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CITY OF DIAMOND BAR
DEPARTMENT OF COMMUNITY & DEVELOPMENT SERVICES
21825 Copley Drive, Diamond Bar, CA 91765
909) 839-7020 Fax (909) 861-3117 Building Inspection Hotline (909) 839-7027
BUILDING PERMIT APPLICATION
JOBSITE
ADDRESS '2 3 f 1 G I c Pruk C IO t
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APN LOT TRACT
OWNER
ADDRESS2Td11 6=#QLj5±1
CITY 0144Vc Cw, ZIP 9(2" TIrL. 94)
APPLICANT T61j4g4 2!4 6Aj!Zb, TELIC a
CONTRACTOR 471
ADDRESS
CITY - ZIP 992re TEL. 40ef
ARCH/ENG/ <f Es -47200
DESIGNER
ADDRESS
CITY ZIP TEL.
OWNER -BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT 1 AM EXEMPT FROM THE CONTRACTORS LI-
CENSE LAW FOR THE FOLLOWING REASON (SEC. 7031.6 BUSINESS AND PROFESSIONS CODE: ANY CITY OR
COUNTY WHICH REWIRES A PERMIT TO CONSTRUCT, ALTER, IMPROVE, DEMOLISH, OR REPAIR ANY STRUG
TUBE, PRIOR TO ITS ISSUANCE, ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS UCENSED PURSUANT TO THE PROVISIONS OF THE CONTRACTORS LI-
CENSE LAW (CHAPTER B (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 FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (5500).):
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 WfTHIN 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).
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 A CONTRACTORS) LICENSED PURSUANT TO THE CONTRAC-
TORS LICENSE LAW.).
1 AM EXEMPT UNDER SEC. B. 8 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
D (COMMENCING WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE, AND
MY LICENSE IS IN FULL FORCE AND EFFECT. ^
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LICENSE CLASS L"Z.o LIC. NO. J I fT-f
DATE 6 -('F1 -0X CONTRACTOR -7 ,k ,faJY7 4- N76'
WORKERS' COMPENSATION DECLARATION 1-9--
1 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
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 AND POLICY NUMBER ARE:
CARRIER 5Twirl FL,
POLICY NUMBER 1? %4 -7 4 R i X00 Q
THIS SECTION NEED NDT BE COMR ErED OFTFE PERMIT IS FOR ONE HUNDRED DOLLARS (5100) OR LESS)
I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I
SHALL NOT EMPLOY ANY PERSON W 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 37GO OF THE LABOR
CODE, I SHALLFORTHWITHCOMPLY WITH ISE PROVISIONS.
DATE: -l`r ~ v APPLICANT: /
WARNING: FAILURE TO SECURE WORKERS' COMPEN TI COVERAGE IS UNLAWFUL, AND SHALL BE
SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS (5100,000), 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. 3087, CIV. C.).
LENDER'S NAME
LENDERS ADDRESS
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
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.
PERMITTEE NAME (PRINT)
SIGNATURE OF PERMITTEE DATE
PRESS
FIRMLY
APPLICATION PERMITJ P/C
DATE (/ NUMBER L Z / #
ISSUE TYPE OCC
DATE CONST. GROUP
ZONING SETBACKS
FRONT RW
REAR
SIDE/SIDE STREET RW
SIDE
PROPOSED USE
NO. DWEL. NO. NO.
UNITS STORIES BEDROOMS
DESCRIPTION SO. FT FACTOR PSF ADJ. AREAIVALUATION
SFR/ADD/REM
C/) Garage/Carport
WPatlo/Deck
LL
0
Pool/Spa
Z Re -Root
Commercial
m
Valuation ADJ.AREA
QUANTITY DESCRIPTION FEE
JQU
tYHUw
w
EDZ_
m
d
ZQ V k1
w/ o m B u• JSr!,
CONSTRUCTION
PLAN REVIEW
ELECTRIC
PLUMBING
MECHANICAL
INSPECTION FEE
ISSUANCE •
SMTP
ENERGY P/C
ENERGY PERMIT
RETENTION FEE:
PRE -ALT FEE:
TOTAL FEES 7
COMMENTS
RECPT NO. AID BY I VALIDATION
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CITY OF DIAMOND BAR
INSPECTION RECORD
SET BACK FLOOR JOIST
FTGS/FORMS/STEEL FHA REQMTS
ELECTRIC GROUND UNDER FLOOR DUCT
GROUND PLUMBING UNDER FLOOR'CONDUIT' `
SLAB GRADE FIREPLACE FOUNDATION
TEMP POWER FIREPLACE BOND BEAM
WATER SERVICE MID H'T. BOND BEAM
ROOF SHEATHING 8 FT. BOND BEAM
FRAMING/VENTILATION 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
FINAL HEATING 1---
FIRE DEPT. FINAL
HEALTH DEPT. FINAL
FINAL ELECTRIC DEV. FEES PAID
FINAL PLUMBING ENERGY
COMMENTS
SEPTIC TANK SIZE
SEEP PIT/U SIZE
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