HomeMy WebLinkAbout15790 ` f,�_ CITY OP DIAMOND BAR _
DEPART'MENT OF COMMUNITY&DEVELOPMENT SERVICES
� . 21660 E.Copley Drive Suite 190
(909)860-3!95 Fax(909)861-3117 PRESS
�'A"' BUII.DING PERMIT APPLICATION FIRMLY
} JOBSITE APPLICA710N � � PERMIT p�� P/Ci/101 .���
a ao�REss2813 Water Course Dr.
o DATE NUMBER_l�IL/ # 1��
� ISSUE 7YpE T��r� pCC
APN LOT �+H rRACT 4 7 8 5 Q DATE CONST. GROUP
o OWNER Diamond Bar West. LLC
o ADDRESS 3480 Torrance Bl ZONING SE7BACKS
� 49543 TE�,310-540-�99Q FRONT
CITY Torrance ZIP REAR RW �
� APPUCANT RiC113Yd Gottld TEL. Gama a n�ra �
CONTRACTOR JCC CORStYUCtlOri SIDESIDESTREET RW ❑
� ADDRESS same 2S owner �
� C�TY ZIP TEL. PROPOSED USE
w ARCH/ENG/
z DESIGNER R. Gould & As O .
a ADDRESS saine 35 owner NO.DWEL. NO. NO.
cn UNITS STORIES BEDROOMS
� CITY ZIP TEL.
� DESCRfPTION SQ.FT. FACTOR PSF ADJ.AR A/VAL ATION
O OWNER•BUILDER DECLARATION SFR/ADD/REM 8�7 ZO � ^—
Q 1 HEREBY AFFiRM UNDEA PENALTY O`PERJURY iHAi I AM EXEMPT FpOM THE CANTRACTORS LI- G2f8Q0/CBfPOfI 7 9 1 J� � D
W CENSEUWiORTHEFOLLOWINPqEASONSEC703158USINESSANDPROFESSIONSCODEANYCITYOR (n (.'�,d
U arjM`/yn{�CHpEpUIfiESAPEflMITTOCANSTRUCT,ALTER,IMPROVE,DEMOLISH,ORFEPAIRANYSTRUP 80 /� 'p
W NqE.PRIOR TO ITS ISSUANCE,ALSO RE�UIFES THE AGPLICpNT FOR SUCH PERMIT TO FILE A SIGNED W Patw/Deck � �• �// / ' AT'f j
� STATEMENT THAT HE Oq SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS ll�
c v vv
� CENSE LAW(CH�PTER e(COMMENqNG WITH SECTION�a00)OF DIYISION 3 OF THE BUSINE55 AND PRO- � POOUSp3
FESSIONSCObE�ORTiATHEDRSHEISEXEMPTTHEi7EFROMANDTHEBA5ISFORTHEALLEGEDEXEMP- (�
V TION.ANYYIOLA710NOFSECTION7o315BYANYAPPLICANTF09AAERMITSU&IECiSiNEAPPLICANTTO Z Re-Raof
� ACIVILPENALTV OF NOT MORE THAN FNE MUN�RED DO�LARS(5500))
� ❑l,ASOWNEROF7HEPROPERTY,ORAIVfA1PLOYEESWITHWAGE5AS7HEIR50LECOMPENSA7iON, COfI1RIBfC121 -
WILL DO THE WORK,AND THE STRUCTUqE IS NOT INTENDED OR OFFERED FOR SALE(SEC 7044,BU51- O
y NESS PND PflOF�SSIONS OOOE THE CONTRACTORS 4CENSE LAW DOES NOT APPLV TO qN OW NER OF � p o r c h 1 9 Z
PROPERiY Nh108UILDS OR IMPROVES TNEREdN,AND NMO�OES SUCH WORK HIMSELF OR HERSELF OR �
WTHqOU6H HIS Oq HEROWN EMPLOYEES,PROVIOED THAT SUCH IMPROVEMENTS ARE NOT IN7ENDED OR m
G OFFEflEDFORSALE�FHOWEVERT7EBUILDINGORIMPROVEMENTI550LDWITHINONEYEAROFCOMPLE-
Z TION,THE OWNEREl11L�Ep WILL HAVE THE fiUqDEN OF PROVING THAT HE OR SHE DID NOT BUILD Op
� IMPF�VE FORTHE PUfiPOSE OF SALE) 4 J.
❑I,AS OWNER OF THE PROPEHTV.AM E%CLUSIVELY CONTRqCTING WITH LICENSED CANTRACTORS
TO CONSTRUCT THE 7R0.1ECT�SEC 7046,BUSINESS AND CROFESSIONS CODE THE CONTRACTORS LI- VaIUBfIOn ADJ.AREA
W CENSELAWDDESNOTAPPLYTOANOWNEROFAPROPERTVWHOBUILDSOqIMPROVE3THEREON,AND
� WMOCONTRACTSFORSIICHPHOJECT5WITHACONTRACTOR(S)L.ICENSfOPURSUAN7TOTHECON7RAG QUANTITY DESCRIPTION FEE
TORS UCENSE LAW)
� ❑I AM EXEMPT UNbER SEC. _B&P C FOR THIS REASON Q
?� U
u" DATE oNMEP F-
Z U
Q� LICENSED CONTRACTORS DECLARATION W
2
I HEREBYAFFIRM 11NDER PEtJALTY OF PERIURY THAT IAM LICENSEO UND[R PROWSIONS OF CNAPTER �
� 9(COMMENLINOWITHSECTION70oo)OFDIVISION30FTHEBUSINESSANDPROFESSIONSGD�E,AN� z
L1J MV LICENSE fS IN FULL FORCE AND EFFECT m
� LICENSECLASS B LIC NO 67I9/+8/�2 = ����-- ,
V DATE CONTRAGTOR_i1_Vle_Cn1l,4YY11(`Yll1" d
W
� WOAKERS'COMPENSA710N DECLARATION Q
� IHEflEBYAFFIRMUNDEHPENALTYOFPERJURVONEOFTHEFOLLOWINGDECLARATIONS Z ' " �- - �-�-� �- -
� �IHAVEANDWILIMAINTAINACERTIFICATEOFCONSENTTOSELF-INSUREFORWOPKEFS' _
� COMPENSATION,AS PROVIDED BY SECTION 370o OF TME LABOR CODE,FOR THE AERFORMANCE U
OF THE WORK FON WHICH THIS PERMIT IS ISSUED � W
� �
W -r
Q �,L I HAVE AND WILL AIAIMAIN WORKEHS'COMPENSATION INSUNANCE,AS RE�UIRE�BY SECTION � ^
370oOFTHELApORCADE,FORfHEPERFORMRNCEOFTHEWORKFORWHICHTHISPERMITIS �
= ISSUED MY WONNERS'COMPENSA7�10�N INSURANCE CARRIER AN�POL)CY NUMBER ARE CONSTRUCTION ��
� CpRRIER �t�j�'�%�-=i^1 LV zzional 1nS21Y �R PLANREVlEW �%
� POLICY NUMBEq `>���i�V�/3�A .__ .—_ �LECTRIC � {f/
Q G
� (IFIlSSECTK7NNE�NOTBE00bPLEfEDOFiHEPEW.UTISFOi7IXJENl1NDRED�d..IAHS(Stm)ORLE55) PLUMBING ✓
W �
' Z iCERTIFYTHATINTHEPERFORMPNCEOFTHEWORKFORWHICHTHISPEFMITISISSUEp,I MECHANICAL �Q _
(,�} SHALLNO7EMPLOYANYPERSONINANYMANNERSOASTOBECOMESUBJECTTOTHE
� WOHKERS'COMPENSATIONLAWSOFCALIFORNIA,ANDAGREETHATIFISHOULDBECOME INSPECTIONFEE _
= SU&IECTTOTHEWORNERS'COMPENSAT70NPROVISIONSOFSEC7ION37WOFiHELABOR —
CODE,I SHALL FORTHWITN COMPLY WITH THOSE PROVISIONS ISSUANCE j
� �
p DA7E• APPLICANT SMIP
J WARNINO•FA7WqE70SECUREWORKEAS'COMPENSATIONCOVERAGFISUNLAWFUL,ANDSHALLBE ENERGYP/C .
LL SU&IECTAN EMPLOVER TO CRIMINAI PENALTIES AND CIYIL FlNES UP TO ONE HUNDFED THOUSAN� ENERGY PERMIT
WLLAflS(5700.000),IN AOOfTiON 70 TME COSTOF COMPENSAiION,DAMAGES AS PROVIDED FOR IN ' ^�)
¢ SECTION37oBOFTHEL4BORCOOE,INTEREST,MIDATTOqNEV'SFEES RETENTIONFEE. J�'1 a B"
d CONS7AUCTION LENDING AGENCY PAE-ALT FE :
�O / i
1 NEREBYAFFNiM UN�ER PENALTY OF PERJURY iHAi THERE IS A CONSTRUCTION LENDING AGENCY /
FORTHE PERFORMANCE OF THE WORK FOR WHICH TNIS 7EFMIT IS ISSUED(SEC ao97,CIV C) �
W •
� LENDER'SNAME
I— LEN�ER'SAD�RE55
W� TOTAL FEES '�3��o l0�'(7,
1 CERTIFY TMAT I HAVE READ TMIS APPUCATION AND STATE TMA7 THE A90VE INFORMATION IS CORRECT
� IAGAEE TO COMPLV WITk ALl C17V MIU COUNTY ORDIMANCES AND STATE lAWS RELATING TO dUI1D1MG
� CANSTRUC710N.AND HEflEeY AU7NORRE REPRESENTATNES OF THIS COUNTY TO ENTEfi UPON THE
z ABOVEMENiIONEDPROPERTYFORMSPECTfONPURPOSES
_ �1���,�� ��D��� COMMENTS
QPE EE E(PRINI)
� f 1 7 c�Q
� IONATUREOFPEHMITTEE ATE
= RECPT.N0. PAID BY YALIbAT10N
~ WHITE—Depanment Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLOENR de Copy.GRE —ApplicanYs Copy
�i"�'�` � IA �3 �A�
! 5����'6Q1� ��
.,t•,,r,. . . • 'I�,.., x<r. r-c•, ar u r•' t��z�a:.:��� '
•r i..•�. , , xi�:r +fil'{'�,�dl`' �' s°•�l;,• .�"�, ;`�S 5yp�:qE ��+�y!"" •
��• •', �'h�:,.r, ..{5 .�i � , ,�,;L.�i.. " ^ "` �' :� ap • S:'� �u.�� j '� � �h7
'��V.J"• �I ,..r.. wr`,'��d ��'i:1',,��� d,� �1 a „F+,o a,. . . �h�' � . _ i.•^ ir l 1,
•�:�' .�':.t. .�'# c�f'�r:i;�:��;i�siw�u «�r,�?�,�. r, ..�d!::� e�+^a+:�'i��P:F�.•:� .c s. f��-+.��itE:a r� ..,�,e�'��� � r
5E�',�11�K:. .. �� : �� FLOOR JC33ST
t=�'�°�:a/F�Fia"�lSI.�`>`d"�'c!' I FHA REG2MTS _---mm��
_____ __�__�_------ --��__._�.�.--._.._.__._..- - �
�,��CTFCSG G�?CbIJNG � I UNDER FLCfOR f3UGT ._._...�..._
__._...___..____� _...__ ----
�R%}UNCi I'LL�����t.z �! ?._ti.pc7__��._�___.— UNC3ER�LOQR COhSDU(T ---------
;L�i�C',-�Hr'�C3� _._-� _ �p� �iftEPLAGE F(Jl1NE?A`T"iOf�� Y
i ci��t��C}Ut��;-? � FIF�GPL�ICE BQNC7�EAM
___ __ ___ _..__ -- -
_.�
'.�daATE{�SER�IIC,� MBD H1'. BC7NC7 BEAM
________ ___ _ ---. '_____
FiQC}F�F2EAT1-i1�'J.�'a i2 2cro� 8 FT. BC3N[�BEAM I,
�'R.,4�i�Gitj�hll'iLI�iT;C?t��_.__,ti�� �_�. _ FIN�L B{�tV[3 BEAM _ �� __ _. �----
RC1�F�CC����i� � 4 P�tE-GFtAD1NG
i�UtJC'a�i�i�A7'11VCa�� 8E�1CNfNG
R011�N EL�C7i3IC ROIJGH CaRAI"}t�1G
___ _.__ �_.�___ _ _________ __.___.__----- _..
RQUCa�!Pa.11tt�iBlNC=s FINISH aRA�lNG
S�4C;�NE�ii��llB �"�'ST �__�__..._...�..... _.�_.__.�.___ F'ClOL ELECTRIC: _ ____ __...._
�X"�. t..a�i'Hl��€�!fvC � ( PC70L FENC9NG
_ �_ ..__..._. ___ __.._ __.._._______ ._ _______ �_._
Y+I�.�.L.d��d�t.lt A'T�Gf�! � POC7�F!l�t�� -
_...�_ _�____ ���._ _- - �.
�'.�'.�i.{���i��i.4��.F`�i��°a�.� j C}��.S'����{V��wr'a. ___.�...__—
�h���}��..�..�t���..��C; �� �4-_^_!__^-M� v �}E��re��!�Q{�.� � � � � -
��:�1'�!3 .�.�___._....__ __.!__ i-00 �I1�HL�i�It'"a. --- .._______
--�I�.._..:--�----_ ----- _
�Ei�7'CC T��4f � N �___� LANC7SCf�P�19ftRfC�a.
__.___._ __ ________Y�i _ . _____,. �_ _____'.__.____.__
S�"EP�dT,G.�. ��_�.� �'�. C?N`�!7'�iNIPS.
faAS R!�i 1�c��'�~__.�� __ �. _._.�_�_ � F1hIAL 7.t�S�lf,d(a` _ �
�1�:,+�i._��5���_. .�_ , �� , FERE t?EE�T. �id+�A�. � ._�.�________._�_�____�.____
s �- �._ .��'� ..._��_ _-------¢--. _._
_�_._..�____.__ ��__ �..�. ._._ ___
��r�;� �;�,�,-r�r�c� �i r����.�tr��a���. r���� ,
�._.______.�___._.______�� __.�____� �.______ _____._.___ _ __ _ _ ____�_
_ _--__ — - ._._
FI�Jn,��L�G7r�1C ' 1 � t'��V. t=FF;F'AlL�
.__._._._ _______.__._.. _._. �_� __..______�_____.____.__.,__..� .._.�_ _.____._____ _.��.
4�st�t�;.,i��.U�t�3€t�lt� �--______---—-_________, �����Y I o
trl�- •�v wr� .._.____,._. ti,tu c�. � ���� � . .—.�..___�____._______�____.___ _______�
' . 't i�,:. � ;�=tr:i�;.r"�:.�"",' ;���.>.+.'��*=����
,h.ra:.'�.t�. .',•r"`,n:
_ _ �
�..<�k���i�i`��� _�;2.�.�.�_1....='aC.._.____�.�-�l.,fL._....�..��_����&.�-�� ��g �f�- �--..' � i
�:.��bfl--_�Q?��___. _..__�_.._ ___.____ - ____ _�__. __.._. .._._
_ �.._______ ��__ .__._�� _y_�.�____._�`��_.__-� _�__-________--_ -�--_.�.�_______.�
__.__._.___�____ _.._.... ._.____..� ......_,� ...__._.r _ �v._ ___.__._..� _...___ -�
t
_____...___:_...�,._____�_..____� __. _.._.�___
,
.._ ____ �.
__�_____�__^__..._.
��P?`9�T����1�� ____.__,
;�����'!�`J�! Si�%� _____ ______._. ._._. _...._ _.______ ____ ._�.__.________�_______._ _.__
•;�; "a;;:��"a '�,.�'k.,�,,A�,+�',.,•�'�+_� � — -- �
`;�., ti�'��� ______.__�._.___---- . ��__._. _._ _
•.-�„r.Y 'n�.:y.:r��.;y��,.�'y+,:y�.. � � �
{,{,- ;'!_,':�;:• + �.�.: �i•.�'� ,. .'_
;,r. ,.`�:�'�.,}� :.R�7i.��., �
ti{�'r.P��"�.���M�'" ' .1�. ..._,......, ....s.-.-.._......-,,..__.,._... .�..._ .. .__'___.__ .._..__..._-._.._
?r;r•,.�_.7P�:�� yS'��,t.'�� ����;� i
' 1 s;r.�'''i�'.F'�J. • .'�l
' ,�p:�:y •,I'• : �. " �._....,_..�_____..�..__.._._...,�..._._____-_..v...._r ,.._..�_.._._�___._.-.-.—.......�—�.._.....,- �
�,5��'y-��'�� '�'_�' ��'.�
.d^'�'r,ti+�h�'�' � ` �'• !'.�,.. L.1' �
r �,��;.'�'; n 7`��_F`��j.�.�ly�: "r,� •��� ___�___.�..._ _._. ._.._..._.__ _-__�._, _
'IJ��i��,rye,[�i�.. �;',r .� � �`.' �,,: �
r. i q . i
. �A�S ,� ._.__�..__ ____..w_s�_. _ _�__��—.�_..�__--
•. ,
. 't y� 4 � M� — --»,�-��..�—�
.f F�� _._..w.,... ._..,......_.__.. _..�..___._ .�
.�-. =�=ti4:^�. . ., . r'r.� ,..r. ...�..........w.. ____.._w._..
� CITY OF DIAMOND BAR �"� i���"�
--- `" - DEPAIZTMENT OF COMMUNIT'Y&DEVELOPIv1ENT SERVICES � r ��
21825 E.Copley Drive � �Y v� /
(909)860-3195 Faa�(909)861-3117 PRESS
"'������ BUILAING PERMIT APPLICATION FIRMLY
o DDRIESS �� I � 1���'�V c_�1t!4�_� DATEICATION ��� °�n f�� NU B R ��� g/C
`_' ,����=�
�--
� ISSUE TYPE OCC
APN LOT TRACT Y7�`..9�� DATE CONST. GROUP
p OWNER ��yp�qa_��t,�r `,fU�t�"—�'—�L—C��-
o ADDRESS ���1�� �C+�VZ+�t� �I�r'c+• ZONING SETBACKS
z CITY i C�v'i*c1A�c..� ZI P�L'�tJ� TEL�Itj S�tL►3`ftZ7 FRONT RW ❑
� APPLICANT TEL. REAR ❑
z SIDE/SIDE STREET RW ❑
¢ CONTRACTOR � �� �I.2 ° �� SIDE �
ADDRESS ' �
� CITY�L 'r, ZIP l TEL.�iC �t�3� PROPOSED USE
� �r�� �--� �-
w ARCH/ENG/ / � - �
z DESIGNER_ �, [�-'��� � �S�.sC�,�-•
w � NO.DWEL. NO. NO.
a ADDRESS ��I•"S�(- ''�'[jr✓a:Ll�-�� ����,
� CITY ZIP TEL. UNITS STORIES BEDROOMS
u�
cn DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREA/VALUATION
� OWNER-BUILDER DECLARATION .1��
0 SFR/ADD/REM
p I HEPEBV AFFIFM UNDER PENALTV OF PERJURV THAT I AM E%EMPT FflOM THE CONTRACTOqS LI- GefBQe/C3fpOfl
W CENSEUWFORTHEFOILOWIN6REASON(SEC70315BUSINESSANOPFOFESSIONSCODEANYpTYOR (n
C1 COUNTYWMICHREQUIRESAPEflMITTOCONSTRUCT,ALTER,IMPROVE,DEMOLISH.ORREPAIRANVSTRUC- W PdhO/DBCk
w TUqE,PRIOH TO ITS ISSUANCE,ALSO RE�UIRES THE APPLICANi FOP SUCH PERMIT TO FILE A SIGNED W
� S7A7EMENT THAT HE Oq SHE IS LICENSED PURSUANT TD THE PROVISIDNS OF THE CONTRACTOAS LI� �
� CENSE LAW(CHAPTER 9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO• POOI/Sp8
O FESSIONSCODE)ORTHATHEORSHEISEXEMPiTHEREFROMANOTHEBASISFORTHEALLEGEDEXEMP- C7
V TIONANYVIOLATIONOFSECTIIXJ70375BVANVAPPUCANTKORHPERMITSUBJECTSTHEAPPLICANTTO Z Re-Roof
AqVIL PENALTV OF NOT MORE THAN FIVE HUNDRED DOLLARS(SSOD))�
� ❑I,ASOWNEROFTHEPROPERTY,ORMVEMPLOVEESWITHWAGESASTHEIRSOLECOMPENSATION, 0 COmRIBfCiel
Z WILL DO THE WORK,AND THE STRUCTUqE IS NOT IMENDED OR OFFERED FOR SALE(SEC]044,BU51- J
� NESS AND PROFESSIONS COOE THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNEF oF �
PROPEflTY WH0 BUIL0.S OR IMPROVES THEREON,AND lYHO DOES SUCH WORK HIMSELF OR NERSELF OR
CC THqOUGH HIS OR HER OWN EMPLOYEE3,PqOVIDED THAT SUCM IMPROVEMENTS ARE NOT INTEN�ED OR m
� OFFEREDf-0RSPLEIF,HOWEVER.THEBUILDINGORIMPROVEMENTISSOLDWITHINONEYEAROFCOMPLE-
Z TION,THE OWNER�BUILDER WILL HAVE TNE BURDEN OF PROVING THAT HE Oq SHE DID NOT BUILD Oft
� IMPROVE FOR THE PURPOSE OF SALE)
�yJ ❑I,RSOWNEFOFTHEPROPER7Y.AMEXCLU5NELYCDNTRACTINGWITHLICENSEDCONTRACTORS
� TO CANSTRUCT THE PROJECT(SEC 70a4,BUSINESS AND PROFESSIONS CAOE THE CONTRACTOpS LI- VflIU8fl0l1 ADJ.AREA
W C�NSELAWDOESNOTAPPLYTOANOWNEROFAPFOPERTYWHOBUIL�SORIMPROVESTHEREON,AND
� WHOCONTRACTSFORSUCHPROJECTSWITHACONTRACTOR(S)LICEN5EDPURSUAN7TO7HECONTRAC- QUANTITY DESCRIPTION FEE,
� TORS LICENSE LAW) O1
� ❑IAMEXEMPTUNDERSEC. B&PC FORTHISREASDN Q �4✓ � �.,v'V <.Q,'e �� �
� '
� DATE OWNER H ,�Cl � ' �
Z W T [' �`
� LICENSED CONTRACTORS DECLARATION W f" �_
� � �
I HEREBY AFFIRM UNDER PENALT`�OF PERJURY TNAT I AM LICENSED UNDER PROVISIONS OF CHAPTER �
� 9(COMMENCINGWITHSECTION7oo0)OFDWISION3OFTHEeU51NE55AN�PROFESSIONSCODE,AN� Z
�X AIY LICENSE IS IN FULI FOFCE AND EFFECT m ' `
� LICENSE CLA55 �~�� LIC NO � ���---- j / C'"�` f"
V DATE �/?–Z��y� CONTRAC70R �� � a N I � �
w �
� �WORKERS'COMPENSATION DECLARATION Q
= U
� IHEREBVAFFIRMUNDERPENALNOFPERJURVONEOFTH�FOILOWIN6DECLARAT10N5
C/� Q
� `IHAVEANDWILLMAMTAINACERTIFlCATEOFCONSENTTOSELF-MSUREFORWORKERS' _
Z CAMPENSRTION.ASPROVIDEDBYSECTION37000FTHElAeORCODE,FORTHEPERFORMANCE U
¢ /OF THE WORK FOR WHICH THIS PERMIT IS ISSUED �
w �� I HAVEAND WIl,L MAINTAIN WORKERS'COMPENSATION INSURANCE,AS HE�UIRE�BV SECTION
Q 37000FTHELqBORCODE,FORTHEPERFORMANCEOFTHEWORKFORWHICHTHISPERMITIS
ISSUED.MYNbRKERS' MPE SATIONINS�NCFCARRI FANDPOLICYNUMBERARE CONSTRUCTION
Q
� CAFRIER � u41 PLAN REVIEW � \
� POLICVNUMBER ��E� �U I E� �� ELECTRIC +�� 'iJ
� (THISSECTIONNEmN0T6ELOMPLEfEDOFhIEPERMII'ISFORIXJEHUNDREDDOIlARS(E100)ORLESS) PLUMBING
w MECHANICAL
Z I CERTIFV THAT IN THE PEFFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUEO.1
(•} SHALL NOT EMPLOV ANV PERSON IN ANV MANNER SO AS To BECOME SUBJECT TO THE
(n WOflKEflS'COMPENSATIONLAWSOFGAUFORNIA,ANDAGREETHATIFISHOULOBECOME INSPECTIONFEE
SUBJECT TO THE WORKERS'CAMPENSATION PROVISIONS OF SECTION 3700 OF THE LABOR �
� CODE,ISHALLFORTHWITHCOMPLYWITHTHOSEPROVISIONS ISSUANCE �
� DATE APPLICANT SMIP �,x � . � �"_`''�'
0 —
� ENERGY P/C
� WARNING FAILURE 70 SECURE WORKFRS'CAMPENSATION COVERAGE IS UNLAWFUL,AND SHALL BE �f �
� SUBJECTANEMPLOYERTOCRIMINALPENAlTIE3ANDCNILFINESUPTOONEHUN�FEDTHOUSAND ENERGVPERMIT � �
OOLLARS�f1 m,000),IN A�OITION TO THE COST OF COMPENSATION,DAMIIGES AS PFiOVIDEO FOR IN
J SECTION 3�oe OFTHE LA80R CODE,INTEREST.AND ATTORNEY'S FEES RETENTION FEE:
�
� CONSTAUCTION LENDING AGENCY PRE-ALT FEE•
p ----___.-____
� IHEREBVAFFIRMUNDERPENALTYOFPERJURVTHATTHEREISACONSTRLICTIONLENDINGAGENCV
� FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PEflM1T IS ISSUE�(SEC 3091,CIV C)
Z
W —
= LENDER'SNAME _.
�
F_- LENDER'SADDRESS
� TOTALFEES ^
� ICERTIFYTHATIHAVEREA�THISAPPLICATIONANDSTATETHATTHEABOVEINFORMATIONISCORRECT 1 �
w I AGREE TO COMPLY WITH ALL dTY AND COUMY OR�INANCES AND STATE L4WS RELATING TO BUILDING � �
� CONSTRUCTION,FNDHEREBYAUTHORIZEREPFESENTATNESOFTHISCOUNTYTOENTERUPONTHE
Z ABOVE�MENTIONFO FpOPERTY FORINSPEGTION PURPOSES COMMENTS
� iq.�_
� � iV�A.-_ �i ��i��
m PERMITTEE AME(PRINT) /�
Q �'1�' V
� �
� SIG UR OFPERMITTEE DATE
= RECPT NO PAID BY VALIDATION
~ WHITE-�epartment Copy,YELLOW-Finance Copy,PINK-Assessor Gopy,GOLDENROD-Fde Copy,GREEN-Apphcanfs Copy
� i���
_�� CITY OF DIAMOND BAR
� DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES -- ���3
� _ � , 21660 E.Copley Drive Suite 190
(909)86(�3195 Fa�c(909)861-3117 PRESS
���� BUILDING PERMTT APPLICATION FIRMLY
�
JOBSITE ApPLICATION PERMIT � P/C
o ADDRESS DATE � NUMBER ���� #
c� ISSUE lYPE OCC
APN u LOT _, TRACT S DATE CONST. GROUP
p OWNER c. �
wADDHESS �3��' _/���� � ZONING SETBACKS
� CITY � -" _ ZI�`Q�TEL�/i�5t1S��`l�'X9 FRONT RW ❑
APPL CANT TEL. REAR �
SIDE/SIDE STREET RW ❑
� CONTRACTOR a�7� +� � �. SIDE ❑
� o1°DRG� Z�p %]/O T�p��1'7�z�� PROPOSEDUSE
� ARCHlENG/ �
z DESIGNER NO.OWEL. NO. NO.
� ADDRESS UNITS STORIES BEDROOMS
� CITY ZIP TEL.
N DESCRiPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION
�
OOWNER-BUILDER DECLARATION SFR/ADD/REM
� 1 NEPEBY AFFlitlA 11NDER PENALT/OF PEflJURY THAT I P)A EXEMPT FROM THE CONTHqCTOflS LI- G81890/COfPOfI
W C619ELAWFONTHEFOLL0INWGREASON(SEC.7o37.58US1NESSANDPHOFESSIONSCODE:/WYCINOR (n
(7 COUN7yWMICHREOUIRESAPERMRTOCON5Ti1UCT,ALTER.IMVpOVE,tlEA10LISH,OpREPAIRANVSTRUC- W pgl101DeCI(
V� TURE,PpqH TO ITS ISSUANCE.k�REOUIRES THE APPLICqNT FOR SUCH PEflMIT TO FILE A SIGNEO W
6TATEMEM TH�T HE OR SH[IS LICENSED PURSUANT To THE PR041SIONS OF THE CON7RACTORS LI-
� CENSE UW(CHAPTEN B(COMMENCINO WI7N SECTbN 7000)OF OIVISION 30F THF 9USINESS AND PRO� � P�OVSPe
FESSIONSCODE�OqTHATHEOFISHEISE%EMPT7HEREFROMANDTHEBASISFORTHEALLEOEDEXEMP- (�
TqN.ANYVIOLATIONOFSECT10N7031.5BYANVAPPLICANTFOpAPERMITSUBJECiSTHEAPPLICANTTO Z Re-Raof
� ACIVILPENALNOFNOTMOqETNANFIVEHUNDFEDDOLUflS(i5oo)) O
� ❑I,ASOWNER�FTHEPROPERTV,ORMVEMPLOYEESWITHWAQESASTHEIfiSOLECOMPENSATION, COffIfflBfGlal
VJILL DO THE WORI(,ANU THE STNIIC?URE IS NOT INiENDEU OR OFFEHEO FOR SALE(SEC.7044.BU51� J
NE55AND PAqFE5570N5 CODE TNE CONTRACTORS LICENSE UW�OES NOT APPLY TO AN OWNEq OF
N VROPEqTYWF10BU1lDSORIMP��STHEREON.MlDNMOOOESSl1CHWORKHIMSELFDRHERSELFOR =
� 7MROUONNISORMEpOWNEMP�OVEES,PHOVIDEDTHAT9UCMIMPqOYEMENT3ARENOTINTENDWOF m
OOFFEREDFOR&ALEIF,HOWE/E0.THEBUILDINGORIMPROVEMENTISSOlDWI7HINONEYEAROFCOMPLE
Z TION,7HE OWNEF-BUILUEN WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD pR
= IMPROVEFORTHEPURPOSEOFSPLE).
❑I,A50WNER OF THE PROPEfifV,AM EXCLUSIVELV CONTpACTING WITN LICENSED CONTRACTORS
¢ TO CONSTRUCT T11E PRQIECT(SEG.7oM,BUSINESS AND PROFE9310NS CODE THE CONTMCTORS LI- VdIUdI1011 ADJ.AREA
W CENSEUWDOESNOTAPPLVTOANONMEROFAPqOPERTVWHOBUII.DSORIMPROVESTHEREON,AND
� NIFIOCONTRRCTSFORSUCMPpOJEGTSWITF7ACON7RRCTOR(5)LICENSEDPURSUANTTOTHECONTpAP QUANTITY DESCRIPTIDN FEE
TORS UCENSE LAW.).
❑I AM EXEMPT UNDER SEC• 8.&P C FOR THIS REASON Q s S
� ¢ �u> . C:�4�.�
LL DATE ONRJEH V .�
� W � •
F UCENSED CONTRAC70RS DECLARATION W '7.
� I HEREBV AFFIpM UNDER PENAI.T�'�F PENURV THAT I AM LICENSED UNOER PROVISIONS OF CHAPTER �
� 9�COMAIENCINO W17H SECTION�000)OF DIVISION 3 OF THE BUSINE55 ANO PROFE&SIONS CODE.AND
��� MV UCENSE IS IN FULL FORCE M�D EFFECT � � �U,.PJ(' J) ^ �i'1
� LICENSECUISS�UC NO � � ( � ��TeT /G C.�
� �/c' �i. C?
v oare�/1 r -- .3 coNrrucroa d D ��
w
� WORKERS'COMPENSATION DECLARATION Q ��4� "fS
U
� I HEflEBV AFFIRM UNOER PENALTY OF PERIURV ONE OF THE iOLIOWING DFCUMTIONS. Z � `✓�� �D G'�
Q
0 _IHAVEAN�WILLIAAINTAINACEiiTIFlCATEOFCONSENTTOSELFdNSUqEFORWOFKERS' 2 i9� Z`I
� GqAPENSAYbN.l�SPR�v�DEDBVSECT10N37000F7HELA80RCO0E,FORTHEPERFOFMANCE U
OF 71�WOFK FOR WHICN THIS PERM171S 1$SUED � �r�, 'J` �` 4/Q
O
Q _I HAVE AND NlILL MAIMAN WORKERS'COMPENSPTION INSURANCE,AS REQUIRED BV SECTION
3700 OF THE LABOA CODE,FOR lNE PERFOAMANCE OF 7HE WORK KOR WHICH THIS AERMIT IS C�'!�``Q(�.1"
ISSUED.MYWORKEfl3'COMPENSA710NINSURANCECAPWEF�,PNJD/./�LICYNUMBEFARE CONSTRUCTION ���
jcnfjRiEn�;��� �� �'`�" PLAN REVIEW
Z PouCYNUMBER_����' 7 " �/ 5— ELECTRIC
a PLUMBING
Q ((FISSECTIONNE�NOTBEL�MPL.EtE�OFiF�PEflMR6FORONEHUrAREDDCLLl�AS(EfOD)OFiLE55�
W MECHANICAL
Z i CERTIFY THAT IN THE PERFORMANCE OFTHE WORK FOR WHICH THIS PERMIT IS ISSUED,I
(�j SHPLL NOT EMPLOV pNV VEF�SON IN ANY MANNEfl SO AS TO BECAME SUBJECT TO THE INSPECTION FEE
� WORKERS'GOMPENSATIONLAWSOFCALIFORNIA,ANOAGREETHATIFISHOULDBECAME �
� SU&IECTTOTHEWORKERS'COMVENSATIONPROVISIONSOFSECTION37000FTHElABOR �SSUANCE 9 �
� /CODE,I SHALL FOHTHVl�M COMPLY WITH THOSE P OVISIONS. �^ ��
p DATE.�'� I��G� APPLICANT SMIP
j ENERGY P/C ,
J WARNINO:FAILURE t0 SECURE WORKEHS'CAMPEN5ATION ERAGE IS UNLAWFUL,AND SHALLBE ,
�y SU&IECTANEMPLOVERTOCflIMINALPENALTIESANDCIVILFlNESUPTOONEHUNOPEDTHOUSAN� ENERGYPERMIT
DOLLARS If700,000),IN ADDITION TO 7HE COST OF COMPENSATION.DAMAGES AS PROVIDED FOfl IN
J SECTION 3708 OF 7NE LABOR GODE.IMEflEST,AND A'ROflNE1"S FEES HETENTION FEE:
�
� CONSTRUCTION LENDING AGENCY PRE-ALT FEE:
O
� I HEREBY AFFIRIA 11N�ER PENALN OF PERJURY THqT TMERE IS ACONSTRUCTION LENDING AGENCY
FOR TNE PERFORMANCE OF TNE WORK FOF7 WNlCH THIS PERMIT IS ISSUED(SEC 309�.CIv C�
� LENDER'S NAME `�" /'w
1— LENDEp'SAODRESS
� ICEPTIFYTHATIHAVEREADTNISAPPLICATIONANDSTATETHATTHEABOVEINFORA7ATIONISCARRECT TOTAL FEES
� I AGFEE 1�WMPLY WITH ALLCI7V AND COUNTV ORDINANCES AND STATE UWS FELATMG T06UILDING
� CONSTRUCTION,ANDHEREBYAUTHORREREPRESENTATIVESOFTHISCOUNTYTOEMERUPONTHE
z ABOVE-MEN710NEDPflOPEfiTVFORINSPECilONW/�1POSES. COMMENTS
� ��R/L/ //'P���
QPERMITTEE N (PRINT)
�, �./�_. /,.�_,,�� � z- �/--4�
y SIONA7UREOFPE E�— DATE
� RECPT.NO- _PAID BY VALIDATION
WHITE--Deperiment Copy,VELLOW—Finance Copy.PINK—Assessor Copy,GOLDENRQD—File Copy,GREEN—ApplicenYs Copy
���� � ��
�������'��� ���� ��
�`i � i . � . I . ' f • . . ' n.�� p�4e�� ,. .
,�;€j.;. .. , �. . ' . �. , : . ,. - .i5'. . . . . . , ' 'f. ,4;:�.�_.. , .. ..
r;{���� '•P �ry�, F°.__. .. •�i � ' --'..�, _. '-..,�•�•,• ;:
+�JLV�kr'�'J'�.�ii , � . � ,. . . � . . � � .�. � .. •. �'�. C �4,liJ("'ui{.j�u�" • . . . . ..,.� �.r , :' J. � , .
--- - - � -- -______ -�--� __. �. j_ ___.-- � -- - - -
_ ___,
r�"'T���1' L�?fiW`i�;:�';r: � i ; i I ''r�.;1F�'�t.�Et,1T� ;_� 'i
_ _ _ . . --_ . _- _ _.. � —__� _ . __ __. . _ .__
- , _
E�.rCTt-t C'C�r�`�3�rvC� f � . !�;"��r-� F_�3 aFt C}l)C?- 1
�__` ! � : .,__ _ - --- - -. ..._._ __.._ ..___--
� ��',��±I�i��i .� `�"\` ._._; --`---- -_ _._.�.._____ � �7{�3.1��i �i�'j�:�' ���P`it-7t�:`?- !
�__ �/��___.__ __ .' _.' ��. ._ . __ __.;�__- ._._._..�__ __..-- -_.__.._ _.. __ _ �..�. .____. . -.__ ___ _-l�.___-' - - . _ _-
�Er�, _ _ t(
..cJ�_ht���.���., _._ ._. � ..._...— _�_v... _'_"_. __.wv__._�"'" . � r�:��n:¢���4f✓�w�li9���Eii i�g�! '� ..._„""' _�i_ �,_.
.,..�n...� ._.... ` ' .,.�_..� " " ' —' _'._' "_
T�-�+13F'�:j:C�'�vz � , � !-E;�'E�" A.�". : �t`�.�C�}�'�'�.�,r � �
�_ _.m
�"_�- _w� . .. a________.___ _ __�.. __-- --_ . . �_ ___ __ � _._____.__
,-� � _
! !�k''.'E-t-� '�'S�i`ilt(�w` ' i 1 i `�L�iii t?"i�.L'�,'.'�i1��`:$u{.�1r: __._ . ..
`
. �
*- - - ----. ___ __._...- - -- . _ ____ _.�. --.__,._�__. �. __._ _ _._. ___. �_ .. �
� #��;��r� b:.a�;,-r�-'tti���i ( I ' o��T �Cr�1���AtJ1 '
—-----�---__ _,.
�----_____ _,.,.___ ___�___.___.._ , --} - - -. ---.__ .._._ _ ..
� _____.�-- .�' - --__
--------- -.___--__
�:����[��i�,rr_���i=t;:�;?C>�!' __ _ _ -_____.._._�____. 1 ; �;P_��,�.���'��3cAP�.� ____ � .�. _ � - - _ _ _ _, _ .. ____..
, , �
. - _�.��_ .,�� ,
i r-i��Ca`". . � i ��'
C'J s� �� i t � �a!-sA!)��:C` ----- -
-- ---�_..._ _._._»>. _______��_._.___.�_ .�___.,..,._�- - -- .,.______._._��.�- --- ---- -_ ._
��r��s ir � _ ._....._ .__.
r$..�k.�a'!� °�d."�„�,ti� , � � � ���10E.�3�Et� � �
��"_—..� .- --"--- - k�.....��.'-='--�._,_�__._--_-.�'--�..._ ' -._
',.-�--..._ ' - _-'__' -- ..
---------....�_--__.-'-�..`.��_.a_..,._,._.�.._.,_�.
� ��7��'� �i.�„w�:}'S��i i (� l.)l.:f��f-i��%a����Cs !
;— _ _..___ .._._� — - -_ -__-----_�.. .__..__ -- ._�__.,� _ _
�..._- -,- —
� }ii?�a�€`I i ma;�v''ii,lA�a: I __-__��_ ___.___._--- -.--�-- � �:..t t �,`+.i.7
-- -- -__ ._._.._._._ _....__ _. ___ __._.___. ._._ w _ #�J
__.___ . �_ �
` � i"'°v 3�:. C-�
. _
.__ __�. _ .�_ v.._.___.__ .-_- -�- � --- --- -.__ . .
i ��t�3{jtf'��.i";.;`;,c.i m����i � ' 3�C��= .L�i>��?`sC: �� � -
;__._- `---._,____�__ __. _;....._-- ^ F -_____,...__......-- r _ -- - -----_....__..� _____--- -..___._- - -- .-
� �'��l. s ;-,. y . ..' ! -f'""�"_ ._. t�C��`)f ` E�V£"i�tvt� k_� ,
" _.1!€�,•'�st�7iS sc� ( �__. '_
g_-___. ._ _.., __ _._ _- -, -.�_ .._ _.. L-- - ------ -- --------- --- ___._. .�._..__._..._.._.__
. ,
r �,�1i.+�L_i_n�7t`'hai�t r`+��'3w;'"` � � ___�''"7f�r.+_ 'Ir�l}-�.7
u
=_.-- _.. .-- - -- -- - -- _.___ ___.__
, - - _____ .._ �___,_.�_ ._._. __� ..,_.__. ..
. ,n,-i7 "�er. ey,�...a, � "
,
; : _.:_a9.:.� t: �;:�.s• t, - , � t`.F�' .:i;:m}.��;Yi€�`i3. �� �
- �.�.w•' ..
1�•t;:.. �
. _...---` - - '-'-.._._._. t..
i �>r^°�r,� r• . . .� - , -- --.._._ --____�.._.__----- , ,--=-- — - - -- -_ ___�_ _---4.._. ..___ - �- - ---
-. , •�
_ _�_
. �,..� I ��.�.�_ ,t;ir �1=^;�';� �
�_ _.u..___ .. . . �
i -s;sv1°�
_ . ._ ..-- -.... _�._ _.__.� ._... —
�, ,.,.
.__._.w_ _.----------_ �--_____._._._ _
i �_ i M ry , , w __ _.. ___w___.._ __+_ -- —_ --- -- - -
"i c:V Y» . . ,�'°b'-'.�.�'�'„a. �"
t .
.
;-,_.._.......-- -- - '_._�.,.. _..-' - _..._..�._._ ___..,.... __.. ,._. _ �
i
. ._ ..,-.. r ._..._, _ .;._ _ . .. ._ _.__ ..
. ,:y�=r..r�,,, , . . _ . -___-i-�-_.`-:oC!��:�,^° --,=r;���i;sw�. _---- -- -� i
» , , ,.
_.___.__-_—______ �_.�__----____.....--- -i--,�-
t W�:�: . .. _� -—___...__� i -�.; , ""��y�� -_._` - -----_--_---__. _,__. , _ .._.. _, ___.
, ,.,..
�.. _�----.. ..._- -----,,.------ _�_ - ----___.._.�;..___. ____..�.__ _,v.__�.�.. _� __ _._ .__._�._..___ __..____.�. �
,'.t.� .` "°.�� i �_l'?� l� t4E'�':G ' '"._ _�� _ . .
� ^ ,
..�_ �. .._......�...� ..�......_..._ " ,.�,._'""__"__...�-- ....._........_...._................ _" '_ '"_ __ " _ ._. , r_
,.i i .,'x,.t�.•r , q ' ' . _' . ' " ' '_ .._ _. .__... _ ' ..-
_,_
r ._...._..
. . ".-r_,,,.
. . :.�n. '..�..=.`da..(, ' , ! ,' '�r j��i�'s
-.r
'_..._ . � i r.�- '. �'s' .. .
�._.._.,�....._r_ ___ .,.�_., ._�_.� ......�... _..,..__.,.._.._._.,..__.. _
. , , o ,.y.E .,. ""'_ _"__ _" '" _ _"__'_'"' _" ' .�" _ " "
_"�f "" ._'_ �."_""_'___._"__..._..._..
' r":�.Y .. * ...�. ' . .. , "' _ ' " '
_.
- I La .. .., ; � , '- �
�r i
.-
.......��il. � ; f"Y'= z ; 1a
� .,, .;_ � ' ..
�
��
' '_" _ __."_�_ __ _.'-t-" .._.�_..._`_' '
• � .-... _ '•- -_. .._ . . ,. . . ..__. _._�..._�_ ...
i
,: .Y:.3 ;;=f✓yi='�El� . ' r .' '. ".��';i�iJ ' '
- . ....� ..._...__..e_ __..� . -... __.'_..._. .__._ _�.. "__..""'" "'"'"` "'"""..._..._...__._ .. " " ' "....._v.v'" "' " ____ '
- ' t�h.'"'.y'1)"°�. i -`. - 't ._ . ' _"'"'_".�.. _. _., .. " "
` � f`t'a`StL..:+g c=v,
p ...., «. ...... .. . . `___. _'... . ._.._.. _.. � ... .�.... _ _.
.. _. '.�. ... .. .
�
(
.�. . ............___•___..._ __"-_._.M..._ ... _
�_..�_...._---_. __......"_"r __._.�_____._....,.m.._,_....e.....«��.—....__........_...�_....__a.. .' _"....__, "_. _'
4....a . _.,_______ . ___ __ _____. ... .�.
.....__._. .... "._.... ._ ..._ ..__ _�"
� .,.._. . _ .... ..�.. . ...
� .. _..r. ..__..._.___. _ _.__'_ ._._. .. ...
�.�_.,_._ ._. "_ ."'_. ..._.__.. � . _....��.. _�. ._.
9
i__ __..,,.___.____�..,__�_--_-.__�___�_.._-'.---
_. .. .
i
,..�.._.__...__. . __ .__,_ __� ------_ __ _.---..�_--- - ,-- --,- --- _. _ _ _ ,� __._. _ � _.__
.r. r, "'- '--- — -- -._ __ . .. ._ . .
p i:�"��1`_ t <�"w _ �, _.. -. -
� �'�""�,r' i.:i'i J.$ ���w`� -- - - ' -- - - . . . __
4� : .. _ _ --- -� __ ._ .
' .. - - - -- --- --
; ,. _ , . , . - - .. ._
� ,
...... . .
••. . _.._.__._ � _.- -- _.
, � . ._. ___ _._..._ _-- - - - �.. . . ..
. ,
. ... �.
l : •.,, . . . . . _ _�___ _..__. .__
:.
_... .__._.__-----._ ._.._. ._ _____ _----
7 . - - - - --
; .
; ' .
� . , . • •. . __. _._�_.__-- - .._...-- -- - , . _ --- ____ -
. .
.
� n -- - _ �_. -- - ..__ ..._. .._ _ . -- -
. .. ._, _ .. .----- __�....
�_...�....�,...�«�...-.�.�.._..�....._......�...,......�.'�.....�...�.�...�..�.�,.�...�.�._�...�,.�,..� ..�...e,...._,�.� ��.....����.......... �...�....,._�..�... w ... .___._ _ r . .
� CITY OF DIAMOND BAB
DEPARTMENT OF COMMLJNITY 8z DEVELOPMENT SERVICES
� 21660 E.Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117 PRESS
4""' BUII.DING PERMIT APPLICATION FiRMLY
� JOBSITE �v S � 1���--��,/„) ,��T v t APPLICATION I ���;y�, PERMIT �S�l,� P/C
o ADDRESS _ `� �� �G��t�� �/ DATE �•rJ NUMBER #
� ISSUE NPE OCC
APN LOT TRACTr �c�U DATE CONST. GROUP
p OWNER ���,�, tyt/ , ! S - ��.--�
o ADDRES � ' C)� ' ' ZONING SETBACKS
z CI C � ZIP��TEL.='�IC' Sz/C1��� FRONT RW ❑
g APPLICANT TEL. REAR ❑
� CONTRACTOR �' C�-<= (Gs- SIDE SIaE STREET RW ❑❑
� ADDRE S ��Z� `:�-' �:
� CITY �- ZIP C 1� TEL. � ' �}/' F'ROPOSED USE
o ARCWENG/
��,, DESIGNER NO.DWEL. NO. NO.
y ADDRESS UNITS STORIES BEDROOMS
� CITY ZIP TEL.
�
�n DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION
Q OWNER-BLIILDER OECLARATION SFRIADDlREM
O
I HEREBV AFFIRM UNDER P��L7V OF PERJURY THAT I AM E%EMPT FROM THE CON�RACiORS LI- Gafflg9/CBfPOII
W CENSEIAWFORhiEFOLLOWINGqEpSW�(SEC70.915BUSINESSANDPROFE9510NSCODEANYCITYOq (n
�� COUNTYWHICliflEIX11RE5APERMflTOCONSTRUGLALTER,IMPROVE.DEMOLISH,ORREPAIRANVSiRUG W Patlo/Deck
w lURE,PRqR TO IT3 ISSU�NCE,ALSO REpUIRES 7HE APCLICAN7 FOR SUCH PERMIT TO FILE A SIGNED W
� STATEMENT THAT HE OR SHE IS�CENSED PURSUAN7 TO THE PROVISIONS OF TME CANTRACTORS U• �
� CENSE UW(CHAPTER 9(COMMENCINO WI7H SECTION 7000)OF DIVISION 3 OF THE BUSINESSAN�PPO� POOUSpB
FESSpNSCOOE)ORTHATHEORSHEISExEMPiTHEREFROMPND7NEBASISFORTHEALLEGEDE%EMP- (�
TqN.ANVV10LA71(NVOFSECTION7q916BYANVAPPLICANTFORAPERMITSU&IECTSTHEAPPLICAMTO Z Re-Root
� ACMLPENN.7VOFNOTMOREIHANFNEHUNDREDDOLIARS(SSOOIJ•
� OI,ASONMEROFTHEPROPERTV.ORMVEMPLOVEESWITHWAGESASTHEIRSOLECOMPENSATION, � CDlf1f118fCI8I -
WILL DO THE WORK,AND THE 9TRUCTURE IS NOT INTENDE�OR OFPERED FOR SALE(SEC 7044,BUSI• J
N NE55 AND PROFESSKNIS CODE 7HE COIiTMGTORS LICENSE LAW DOES NO7 APPLY TO AN OWNER OF =
PROPEIiTV WFIO BUItDS OR MPROVES 7HEREON,AND WHO OOES SUCN WORK HIMSELF OR HERSELF OH
Q THROUfiM HIS OR HERONM EMP40VEE3,PROVIDED THAT SUCM IMPflOVEMENTS ARE NOT INTENDED OR m
111 oFFEREDFOR5ALEIF,HOWEVERTFIEBUILOINGOFIMPROVEMEM550LDWITHINONEVfAROFCAMPLE
Z T�,h1F,qWNEq.BULLAER WILL HAVE TNE BURDEN OF PROVING THAT HE OR SHE OID NOT 9U11.0 OR
� �MPROVEFOH7HEPURPoSEOFSALE)
W ❑I,ASOWNEROF7HEPqOPERTY,AME%CLUSIVEIYCONTMCTINGWRHLICENSEDCONTRAGTORS
� TO CONSTpUCT THE PRQIECT(SEG 70M OUSINESS AND PROFESSIONS CODE THE CONTRACTORS LI- VdIUaSlOfl ADJ.AREA
W CENSEUWDOESNOTAPPIVTOANOWNEROFAPHOPERTYWHOBUILD50RIMPROVESTHEqEON,AND
� WFIOCONTiUCTSFORSUGHPR0.1EC75W17HACONiMCTOq(5)LICEN5EDPURSUANTTOTHECONTMG QUANTITY DESCRIPTION FEE
Y TORSLICENSELAWJ.
� O I AM EXEMPT UNUER SEC B 8 P.C.FOR THIS REASON Q
3 ¢ 'L (�7 �i��e GT�
D�TE OWNER �
� W
LICENSED CONTRACTORS DEGLARATION -�
� W
1 HEREBYAFFIflM UNDER PENALN pF PERJURY TiAT 1 AM LICENSED UNDER PROVISIONS OF CHAPTER �
� Y(CnMMENCINC7W17N5EGT10N7�Op)OFOIYISI�N30FTHEBUSINESSANOPFtOFE55lON5CO0E.AN0 Z
W LICENSE IS IN FULL FOHCEAND EFFECT
o C�' '�'�y uc Ho. ��`��Z.`�.- �
r IICENSE CLAS �
V OAiE �( CONTRACTOR � �� �-
W
� WORKERS'COMPENSATION DECLARATION Q
� I HEREBY AFFIRM t1NDER PENALTY OF PERJURY ONE OFTHE FOLLOWWG DECURATIONS. Z
� _INAVEANDWILLMAINiAINACERTIFICATEOFCONSENTTOSELF-INSUREFORWORKERS' _
� COMPENSATION,ASPROVIDEDBVSEGTION37000FTHELABORCODE,FOflTMEPERFORMANCE �U
OF7NE WORK FOR WHICH THIS PERMIT IS ISSUEO �
�
!I HAVEAND WILL AUINrAIN WORKEHS'COMPENSATION INSURANCE,AS REOUIREO BY SECTIDN
Q 37000FTHEUBORCODE,FORTHEPERFORMANCEOFTHEWORKFOi1WHICHTHISPERM1715
� ISSUE�.MYWOqKE CO ENSA710N .IJR9AN HRIEAAN�POLICVNl1MBERARE. CONSTRUCTION
� CARRIEH ��� �v�� PLAN REVIEW
z POLICYNUMBER z- ��p ��L�i`�'L>� ELECTRIC `�
¢
Q (fFASSECfIONNFIDNOT8E001dPLEfED�F'fNEPEi7�IRlSFORaNEM1MFlEDDOLIA0.S(StoD)ORLESS} PLUMBING
Z i CERTIFYTHAT IN hIE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I MECHANICAL
(!j SHALLNOT EMPLOV ANY PERSON IN ANY MANNER SOAS TO 6ECAME SUBJECT TO THE
� WORKERS'GOMPENSRTIpry LAWS OF GAIIFORNIA.AND AGREE THAT IF 1 SHOULD BECAME INSPECTION FEE
= SUBJECT TO THE WORK&RS'COMPENSA710N PROVISIONS OF SECTroh!370o OF 7HE LABOR
COOE,I 6HPLL FORTHW17H COMPLV WITH THOSE PROVISIONS ISSUANCE
� SMIP
p DATE: APPLICANT
� WARNING FAILURE TO SECURE WORKERS'COMPENSATION CAVERAGE IS UNLAWFUL,AND SHALL BE ENERGY P/C
� SU&IECTANEMP�OYERTOCRIMINALPENAlTIESANOCIVILFINESUPTOONEHUNDREDTHOUSAND ENERGVPERMIT
DOLIAflS(5100.000).IN A�OITIOry70 THE COST OF COMPENSATION,DAMAGES AS PflOVIDEO FOR IN
� SECTION3]oeOFTHEUBORCODE.INTEREST.NJDATTOHIJEV'SFEES. RETENTIONFEE:
d CONSTAUCTION LENDING AGENCY PRE-ALT FEE:
O
� t HEREBV AFFIRM UNDER PENALTV OF PERIURV THAT THERE IS A CONSTPllCT10N LENDMG AGENCV
FOR THE PEFiFOFi1dANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC 3097,CIV.C)
Z
W
� LENDER'S NAME
F-� IEN�ER'SADDRESS
a I CERTIFYTHA71 HAUE REPD THlS APPLICATION ANO STATETHRTTFIEABOYE INFOPMATION IS CAHREGT, TOTAL FEES
w 1 A6REE TO CAMPLV WITH ALI.CITV AN�CAUNTY ORDINANCES AND STATE LAWS RELATING 70 BUILOING
� CONSTRUCTION.AND HEflEBY AUTHORRE REPRESENTATNES OF THIS COUNTV TO ENTEfl UPON THE
� ABOVE-MENTIONEO PROPERTV FOR INSPEC710N VURPOSES COMMENTS
�
_ �J tL i�vl�.�j �� �J'►�t'iC� �
� PERMITT NAIAE(PRIN'�
� �� � ��
� 5 ATU OF PERMITTEE DAT
= RECPT.NO. PAID BY ��_VALIDATION
~ WHITE—De anment Copy,YELLOW—Finance Co PINK—Assassor Co QOLDENROD--File Co GREEN— IicanPs C
P PY. PY. PY. APP oPY
�6�"� F ���,9���� �
3������°���t ������
. . �.�.,�.....�.�- . . .��:
,��' .. . . . , . .�� i�4.,, : .. � ' �
. �.'. . . . . . , -� � � . . � ' �Y�. . . � ., ' .. , .[. ',1•• .. . . . . • •
..'.r.;� •.v. :. . .. �.
.
( 1"� -s' £ � � '���-„ -l�`f°'
��_ �3 xF�,� _y __" " _'___��—F t,.CJ� J..,.1T L
� _ -- - -
-- ---
,— - - ---- ----�--- , _ _� , f -- - --- --- -
- -- -
. , � ;� �
a :=T,�'���FC?F�'t�'�:s��;""E��. , : �.$,)
. ��____ _.. _ -------- - - --__�..� ------ - - � - -
.__.. ___.._. _ .
' ` " E I�;(=F'�C;�._,:i. _--__----- - -- ----- , t�P�;���� i.C}C.h� �)�°C;�
t�t:Ci�.� ` _.. _--- - --- --- __...____._.
�------- �t_ _IW __._____ �. ,
- -----
� �",f",f.��„liori �'i i;i:;='^i '.(� ___._. . . _ _ -__- --- � ( ����.'t-}-i`''E�`������i`}�J(T
, . _ ..__._ -- ___ -- - - -- � --:._. _ . .__ - -------.... __.
,
�_ _..._,___ .- ----- ------
��i;F=�i'>x' i ` !F;C;`= �,C`�!=�^.�t,'�.•i7�T��11 -- -- _ __.._��.___. ,
. �...__. ._. .___._,.,_�.. ___ ;,,. .____------- i ` „ __... _.
�-�tr._-'%z�,�'�='P:iyhr;=�� � ��'>=��`� �'c 3�.'�d��::J��ls.!L� ' ,
_ .
, E i
��a-17�0d , :1 - -- ---- --
, . .. —
�,��.__. . .... :. .... ..- - .__�_ � _ _-- ---- �______-- -�--
Y'3�i�:"'i����k.f�C�3-� � ' ' �1'.k.� i�'t �:.�'�."�I`�ta c'�..�.�".r�:�`�t _ � . _ _ '
�,__.._�. . .. __-_ - '-_.__ _ ... __ ._..__.._.�.---'--___--'__' -" '_�_ ..... _ _'�-'-- -
; �',�'�1�'s��>''.tt'_i'.':`,i:� !_ _ i_ - ------- ! ����"�. �t���11��f�� ��_____� �__.__.._ _r___ -'- -----__ .. ...
;---- �
j �-=?t�i�4'�!'s;^,t:�,1�-4_'� -���4 --z�j �..+�.,,.,.s.� r`'S.'t'p1: s��;�9G`o�,R�tt�____._��� .. ' __ __ _ - � --__ _ _ - _._----
___. . __
_:.
,;
. — -- - - ; , �
.
F :.�.i6"`�.r..3-v�+^�t^�-r�. � ['�� _
} l��..i�ie l•J• - . � ( YS�"'n�...� '
. . �� . ._"_..__...................__.......� —�___..._ __. _....__._._" _—.__ - _
i. '
{......,. J...__" _____.._�_.. � -
� _ _
..., ........,_... . ..._. ..._..__._"_____.__"____ _ '
, _+-_ _ ____ ___.. _.___-'
s (� t ' A,`Y ` � 1y A� t+ )y
( I't�6ilj7..� ..i°Y"ry^f��e.d � � f t dP�316��?'Y��MV,1'� � . :
�� �__i_
�..._.m_...___._ ..'_................. ._. _ } � .n...,. ....._.w_.._ _ _ _•_•__._ ..__. __�.____�__..._............. ___ ._ . .,."__"....,... .
�k� _.""" _
f �(."t;:C:i�P^� �� �t"` "f?IC% :3-�2`L''Jt i '�— � � �r..�','t'.�-t� ����1�i�oC`-,
��_. __ ..�_--- ------ -,.. ,�__- --- --'- - -- - -_-__-..�_-__--_. t __---— __ �._�� __------- -
' �:,�::;'.x�,�':,_ :.'�M��'C'��� �'-�2 - ^C�d��,`',.:-t i�`.=�r`��i��:� i
�.� ` _
�
. . _ � � ; � r
,
i___ .--- ----- --------- _•-�� _ _ ___---------- - , .. _ ___m�.__..,�,_ ----� __ _------..._.. - -
� z �T,•..> r,-r; - � �� ,- . -- ._.�
„ � _ .
,�-•�,..���� ,';�r t_. , :�. r _ ��'il.a
�.
�. '
� € �r _1..
... .��..�/ �.. - � — -- - --- - _
��.,... - -- ..�. _ -- __- ____ . - y- --_, ------
A �.
; '�r`... �.,-zi`-�`��i �1��; ,�/ i � C7d..iLJw t-�'.P�C,,,1�{t'.�....�.��__.�_.... - -------._.__ _ - .
�__._-- - ..__.,_..___.___._ __----,`S__ _ , .____.__----., .,._..... ,__`_____._ _ _ ._------- -....
� �rt�ia,3 t !!s'��s'`e: Gi r ft,�,'s;�? � ��� . ��: �wi:_i 914f1�. � .
. �
� �
r'-'�.___._. . X -- - _ _._�_._._..__.__ ...___--- `--.______ _,_.__.� . ._�..—_v.._._.__. __ �.__....._-"�_ _,,._..,......_____----' ' - - �-
� _..�--- `j
` r�'.m, .�. , ' . . . . � ,—._ .'.�--�' y�
.- s, �
�! � 9 T "�'A. i (^{.i� . i �'�`t:YAw3. �
� `
. ... . _. .... .. ___..._..�.. � �... ..�..___......_... �.._._..__. _ _ __ . ....__
_� ._p.�..�,..m_L .__p .. '" ""__."_�_'r
I ;�µ� '� 4��Y� j I � `,�t-L°g-r 1�'�GJl�t'9 I
s.__..____ _ . _.._. __ _.. _�'�, ______ _ __� �_ __ .._. _.__----- _.__.___ � - -- ----
_..., ,__
, :>�v�y��.� � i ; : ��;����,��:��.;�, I °
_.__�._._�.__.. .. .... ..... ...--..__�_. ___._._._�--- . _.'. __.___._.___. _ ___.---.-- , --_�.. __--_-..------ -
__�_
'7' .. _��_._�_.,' .-Y4
�:.. .'�. ,.:'�`€, i_�1i'�=`_`�":-:�'-�'�r�. ,'tt'�. �
,_ _____ _�.______�__ ______._ ._..� _._._.__..._ _.___.___ __._ _____.____�.___�..._._- - - -
_ ._� __...._ - - - _�
_;,,. ,�.,. "w"_" E in„
. .:,-,._:_. . .. . ,.. � . . .,.-. .
� ___._ � --- '�'-_M__�'— , ___._ .__,_,__._- "' ' '-. --
�
_ .. . -'�_._..._�_..._._.__" _____..__._. ..,..._.__i�-,��.,t�'- ..s'v.s.,,._�� �
. ` _ _.;:.�"_
•_..,.-. . ._`�, .� .
,__ -- --_______- -----� - - -- -- --- -- ' ' �- -, - " ---- --_ _ _...- -�� -'- ----_ , . . .._ _ . . . .
.
,_
. _ , -..� . � ��� - -
:
, .,.. .. . ;u l ��- . . . ..
. . _...�.< .�(.�
___._._
�.. . .
_ .
, .. � ,. ..:. _.;.���
,..____ _._____��_�.._____._. .- - -- m_.______.._ _ __ _----......�_ . .._.____ __ _ _
.
� „ti - �, �a -;�
.. ,�. ---._;...� .. �y
._�,
. ,. �.0 �,'J � � . _ _. , . _� . ,..
. . «.. - NiC/ ...,"• .__.___ _.. .' _........ ._ .......__.__.__..«-.. .._... .
; .- ----._._..0.._.___..----'-'- --__�._..--// ---- . ._____.--' --- -- - -------_._._...�_ . -'---__ ___ ._..�.�__...__....�....._. .___.... .. _ J
.- -.�- ,p:_�..t.- - -
.r:..�
. � q
_ .y,.. .,,, . , . � /7yi'� � „ _
. k,.. ,_ .c � ��r ' - .
t�� -
- � - -- ----- -�- "-- -- --:a=-�_..-- -__ - - ---�- —�`- - -- - " -----— '' - ---- --- ' ---- - -
,...�,.;,,��,,..� .�.� 6S-A� ,,/�
. , �_ ., �•. --s;,,(S/
:..=,e .t�� a.M..t v . .- ��� _ _ -- -- - - _._.
_._.� ________._. . s .__�_.__ _.__- -
-—�_ _� _----_._.. ..
,
���-_����� v_�o,..�__A,�a�,�.�-- ----
--- ---- -- _
; l��� � ��—�3-��
�_�.___ _��..._ ._._ w.__..__.__ __.. �___.. _ . _____ ._.._----_.__,------ - _. _.___..__.____ --.-. -- - - -
;
,_�.....___._.__�_ .__ ._..--- ._._.__.__.. _��__._____-----_ - ----------_ _---- - -----__._._..__�____�__._ . __
; ..
�
. . . ,_._.._.---____� ___. .__._ .________...___. ___ .__... .._ _ ___ .�. ._____._._.� ___..__ .. _-----... �
�....�_._ .__._�..._.._____.
E
- -- . _.__.--�- - -- . . ._--- -
. . __-----..._. ...�__._ _._.__.._.-----._..,...._.._._.____.�--__ ._ ___.____....._._..�-------...__ ._.____.____.__.��__�___
7--._.__.- ---- ---- - - ---- ---- -----------__�..__._ _ ... _ __._._------
a
�';..,___._,...._�.__._._Y_,_.._.._�_,_----- -. _�._ _._�___.,. _ - - ---'---�_ . . . _________.
� �y:_'..�"f":i✓ �'+"L:.Czi�,, :.... ---._.'___._____--' ---_.__._ �_.-'--'.-
j . �_. ""._'._..'_
� :'�-.�:.g�;;t., , c4-�.-- --- __--__... _._�_�._...._- - .. .- - - - - ---- - - - --
, �__... . .��� ,�. _ _.__ "�
i - � - : � _—_____ _ _ - __ _..__ _.. ._._-- - - --_ ------
, ..
, .. . . .
� ., ... . . . . ________.. .._�__---- — ----- --- - . .,. - - .
,.• . . _.. .. . _�,_.,_.,_.._..__.__..._._.._.�._._ ._. __.._
s '
z • .
! , ,. . ..,. .. _.._ ___._.. ...._ . ._ .._. _._ _._,. .. '--�.... .
_ , .: ...
� '��� ___._.. ___._.__.,_._._.-.' ' "- -'- '-"..__ .�
,- - -....,__ �_._._____ .,.'_"'_ '-'. ..... . _._ _--'_
i
: '.�.,.� � � _ ----- - -----___ __� .e .. __ ._ --._....,
� .�. .� _ _ --
a ,',' �
s ..
g _�--- - - -- — � -- �. .. ...._. .. .
� _ �� ci�oF�rp,Morm Bax �� 1Y�t�
� DEPARTMENT OF COMMLJNITY&DEVELOPMENT SERVICES '� „ �_U�
21825 E.Copley Drive
(909)860-3195 Faac(909)861-3117 PRESS
����r� BUILDING PERMIT APPLICATION FI RM LY
aJOBSITE • 1 � ri. APPLICATION , PERMIT 'P/C
ADDflESS z�`� �1���L�� Cf'Kf��µl. DATE �� ��T NUMBER �O # I� '
`� APN LOT TRACT ISSUE T'pE
OCC
DATE_. CONST. GROUP
p OWNER _ 'T��i
o ADDRESS ZONING SETBACKS
z CITY ZIP TEL. FRONT RW ❑
� APPLICANT TE�. REAR �
z SIDE/SIDE STREET RW ❑
a CONTRACTOR r . , r�� �I SIDE p
ADDRESS °� ' J
� C�TY 'fi .ZIP 'j'�L'�%�TEL. - PROPOSED USE 'f,G °'��
o ARCH/ENG/
w DESIGNER NO.DWEL. NO. NO.
a ADDRESS
v� UNITS STORIES BEDROOMS
� CITY ZIP TEL.
� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUA710N
p� OWNER-BUILDER DECLARATION SFRlADDlREM
O
p I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM E%EMPT FROM THE CONTRACTORS LI- Gafd E/C0f 0
W CENSE LAW FOR THE FOLLOWING REASON(SEC 7031 5 Bl1SMES5 ANO PROFESSIONS CODE ANV CI7Y OR (n 9 P n
U COUNTVWHICHRE�UIRESAPERMITTOCONSTfiUCT,ALTER.IMPROVE,DEMOLISH,ORREPAIRANVSTRUC- W patwlDeck
W TUR£,PRIOR TO lT5 iSSUANCE,AL50 RE�UIRES THE APPLICANT FOA SUCH PEflM17 i0 FILE q SIGNED w
� STqTEMENT THAT HE Oq SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI-
CENSELAW(CHAPTER9(COMMENCINGWITHSECTION�oOo)OFDIVISION3OFTHEBUSINESSANDPRO- � POOUSPe ^, �
� FESSIONSCODE)OflTHATHEORSHEISE%EMPTTHEREFROMANDTHEBASISFORTHEALLEGEDE%EMP� (�
V TIONANYVIOLATIONOFSECTlON7p3t58YANYAPPLICANTFORAPERMITSUB.IECTSTHEAPPLICANTTO z Re-AooS
A qVIL PENALTV OF NOT MORE THAN FIVE HUNDRE�DOLI�IRS(tsoo))
� ❑I,ASOWNEROFTHEPROPER7Y,ORMYEMPLOYEESWITHWAGESASTHEIRSOLEGOMPENSATION, � COflllflBfdel
Z WILL DO THE WORK.AND THE STRUCTUflE IS NOT INTENOED OR OFFERFO FOR SALE(SEC�047,BU51- J
� NESS ANO PROFESSIONS CODE THE CONTRACTORS LICENSE LAW DOES NOT APPLV TO AN OWNER OF j
PFOPERTY WHO BUILD3 OR IMPROVES THEREON,AND WHO DOES SUCH WORK HIMSELF OR HEFSEI,F OR
� THROUGHNISORHEHOWNEMPLOVEES,PROVI�EDTHATSUCHIMPROVEMEN7SARENOTINTEN�EOOR m
Q OFFEREDFORSALEIF,HOWEVER,THEBUILDINGORIMPPOVEMENTISSOLDWITHINONEVEAHOFCOMPLE
Z TION,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PFOVING THAT HE OR SHE DID NOT BUILD OR
� IMNHOVEFUHTHEPURPO5EOFSALE)
W ❑I.ASOWNEROFTHEPROPERTV,AMEXCWSNELYCONTRACTWGWIiHLICENSEDCONTRACTORS
� TO CONSTHUCT THE PROJECT(SEC']oa4,Bt151NESS AND PROFESSIONS CODE THE CONTRqCTORS LI- VeIl12�lOf1 ADJ AREA
W CENSELAWDOESNOTAPPL7TOANOWNEROFAPROPERTVWHOBUILDSORIMPROVESTHEREON,AND
� WHOCONTRACTS�ORSUCHPROJECTSW{THACONTRACTOR(S)LICENSEDPURSUANTTOTHECONTRAC- QUANTITY DESCRIPTION FEE
Y TORS LICENSE LAW)
� ❑I AM EXEMPT UNDEF SF_C B&PC FOR THIS REASON Q y�~�,/ �,/
?� U
� DATE owNER ~ � � �r
Q W 1
� LICENSED CONTRACTORS DECLARATION W
a -
Q I HERE6Y AFFIRM UNDER PENA�TY pK PERJURY THAT I AM LICENSED UNDER PPOVISIONS OF CHAP7ER � ,� ",{y�
d 9(COMMENCINGWITHSECTION7o00)OFDIVISION30FTHEBUSINESSANDPROFESSIONSCO�E,AND Z �J
X MY LICENSE IS IN FULL FORCE AND EFFECT
U-� ��-.� 1 m �i 'r�S 1
� LIGENSEGLASS �� �-� _ ,. LIC NO _� I.��� ��t`�� ,__. j ~�
V DATE � ���� CONTRAC70R Cr-���'i •�(��t� d
W
� WORKERS'COMPENSATIONDECLARATION Q �� , � c1 "'�
[n U e�
� I HEREBV qFFIflM UNDER PENALTY OF PERJUPY ONE OF THE FOLLOWING DECIAflATIONS Z
Z _IHAVEANDWILLMAINTAINACERTIFICATEOFCONSENTTOSELF-INSUREFORWORKEFS' _
Q CAfAPENSATION,AS PFOVIDED HY SECTION 3700 OF THE LABOR CODE,FOR TNE PERFORMANCE U
OF THE WORK FOR WHICH THIS 7ERMIT IS ISSUEO W
� �
w _IHAVEANDWILLMAINTAINWORKEF5'GOMPENSATIONINSURANCE,ASRE�UIREDBYSECTION �,+j ///���
Q 37ooOF7HF.lABORCODE,FORTNEPERF�RMANCEOFTHEWOPiCFORWHICHTHISPERM1T15 ��{..�,�p '
ISSUED MY WORKErRS'C�Oy7�'PrENSATION INSURANCE CARRIER AND POLICY NUMBER ARE CONSTRUCTION f-� 1 V
� CARRIEP �¢I i t.+ �,�� _ PLAN REVIEW _ ��� V
Z POLICYNUMBER ����. �� ELECTRIC _ _ _. .�
Q _ _.
0 (iHI55EGT10NNEmNOTBENMPLETEDOFTHEPERMfTISFORONEHUNDRED00t1ARS(5100�ORLESS) PLUMBING� ��� � � �
W ` '
Z I CERTIFV THAT IN 7HE PERFOflMANCE OFTIIE WORK FOR WHICH Tli'�S P[fIMIT I515S1/ED,l MECHANICAL �--1� i�C�
(,�J SHALLNOTEMPLOYANYPEfi50NINANYMANNEfl50A5TO8EGOMESUBJECTTOTNE
� WORKERS'COMPENSATION LAWS OF CALIFORNIA,AND AGFEE 7HAT IF I SHOULD BECOME INS:�ECTION FEFi�' p i ,� ' )T���� �(����U
� SUBJECTTO TNE WORKERS'COMPENSA710N PROVISI�NS OF SECTION 370a OF THE LA80R e��,�� - -
� CO�E.ISHALLFORTHWITHCOMPLYWITHTHO EPROVISIONS ISSUANCE
p DATE� . E � APPLICANT f-' AI�`� SMIP �P
w WARN�NG UR q�ELUREWORKER5COMPENSATIONCOVERAGE UNIAWFUL,ANOSHALL6E ENERGYP/G-
J
� Sll&IECTANEMPLOVERTOCflIMINALPENALTIESANOCIVILFINESUPTDONEHUNDflEDTHOUSAND ENERGYPERMIT
DOLLARS({100,000).IN ADOI710N TO THE COSi OF COMPENSATION,DAMAGES AS PqOVI�ED FOR IN
J SECTION3]090FTHELABOflCOOE,INTEREST,ANDATTORNEY'SFEES RETENTIONFEE: o
Q
� CONSTRUCTION LENDING AGENCY PRE-ALT FEE
O
� t HEHEBY AFFIRM UN�ER PENAITY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUEU�SEC 3W],CIV C�
�
W
2 LENOEF'S NAME � �
� _ __—
1= LENOER'SA�DRESS
� ICEflTIFYTHATIIiAVEREA�THISAPPLICATIONANDSTATETHATTHEABWEINFORMATIONISCORFECT TOTAL FEES ���Qj _� ���� �
� IFGREETOCOMPLYWITHALLC17ypN�GOUNTYORDINANGE5AND5TATELAWSRELATIN6TO8UILDING �
� CONSTRUCTION.AND HEREBV AUTHORRE REPRESENTATIVES OFTHIS COUNTY TO EMER UPON THE
ZABOVEMENTIONED PRO RTV FOR INSPECTION f'URPOSES COMMENTS
� __ ��` ��, -
m PEFMITTEE NAME(PRiNT) �
a _._..-_-.-�_ �(�,'b
�
�/j SIGNATUREOFFEHMITTEE DATE
= RECPT NO PAID BY VALIDATION
~ WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENROD—Fde Copy,GREEN—ApplicanYs Copy
PRESS FIRMLY
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES 21660 E. Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117 BUILDING PERMIT APPLICATION
JOBSITE _,.,
ADDRESS ioi 1 3 Water Course Dr.
APN LOT 48 TRACT 47850
OWNER Diamond Bar West, LLC
ADDRESS 3480 Torrance Blvd. Ste. 300
CITY Torrance ZIP 90503 7E010-540-3990
APPLICANT Ri chard Gold d TEL.samp nbnwi
CONTRACTOR JrCC Construction
ADDRESS same as owner
CITY ZIP TEL.
ARCH/ENG/
DESIGNER R.Gould&Assoc.
ADDRESS same as owner
CITY ZIP TEL.
OWNER-BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE LAW FOR THE FOLLOWING REASON (SEC 7031 5 BUSINESS AND PROFESSIONS CODE ANY CITY OR
COUNTYWHICH REQUIRES A PERMITTO CONSTRUCT,ALTER,IMPROVE,DEMOLISH,OR REPAIRANY sTRUC-
TUNE, PRIOR TO ITS ISSUANCE,ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI-
CENSE LAW(CHAPTERS(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 ALLEGED EXEMP-
TION.ANY VIOLATION OF SECTION 7031 5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS($500))
O1,AS OWNER OF THE PROPERTY. OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC 7044, BUSI-
NESS AND PROFESSIONS CODE THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY WHO BUILDS OR IMPROVES THEREON,AND 100-IO DOES SUCH WORK HIMSELF OR HERSELF OR
THROUGH HIS OR HER OWN EMPLOYEES. PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FORSALE IF. HOWEVER,THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF COMPLE-
TION,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE)
DI,AS OWNER OF THE PROPERTY.AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC 7044, BUSINESS AND PROFESSIONS CODE THE CONTRACTORS LI-
CENSE LAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S)LICENSED PURSUANT TO THE cONTRAC.
TORS UCENSE LAW)
0 I AM EXEMPT UNDER SEC. B&PC FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT lAM LICENSED UNDER PROVISIONS OF CHAPTER
a (COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND
MY LICENSE IS IN FULL FORCE AND EFFECT
LICENSE CLASS B LIC NO 671982
DATE CONTRACTOR :ICC Cons t ru cs t i al
WORKERS'COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS
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. I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION
3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED My WORKERS'COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE
CARRIER Sir)f.
POLICY NUMBER s',: L,A 0 138A
(THIS SECTICN NEED NOT BE CCMPLETED OF11-IE PERMIT IS FOR ONE HUNDRED COLLARS(SI co)OR LESS)
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,i
SHALL 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 LABOR
CODE,I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS
DATE* APPLICANT
WARNING FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS($100,050),IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3708 OF THE LABOR CODE,INTEREST,AND ATTORNEYS FEES
CONSTRUCTION LENDING AGENCY
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCT/ON LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC 3007,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 ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
CONSTRUCTION.AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES
T—•(CH PSk.F P 61 (;)Li LI)
.^.-11FM ARTIPJffIllifill 00
NATURE OF PERMITTEE "ATE
1
AP P LI CATI O N CII DO le rD
DATE
PERMIT „iv f a PIC00...3
NUMBER.. I hi iv # 50
ISSUE
DATE
TYPE OCC
CONST. GROUP
FRONT SEfBACKS
ZONING REAR
SIDE RW 0
D
SIDE/SIDE STREET RW I ill
0
PROPOSED
N0.
UNITS
USE
DWEL,
N0. N0,
STORIES BEDROOMS
CI)
Lu FACTOR PSF ADJ.AR A/VAL ATION
W DESCRIPTION SQ. FT. Kniumrazirux ,et
U- 1 I MI= a 3•IifO
0 FWD-•d IliMiliih .
z
SFR/ADD/REM 8,720
Garage/Carport 791
Patio/Deck 80
PooVSpa
Re-Hoof
5 I I I grIBMITO r
-.I Commercial En fiIMMI
5
co
Porch 192
. cif-)
Valuation 'X) ADIAREA
QUANTITY i FEE
DESCRIPTION
...J
6
E
F-
0
LU
..J
LU
0
z
cT3
2
D
--I
r).
I
<
0
2
<
0
LI]
CONSTRUCTION
PLAN REVIEW
ELECTRIC
PLUMBING
MECHANICAL
INSPECTION FEE -. 13 1-0
ISSUANCE
SMIP
ENERGY P/C
ENERGY PERMIT
RETENTION FEE.
PRE-ALT FE•
V
5
5-06_dr)
i(V
71,,10
35I -y-
43.9E(
2' --e'
pup
TOTAL FEES 53c:10,0 Ateoelo.ti-g�
COMMENTS 3
-../
RECPT. N0. H! PAID BY 4444 VALIDATION
WHITE—Department Copy,YELLOW—Finance Copy, PINK—Assessor Copy,GOLDENR Ile Copy,GRE Applicant's Copy
CITY OF DIAMOND BAR INSPECTION RECORD
2 .��-ul"�: . :.� �����". � ..- u • .�."'� ul. � �'f:::�� rr �rrr:'r' I 't}Iu.C'1'
.. )im- ,-0,,,,,, 1.-wzwrerm
.1. L.,., .:.,.-..k.r,. - ..a.t. - .. . . .."•0047.. •,:,..4,7Z1.41.11:cht . -*-1"
..L.C..,:eakelii 44.473...r.e.. .,I"' " ' -eikAftiviRs h.4.iftk: 2. . . , • •' •' .4'
SET BACK FLOOR JOIST
[-- FHA REQMTS
FT GS/FORMS/ST EEI ..
ELECTRIC GROUND_ UNDER FLOOR DUCT
GPOU-ND PLUMBING ' 1,-^-00 e UNDER FLOOR CONDUIT
rgt FIREPLACE FOUNDATION
SLAB GRADE t•-•
TEMP POWER FIREPLACE BOND BEAM
WATER SERVICE MID HT. BOND BEAM
ROOF SHEATHING 8 FT,BOND BEAM
2,-To-o\
FRAM—INGNENTILIATION I FINAL BOND BEAM
ROOF COVER PRE-GRADING
ROUGH HEATING BENCHING
ROUGH ELECTRIC ROUGH GRADING
R6-6-G-H PLUMBING FINISH GRADING
ST-1-05.NERTI:OB TEST POOL ELECTRIC
E----X.T. LATH/SIDING POOL FENCING
WALL INSIJLATON POOL FINAL
CEILING INSULATION OFF SITE IMPS.
DRYWALL NAILING DEDICATIONS
—r !it-l.-ot) FINAL ENG.
EWER 1
SEPTIC TANK , LANDSCAPE/IRRIG.
, ON SITE IMPS,
SEEP PI r/L.L.
GAS AM TEST FINAL ZONING
FINAL CONST. i , ----- FIRE DEPT. FINAL.
FINAL HEATING HEALTH DEPT. FINAL
FINAL Fa ECTRIC 1 DEV, FEES PAID
FINAL PLUMBING i n . LU"CA "b_.,---e- ENERGY d_
s V-- .1-. o W.tX AZ 1'5°'
COMMENT, ALL cwAtfl--(O1)2-W-c-A4-.9& fo3 Doz-
SEPTIETANK SIZE SEEP PITILI SIZE
4
DIAMOND BAR I
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES/n
21825 E.Copley Drive
(909)860-3195 Fax(909)861-3117 PRESS
BUILDING PERMIT APPLICATION FIRMLY
JOBSITE ,
ADDRESS 2:-. I (Aif&A-c.4,
APN LOT TRACT 1-1.5,f...5-C-'
IS
OWNER "c)ieiving.,... ' ItAr IiAlt*.It L. 1,--C..
ADDRESS 34 Sep-re-revo-co Ti14.P4-
CITY 1 oirra4...,..4._ ZIP9C21). TEL. i V)SIkea)
APPLICANT TEL.
CONTRACTOR .11-1-'M k c A4, -
ADDRESS I b 2:5.Asc.., .f
CITY .4,11% 1)114,,:._5 ZIP 9 t-iL>TEL. 7-1C I t C.3-,
ARCH/ENG/ , 1 \
DESIGNER R., E.--t---..4.0 10._ ..q. A�SCJC--
ADDRESS :.,. :tc:_.Te.)%rire..lt..-e-(t F 1.-loci,
CITY ZIP TEL.
OWNER-BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE LAW FOR THE FOLLOWING REASON (SEC 7031 5 BUSINESS AND PROFESSIONS CODE ANY CITY OR
COUNTY WHICH REQUIRES A PERMITTO CONSTRUCT,ALTER. IMPROVE,DEMOLISH,OR REPAIRANY STRUC-
TURE,PRIOR TO ITS ISSUANCE,ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS Lt.
CEASE LAW(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 ALLEGED EXEMP-
TION ANY VIOLATION OF SECTION 7031 5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS($500))-
0 I,AS OWNER OF THE PROPERTY,OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION.
WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC 7044, BUSI-
NESS 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 EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE IF. HOWEVER,THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE YEAROF COMPLE-
TION,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE)
DI,AS OWNER OF THE PROPERTY.AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC 7044, BUSINESS AND PROFESSIONS CODE THE CONTRACTORS LI-
CENSE LAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND
WHOCONTRACTS FOR SUCH PROJECTS WITHA CONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAC-
TORS LICENSE LAW)
0 I AM EXEMPT UNDER SEC, B&PC FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY 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 LICENSE IS IN FULL FORCE AND EFFECT
LICENSE CLASS e•-• -n. (0 LIC NO /ty 2-2. 'Z._ .
DATE 5-7,-2,/c„/ CONTRACTOR 1.) 1.--t5 Mt 4,
WORKERS'COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS
I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'
COMPENSATION,AS PROVIDED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE
trF THE WORK FOR WHICH THIS PERMIT IS ISSUED
IHAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION
3700 OF THE LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED,MY WORKERS' :p: SATION INSI:ANCE CARI R AND POLICY NUMBER ARE
t"'-LA01 CI
CARRIER
POLICY NUMBER 2;1'1 -o I c) 1 344.1n '7
(THIS SECTION NEED NOT BE COMPLETED OFTHE PERMIT IS FOR ONE HUNDRED DOLLARS($100)OR LESS)
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1
SHALL 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 LABOR
CODE,I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS
DATE APPLICANT
WARNING FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS($100,000),IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3708 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES
CONSTRUCTION LENDING AGENCY
I HEREBY AFFIRM UNDER PENALTY OF PERJURY 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
i I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT
' I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
, CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
.. ABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES
i
1
i Z3 L1 mik._ !_-, L;, -1 -eco ke,>
3 PERMITTEE AME(PRINT) ....04,
3 'all.....- 2-70 r
) SIGIrTU70F PERMITTEE DATE
APPLICATION
DATE
(PERMIT c\) PERMIT
\-)I NUMBERi to 4"-- P/C
#
ISSUE
DATE
TYPE OCC
CONST. GROUP
FRONT SEfBACKS
ZONING REAR
SIDE RW 0
0
SIDE/SIDE STREET
RW 0
D
N0. PROPOSED
UNITS
USE
D W EL.
N0. N0.
STORIES BEDROOMS
CO
UJ
w DESCRIPTION FACTOR PSF ADJ.AREA/VALUATION
U..
0
z SQ. FT.
SFR/ADD/REM al Z-V
Garage/Carport I
11 I
Patio/Deck
PooVSpa
Re-Roof
5
–) Commercial
5
co
Valuation ADJ.AREA
QUANTITY DESCRIPTION FEE,
../
C.)
F- ,
o zinc A wi Sev v c-e— S ,0
-J
I.11
• .. 0
MINNZPRAIMI
IriMIIr..AJIMIIE %
lll.wwmaim A ..t.
simmi
IIIIIKWINEMA
0
z
rro
M
M
J
iiIIMINVEINOLI
<
<
I
0
w
CONSTRUCTION
PLAN REVIEW
ELECTRIC
PLUMBING
M ECHANICAL
INSPECTION FEE
ISSUANCE
SMIP
ENERGY P/C
ENERGY PERMIT
RETENTION FEE:
PRE-ALT FEE.
.157rItn–
--...,
--imma.
ci,
MAY ;-! 2i.-)ri
TOTAL FEES 1 ')1, Lij
COMMENTS
RECPT NO .5S I(Z„ PAID BY cp---1 K"-'1 VALIDATION O-C----'
WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy, e Copy, M1-OON—AppIlCant s Copy
WHITE--Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—Applicant's Copy
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES 21660 E. Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
ort
PRESS FIRMLY
APPLICATION s,I NUMBER I CV P/C
DATE 1 0. PERMIT -49 0 0 4 #
ISSUE
DATE
TYPE OCC
CONST. GROUP
FRONT SEfBACKS
ZONING REAR
SIDE/SIDE
SIDE RW 0
0
STREET RW CI
P
N0. PROPOSED
UNITS
USE
D W EL.
N0. N0.
STORIES BEDROOMS
DESCRIPTION SQ. FT. FACTOR PSF ADJ.AREA/VALUATION
SFR/ADD/REM
CII Garage/Carport
LLI Patio/Deck
w
ii- PooVSpa
0 Re-Root
z
a Commercial
5
m
Valuation ADJ.AREA
QUANTITY DESCRIPTION FEE
Zti 8/2,0
0 IV .ao
t7 ..
C.) $ .0
La " 0
J '0
tri ---4 it/i? <
imaimi^ i .'42;
0 ,
z
55
M
-J
0-
.11M10 MEMIIIIIII
IIMMEartiall
IFfe9 A
-I
o�
E c9e,e-t 745- Of
< -
0
tu
11111MINEE i e),40
iIiMPWWIRMIN I
IIMMIIMPIIPIPM 0 5; EO
CONSTRUCTION
PLAN REVIEW
ELECTRIC
PLUMBING
MECHANICAL
INSPECTION FEE
ISSUANCE
SMIP
ENERGY P/C
ENERGY PERMIT
RETENTION FEE
PRE-ALT FEE: s-/q100
..t -
.257a)
457,49�1
t
TOTAL FEES
COMMENTS
� 1 0 PAID BY VALIDATION
RECPT. N0. _50
WARNING FAILURE To SECURE WORKERS'COMPENSATION ERAGE IS UNLAWFUL,AND SHALL BE SUBJECT AN EMPLOYER TO
CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS($100,000),IN ADDITION TO THE COST OF
COMPENSATION, DAMAGES AS PROVIDED FOR IN SECTION 3709 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES
jOBSITE
ADDRESS 4,-10< g az.74c-Rz.
APN LOT TRACT OWNER
ADDRESS ',347! r9
ziFiroce?TELIo s-2.w3c5e,
APPLICANT TEL.
CONTRACTOR .5-reir-wi fi/45e.ADDRESp 41-4". Ar7g-
CITY 6-
ZIP AIIIr �rZ7/f,z,
ARCH/ENG/
DESIGNER
ADDRESS
CITY ZIP
TEL.
OWNER-BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LICENSE LAW FOR THE
FOLLOWING REASON (SEC. 7031.5 BUSINESS AND PROFESSIONS CODE:ANY CITY OR COUNTY WHICH REQUIRESAPERMIT TO
CONSTRUCT,ALTER,IMPROVE, DEMOLISH,OR REPAIR ANY STRUCTURE,PRIOR TO ITS ISSUANCE,ALSO REQUIRES THE
APPLICANT FOR SUCH PERMIT TO FILE A SIGNED STATEMENT THAT HE OR SHE IS LICENSED PURSUANT To THE PROVISIONS
OF THE CONTRACTORS LICENSE LAW(CHAPTER 9(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND
PROFESSIONS CODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMPTION.ANY
VIOLATION OF SECTION 7031.5 BY ANY APPLICANT FORA PERMIT SUBJECTS THE APPLICANT TO A CIVIL PENALTY OF NOT
MORE THAN FIVE HUNDRED DOLLARS(BIOS))
DI.AS OWNER OF THE PROPERTY,OR MY EMPLOYEES WITH WAGESAS THEIR SOLE COMPENSATION,WILL DO THE WORK,AND
THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC. 7044, BUSINESS AND PROFESSIONS cope THE CONTRACTORS
LICENSE LAW DOES Nor 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 EMPLOYEES,PROVIDED THAT SUCH IMPROVEMENTS ARE NOT
INTENDED OR OFFERED FOR SALE IF, HOWEVER.THE BUILDING OR IMPROVEMENT IS SOLD WITHIN ONE yEAR OF
COMPLETION,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR IMPROVE FOR
THE PURPOSE OF SALE).
0 I,AS OWNER OF THE PROPERTY,AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS TO CONSTRUCT THE
PROJECT(SEC. 7044,BUSINESS AND PROFESSIONS CODE THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER
OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND WHO CONTRACTS FOR SUCH PROJECTS WITH A coNTRACTOR(s)
LICENSED PURSUANT TO THE CONTRACTORS LICENSE LAW).
OWNER
LICENSED CONTRACTORS DECLARATION
HERESY AFFIRM UNDER PENALTY 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 LICENSE IS IN FULL FORCE AND EFFECT
LICENSE CLASS 073 LIC NO 6'V" 7 7
DATE / -- CONTRACTOR WORKERS'COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS.
(HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'COMPENSATION,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 INSURANCE,AS REQUIRED BY SECTION 3700 OF THE LABOR CODE,
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. MY WORKERS'COMPENSATION INSURANCE
CARRIER ATICY NUMBER ARE
CARRIER ;en. '7-,�A. ./.4 11, •
POLICY NUMBER z ser(10 Ze-- )
(THIS SECTION NEED NOT BE COMPLETED OF THE PERMIT S FOR ONE HUNDRED DOLLARS(5103)OR LESS).
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL 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 LABOR CODE,I SHALL
FORTHWITH COMPLY WITH THOSE P" +VISIONS.
DAT/4"6'0 APPLICANT'
DATE
PERMITTEE N (PRINT) 61
SIGNATURE OF PE ITS
CONSTRUCTION LENDING AGENCY
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC 3007,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 ALL CIT.,AND COUNTY ORDINANCES AND STATE LAWS RELATING To BUILDING CONSTRUCTION,AND HEREBY
AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE ABOVE-MENTIONED PROPERTY FOR INSPECTION
PURPOSES.
/69,ete)-1 A4,:Pe7,e)
�Z—
DATE
0 I AM EXEMPT UNDER SEC.
8&P C FOR THIS REASON
CITY OF DIAMOND BAR INSPECTION RECOF-ID
EISCTL
r't
CEEr
,ON NOE,
17 /ONINO
EL lE
FIT-,11„
SET BACK. I FLOOE JOIST
FTGS/EO.P.LiSiSIT, E:-R_ i
ELECTRIC GROUND ; I FHA HEOMTS
....._�
^ UNDER FLOOR DUCT
^ I UNDER FLOOR CONDUIT
----t�
GROUND rl t;TIR"'-:',
SLAB GRAPE i F:REEACE FOUNDATION
17.:-MP P(.�;',N'tER FFEP ACE BOND BEAM
WATER SERVI!.:':-': ; MID Hi. BOND I:IsEAtv:
ROOF SI-TFfI-IING I I FT. BOND BEAM
i. ' FINAL BOND BEAM
I PRAMINciiVF.N1ILIAToN
1 ROOF COVI:R
,' BENCHING
i---- —
ROUGH HFA,TING
, . ROR(11-'GRADING
... I ORADING
ROUGH ELECTRIC
ROUGH
SHOWER 46 VES ,P00:, ELECTRIC
EXT. I ATiEi RDIING
't
,P00/FENCING 1 POOL EINAL OFF I.-31117 IMPS.
II- ',I
F-1R IG.
WLL INSUI,ATION
CT:II INTOINII3IiI ATICIN
I EWE'
1,
WHITE—Department Copy,YELLOW—Finance Copy, PINK—Assessor Copy,GOLDENROD—File —p cant s Copy
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES 21660 E. Copley Drive Suite 190
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT'APPLICATION
PRESS FIRMLY
APPLICATION
DATE
t C i"-y% PERMIT 1 (1 (1/7 P/C
I- I"-\-A) NUMBER I"' I #
ISSUE
DATE
TYPE OCC
CONST. GROUP
FRONT SEfBACKS
ZONING REAR
SIDE RW 0
0
SIDE/SIDE STREET RW 0
0
PROPOSED
N0.
UNITS
USE
D W EL.
N0. N0.
STORIES BEDROOMS
CO
ILI
w DESCRIPTION SQ. FT. FACTOR PSF ADJ.AREA/VALUATION
LL-
0
Z
SFR/ADD/REtvi
Garage/Carport
Patio/Deck
PooVSpa
Re-Roof
a
.-1
5
CD Commercial
Valuation ADJ.AREA
QUANTITY DESCRIPTION FEE
i
<
0
Fr
1-
0
LU
--I
LU
/ 1"-- petu Or
(.1
Z
C73
D
I
a
-)
<
C.)
Z
<
2
0
IL
CONSTRUCTION
PLAN REVIEW
ELECTRIC
PLUMBING
MECHANICAL
INSPECTION FEE
ISSUANCE
SMIP
ENERGY P/C
ENERGY PERMIT
RETENTION FEE:
PRE-ALT FEE:
2c.1,—00
9,,,,-O1
TOTAL FEES
COMMENTS
RECPT. N0.t41 Lc7
PAID BY ) 1 1 i 1, N VALIDATION M7—
JBSITE ,. .- 3 1,I
0 .--2 4--) (sr.--.V v s
ADDRESS.4-• I t,"'cd—eve-01)
-1 S f---; 0
APN LOTTRACT
........ ,
OWNER Viet 1/1•16n4C1 tW tile s 1---C-
ADORES 3t 9 si'D z — • i
a CR:RI&VC ZIP 0.--3-rEL.O SVO q--i0
APPLICANT TEL.
CONTRACTOR fl_.- 13 EitZ-C-1-1^(e...--
ADDRE,5S .02.-S �..le- e---- •
41
CITY 11.4,1 vwt S ZIP 111-1. TEL 0 1 I,Zi97.7
ARCH/ENG/
DESIGNER
ADDRESS
CITY ZIP TEL.
OWNER-BUILDER DECLARATION
I HERESY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE LAW FOR THE FOLLOWING REASON (SEC 7031 5 BUSINESS AND PROFESSIONS CODE ANY CITY OR
Ca./NTT WHICH REQUIRES A PERMITTO CONSTRUCT,ALTER,IMPROVE, DEMOLISH,OR REPAIR ANY STRUC-
TURE,PRIOR TO ITS ISSUANCE,ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI.
CENSE LAW(CHAPTERS(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 ALLEGED EXEMP-
TION.ANY VIOLATION OF SECTION 7031 6 BY ANY APPLICANT FORA PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS($500).).
DI.AS OWNER OF THE PROPERTY,OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC 7044, BUS1
NESS AND PROFESSIONS CODE THE CONTRACTORS LICENSE LAW DOES NOT APPLY 70 AN OWNER OF
PROPERTY WHO BUILDS 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/S SOLD WITHIN ONE YEAR OF COMPLE-
TION,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE)
DI.AS OWNER OF THE PROPERTY,AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC. 7044, BUSINESS AND PROFESSIONS CODE THE CONTRACTORS LI-
CENSE LAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS WITH A CONTRACTOR(S)LICENSED PURSUANT TO THE CONTRAC-
TORS UCENSE LAW.).
0 I AM EXEMPT UNDER SEC B 1 P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
0(COMMENCING WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND
MY LICENSE IS IN FULL FORCE AND EFFECT
LICENSE CLASS 6-/0 LIC NO LI T?
DATE 1 i"&fr0 CONTRACTOR
WORKERS'COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS.
I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'
COMPENSATION,AS PROVIDED BY SECTION 3700 OF THE LABOR CODE, FOR THE PERFORMANCE
i OF THE WORK FOR WHICH THIS PERMIT IS ISSUED
V I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REQUIRED BY SECTION
3700 OF THE LABOR OODE,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED. MY WORICOTEe1.......4SATI0NINSURANCE PRIER AND POLICY NUMBER ARE.
CARRIER ki A f-0 ?
27.-
POLICY NUMBER .1C1�-.00 oc.)134&;1
(THIS SECTION NEED NOT BE CCMPLETED OF THE PERMIT IS FOR ONE HUNDRED COLLARS($100)OR LESS).
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
SHALL 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 LABOR
CODE,I SHALL FORTHWITH COMPLY WITH THOSE PROVISIONS
DATE: APPLICANT
WARNING FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL,AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS(8100,000),IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3700 OF THE LABOR CODE,INTEREST,AND ATTORNEYS FEES.
CONSTRUCTION LENDING AGENCY
I HEREBY AFFIRM UNDER PENALTY OP PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
• FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED(SEC 3007.CIV. C)
i
. LENDER'S NAME
• LENDERS ADDRESS
i
; I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
' I AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
, CONSTRUCTION.AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
' ABOVEMENTIONED PROPERTY FOR INSPECTION PURPOSES
—,....... .-
,)a WI e_5 1, I' i,or.)ke>
PERMITT NAME(PRINT)
e1t44-4 i i 00
SI AN OF PERMITTEE
La-
QC:1
L.0
CO
CZ)
CITY OF DIAMOND BAR INSPECTiON RECORD
. - .
� � ��
3ET ELACK
rs°7 GS/FOE-4MS/,,TEE
TR/C OPOUND"'FT_
°f°IAB GRA TEMP POW
WATER SEPVICP
RCC EAT
FP
F—C
I-FH-A REOMT:.--;
UNDER FLOOR OUGT
I UNDF.Fi r:L00R CONDUIT !F;EDLACE-,FC_A,NDATI N iTh---1.PI_A.CE 30ND EI5'AM F7 IIIOND 3E,,8 FT BOND BEAM POND
BEAM PP TRADiNG RPNCHNO
1-2y-.7t
'LECTRIG NO NO
44-11 401
J:3—q71299—(:011
d#Ote..
E I MPS.
MEN -7'I I- t, 2_
ad AD 6.44A'
p2,71). I
DIAMOND BAR 1
4160'
PRESS FIRMLY
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
21825 E.Copley Drive
(909)860-3195 Fax(909)861-3117
BUILDING PERMIT APPLICATION
JOBSITE• 7 g 8
ADDRESS 4- 0%.4.1-i?k a iii0l:t.
APN LOT TRACT
OWNER 1-c 4 i
ADDRESS
CITY ZIP TEL.
APPLICANT TEL.
f
OA,-., f of.."47,4A
CONTRACTOR (6 7,5-z 4-, i
—i_
ADDRESS"IA
CITY ke.g,,_
tr -ii ZIP lijk(21.,TEL.- —-
AG_4_14
ARCH/ENG/
DESIGNER
ADDRESS
CITY ZIP TEL.
OWNER-BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LI-
CENSE LAW FOR THE FOLLOWING REASON (SEC 7031 5 BUSINESS AND PROFESSIONS CODE ANY CITY OR
COUNTY WHICH REQUIRES A PERMITTO CONSTRUCT,ALTER,IMPROVE, DEMOLISH,OR REPAIR ANY STRUC-
TURE,PRIOR TO ITS ISSUANCE,ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI-
CENSE LAW(CHAPTER 9(COMMENCING WITH SECTION 7050)OF DIVISION 3 OF THE BUSINESS AND PRO-
FESSIONS CODE)OR THAT HE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THE ALLEGED EXEMP-
TION ANY VIOLATION OF SECTION 7031 5 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS($500))
0 I,AS OINNER OF THE PROPERTY,OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
WILL DO THE WORK,AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE(SEC 7044, BUSI-
NESS 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 EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT INTENDED OR
OFFERED FOR SALE IF, HOWEVER,THE BUILDING OR IMPROVEMENT IS SOW WITHIN ONE YEAR OE COMPLE-
TION,THE OWNER-BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE)
ID I,AS OWNER OF THE PROPERTY,AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT(SEC 7044, BUSINESS AND PROFESSIONS CODE THE CONTRACTORS LI-
CENSE LAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUILDS OR IMPROVES THEREON,AND
WHO CONTRACTS FOR SUCH PROJECTS WITH ACONTRACTOR(S) LICENSED PURSUANT TOTHE CONTRAC-
TORS LICENSE LAW)
0 I AM EXEMPT UNDER SEC B&PC FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
9(COMMENCING WITH SECTION 7550)OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE,AND
MY LICENSE IS IN FULL FORCE AND EFFECT
.."3 ) ../k- 1-Ii
e 1-'
LICENSE CLASS -. "4-4 LIC NO
DATE 4). 0 A_ CONTRACTOR C---1 e a: ?c z_
WORKERS'COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS
I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF-INSURE FOR WORKERS'
COMPENSATION,AS PROVIDED By SECTION 370o 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 LABOR CODE, FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED MY WORKERS'CO pENSATION INSURANCE CARRIER AND POLICY NUMBER ARE
CARRIER S. ( I r-j,ic.,,:",
POLICY NUMBER 6•.<76,s-i.- c-f
(THIS SECTEN NEED NOT BE COMPLETED OF THE PERMIT IS FOR ONE HUNDRED DOLLARS(SI CO)OR LESS)
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I
SHALL 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 LABOR
CODE,I SHALL FORTHWITH COMPLY WITH THO E PROVISIONS
DATE' "'.� APPLICANT r",IvfAi""'
--7
WARNING UR O8ECURE WORKERS'COMPENSATION COVERAGEIS UNLAWFUL,AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP To ONE HUNDRED THOUSAND
DOLLARS($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3708 OF THE LABOR CODE,INTEREST,AND ATTORNEY'S FEES
CONSTRUCTION LENDING AGENCY
I HEREBY AFFIRM UNDER PENALTY OF PERJURY 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 ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
CONSTRUCTION,AND HEREBY AUTHORIZE REPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE-MENTIONED PRO RTY FOR INSPECTION PURPOSES
4 ..I.N. 11,V*4
PERMITTEE NAME(PRINT) -------,_ A
(t,---0
SIGNATURE OF PERMITI-EE DATE
APPLICATION
DATE
- .4...._ 1 4-6 i NUMBER 11 ocipic 0 I_351
#
ISSUE
DATE
TYPE OCC
CONST. GROUP
FRONT SEfBACKS
ZONING REAR
SIDE RW CI
0
SIDE/SIDE STREET RW 0
0
PROPOSED
N0.
UNITS
USE
DWEL. r(76 ff,_
N0. N0.
STORIES BEDROOMS
cn
w
w DESCRIPTION SQ. FT. FACTOR PSF ADJ.AREA/VALUATION
Li-
0
Z
SFFVADD/REM
Garage/Carport
Patio/Deck
Pool/Spa 7/3:, +
Re-Root
E
) Commercial
5
m
Valuation , 0 ADJ AREA
QUANTITY 1
DESCRIPTION FEE
0
E
1- AI cro ,_tec-
0
iii
J
L1J ...2-, cti 1 0
r) 1...Nit
( ?7-1 C
(..D
z
(I - , 1 ...•
D
J
11
„',:..-7 ff P
i 'HZATZt.
a
c.)
2 ca( i< 1.6, 44(O,-J-ei(
a
x
�••)
in 90-S'o
CONSTRUCTION
PLAN REVIEW
ELECTRIC
PLUMBING., "
MECHANICAL
INSPECTION PF-
ISSUANCE ")
SMIP
ENERGY P/C-
ENERGY PERMIT
RETENTION FEE:
PRE-ALT FEE 2)314 1 0
3,-L 10
H-).
./) [1 Oil I(3cs .. —
el :' 1 '- -
......,C.—
An
11=11=11111.1 ill qb
TOTAL 5-I tip s-,
COMMENTS FEESL
5 2("" -c6(\
RECPT NO PAID BY 3_,...yl._VALIDATION
WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—Applicant's Copy
n