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CITY OF DIAM( BAR
J(� DEPAR' IT OF COMMUNITY & DEVELOPMENT SERVICES
21825 Copley Drive, Diamond Bar, CA 91765
(909) 839-7020 Fax (909) 861-3117 Building Inspection Hotline (909) 839.7027 PRESS
BUILDING PERMIT APPLICATION FIRMLY
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ADDRIESS
DESCRIPTION SO FT FACTOR PSF T ADJ AREAIVALUATION
APN LOT TRACT
OWNER
ADDRESS
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OWNER -BUILDER DECLARATION
I HERESY AFFRN UNDER PENALTY OF PEflA1RY THAT I All EXEMPT FROM ME CONTRACTORS LL
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STATEMENT"A
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PERMIT SUBJECTS ME APPLICANT TO
TICKAN!VALTY
OF HUNDRED OLLAFOgA
ACINAR PENALTY OF NOT MORE TI/JI FIVE HUNDRED DOLLARS NOM)) I
❑L ASOWNEROFTHE PROPERTY OR MY EMPLOYEES WITH WADES"THEIR SOLE COMPENSATION
YII W THE WOUL AND THE STRUCNRE M NOT IMENDED OR OFFERED FOR SALE (SEC ]PM BUSI
NESS LAID PROFESSIONS CODE THE CONTPACTOR9 LICENSE LAW DOES ACT APPY TO NI DINNER OF
PXOPFRTY AND SURDS ON IMPROVED THEREON. AND ANDDOES SUCH MOWN HIMSELF OR HERSELF OR
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OFEIIEDFOgBKEIF HOWEVER PEMEMRHAT
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VALL HAVE TXE BURDEN OF PROVING THAT NE OR SHE DID HOi BUILD OR
TON TSE OR HAVE THEHEHE DID NOTBUIU O
THE PURPOM
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pIASUCT
OPNTWCTION
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THE BUSINESS
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FOR 9UGlPRWECTB WITIACORINCTON9I LILENBEDPURBUIM TOTIE WIIfMO
ED PURSUANT
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❑ IMI EXEMPT UNDER SEC B L PC FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
1 HERESYAFFIRMUDERPENPi WPER WNUTIMILCENSEDUDERPfl SIONSOFOUPTER
i(COMMENCWOwNXSERMON]UV)OFDMSIONSMTHEBUSINESSANOPMFEWMBfN AND
W INCENSE W W M/LJ�'ZOEMD EFFECT .P
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DATE ....A
WORKERS COMPENSATION DECLARATION
1 HEREBYAFFIRM UNDER PENALTY OF PERMRY ONEOF THE FOLLOMWO DELL RATIOMS
IHAVEMDRILLWJNTNNACEWIF;4TEMCONSE M SELF INSUREFORYORKERS
COMPENSATION AS PAWOFG BY SECTION NW OF THF .AWA CCOE FOR THE PERFORMANCE
OF ME MORN FORNHICH NIS PERMIT IS ISSUED
HAVE AND WILL MAINTAIN WORKERS COMPENSATION INSURANCE AS REWIRED BY SECTION
PDD OF THE IABOR E FOR THE PFRFORMAVCE OFTNE WORK FOR WNIIW iH19 PERMITIS
ISSUED NY WORKER NPENUTIONN SUR/µCEUANERMIDWLICYNUMBERME
CARRIER AAi/lAl ., I i
POLICY NUMBER
nN6eEcAcH NEBNOT BEODAq£I®OFTNE: PpMTB MnONENIIQ®DOUNl9 RIR ONE&%
I CERTIFY THAT IN THE PERFORMANCE OF THE WORN FOR WHICH! THIS PERMIT & ISSUED I
BWLL NOT EMPLOY MY PERSON IN ANY MANNER SO AS TO BECOME SUBJECT TO THE
MOANERS COMPENSATION UWS OF CALIFORNIA, AND AGREE NAT IF I SHOULD BECOME
SUBJECT TO THE MAKERS f PENSAT OF THE LABOR
rONSM.9.0 ��SSEECC�T�I]ON/fST.
�� ON cOMPLY v�TLI T IP/%I�{ pl a V4 E. "
I
OTTE APPLICANT -.
WARMNO FKURE TO SECURE WORKERS COMPENSATION COVERAGE IS UNUWNL AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CML FINES UP TO ONE HUNDRED THOUSAND
OOLLABS IFIO7=1 IN ADDITION TO THE COSTOF COMPENSATION DAMAGES AS PROVIDED FOI IN
SECTION S]DI OF THE LABOR CODE INTEREST AND ATTORNEYS FEES
CONSTRUCTION LENDING AGENCY
I HERESY AFFIRM MHOM PENMTY OF PERARY NAT MERE IS A CONSTRUCTION LENDWO AGENCY
FOM ME PERFORMANCE OF ME MOAN FOR WIWI MIS PERMS IS ISSUED ISM SM GV C I
LENDERTS NAME
LENDERSADDRESS
I CERRFYTUT I HAVE READ THISMPICATIONANO STATE MATTHEABOVE INFORMATION ISCORRECT
I AGREE TO COMPLY VAN ALL SAY AND COUNTY ORDINANCES AND STATE UWS RELIT WG TO INA DWG
CONSTRUCTION, AND XEREBRID
YAIRRE REPRESEMATNES OF MLS COUNTY TO ENTER UPON THE
ABOVE MENTIONED PROPERTY FO Iq NSVECT� S
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APPLICATION III II0 NUMBPERMFF
DATE
ISSUE j V V'� OIC
TYPE OCC
DATE O CONS L ROUP
ZONING SETBACKS
FRONT RW ❑
REAR ❑
SIDE/SIDE STREET RW ❑
SIDE ❑
PROPOSED USE
NO DWEL NO NO
UNITS STORIES BEDROOMS
DESCRIPTION SO FT FACTOR PSF T ADJ AREAIVALUATION
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COMMENTS
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CITY OF DIAMOND BAR
INSPECTION RECORD
SETBACK
FLOOR JOIST
FIGS/FORMS/STEEL
FHA REOMTS
ELECTRIC GROUND
UNDER FLOOR DUCT
GROUND PLUMBING
UNDER FLOOR CONDUIT
SLAB GRADE
FIREPLACE FOUNDATION
TEMP POWER
FIREPLACE BOND BEAM
WATER SERVICE
MID HT BOND BEAM
ROOF SHEATHING
8 FT BOND BEAM
FRAMINGNENTILATION
FINAL BOND BEAM
ROOF COVER
PRE -GRADING
ROUGH HEATING
BENCHING
ROUGH ELECTRIC
ROUGH GRADING
ROUGH PLUMBING
FINISH GRADING
SHOWER/TUB TEST
POOL ELECTRIC
EXT LATH/SIDING
POOL FENCING
WALL INSULATION
POOL FINAL
CEILING INSULATION
OFF SITE IMPS
DRYWALL NAILING
DEDICATIONS
SEWER
FINAL ENG
SEPTIC TANK
LANDSCAPE/IRRIG
SEEP PIT/L L
ON SITE IMPS
GAS AIR TEST
FINAL ZONING
FINAL CONST
FIRE DEPT FINAL
FINAL HEATING
HEALTH DEPT FINAL
FINAL ELECTRIC
DEV FEES PAID
FINAL PLUMBING
ENERGY
COMMENTS
SEPTIC TANK SIZE
SEEP PIT/U SIZE
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