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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
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ADDRESS Go94'5 1GQL0M5PPI`,L, V XIVE
APN LOT TRACT
OWNER
ADDRESS 100 N • P.11Plrt"l CA 511 rm -Zoo
CITY W-("0VIt4A, ZIP n9 TEL.
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APPLICANT �fNt7)1=]LF WN� TEL71
CONTRACTOR ILSPEn 1Nl K; CM457"GTtO N
ADDRESS
CITY !Zft-iT Afv ZIP _92J TEL
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DESIGNER U
ADDRESS .7
CITY 1h A 4jIffHi- ZIP4/� TEL
OWNER -BUILDER DECLARATION
I HERESY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS U-
CENSE LAW FOR THE FOLLOWING REASON (SEC. 7031.6 BUSNESSAND PROFESSIONS CODE:ANY CITY OR
COUNTY WINCH REOLARESA PMMrTTO CONSTRUCT.ALTER IMPROVE, DEMOLISH. OR REPARANY STRUC-
TURE, PRIOR TO RS 16SVM10E, ALSO REWIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PRCVSKOIS OF THE CONTRACTORS LI
CENSE LAW (CHAPTER 9 ICOMMENCINO WITH SECTION 7000) OF DIVISION S OF THE BUSINESS AND PRO-
FESSIONS CODE) OR THAT HE OR SHE IS EXEMPT THEREFROM ANDTHE BASIS FOR THE ALLEGED EXEMP-
TION. ANY VIOLATION OF SECTION 7031.E BY ANYAPPUCANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (6500).):
❑ LASOWNER OF THE PROPERTY.OR MY EMPLOYEES WITH WAGES AS THEIR SOLE COMPENSATION,
WALL DO THE WORK AND THE STRUCTURE IS NOT INTENDED OR OFFERED FOR SALE (SEC. 7/41, BUSI-
NESS AND PROFESSIONS ODOE: THE CONTRACTORS LICENSE LAW DOES NOT APPLY TO AN OWNER OF
PROPERTY WI/0 BUILDS OR IMPROVES THEREON. AND WHO DOES SUCH WORT HIMSELF OR HERSELF OR
THROUGH W S OR HER= EMPLOYEES, PROVIDED THAT SUCH IMPROVEMENTS ARE NOT MENDED OR
OFFERED FOR SALE 6.HOWEVER THE BIJUNG OR IMPROVEMENT tSSOLD WITHIN ONE YEAROFCOMPLE-
TION, THE OWNER -BOLDER WALL HAVE THE BURDEN OF PROVING THAT HE OR SHE 010 NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE),
O L AS OWNEROFTHE PROPERTY. AM EXCLUSIVELY CONTRACTOO WITH LICENSED CONTRACTORS
TO CONSTRICT THE PROJECT (SEC. 70N, BUSINESS AND PROFESSIONS CODE: THE CONTRACTORS LH
CENSE LAW DOES NOT APPLY TO AN OWNER OF A PROPERTY WHO BUMS OR IMPROVES THEREON. AND
WMOCONTAACTS FOR SUCH PROJECTS WITH ACONTRACTONS) LICENSED PURSUANT TOTHE CONTRAC-
TORS LICENSE LAW.J.
O 1 AM EXEMPT UNDER SEC. B. t P.C. FOR THIS REASON
DATE! OWNER
LICENSED CONTRACTORS DECLARATION
1 HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT LAM LICENSED UNDER PROVISIONS OF CHAPTER
a ICOMMENCNG WITH SECTION 7000) OF DMSKON S OF THE BUSINESS AND PROFESSIONS CODE, AND
MY LICENSE IS N FILL FORCE AND EFFECT.LICEN
b SE w
DATE lX1ASS + DcONTMCTORjLc-1AIIV� IYJIrST.
WORKERS' COMPENSATION DECLARATION
I HERCBYAMRM UNDER PENALTY OF PERJURY CNE OF THE FOLLOWING DECLARATIONS:
I HAVE AND WILL MAINTAIN A CERTIFICATE OF CONSENT TO SELFJNSURE 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 REWIRED BY SECTION
3700 OF THE LABOR OOOE, FOR ME PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS
ISSUED, MY WORKERS' COMPENSATION INSURANCE CARRIER AND POLICY NUMBER ARE:
CARRIER 19F EE uAI`�
POLICY NUMBER ,
(R6S SECTION NEED NDTBECOMPLErEDOFTHE POW 6FORONEI ALMDOLLARS R+ar)OnUES%
I CERTIFYTHAT LATHE 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 IFORNIA AND AGREE THAT IF I SHOULD BECOME
SUBJECT TO THE WORKERS=P0FNSA PROVISIONS OF SECTION 3700 OF THE LABOR
CODE.I SNAIL FORTHWITH COMPLY WI PROVISIONSr,•,
DATE: O� APPLICANT 1
WARNING: FAILURE TO SECURE WORKE COIJPENS ION COVERAGEIS UNLAWFUL. AND SHALLBE
SUBJECT AN EMPLOYER TO CRIMINAL PEN VLFNESUP TO CNE MUNDR[D THOUSAND
DOLLAR.S(S100,000). N ADOMON TO THE COST OF ENSATKON. DAMAGES AS PROVIDED FOR IN
i SECTION 3708 OF THE LABOR CODE, INTEREST. AND ATTORNEY'S FEES.
CONSTRUCTION LENDING AGENCY
I NEREBY AFFInM UNDER PENALTY OF PERJURY THAT THERE IS A CONSTRUCTION LENDING AGENCY
FOR THE PERFORMANCE OF THE WORK FOR W KICII THIS PERMIT IS ISSUED (SEC. $097. CIV C.).
LENDERS NAME
LENDER'SADDRESS
I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
1 AGREE TO COMPLY WITH ALL CITY AND COUNTY ORDINANCES AND STATE LAWS RELATING TO BULGING
CONSTRUCTION• AND HEREBY AUTHORIZE REP RESENTATNES OF THIS COUIMTYTO ENTER UPON THE
ABOVE -MENTIONED PROPERTY FOR INSPECTION PURPOSES.
I
PERMITTE E (PRINT) f l
O/091GNATUREO DATE
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FIRMLY
APPLICATIO77�C Q �� PERMIT PICoaa,36
DATE // .J NUMB& X J
ISSUE TYPE OCC
DATE CONST. GROUP
ZONING SETBACKS ` I
FRONT L' `RW ❑
REAR ❑
SIDE/SIDE STREET RW ❑
SIDE ❑
_Lj
PROPOSED US A �►. N 4
NO. DWEL. NO. NO.
UNITS STORIES BEDROOMS
DESCRIPTION
SO. FT.
FACTOR PSF
ADJ. AREA/VALUATION
SFR/ADD/REM
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Garage/Carport
W
Patlo/Deck
LL
POOVSpa
ZRe
-Roof
Commercial
-
m
PIDD ADJ.AREA
Valuation Z*
QUANTITY
DESCRIPTION
FEE
v
Z
1
v
S,23
4
U
Q
W
CONSTRUCTION
PLAN REVIEW
ELECTRIC
PLUMBING
MECHANICAL P.
INSPECTION FEE
ISSUANCE 1_)IAM'ONT) R
SMIP 13(m TNr ?.;T)
ENERGY PIC
ENERGY PERMIT a1A
RETENTION FEE:
PRE-ALT FEE: ^
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TOTAL FEES
COMMENTS
ell
RECPT. NO. PAID BY VALIDATION
3 WHITE --Department Copy, YtLLUw-4•InanC9 L:OW. FIN&—AAsaessar wpy, uuLULNHUL/ IIEI L,OPW, U"rL:N—nppllcanI 5 L.Opy I
CITY OF DIAMOND BAR
INSPECTIONRECORD
is
;FIGS/FORMS/S
?70 0
524' -
FLOOR JOIST_,
FHA P,EQMTS
;ELECTRIC GROUND... ..
=
UNDER FLOOR DUCT
_
.GROUND PLUMBING
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UNDER FLOOR CONDUITS•:
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ISLAB GRADE . ..__
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FIREPLA'CE'FOUtJDQ ,ION
'TEMP POWER, _.. -
FIREPLACE DdS D`EiEAM f
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FRAMING,NENTILIATION
FINAL BOND BEAM
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PRE -GRADING .,.
TROUGH HEATING
IROUGH ELECTRIC_ i
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ROUGH GRADING
FINISH GRADING
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;ROUGH PLUMBING
'SHO✓VERJTUB TEST
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POOL ELECTRIC
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POOL FENCING
(WALL- INSULATION
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POOL FINAL
ICEILING INSULATION. m
OFF SITE IMPS.
IDRYWAL.L NAILING—
DEDICATIONS
;SEWER .. - ..
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FINAL ENG.
;
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ISEPTIC TANK
LANDSCAPE/IRRIG:
;
PIT/L.L. ....
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ON SITE IMPS.
JSEEP.
C-,AS AIR TEST
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FINAL ZONING
:FINAL. CONST .' _.- .
FIRE DEPT. FINAL
;FINAL HEATING
c:?
HEALTH DEPT. FINAL
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IFINAL ELECTRIC' .:�
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DEV. FEES PAID
;i:;i,1t. PLUMBING ., . .......
ENERGY
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CQP��P✓JENTS S.
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SEPTIC TANK SIZE- .mm
SEEP PIT/U SIZE
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