7Y ZIP TEL. UNITS STORIES BEDROOMS
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cn DESCRIPTION S .FT., FACTOR PSF ADJ.AREANALUATION
p� OWNER-BUILDER DECLARATION SFR/ADD/REM
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I HEFEBY AFFIRM UNDER PENALTY OF PEfiJURY THAi I pM EXEMPT FROM THE CANTRACTORS LI� G2f2J0/CelPOrt
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V COUNTVWHICHRE�UIRESAPERMITTOGONSTRUC7,ALTER,IMPROVE,DEMOLISH,ORREPAIHANVSTRUF
WTUFiE.PRIOF TO ITS ISSUANCE ALSD REOUIRES iHE APPLICANT FOR Sl1CH PEFMIT TO FILE A SIGNED W Paho/Deck
� STAIEMENT THAT HE OR SHE IS 4CENSEO PURSUAN7 TO THE PROVISIONS OF THE CONTRACTOFS LI- �
� CENSE LAW(CHAPiER 9(COMMENCING WITH SECTION 7000)OF DIVISION 30F THE BUSINESS AND PRO- POOUSPd
� FESSIONSCADE)ORTHA7HEORSHEISEXEMPTTHEREFROMANDTHEBASISFORTHEALLEGEDEXEMP- (�
TION.ANVVIOLATIONOFSECTION7o315BVANVAPPLICANTFORAPERMITSUeJECTSTHEAPPLICANTTO � qe-Roo1
A CIVIL PENALTY OF NOT MORE TMAN FIVE HUN�REO DOLLARS(SSW))
Z ❑I,ASOWNEROFTHEPROPEFiTY,ORMVEMPLOYEESWITHWAGESASTHGIRSOLECOMPENSATION, � COrt1A18fGel
WILL DO THE WORK,AND THE STRUCiURE IS NOT INTENDED OP OFFERED FOR SALE(SEC]nd4,BU51- J
� NE55 AND PfiOFESSIONS CADE iHE CONTRACTORS LICENSE lAW DOES NOT APPLY TO AN OWNER OF ?
PROPERTY WHO BUILDS OR IMPROVES THEFEON,AND WHO DOES Sl1CH WORK HIMSELFORHERSELFOR
� THROUGHMISORHEROWNEMPLOYEES.PflOVIDEOTHATSUCHIMPROVEMENiSARENOTINTENDEDOfi m
QOFFEREDFORSALEIF,HOWEVEF,7F{E9UIl�INGORIMPROVEMENTISSOLDWI7HINONEYEAROFCOMPLE-
Z TION,THE OWNER�9UILDER WILL HAVE THE BURDEN OF PROVING THA7 HE OR SHE�I�NDT BUIL�OF
� IMPROVE FOR THE PURPOSE OF SALE)
W ❑I,ASOWNEROFTHEPROPERTV,AMEXCLUSIVELVCONTRACTMGWITHLICENSEDCONTRACTORS
� TO fANSTRUCT 7HE PROJECT(SEC 7a4a,6USINESS AND PROFESSIONS CODE THE CONTRACTOF5 LI� V8IU9llOf1 ADJ AREA__
W CENSELAWDOESNOTAPGIVTOANOWNEFOFAPR�PERTVWHOBUILOSORIMPROVESTHEREON,ANO —
� WHOCONTRACTSFORSUCHPROJECTSWITHACONTflACTOq(S�LICENSEDPURSUANTTOTHECONTRAG QUANTITY �ESCRIPTION FEE
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� ❑I AM EXEMPT UNDEF SEC B 8 PC FOR THIS REASON Q
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OWNER-BUI�DER DECLARATION
I HEREBY AFFiRm UNDER PENA�TY OF PEELIURY THAT I AM EXEMPT FROM THE CONTRP,CTORS LICENSE�AW FOR THE
FOL�OWING REASON(SEC. 7031 0 BUSINESS AND PROFESSIONS CODE ANY Crry OR COUNT(WHICH REQUIRES A PERMITfO
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OF THE CONTRACTORS LICENSE�P,W(CHAPTER 9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND
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THAN FIVE HUNDRED DO�LARS(9500)):
LAS OWNER OF THE PROPERTy,OR MY EMP�OYEES WITH WAGES As THEIR SOLE DOMPENSATION,WI�L DO THE WORK,AND
THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SA�E(SEC 7044,SUSINESS AND PROFESSIONS CODE THE CONTRACTORS
LICENSE LAW DOES NOT APPLY TO AN OWNER OF PROPERTY WHO BUILDS OR IMPROVES THEREON,AND WHO DOES SUCH
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SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
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COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 375e OF THE LABOR CoDE,INTEREST,AND ATfORNEY'S FEES,
CONSTRUCTION LENDING AGENCY
I HEREBY AFFIRM UNDER PENA�TY OF PERJURY THAT THERE IS A CONSTRUCTION�ENDING AGENCY FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC. 3057,ciV C)
LENDER'S NAME LENDER'S ADDRESS
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CENSE IAW FOR THE FOL�OWING REASON(SEC 7031 5 BUSINESS AND PROFESSIONS CODE ANY CITY OR
COUNTY WHICH REQUIRES A PERMIT TO CONSTRUCT,A�TER,IMPROVE, DEMO�ISH,OR REPAIR ANY STRUG
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— FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC 3097,CIV C)
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FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC 3097,CIV C)
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LENDER'S NAME
E
— LENDER'S ADDRESS
—7..��
C I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT
U
I AGREE TO COMPLY WITH AL�CITY AND COUNTY ORDINANCES AND STATE�AWS RE�ATING TO BUI�DING
CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE—MENTIONED PROPERTY FOR INSPECTION PURPOSES
5
1
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APP�ICATION
DATE
c„").3,...6 kERMIT i ni PJC
•- UMBER #
ISSUE
DATE
TYPE OCC
CONST. GROUP
FRONT SETBACKS
ZONING REAR
SIDE RW 0
D
SIDEJSIDE STREET RW 0
D
N0. PROPOSED
UNITS
USE L .., •,•
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N0. N0.
STORIES BEDROOMS
DESCRIPTION SQ. FI'. FACTOR PSF ADJ.AREA/VALUATION
SFR/ADD/REM
Cr) Garage/Carport
Li]I-1-i Patio/Deck
IL
CD
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Commercial
Valuation AD7.AREA
QUANTITY DESCRIPTION FEE
6
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CONSTRUCTION i - I
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E�ECTRIC
P�UMBING
MECHANICAL
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ISSUANCE
SMIP
ENERGY PJC
ENER6Y PERMIT
RETENTION FEE:
PRE-ALT FEE:
--- ...^.azAI�IIl6
i
0 MT,)
').I: ;Lt. 1111 , t.j0
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COMMENTS
i A
RECPT NO nie 'AID BY 111 VALIDATION tip
WHITE—Department Copy,YE�LOW—Finance Copy, PINK—Assessor , ,
/
PRESS FIRM�Y
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVE�OPMENT SERVICES 21660 E.Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
JOBSITE zst z
ADDRESS st-6 ikkr TON
APN LOT J/ TRACT
OWNER rei atht/ al&cif
ADDRESS_., ./1-1-4 lA-hotri, ThAm,
CITY niA^txtAupka Sow- ZIP Ti 9�t TELI 6.4..)qR 41 1
APP�ICANT Ro1Zot Ya-A, TE41.9 6y3-644/
CONTRACTOR A-4 Ca4te„J....�i ,,,,...
ADDRESS Z...
CITY pamo oel, ZIP 444 TEL. i2-Z--tatc
ARCH/ENGJ' ..,
DESIGNER 16-C.AtievAi�s,
ADDRESS I I t) > 1- ql-Co�dc-N. te
CITY 4&ZIP TEL.OJ94( --02.ry
OWNER-BUI�DER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE I.AW FOR THE FOL�OWING REASON(SEC.7031 5 BUSINESS AND PROFESSIONS CODE ANY CITY OR
COUNTY WHICH REQUIRESA PERMIT TO CONSTRUCT,ALTER,IMPROVE, DEMOLISH,OR REPAIR ANY STRUG
TURE, PRIOR TO ITS ISSUANCE.ALSO REQUIRES THE APP�ICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS UCENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI-
CENSE�AW(CHAPTERS(COMMENCING WITH SECTION 7000)OF DIVISION 301 THE BUSINESS AND PRO-
FESSIONS CODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE A�LEGED EXEMP-
TION.ANY VIOLATION OF SECTION 7031 6 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APP�ICANT TO
A CIVI�PENA�TY OF NOT MORE THAN FIVE HUNDRED DOLLARS(BSoo).).
EI I,AS OWNER OF THE PROPERTY,OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
WI�L DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC 7044,SUSI-
NESS AND PROFESSIONS CODE THE CONTRACTORS�ICENSE LAW DOES NOT APP�Y TO AN OWNER OF
PROPERTY WHO BUII.DS OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE IF, HOWEVEFL THE BUILDING OR IMPROVEMENT IS SO�D WITHIN ONE YEAROF COMPLE-
TION.THE OWNER-BUI�DER WIL�HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUI�D OR
IMPROVE FOR THE PURPOSE OF SALE)
0 IAN OWNER OF THE PROPERTY,AM EXC�USIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PRO]ECT(SEC. 7044,BUSINESS AND PROFESSIONS CODE THE CONTRACTORS LI-
CENSE t_AW DOES NOT APPI.Y TO AN OWNER OF A PROPERTY WHO BU/�DS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAG
TORS UCENSE lAW.).
O I AM EXEMPT UNDER SEC. B. &PC. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DEC�ARATION
I HEREBY AFFIRM UNDER PENA�TY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND
MY�ICENSE IS IN FUL�FORCE AND EFFECT
LICENSE CLASS A_C=29CS3LIC NO 60?3,ct 0
DATE �)---81"--Of CONTRACTOR kt 1_I orocker—.�.
1
WORKERS'COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENA�TY OF PER]URY ONE OF THE FOLLOWING DECLARATIONS
I HAVE AND WIL�MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'
COMPENSATION,AS PROVIDED BY SECTION 3700 OF THE�ABOR CODE, FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED
>e, I HAVE AND WIL�MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION
3700 OF THE�ABOR CODE,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. My WORKERS'COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE
CARRIER 51ak fund
POLICY NUMBER ,_.?12..—Ol,
(THIS SECTION NET> NOT BE OOMPLEIED OF THE PERMIT IS FOR ONE HUNDRED CO�LARS(0100)OR�ESS).
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
SHAL�NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE
WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I SHOULD BECOME
SUBJECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE(ABOR
CODE,I SHALL FORTHWITH COMPLY WITH THOSE ISIONS
DATE a%""f--ei APP�ICANT
WARNING FAILURE TO SECURE WORKERS'COMPENSATION C VERAGE IS UN�AW LANDS A�L BE
SUBJECT AN EMPLOYER TO CRIMINAL PENA�TIES AND CIVIL FINES UP TO ONE HUN RED THOUSAND
DOLLP,RS(Sioo,000),IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3708 OF THE LABOR CODE,INTEREST,AND ATfORNEY'S FEES
CONSTRUCTION LENDING AGENCY
I HEREBY AFFIRM UNDER PENA�TY OF PER]URY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC 3097,CIV C)
LENDER'S NAME
LENDER'S ADDRESS
i CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION Is CORRECT
I AGREE TO COMPLY WITH AL�CITY AND COUNTY ORDINANCES AND STATE�AWS RE�ATING TO BUILDING
CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES
120677-1Z )lAAl
PERMIITEE NAME(PRINT)
�
If,- 4
SIGNATURE OF PERMI'rfEE. if DATE
APP�ICATION PERMIT
DATE NUMBER(tili 2b P/C
0 0 i #Ol '013
ISSUE TYPE OCC
DATE O CONST. GROUP
FRONT SETBACKS
ZONING REAR
SIDE RW 0
0
SIDEJSIDE STREET RW 0
0
N0. PROPOSED
UNITS
USE c141lnviit Spok 8ors s6-fre-
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u-
0
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SFR/ADD/REM
Garage/Carport
Patio/Deck
Pool/Spa
Re-Roof
5
-J Commercial
5
m
Valuation '").—D OCX) AD)AREA
QUANTITY DESCRIPTION FEE
.4
0
EE
F- I )06 1 ele6 5 .t0
0
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0
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PLAN REVIEW
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ISSUANCE
SM1P
ENERGY P/C
ENERGY PERMIT
RETENTION FEE:
PRE-ALT FEE: &34:7
67215111M-
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JAN 1 5 2001 160. CC)
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TOTAL FEES Nig,st 677,64)
COMMENTS
..... AB An
RECPT. NO. '11111111 PAID BY -11111114 ALIDATION MT v
WHIT—Department Copy,YE�LOW—Finance Copy, PINK—Assessor Copy,GO�D RO e Copy,GREEN—ApplicanYs Copy
CiTY OF DAMOND BAR INSPEC7iCW rTCOPO
i^ •i
r • - •
POC,'
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVE�OPMENT SERVICES 21660 E.Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
APP�ICATION
DATE
PERMIT P ...-3'I „--
1 f/ NUMBER ". .'//C&3#
ISSUE , IYPE OCC
DATE CONST. GROUP
FRONT SETBACKS RW
ZONING REAR
SIDE 0
0
SIDEJSIDE STREET RW o
CI
N0. PROPOSED
UNITS
USE 4 •A ..4 '
DWE�.
/
,..-waimrsigaraiiirairlatriiifilt
11
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N0. No
STORIES BEDROOMS
DESCRIPT• SQ. Ff. IIIIIIMENWIIMIEffiMill, AD7. REANA�UATION
cn FACTOR PSF 6
SFLA111/11161111WK
Garage/Carport
111M1111071�OWErs
W
w
LI- Patio/Deck 6-7/
0
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PooVSpa
Re-Roof
5
I Commercial
5
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Valuation 6 ADJ AREA
QUANTITY DESCRIPTION FEE
<I
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I-
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0
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EI.ECTRIC
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MECHANICAL
INSPECI'ION FEE t3-11. 'S0
ISSUANCE
SMIP
ENERGY P/C
ENER6Y PERMIT
RETENTION FEE
PRE-A�T FV.........
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(YU
5
'..'r".4 41+:9
------1"-a--
ii4/ 13
5"cc)-
TOTAL FEES FEES 9(06„ r-1 3 {12 51, +3
COMMENTS
i
RECPT. NO. PAID BY VALIDATION
I CERTIFY THAT I HAVE READ THIS APP�ICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT I AGREE T COMPLY
WITH AL�WY AND COUNTY ORDINANCES AND STATE�AWS RE�ATING TO BUILDING CONST CTION,AND HEREBY AUTHORIZE
REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ABO MENTIONED PROPERTY FOR INSPECTION pURPOS
WHITE--Depanment Copy,YE•W--Rnance Copy, PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—Applicant'S Copy
PRESS FIRM�Y
LICENSE CLASS LIC NO
DATE CONTRACTOR
WORKERS'COMPENSATION DECLARP,TION
I HEREBY AFFIRM UNDER PENA�TY OF PER7URY ONE OF THE FO�LOWING DECLARA,TIONS.
I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'COMPENSATION,AS PROVIDED BY
SECT/ON 3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED
I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION 3700 OF THE IABOR CODE
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. MY WORKERS'COMPENSATION INSURANCE
CARRIER AND PO�ICY NUMBER ARE
CARRIER
POLICY NUMBER
(THISSECTION NEED NOT BE COMP�ETEDOF THE PERMIT IS FOR ONE HUNDRED DO�LARS($100)OR�ESS),
j CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHAL�NOT EMPLOY ANy PERSON
IN ANY MANNER SO AS TO BECOME SUBJECT TO THE WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGREE THAT IF I
SHOU�D BECOME SUB)ECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR CODE,I SHALL
FORTHWITH COMP�Y WITH THOSE PROVISIONS.
DATE. APPLICANT
WARNING. FAI�URE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFU�,AND SHALL BE SUB7ECT AN EMP�OYER
TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLIARS oo,Dool, PI ADDITION TO THE COST OF
COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 37os OF THE�ABOR CODE,INTEREST,AND Al"fORNEY'S FEES
CONSTRUCTION LENDING AGENCY
I HEREBY AFFIRM UNDER PENA�TY OF PERJURY THAT THERE IS A CONSTRUCTION�ENDING AGENCY FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC 3097,CiV.C)
LENDER'S NAME
LENDER'S ADDRESS
JOBSITE _.;
, ,,, I/
ADDRESS (i °�C-5-f,)rlil'i,2 .t'll("'
AIA'--Wi-- 7 r TRACT OWNER/"(•\-"'-I'r::',,,,- 1„6- 1-,'%,--„f, L:(
ADDRESS
cCITY.fivti.0. ,7 i zip ' i TEL. ,'-,(':-. ,
APPLICANT i,"-;'-e.IT,;.,,, /+7; ,r_ TEL'
CONTRACTOR ADDRESS
CITY ZIP TEL. ARCH/ENG/
DESIGNER
ADDRESS
CITY ZIP TEL.
OWNER-BUI�DER DECLARATION
I HEREBY AFFIRM UNDER PENA�TY OF PER]URY THAT I AM EXEMPT FROM THE CONTRACTORS�ICENSE�AW FOR THE
FOL�OWING REASON(SEC. 7031 5 BUSIN ESS AND PROFESSIONS CODE ANY CITY OR COUNTY WHICH REQUIRES A PERMrT TO
CONSTRUCT,A�TER,IMPROVE. DEMO�ISH,OR REPAIR ANY STRUc.,,-TURE, PRIOR TO as ISSUANCE,ALSO REQUIRES THE
APPLICANT FOR SUCH PERMIT TO FILE A SIGNED STATEMENT THAT HE OR SHE IS�ICENSED PURSUANT TO THE PROVISIONS
OF THE CONTRACTORS LICENSE�P,W(CHAPTER 9(COMMENCING WITH SECTION 7000)OF DIVISION)OF THE BUSINESS AND
PROFESSIONS CODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE AL�EGED EXEMPTION.ANY
VIOLATOR OF SECTION 7031 5 BY ANY APPLICANT FOR A PERMIT SUB]ECTS THE APPLICANT TO A CIVIL PENALTY OF NOT MORE
THAN FIVE HUNDRED DOL�ARS($500).)'
I,AS OWNER OF THE PROPERTY,OR MY EMPLOYEES WITH WAGES AS THEIR SO�E COMPENSATION,WILL DO THE WORK.AND
THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SA�E(SEC. 7044, BUSINESS AND PROFESSIONS CODE THE CONTRACTORS
LICENSE LAW DOES NOT APPLY TO AN OWNER OF PROPERTY WHO BUILDS OR IMPROVES THEREON.AND WHO DOES SUCH
WORK HIMSELF OR HERSELF OR THROUGH HIS OR HER OWN EMP�OYEES,PROVIDED THAT SUCH IMPROVEMENTS ARE NOT
INTENDED OR OFFERED FOR SALE IF, HOWEVER.THE BUI�DING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF
COMP�ETION,THE OWNER-BUI�DER WI��HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUI�D OR IMPROVE FOR
THE PURPOSE OF SALE).
O LAS OWNER OF THE PROPERTY,AM EXCLUSIVE�Y CONTRACTING WITH LICENSED CONTRACTORS TO CONSTRUCT THE
PROJECT(SEC. 7044, BUSINESS AND PROFESSIONS CODE.THE CONTRACTORS�ICENSE LAW DOES NOT APPLY TO AN OWNER
OF A PROPERTY WHO BUI�DS OR IMPROVES THEREON.AND WHO CONTRACTS FOR SUCH PRO)ECTS WITH A CONTRACTOR(S)
LICENSED PURSUANT TO THE CONTRACTORS UCENSE�AW)
flejr: affarMIMIW40741:41,^%
LICENSED C NTRACTO-I. DEC�ARATION •
I HEREBY AFFIRM UNDER PENALTY 0 ERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTE 9(COMMENCING WITH
SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND MY LICENSE IS IN FULL FORCE AND EFFECT
DI. EMPT UNDEFI SEC.
P.0 FOR THIS R S
CITY OF DIAMOND BAR INSPECTION RECORD
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DEPARTMENT OF COMMUNITY&DEVE�OPMENT SERVICES(3
..j:12 21660 E.Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117
ION
BUILDING PERMIT APPLICA7
JOBSITE.
ADDRESS 9-W J„ft ti4
APN LOT TRA T 905- 4
OWNER A II. _A A 111 1111 A l.d A_
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CITY"�A)olt. . ZIP iiii E�halliMer
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CITY .l ,..J.... ../Z ZIP"" TELE,242;i7
ARCHJENG/
DESIGNER Air, .
ADDRESS W. ."' 1 2F+11117.43:iW-DR/IL in
CITY. ""'.401,._i iPf 2e,6 4 TE�.
.45f. .......
OWNER-BUI�DER DECLARATION
I HEREBY AFRRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE�AW FOR THE FO�LOWING REASON (SEC 7031.5 BUSINESS AND PROFESSIONS CODE ANY CITY OR
COUNTY WHICH REQUIRES A PERMIT TO OONSTRUCT,A�TER. IMPROVE, DEMO�ISH,OR REPAIR ANY STRUC.
TORE. PRIOR 10 11$ISSUANCE,A�SO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRP,CTORS LI.
CENSE IAW(CHAPTER 9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSIONS CODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE A�LEGED EXEMP-
TION,ANY VIOLATION OF SECTION 7031.5 BY ANY APP�ICANT FOR A PERMIT SUBJECTS THE APP�ICANT TO
A CIVIL PENA�TY OF NOT MORE THAN FIVE HUNDRED DOL�ARS($500)I.
DI,AS OWNER OF THE PROPERTY,OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
WI�L DO THE WORK AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC. 7044,BUSI-
NESS AND PROFESSIONS CODE:THE CONTRACTORS LICENSE tAW DOES NOT APP�Y TO AN OWNER OF
PROPERTY WHO BUI�DS OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE IF, HOWEVER THE BUI�DING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF COMP�E-
TION,THE OWNER-BUI�DER WIL�HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUI�D OR
IMPROVE FOR THE PURPOSE OF SALE).
01,AS OWNER OF THE PROPERTY,AM EXCLUSIVELY CONTRACTING WITH �ICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC 7044,BUSINESS AND PROFESSIONS CODE THE CONTRACTORS LI-
CENSE�AW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUI�DS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAG
TORS UCENSE tAW).
0 I AM EXEMPT UNDER SEC B 9 P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DEC�ARATION
r*I HEREBY AFFIRM UNDER PENA�TY OF PER]URY THAT I AM LICENSED UNDER PROVISIONS or CHAPTER
9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND
MY L/CENSE IS IN FUL�FORCE AND EFFECT.
LICENSE CSS LIC NO 0 1
2.iiP 4/4 ir,SA'..
it. CONTRP,CTOR..911J.. .AWI:,.;
MI --
WORKERS'COMPENSATION DECLARATION
i HERESY AFFIRM UNDER PENA�TY OF PERJURY ONE OF THE FOL�OWING DEC�ARATIONS
I HAVE AND WIL�MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'
COMPENSATOR,AS PROVIDED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURP,NCE,AS REQUIRED BY SECTJON
3700 OF THE�ABOR CODE,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WORKERS'COMPENSATION INSURANCE CARRIER AND PO�ICY NUMBER ARE
CARRIER .
POLICY NUMBER ///dr. .-
(THIS SECTION NEED NOT BE COMPLETED OF THE PERMIT IS FOR ONE HUNDRED COLLARS($100)OR�ESS).
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
SHAL�NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO COME SU. OCT TO THE
WORKERS'COMPENSATION (AWS OF CA�IFORNIA,AND A„I E THAT IF • • . •
SUBJECT TO THE WORKERS'COMPENSATION PRO ..../....;,,, -
CODE,I S ALL F RTHWITH COMPLY WITH '• pe.lr.,:i•ii,•
DATE:/2- ^/....-..--'
APPLICANT
I
I WARNING. FAI�URE TO SECURE WORKERS'COMPENSATION VERAGE IS UNLAWFUL,AND sBial. BE
., SUBJECT AN EMPLOYER TO CRIMINA�PENALTIES AND CIVI�FINES UP TO ONE HUNDRED THOUSAND
DOLLARS($100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN
1 SECTION 3709 OF THE LABOR CODE,INTEREST,AND ATfORNEY'S FEES.
CONSTRUCTION LENDING AGENCY
)
I HEREBY AFFIRM UNDER PENA�TY OF PER]URY THAT THERE IS A CONSTRUCTION LENDING AGENCY
- FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC 3097,co,C).
LENDER'S NAME
- LENDER'S ADDRESS
r•
, I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT
I AGREE TO COMP�Y WITH A��CITY AND COUNTY ORDINANCES AND STATE�AWS RE�ATING TO BUILDING
CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
,.3 ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES
J- ..w. 4 44141:45
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APP�ICATION A. PERMIT} 113
DATE NUMBER # CI - C/S
ISSUE MI' OCC
DATE CONS T. VP GROUP'
SETBACKS
ZONING FRONT
SIDE REAR RW iii
LI
SIDE/SIDE RW 0
STREET
0
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DESCRIPTION SQ. FI'. FACTOR PSF ADJ.AREANA�UATION
SFR/ADD/REM li Tit 0')/(490
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cn GarageJCarport S 2 0
L�I
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0
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Valuation
41101°'CreZIAREA
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QUANTITY r DESCnIPTION FEE
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CONSTRUCTION
PLAN REVIEW
E�ECTRIC
P�UMBING
• MECHANICAL
INSPECTION FEE
ISSUANCE
SMIP
ENERGY P/C
ENER6Y PERMIT
RETENTION FEE:
PRE-ALT FEE. it..cog. it)
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TOTAL -5,51.1-11
COMMENTS FEES *et 1 7d
IP ,,
Avow . I•".
RECPT. NO, PAID BY VALIDATION
WHITE—Department Copy, mance t]opy, FINIS—ASS8SSOr opy.
CITY QF DIAMOND BAR INSPECTION RECORD
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SET BACK• j-Z8---4 4 F�OOR JOIST
FTCS/FORMS/STEEL AI FHA REOMTS
---ELECTRIC GROUND i-2 8-tx, kW I UNDER FLOOR DUCT
GROUND P�UMBING /-z6.--40 4- UNDER FLOOR CONDUIT
/..zY-00 ot,
-I FIREP�ACE FOUNDATION
AB GRApE, ;AI_
TEMP POWER FIREPlACE BOND BEAM
iir,A.
awr MID HT. BOND BEAM -
Mr"
WATER SERVICE r'
ROOF SHEATHING I17 go 8 FT. BOND BEAM
FRAMINGNENTI�IATION .. FINAL BOND BEAM
A.^ PRE-GRADING
- Af ,,,,, BENCHING
ROOF COVER 04111......
-ROUGH HEATING
ROUGH E�ECTRIC ROUGH GRADING
ROUGH P�UMBING I FINISH GRADING
sHowEnrib6'TrE-si— POOL E�ECTRIC
EXT. LATH/SIDING -25-- * P00�FENCING
WAL�INSULATION --1. ...ifilt. P00�FINAL 1
CEI�ING INSUTATION �1,..., .
, OFF SITE IMPS.
FINAL ENG, LANDSCAPEARRIG. ON SITE IMPS. FINAL ZONING FIRE DEPT. FINAL t HEALTH DEPT,
DEV. FEES PAID ENERGY
• I -
SEWER SEPTIC TANK SEEP PIT/Ll_
AS AIR TEST FINA�CONS. FINAL HEATING AL ELECTRIC
NA�P�UMB:NG
z
-141J671-gi4L-'-Ae: 74j1---C'(f-�i
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—44�-ei--cle.8,4
COMMENTS
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3_.(al/„,_.,_7:,7,4-._Zeta,ir ykk fictii r .
L.- -- - '- " ---/
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SEPTIC_TANK Si�E _-4/ea,..0_ae.4,
SEEP PITIU SIZE 0,
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oet 9
COUNTY SANITATION DISTRICTS
OF LOS ANGE�ES COUNTY
1955 Workman Mili Road,Whittier,CA 90601-1400 Mailing Address: P.O. Box 4998,Whittier,CA 90607-4998 Telephone: (562}699-
7411, FAX: (562)699-5422
aiwintecrigia: 7:00 a.m. -4:00 p.m. Mon. -Thurs.7:00 a.m. -3:00 p.m. Fri.
SEWERAGE SYSTEM CONNECTION FEE
CHARLES W.CARRY Chief Engineer and General Manager
Account No.: 0400926 District No.: 21
Date: December 07, 1999
Property Owner: PEICHIN�CHENG
Address of Property: 2856 WAGON TRAIN LANE DIAMOND BAR,CA 91765
Thomas Guide Page:
Contact: TONY TANG
Phone: 626-444-3338
Mailing Address: 10926 RUSH ST. #B168 SOUTH E�MQNTE,CA 91733
County Assessor Map Book, Page,and Parcel Number: 8713-025-002 Structure is Proposed.
User Category and Units of Usage:
Category: OlA
Number of Units:
Square Footage:
CONNECTION FEE CALCU�ATION
1.00
Number of Units of Usage
X $1,290.00 Connection Fee Per Unit of Usage
$1,290.00
Connection Fee
COMMENTS:
$1,290.00
Connection Fee Due
Fee Payment Received From: PEICHIN L CHENG Amount: $1,290.00
D.C.:
Ck. No.: 01939
Processed by: �EH
Date: December 07. 1999
BUILDING DEPT COPY 4.17)Recycled Paper
VALID ONLY WHEN STAMPED
WALNUT VA�LEY UNIFIED SCH00�DISTRICT
880 SOUTH �EMON AVENUE WALNUT CA 91789
-Arv
Signa e of Applicant
The person signing represents that he/she is authorized to sign on behaif of the owner/developer and that the information provided
is true and accurate to the best of his/her knowledge.
FEE SCHEDULE:The development fees levied by the Walnut Vailey Unified TOTAL FEES DUE
$ ,72)q5-2.
Commercial/Industrial $0.31Jsq.ft. 0-4 ,y
are: (EFF.8/17/98) Residential Development $1.93Jsq.ft. Receipt#
Date t-2Fees are assessed on TOTAL square footage"living space"of AL�new or remodeling constructi n pr jects OVER 500
sq.feet
(eliminating garage or uncovered patio}.
V----
,This is to certify that all fees due to the Walnut Valley Unified School District under provision of Government Code Section 65995
have been received and a building permit may be issued.
This is to certify that the above described development has been determined to be EXEMPT from the development fees
of
Government Code Section 65995 and a building permit may be issued.
Exemption]ustification: PRO)ECT IS 500 OR LESS SQUARE FEET
OTHER
NEW LOT ADDRES USE 0 UILDING
" .C6 t-carCOit.,IK-15�11A,
sidential/o
City
HOME IMPROVEMENT OR REMODE�ING PRO]ECT ADDRESS DESC
Diamond Bar Walnut
Signature of Superintendent of Buildings
TOTA�SQ. FT.
TO BE COMP�ETED BY SCH00�DISTRICT
School District under provision of Government Code§65995
101am e-gockers-tn;/4—
Assistant Superintendent
Fiscal and Facilities Management
i/87 Rev. 2/88; 6/88;8/89; i/90; 8/90; 10/90; 8/92;6/93; 11/93; 8/94;6/96; ij97; 8/98
P�EASE SEE NOTICE OF 90-DAY PERIOD FOR PROTEST OF FEES ON REVERSE SIDE
CERTIFICATE OF COMP�IANCE With Fee Provisions of
Government Code Section 65996
CL,G. EV-1/1.45-/Pe Ofi
441%7?/
DEVE�OPER/OWNER ADDRESS 2976. •CITY/ZIP MI-COW TELEPHONE q2.6)
NOTICE OF 90-DAY PERIOD FOR PROTEST OF FEES
Section 66020 of the Government Code enacted as.Assembly pi113(191,sei forth as Chapter 549,Statutes a the State of
,California, 1996 effective January 1; 1'997, requites that this schooi district provide a written notice to the project appiicant� tit the
tinitr 6f'payment, bf 14ho01 fees, mitigation payments or other exactions.This notice is to adyisejtputhae_aily Piolest
to such amounts or the validity.thereof in accordance with Seciloil,-66020tof theeovernment Code and other applicable law,
commences with such payment or performance of any other requirement as described in Section 66020 of the Government Code.
Additionaily,this notice advises that the protest thereof must occur within 90 calendar days thereafter.
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVE�OPMENT SERVICES 21825 E. Copley Drive
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
JOBSITE
ADDRESS akS 14 V\K\lii-V`he��
APN LOT TRACT
OWNER
ADDRESS
CITY ZIP TEL.
APP�ICANT TEL.
MEI
CONTRACTOR ttaidiRAITIAMIWAIFAVI
ADDR . lOinAiIiMPIT- .
CITY.. i.. i zip OMR TE�J114 f
ARCH/NG/ .
DESIGNER
ADDRESS
CITY ZIP TEL.
OWNER-BUI�DER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI.
CENSE IAW FOR THE FOL�OWING REASON(SEC 7031 5 BUSINESS AND PROFESSIONS CODE ANY CITY OR
COUNTY WHICH REQUIRES A PERMIT TO CONSTRUCT,ALTER,IMPROVE, DEMO�ISH.OR REPAIRANY STRUC-
TURE, PRIOR TO ITS ISSUANCE,ALSO REQUIRES THE APP�ICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI-
CENSE t.AW(CHAPTER 0(COMMENCING WITH SECTION 7005)OF DIVISIONS OF THE BUSINESS AND PRO-
FESSIONS CODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE A�LEGED EXEMP-
TION.ANY VIOLATION OF SECTION 7031 5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APP�ICANT TO
A CIVI�PENA�TY OF NOT MORE THAN FIVE HUNDRED DOLLARS(B550))
0 I,AS OWNER OF THE PROPERTY,OR MY EMPLOYEES WITH WAGES AS THEIR SO�E COMPENSATION,
WI�L DO THE WORK.AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC 7044,BUSI-
NESS AND PROFESSIONS CODE THE CONTRACTORS�ICENSE LAW DOES NOT APP�Y TO AN OWNER OF
PROPERTY WHO BUI�DS OR IMPROVES THEREON.AND WHO DOES SUCH WORK HIMSELF OR HERSELF OR
THROUGH HIS OR HER OWN EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE. IF, HOWEVER,THE BUILDING OR IMPROVEMENT IS SO�D WITHIN ONE YEAROF COMPLE-
TION,THE OWNER-BUI�DER WIL�HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUI�D OR
IMPROVE FOR THE PURPOSE OF SA�E)
DI,AS OWNER OF THE PROPERTY,AM EXC�USIVE�Y CONTRACTING WITH �ICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC 7044, BUSINESS AND PROFESSIONS CODE THE CONTRACTORS LI-
CENSE(AW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUI�DS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAC-
TORS�ICENSE�AW(
0 I AM EXEMPT UNDER SEC B&p C FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DEC�ARATION
I HEREBY AFFIRM UNDER PENA�TY OF PER7URY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE.AND
MY�ICENSE IS IN FUL�FORCE AND EFFECT
LICE SE SS ....., 0 4t,
LIC. NO a
DATE CONTRACTOR MiMlnalif
WORKERS'COMPENSATION DE t_A ATION
I HEREBY AFFIRM UNDER PENA�TY OF PER]URY ONE OF THE FOLLOWING DECLARATIONS
I HAVE AND WIL�MAINTAIN A CERTIFICATE or CONSENT TO SELF-INSURE FOR WORKERS'
COMPENSATION,AS PROVIDED BY SECTION 3700 OF THE t_ABOR CODE, FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT is ISSUED
I HAVE AND WIL�MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION
3700 OF THE IABOR CODE,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED MY WORKERS'COMPENSATION INSURANCE CARRIER AND PO�ICY NUMBER ARE
CARRIER
POLICY NUMBER
l. (THIS SECTION NEED NOT BE COMFLETED OF THE PERMIT IS FOR ONE HUNDRED DOL�ARS(5100)OR�ESS)
! I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
i SHAL�NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE
5 WORKERS'COMPENSATION t_AWS OF CA�IFORNIA,AND AGREE T,AT IF I SHOULD BECOME
SUB ECT TO THE WORKERS'COMPENSA ON PROVISION •F 5:TION 3700 OF THE�ABOR
.7 A
CO E, AL�FORTHWITH comP�Y wiT Nei E PROVI- . •
) r
1 DATE APPLICANT h... I• A i.s.
1
1 WARNING FAILURE TO SECURE WORKERS'COMP•SATION COVERAGE IS UNIAWFU�,AND SHAL�BE
- SUBJECT AN EMPLOYER To CRIMINA�PENALTIES D CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS($100,000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN
:I SECTION 3708 OF THE LABOR CODE,INTEREST,AND ATfORNEY'S FEES
3
CONSTRUCTION LENDING AGENCY
- I HEREBY AFFIRM UNDER PENA�TY OF PER]URY THAT THERE IS A CONSTRUCTION LENDING AGENCY
- FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC 3097,CIV C}
5
LENDER'S NAME
LENDER'S ADDRESS
z
E.
5 I CERTIFY THAT I HAVE READ THIS APP�ICATION AND STATE THAT THE ABOVE INFORMATION is CORRECT
L" I AGREE TO COMP�Y WITH AL�CITY AND COUNTY ORDINANCES AND STATE LAWS REIJaTING TO BUILDING
, CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES
S II
...i V\' R.% ' -1\vf\
3
)3 PERMI NI
Ty ,
' ir
0
0 SIGNATU PERM E • DATE
E -
APP�ICATION
DATE
°. .X-(y)_PERMIT \I D
'-NUMBER )..,#
ISSUE OCC
DATE
TYPE
CONST. GROUP
FRONT SETBACKS
ZONING REAR
SIDE/SIDE
SIDE RW O
0
STREET RW EI
EI
N0. PROPOSED ,
UNITS
USE
DWE�.
N0. STORIES
N0. BEDROOMS
DESCRIPTION Sc. FT., FACTOR PSF AD).AREA/VALUATION
SFR/ADD/REM HY 1
u)
U-I
LU GarageJCarport
Li-
0
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Patio/Deck
PooVSpa
Re-Roof
Ei
—I Commercial
5
co
Valuation AD7 AREA
QUANTITY DESCRIPTION FEE
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CONSTRUCTION
LAN REVIEW
P�AN
P�UMBING
MECHANICAL
INSPECTION FEE
ISSUANCE
SMIP
ENERGY P/C
ENERGY PERMIT
RETENTION FEE.
PRE-ALT FEE.
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VA.I�LAVeI.
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TOTAL ---
COMMENTS FEES \\ ,
-,- ,c.
RECPT. NO PAID BY VALIDATION
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WHITE—Department Copy,YE�LOW—Finance opy, —ssessor i.]opy, ,
9,44z-4ei