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/ . �-� _ ' CITY OF DIAMOND BAR ----��``' - DEPAR'TMENT OF COMMUNiTY&DEVEIAPMENi'SERVICES 4 21 S25 E.Coptey Drive I " -" (909)860-3195 Fax(909)861-3119 PRESS '''.%+�....' BUILDINGPERMITAPPLIGATION FIRMLY o �DDRIESS �I��� ��;����� C7� DATEICATION J. �� NUM$R #fC �o ISSUE j TYPE OCC APN LOT TRACT DATE �1 CONST. GROUP °� OWNER �" 3;- ''s.:.'�. n,m �°� o ADORESS ��'- � ,` �,'+ `- >'�. ZONING SE7'BACKS , Z CITY .� ZIP ` � ':TEL. C�'�,'�x� . �8�� FRONT RW ❑ . o, APPLICANT TEL. S DE/$IDE STREET RW ❑ ' z m CONTRAGTOR i�- '�`,�°'�. � ' ` SIDE ❑ � ADDRESS �"� :`� ,'`s �` _ — o �':"::. �?�F' , at� tita PROPOSEQ'U5E _ o` CITY ';, ,� a . �"° I ZIP TEL . � wo ARCI'U�NG/ iz DESIGNER NO.DWEL. NO. NO. a ADRRESS �' GTY ` ZIP TEL UNITS STORIES BEDROOMS cn �n DESCRIPTION SQ.Ff: FACTOR PSF ADJ.ARE,4/1/ALUATION ; � OWNER-BUILDERDECLARATION gFR/ADD/FlEM I O b. : - fHEfiEBY AFFIRM UN�EA-PENALTV OF PEqJURYTHAT 1 AM EXEMPT FROMTHE CONTMCTORS.LI- ��_'G8f8g9/C2tPOK�: �� - . �,: ,..l�tJ �.:CENBEUWFORZ}1EFOLLGN(MGIIFASON�{9EC,799J;58US1NESSANDPE30FE35qNSGOdE;ANYCidYDA .-- - � � � ��� � � - ... C3 �COUNTY�WHICFfAfOlJIRESAPEHMITITO.GON3iRUG�ALiE&JMPii0YE,0€AK)f:IS91:�FiHE7A1H�ANY5TN8G,..:.. �-:de:,�'•�---,->.;..-.r --_:--_�, �:. . .::� ». .. . . ....._ ___.._. .__._ .. .. _ .�:..._ :. . � �'�,TURE.PRIOR TOlCS ISSUIWCE,AL�yO REQUIPE$iHE APPLICANT FOR SUCH PERMII TO FlLEASIGNED - � Pa��OroeC�C - .�� , � ;STATEMEN7 THAT HE OR SHE IS LICENSED PURSUANT TQ THE PROVISIONS OF THE CONiRAC70R5.L4 �-- _ - _�,�. �CENSE LAW(CH�PTER Y(COMMENGING WIFH SECTbN 7000�OF DINSION 3 OF THE BUSINESS ANO PRO- � POOI/SP3 � . � � 0�. �FESCpNSCODE}ORTHATHEORSHE.ISEXEMPTTH6fl6FROMM1�iHEBA515FOHTHEALLEGfDEXEMP• (�., _ . . U..� ",710NrANYVqLAT1DNOF5ECTION7031SITY�ANYAPPLICANfFOAAPEqMiTSUB.IECTSTHEAPPI.ICANTTO Z Re-ROD1 - - .f... . � '�,rvACMLPENALTYOFNOTMORE7HANFIVEHUNDRED�OLLARS(550o).$ � - - , � � �OI;ASOWNEROFTHEPROPEHTY,ORMYEMPLOYEESWI7HYfAGE5A5THEIR50LECOMPENSATION; 0 COCf1T6fCiel � �� Z"�'WILL�D0�1HE WORIC,AN�THE STRUCTURE IS NQT INTEND�OR OFFERED FOR SALE(SEC.704d,BUSI- . J � i� - � �NE551WD PROFESSIONS CODE:THE fAN7HAC70R5 LICENSE LAW OOES NOT APALY 70 AN OWNER OG �- � y - . Pq07ER7YWHOBU4A50RIMCROV�STHEREON,ANDNMO.�OESSUOiWORKHIMSELFORHERSELFOR � Q., 7Hfi0UGHHISORHEAOWNEMPLOYEES,PROVIOEDTHATSUCHiMPROVEMEMSARENOTINTEPDE�OR _ m � . . . . W �.�;OFFEREDFORSAL.E.IFtiDWEVERII-IEBUILDW�ORIMPROVEMENTISSOIDWITHMONEYE11FiOFCOMPLE- - ��� 0�� ;i10M.THE OWNER�BUILDEA WILL MAVE THE BUfl�EN OF PROYING TH�T XE OR SHE UID NOT BULLD Oii Z'' ��IMPflOY£FOR7HE POFPOSE OF SALE). � - �� � - � � _�� �I,ASOWNEROFTHEPHOPERTY.AMEXCLUSNELYCANTRACTINGWITHLICENSEDCOMRACTORS � i �'. ."TO CANSTHUCT hfE PRDJECT(SEQ 70K,BUSINESS AN�PqOFESSiONS COOE:THE COMRAGTORS U•�� VfllOfl�i011 - ADJ.AREA � � W;�;CENSELAWDOEflNOTAPPLYTOAN��.ONMEROFAPROPERTYWHOBUIL�50RIMPROVESTHEREON.AND � _� �WHOCANTRACTSFORSUCHPROJECTSWI7HACONTRACTOR(SjUCEt�EDPURSUANTTO7HECONTMG "wa. QUANTITY DESCRIPTION - FEE , 70R5 LICENSE LAW.). . � - �" � - � � S �,�� ' ❑.1 AM EXEMPT UNOER SEC. � -- B.&P.C.FORTHIS AEASON Q - � �i �"6p: ` � ' �. ;. �'.. . U ... . , , � , .k Z,. DATE 'Y xr-� OWNER�'�,, �,,., : . ._ - U . _. ..._ .... . , . . . 0 ' , W � UCENSED CONTRACTORS DECLARATION W �� : �� �IHEREBYAfFIRMUNDEAPHJALNOF.P@RRIRYTHATIAML�CENSEOUN�ERPiiOVI510NSOFCHAPTEF.� � - . -` . �,1� d�� B�COMMENCINGWITHSECTION7000)OFOIVISION30F1HEBUSINESSANDPROfE5510N5CADE,ANU Z � - � � � - s� ,� MY L�CENSE IS IN Ft1LL FORCE AND EFFECL , m - - �. �+ K�..,.� �+ {, O�.`LICENSE CLA�S€:� ��� LIC.N0. `��"��'�" ��''��� � j .. _ � . , ~� � � CONTRACTOR �. �' �' J M� .W.:„DATE .. � a�_ ,,,. a' . . _ . . . . k � } f � � �,,. �f �-WORKERS�COMPENSATION DECtARATION Q � �.� IHEREBYAFFIRMU!lDERPBJALNOFPERJURVONEOFTHEFOLLOWINGDECLARATIINJS: Z � � . � '2 _I,HAYEANDWILLMAINTAINA'CEHTIFICA7EOFCONSENTTOSELP�INSUHEFORWORKER9'-� _ � . . - � - ¢ COMPENSA710N,ASPROVID�OBYSECTION370oOFTHELA60RCODE,FORTNEPERWRMANCE �U Q�, OFTHEWOBKFORWHICHTHISPEflMITIStSSUED. g _I HAVE AND WILL MAIN7AIN WORKERS'COMPENSATION INSUPANCE,AS fiEaVIRED BY SECTION- � .. . ,- . -:�.:' ..., �..:'_ ." - - ' .. �x .. ...v�_. .._...N ¢ �CARRI���O�DEFOR�EP�E_RWR�MAN�cCEE�OAFTHEWOfi�SPE�q�{�7�g �;. .PLAN�REVIEW�,.�.-�.- . -'.. -.'s*'�H r.. . i 4' �.���4. l+"a+�IM�iwY 2 Y 4e"k�,�.e� �. . . an�.Rsb�� �; Z doucv Nuueea ELECTRIC ¢ 0. . (fHI55ECTK7NN�NOTBEODMPLEfmOF7F�PERMITISFORONEHIN�ARE00q1ARS(yypp�pRLES$� PLUMBING �.- � ? WOflKE STCOM ENSATION�RMANCE OFTNE WORK FOR WHICH THfS PEHMIT IS ISSUED,1 � MECHANICAL ��'� ' �.t �"'� �' � �_ " C��.. SIiALL NOT EMPLOY ANY PERSON�NANY MANNER 50 AS TO BECAME SUBJECT TOTHE - - ' . - (/j FAWSOFCALIFORNIA,ANOAGflEE7MATlFISHOUL68E.COME -INSPECTIONFEE ., ' , . F SUBJECTTOTHEWORKERS'COMPHJSATIONPROVISIONSOFSECT�ON37000FTHELABOR � . .. _ ' � CO O EJ SHALL FORTHWI TH COMPLY WITH THOSE PPOVISIONS. - I S S U A N C E ��II O . . _ � . . p DATE: APPLICANT: - - - SMIP . ,., � J WAflNiNG:FAILURETO SECURE WOBKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALLBE ENERGY P/C � _ � . �� SU&IECTANEMPI.OVERTOCRIMINALPENALTIESANOCIVILFINESl1CTOONEHUN�FEDTHOU5IW� � , -.. .- � -_-...,/ ?;� DOLlARS{51�0.000),INADDITIONTO',THEC0.STOFCDMPENSNION,DAMAGESASPROVIDEDFORIN- - �NERGYPERMIT,- ' J, SECTIDN3�oeOFTHELABORCODE;INTEqEST,ANDAiTORNEY'SFEE& i � [c REFENTION FEE: � O � CONSTRUC770N LENDING AGENCY PRE-ALT FEE: # � ' � I HEREBV AFFIRM UN�ER PENALN OF PERIURYTHATTHERE IS ACANSTRUCTION LENDING AGENCY-' - - � � FOR THE P[RFORMANCE DFTHE WOqK FOR WHICHTHIS PERMITIS ISSUED(SEC.�08],CIY C.. ' _ , , Z � . -� . , . ' . � .._..� LENDER'S'NAME - - . - ' . . s Fi LENDERSAl1DRES5 � /� � � W ICERTIFYTHATIHAVEREAOTHISAPPLICATIDNANDSTATE7HATTMEABOYEINFORMATK3NISfARRECT. TOTAL FEES ' . - � '� �.,,�7!`>�� � � IAGREETOCAMP�YWITHALLGTYANDCOUMYORDMANCESANDSTATELAWSRELATMGTOBUIL�ING- - V - � CONSTHUCTION,ANDHEREBYAUTHORIZEREPRESEN7AiIVE50FTHI5COUNTYTOENT9'�UPONTHE ' � ' Z ABOVE�MENiION�PROPEHTY FORINSPECTIDN PURPOSES. �COMMENTS - � - O u � m PEAMITTEENAMFs(PyINn � • - � - � UJ ":'„�., �..�..M't_...,�,-,..,� � . . ,�,.. ,;f . . . � y SIGNA7UfiEOFPERMITTEE - ~ � . DATE - �. �} F�i � � . . � � HECPT.NO. % ��. �. �PAID BY � �- . ' ' � VALIDATION,T,_ ��. � WHITE—Department Copv YECLOW—Finance Co[rv.PWK—Assessor Corn.GOLDENRO ile Caov.GAEEN—Aee�iranYc Cnnv� , : � �_. �' „.,. 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