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'"�' CITY OF DtAMOND BAR ���� P/c��i c�-���
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PRESS
�EPARTMENT�F SUIL�ING AN�SAFETY
� BUILDING PERMIT FIRMLY
JOBSITE APPIJCATION .-�,��. PERMIT UO$E
ADDRESS � /` �T� �NUMBER �
ISSUE �--�� TYPE OCC.
► APN LOT TRACT DATE �=,�_��CONST. GROUP
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o CROSS ST ET ZONING �TBACKS ��r+�s
°� OWNER FRONT qW �
� ADDRESS REAR 0
W CITY ZIP TEL.��1 SIDE/SiDE STREET RW �
o APPLJCANT � TEL�S9S-I�1�' SIDE 0
z
4 CONTRACTOR
o ADDRESS SEWAGE � PUBLIC PMT#�
DISPOSAI. � pRNATE SU.FT./100 GAL
.�., CITY_�oe/n�t ZIP TELS�
= STATE
y UG.NUMBER .T I�f D/� GRADING � CU.YDS.ExC. CU YDS FILL
y ARCHiEN�i � TYPE SQ F1' :�ACTOR P5 . � ::`ADJ. AREANALUATI�N '-
`=' DESIGNER -T � �1.� 1
o ADDRESS ,� 2
= CITY_//G� ZIP�Qf�TEL. � 3
� PROPOSED USE o��••�f t Poul �_c�c� Z 4
'' � GARAGE
o NO.DWEL. NO. NO. ",,,,3" pQRCH
y UNITS STORIES BEDROOMS
•. � LOT DIMENSIONS m VALUATION ADJ.AREA
o NO.OF BLDGS HOW fluANT�TY �ESCRIPT QN : ";;,.' ':'::"':::: `
WON LOT USED <. FE� .:,'i;.';; .;.. �:: .:;' ;::. :.
� N `7 .�C�
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� IICE 0 CONTRACTORS OECLARATION:I herzhy dlirm thst I�m licenaed urider provisiom oi Ch�pter B�wmmencinp ���.
Y wi�h Sauon 1000)ol Uivision 5 of the Busiireas�nd Ralessians Cade,m0 my license is in full hrce inU eFfect t�
3 ❑ �
�— QNNER�BUII�ER UECLABATION:I herehy effi�m thal I am emmpl lrom the Commcror'�L¢enm law hr me fdtrninp � .�
x reasan ISec.7031.5,Basiness and Rahssion�Cade.Any titV a eoumy which requires o prmit ro wnatruet .(7
o alter,mpmve,demdish,rc repeir airy rtmcture,piior Oo ils iasuence.Yto r�puirea Me�ppl'rsm hr wch p�rmu �
6 m lile a signed stacemem that he is IicenseO puwant m tl�e provieions o1 me Cmtretmr'a Liceme Lew ICh�ptr �:�
� 9(commencinp with Sectlon)Of101 0l Oivision 3 d Me Busineas�nd Proleuiona Code�w that he it�inmpt Ihmhom �� � � `
� �nd Me hasis for tl�e alleged exemption.Arty vidNian ol Sxtion 7031.5 6y�ny�pplicent fw�permit�u6pat� .a
W the applicant m e civil pen�lty ol not more than fNe hundnd dollaw IS500�.�: J
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� ❑1,as avire�ot the properlY.a mY amployees with wapes a Meir�de eampenaation,will do the work,erd
� The structure u mt intended o�olfertl Iw sale(Sec.7064,BuuMcc�nd Prolee�ians Cdr.ihe Contrxtar'1 ticenx �,sq � Q
� law does mt apO�Y to en owner oF property who huilds or impavee Ihereon,a�who dces such work himselt, �„� •
' oi[hmugh his own employees,prwided�hat auch imprwemend ne nat inhnNA a o11enU loi sak.If,bqxever, �;�
po the 6wldinq w imProvemeM is sold within ona yeer ol canpletion,ihe axneo-builder will hew the burden of qwinp :�..q
y tha�M did not huild m impmve for me puryaee of fele.) ��
� ❑I,as owrer of ihe properry,un exeluenaly wntrenmy with licensed conlnctort to construct IAe pqect(Sa.
0 704M1,Busiross md Protasiona Lade:The Conv�cmr'�Licen�e 4w Ooes not i00W m�n wmer W praperty wM
i huilds o�improves therton,md whe cantr�ch fd arh pmjects witA�contrxtar�f)Gemsed qrw�nl lo Ye Cmtnc[ar's � ��'
'� License Law.l uC,.'O
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FW., '�1 am eMempt under Ssc. ,8.&P.C.(AtUch Grdfieah) V�EW �
0 oa�e ' ' ' •oweer _ ' " � ` ELECTRIC '�" ,
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y 1MORNENS'COMPEN9ATUN DE0.ARAlIIXJ I Mrehy eM�rm Iha�I heve�ceruticata af aon:em to teil-nsure,tr �.� . ,
a oeraficate of Work�ri Campensauon In�wmo�,a a ce�6fied eopy�thxeaf(Sec.3800,LW.C 1. E��
6 �Catired wpY is hereey furnishee . �- � � � - ECHANI
c �mtified copy ia filed with tAe BuilGinp Inspection Department or Depuhnent. ^� GRADING
W
�� LEFifIFICATE Of EXEMPTION FFIOM WOqIfERS'COMPEN$AiION INSUNANCE:This ucbon need not he completM SSUANC
� i1 the permit�s for ane hundred(5100)or k�z�"�er1�j,,mlD���il`ie�perfarmance of Ae waM toi wAich tAis F.�.
p9rmit is issucd,I ehall aDt emplay eny perwn irv ii'ry•mliilnet`s4}9�o he}ome w6jxt W tFe N6rkms'Compenalian � S`
�s l�ws of C�likmia. ` ••: �� •:i 1.:,.,.'
w
� ' • - PARK FEE
p �ah Applioant �• ..
� FqlICE TO AP%.ICAM.H,etter makinp �� plicate al Memppup, shou�d become�uqect m me vWorper': . SCHOOL FEES '��
—� Campensatim provisims of the le6ar C�},y�•lnusNa��ith�o'Ma�i,' i�h weh qwi�iam a this pimn�haH - .,
� h deemed revoked. �� ! E "
-'-' �ic`�.c�D ) lrL(
pc OIVISIpJ OF INOUSTRIAL SAFETY YERMIT CEfliIFICAlION: , -
W ..��... �.�. � � ..
o ❑I hereby certify the[�ro uav7Nen,li�e(SI N'mOt�ihe�in deptA pp7 w�ucli-1.�DyRan if npui�d b deseend. � �
� will 6e mede in eannec�nn witA Work�auMnized 6y.this perma,��nd qwt xn WilEny tteuetue,uaNaldinp.Wsawork. .
x
a demoFtpn m dismmtFnp thereol.��4ill-�h��mora Man�lMrry-si+��361 he��hpR.�hep.32.Gry 2.Art P.Sx
W 341.Title 8.C.A.C�.
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3 ❑0.s ownerbuilde�.I will not empky aryoro la do worY whch would rpnin��xme hom IM 6viaqn d
p— Industriel Safety,u nored�6we,unless su[fi peraon h�s�permil b do euth worM imm lhe ONieqrt
g < :
W ❑Orvis�m of Mdu�vial SeFery Pormrt No. TOTAL FEES
d
� CpV51AUCfpN IENDING AGENCY:I herehy aMi�m Ihat IMn w�wnsUuctqn YnOinp pary Ipr yip per�prmy¢e
z ol�he work Iw wnkn�his qrmil u isaueE�Sa.3097,Gv.C.1.
� LeMer'a Name
m lende�e Address COMMENTS
'� CERfIfIGttE OF COhAPIIANLE ANO AUTFqRIZATION OF EN1I11':I prury I Iwue naE tlii�pplintqn md rt�p
va. Mat Me inlormetian piwn u carcct.I agne w mmply witli�tl pen Iwva rM dry erAmncn n4tnp to 6uiNinp
y canshuaian.xd wthwiea�reprxem�[i+�d 9ie Dapertmem d Buildinp nd SeMY b�pr Won IM paprlY
, � fa whkA I have d toi ' ermi[fa the q�pose o1 mekinp p�petlqnf. . �
�„� x � ' V " ����O RECPT NO. 1��C�_PAID BY �U�� VAUDATION�
Mv Kam a Apent
`r„�WHITE—Department Copy,YELLOW—Finance Copy,PINI4—/�Ssessor Copy,GOLDENROD—FHe Copy,GREEN—AppllcaMs Copy
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