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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
JOBSITE p
ADDRESS ` e
APN LOT TRACT
OWNER
ADDRESS
CITY I�G ZIP TEL.
APPLICANT TEL.
CONTRACTOR
ADDRESS
CITY ZIP TEL.
AR �
DES! ERViQ rlSc�t.�
ADDRESS
CITY ZIP TEL.
OWNER -BUILDER DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM EXEMPT FROM THE CONTRACTORS LN
CENSE LAW FOR THE FOLLOWING REASON (SEC. 7031.6 BUSINESS AND PROFESSIONS CODE: ANY CITY OR
COUNTYNMICH REQUIRESA PERMIT TO CONSTRUCT, ALTER, IMPROVE, DEMOLISH, OR REPAIR ANY STRUC-
TURE. PRIOR TO ITS ISSUANCE, ALSO REQUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED
STATEMENT THAT HE OR SHE IS LICENSED PURSUANT 70 THE PROVISIONS OF THE CONTRACTORS LI-
CENSE LAW (CHAPTER Y (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 7MI.6 BY ANY APPLICANT FOR A PERMIT SUBJECTS THE APPLICANT TO
A CIVIL PENALTY OF NOT MORE THAN FIVE HUNDRED DOLLARS (SSW).):
❑ 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 BURDWG OR IMPROVEMENT IS SOLD WITHIN ONE YEAR OF ODMPLE-
TION, THE OWNER -BUILDER WILL HAVE THE BURDEN OF PROVING THAT HE OR SHE DID NOT BUILD OR
IMPROVE FOR THE PURPOSE OF SALE).
❑ L AS OWNER OF THE PROPERTY, AM EXCLUSIVELY CONTRACTING WITH LICENSED CONTRACTORS
TO CONSTRUCT THE PROJECT (SEC. 70H, BUSINESS AND PROFESSIONS COOS THE CONTRACTORS LI-
CENSE LAW DOES NOT APPLY TO AN OWNER OF PROPERTY WHO BUILDS OR IMPROVES THEREON, AND
WHO CONTRACTS FOR SUCH PROJECTS WITH ACONTRACTOR(S) LICENSED PURSUANT TO THE CONTRAC-
TORS LICENSE LAW.).
❑ 1 AM EXEMPT UNDER SEC. B. a P.C. FOR THIS REASON
DATE OWNER
LICENSED CONTRACTORS DECLARATION
1 HF-6)EBY AFFIRM UNDER PENALTY OF PERJURY THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER
Y (� JMMENCWO WITH SECTION 7000) OF DIVISION 3 OF THE BUSINESS AND PROFESSIONS CODE, AND
L/Y LICENSE IS IN FULL FORCE AND EFFECT.
LICENSE CUSS LIC. NO.
DATE CONTRACTOR
WORKERS' COMPENSATION DECLARATION
I HEREBY AFFIRM UNDER PENALTY OF PERJURY ONE OF THE FOLLOWING DECLARATIONS:
_ I HAVE AND WILLMAINTAIN A CERTIFICATE OF CONSENT TO SELF -INSURE FOR WORKERS'
COMPENSATION, AS PROVIDED BY SECTION 37DO OF THE LABOR CODE, FOR THE PERFORMANCE
OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.
1 HAVE AND WILL MAINTAIN WORKER5 COMPENSATION INSURANCE, AS REQUIRED BY SECTION
37000E 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
POLICY NUMBER
SECTION NIA NDT BE OON. PLETEDOFTFE PERMIT IS FORONE HUNORED DOLLARS (S10)) OR LESS).
I CERTIFY THAT IN THE 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
RKERS' COMPENSATION LAWS OF CALIFORNIA AND AGREE THAT IF I SHOULD BECOME
SUBJECT TO THE WORKERS' COMPENSATION PROVISIONS OF SECTION 37M OF THE LABO
CODE. I SH�AALL--''FORTHWITH COMPLY WIT PROVISION .
DATE:W APPLICANT: I
WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL AND SHALL BE
SUBJECTAN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSAND
DOLLARS ($100.000), IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR IN
SECTION 3700 OF THE LABOR CODE. INTEREST AND ATTORNEYS 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. 30Y7, CIV. C.).
LENDERS NAME
LENDER'S ADDRESS
I CERTIFY THAT I HAVE READ THIS APP TION AND STATE THAT THE ABOVE INFORMATION IS CORRECT.
1 AGREE TO WITH ALL CITY D COUNTY ORDINANCES AND STATE LAWS RELATING TO BUILDING
CONS 7 RIZE REP ENTATIVES OF THIS COUNTY TO ENTER UPON THE
IONE PROPERTY O C N P SUS.
PE /
F PE TTTE DATE
MAY 019 2003 PRESS
FIRMLY
APPLICATION
PERMIT
I
DATE_
1 J
NUMBER V # 1
ISSUE
TYPE OCC
DATE
CONST. GROUP
ZONING SFMACKS
FRONT RW ❑
REAR ❑
SIDE/SIDE STREET RW ❑
SIDE ❑
PROPOSED USE
NO. DWEL. NO. r7 NO.
UNITS �_ STORIES / BEDROOMS
DESCRIPTION
SO
FACTOR PSF
ADJ. AREA/VALUATION
SF DD EM
Cl)
Garage/Carport
WPatio/Dock
u
Pool/Spa
Z
Re -Roof
C1
Commercial
-
m
Vetuati ADJ.AREA
QUANTITY
ESCRIPTI
FEE
U
A
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N
U
W
LU
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0
Z
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U
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CONSTRUCTION Ji
PLAN REVIEW
ELECTRIC
PLUMBING
MECHANICAL
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INSPECTION FEE
ISSUANCE
SMIP
ENERGY P/C
ENERGY PERMIT -. JT-
RETENTION FEE:
R�2ALT FEE � ;
00
TOTAL FEES N
r
OMMEN
kRECPT.NO.
PAID VALIDATION
V / WHITE-0epartment Copy, YtLLUW—Finance L:opy, FINK —Assessor Copy, GOLDENROD —File Copy, GREEN —Applicant's Copy
/ J
CITY OF DIAMOND EAR
INSPECTION RECORD
SET BACK
FLOOR JOIST ,
4 `
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 HT. BOND BEAM
ROOF SHEATHING
8 FT. BOND BEAM
FRAMINGNENTILIATION
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
j
COMMENTS
fl-T
I
SEPTIC TANK SIZE
SEEP PIT/U SIZE
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IN