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& DEVELOPMENT SERV
21810 Copley Drive, Diamond Bar, CA 91765 Red Final 4
(909) 839-7020 Fax (909) 861-3117 Building Inspection Hotline (Vmzp"
,.� BUILDING PERMIT APPLICATION Imo& A, ^ _a,:.:_: A x . IRMLY
SOBSITE g� r'
ADDRESSX 1524
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APN LOT TRACT
OWNERX -DA
ADDRESS
CITY . D596"vRl�
APPLICANT TEL,
CONTRACTOR
ADDRES5
CITY ZIP TEL.
DCfGNER w �p'�
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ADDRESS° ro d:
CITY TEL. _ F C I
OWNER-13UILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT tAM FXEMPT FROM THE CONTRACTORS LI-
CENSE LAW FOR THE FOLLOWING REASON (SEC. 7031.fi BUSINESSAND PROFESSIONS COD£:ANYCITY OR
COUNTY WHICH REQUIRESA PERMITTO CONSTRUCT,ALTER, IMPROVE, DEMOUZ OR REPAIRANYSTRUC•
TUBE, 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 a (COMMENCING WITH SECTION 7W01OF DIVISION OF THE BUSINESS AND PRO-
FESSIONS CODE) OR THATHE OR SHE IS EXEMPT THEREFROM AND THE BASIS FOR THEALLEGED EXEMP-
TION.ANY VIOLATION OF SECTION 7031.5 BY ANYAPPLICANT FORA PERMIT SUBJECTS THE APPLICANT TO
AWL PENALTY OF LIOTMORE THAN FIVE HUNDRED DOLLARS
❑ 1, AS OWNER OPTHE PROPEnTY, OR MY EMPLOYEES W ITH WAGESAS THEIR SOLE COMPENSATION,
WALL DO THE WORK, AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 1044. BUSI-
NESS AND PROFESSIONS CODE: THE CONTRACTORS LICENSE LAW DOES. NOTAPPLY TO AN OWNER OF
PROPERTY WHO BUILDS OR IMPROVESTHEREON,ANO WHOOOES SUCH WORKHIMSELF ORHERSELFOR
THROUGH HISOR HEROWN EMPLOYEES, PROVIDED T14ATSUCMMPROVEMENTS ARE NOTWTENDEDOR
OFFERED FORSALE IF. HOWEVEFLTHE BUILDING OR IMPROVEMENT €S SOLD WITHIN ONEYEAROFOOMPLE-
TX) , THE OWNER -BUILDER WALL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
OVE F_qR THE PURPOSE OF SAL4
i ;L11,A$$ OWN ER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WLTH LICENSED CONTRACTORS
j0 OONS CVT THE PROJECT {SEC, 7044, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS Lt-
�,C{NS -lAW DOES NOTAPPLY TOAN OWNER OFA PHOPERTYWHO BUILDS OR IMPROVES THEREON, AND
V7fi2�CONTRACTS FOR SUCH PROJECTS MTHAC.ONTRACTOR(31EICENSED PURSUANTTQT#iECONTRAG
TORS LICENSE LAW.). 5y,
LI I AM FXEMPT UNDER SEC. B. &!.C. FOR THIS REASON
DATE '.� "' L - OVINE .:°'�+.-"- '.. .:_.:�.-•:.:�.
I LiCENSEDCONTFtAC s_6FcLA&TION
I HEREBY AFFIRM UNOER PENALTY OF PERJURY THAT IAM LICENSED UNDER PROVISIONS OF CHAPTER
(COMMENCING WITH SECTION 70M) OF DIVISION a OF THE BUSINESS AND PROFESSIONS CODE, AND
�Y LICENSE 13IN FULL FORCE AND EFFECT.
LICENSE CLASS LIC, NO,
DATE CONTRACTOR
WORKERS' COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
l NAVE ANG WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELF -INSURE FOR WORKERS'
�COMPENSAT",AS PROVIDED BY SECTION 3700 OFTHE LABOR CODE, FOR THE PERFORMANCE
OFTHE WORK FOR WHICH THIS PERMIT IS ISSUED.
_IHAVEAND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE;AS REQUIRED BY SECTION
3700 OF THE LABOR CODE, FORTHE PERFORMANCEOF THE WORX FOR WHICHTHM PERMIT IS
ISSUED.
MY WORKERS' COMPENSATION LNSURANCE CARRIER AND POLICY NUMBERARE:
CARRIER
POLICY NUMBER
irwrecToN NEEoNOTBEOOI,IFLETEDcf!t EPETw IS rOna4EHMDREODOUARS(510D)ORLEs4
1 CENTIFYTHAT INTHE PERFORMANCE OFTHE WORK Pon WHICH THIS PERMIT IS ISSUED, I
SHALLNOT EMPLOYANY PERSON IN ANY MANNER SOASTO BECOME SUELkOTTOTHE
WORKERS' COMPENSATION LAWS OF CALIFORNWAND AGREETHAT IFL SHOULD BECOME
SUBJECT TO THE WDRKLRs' COMPENSATION PROVISIONS OF SECTION 37000F THE LABOR
CODE, I SHALL FORTHWITH COMPLY WITHTHOSE PROVISIONS.
DATE; APPLICANT. .
WARNING: FAVDRETO BECDRE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL,AND 8HALi8Li
SUBJECT AN EMPLOYEnTO CRIMINAL PENALTIES AND CIVILFINES UPTO ONE HUNDRED THOUSAND
DOLLARS ($100,000), IN ADDMONTOTHE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 370E OF THE LABOR CODE, INITHESTANDATTORNEY'S FEES, -
CONSTRUCTION LENDING AGENCY
I HEREBY AFFIRM UNOER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED (SEC. 3087, CIV. C.).
LENDER'S NAME
LENDER'S ADDRESS
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THATTHE ABOVE INFORMATION IS CORRECT.
1 AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
CONSTRUCTION, AND HEREBY AUTHORIZE RFPRESENTATIVES OF THIS COUNTY TO ENTER UPON THE
ABOVE -MENTIONED PROPERTY FOR INSPECTION PURPOSES.
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PERMITTEE NAME (PRR4T) �.":. • t [ r,
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IGNATURF:O�PERMITTEE.:.-, xM;"-'' ...� DATE
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WHITE —Department Copy, YELLOW —Finance Copy, PINK —Assessor Copy, GOLDENROD —File Copy, GREEN Applioanl's Copy
CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY
APPLICATION PERMIT P/C a
DATE NUMBERy
ISSUE _ TYPE OCC
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DATE CONST GROUP
ZONING SETBACKS
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NO. DWEL NO. NO.
UNITS STORIES BEDROOMS
DESCRIPTION
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FACTOR PSF
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F ADD/MM
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ELECTRIC k --. a e.y> < 1f
PLUMBING XR F- - ( `
MECHANICAL
INSPECTION FEE
ISSUANCES
SMIP" -
ENERGY PIC V sz)
ENERGY PERMIT +
RETENTION FEE:
PRE-ALT FEE:
TOTAL FEES 1 1'� q .�, F 1'e.:�' •=`E
COMMENTS
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RECP NO. _-?aL PAID BY E VALIDATION
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ft*07 CITY OF DIAMOND BAR
,,7 . °
= it , ism"i ilw INSPECTION RECORD
SET BACK
FTGS/FQRMS/STEEL
ELECTRIC GROUND LAP4A
GROUND PLUMBING
SLAB GRADE
TEMP POWER
WATER SERVICE
ROOF SHEATHING
FRAMING/VENTILATION
ROOF COVER
ROUGH HEATING _.
ROUGH ELECTRIC - T
ROUGH PLUMBING
SHOWER/TUB TEST
EXT. LATH/SIDING
WALL INSULATION
CEILING INSULATION
DRYWALL NAILING
SEWER "--
SEPTICTANK T^-
SEEP PIT/L.L.
GAS AIR TEST
FINAL CONST. -
FINAL HEATING
FINAL ELECTRIC
FINAL PLUMBING
FINAL PLANING
FINAL ENGINEERING
COMMENTS
SEPTIC TANK SIZE ✓ 7c) i r ;
SEEP PIT/U SIZE
_FI_OOR JOIST
FHA REQMTS
UNDER FLOOR DUCT --
UNDER FLOOR CONDUIT__
FIREPLACE FOUNDATION__
FIREPLACE BOND BEAM
MID HT. BOND BEAM -
8 FT, BOND BEAM
FINAL BOND BEAM"
PRE-G_RADiNG
BENCHING
ROUGH GRADING
FINISH GRADING
POOL ELECTRIC
POOL FENCING
POOL FINAL
OFF SITE IMPS.
DEDICATIONS
FINAL ENG.
LANDSCAPEABRIG.
ON SITE IMPS.
FINAL ZONING
FIRE DEPT. FILIAL
HFALTH DEPT, FINAL
DEV. FEES PAID
ENERGY