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� CITY OF DIAMOND BAR
DEPARTMENT OF COMMiJNITY&DEVELOPMENT SERVICES
w 21660 E.Copley Drive Suite 190
(909)86Q3195 Faa(909)861-3117 PRESS
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JOBSITE / APPLICATION ��a PERMIT P/C ({�
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� APN LOT l65 TRACT 2_5�187 DA EE � CONST. GROUP
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�n DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION
Q OWNER-BUILDER DECLARATION SFR/ApD/REM
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' p I HEREBV AFFIRM UNDER PENALTY OF PEfWRV THAT 1 AM EXEMP7 FROM THE CONTMCTORS ll- Gflf8Q0/CBfP01I
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� T1RE,PRIOR TO RS ISSUANCE,ALSO REOUIRES THE MPLICANT FOR SUCH PERMIT 70 FILE A SIQNED w
� STATEMEHT THAT HE OR SME 13 IJCENSED PURSUAN7 TO 7HE PROVISIONS OF hIE CONiMC70FiS L4 �
� CEN9E LAW(C1iAPTER Y(COMMENCMO WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO- POOUSPB
FESSqNSCODE)ORTHATHEORSHEISD(EMPTTHEREFROMANDTHEBASISf-0RTHEALLEQEDE%EMP- �
T10N.ANYVIOLATqHOFSECTION7031.6BVNIVAPPLICANiFORAPERMRSU&IECT9THEMPLIGWTTO Z Re-Roof
� ACML VENAL7Y OF NOT MORE THAN FNE NUNDRED DOLLARS(f500�.):
� OI,ASOVJNEROF7HEVROPERTI,ORMYEMPLOVEESWITHWAGESASTHEIRSOLECOIAPENSATqN, 0 COmmBfCi81 � '
MALL DO THE WORK,AND 7HE STRUCNRE IS NOT INTENDED OR OFFERED f-0R SALE(SEC.7oar,BU54 J
N NE9S AND PROFESSIONS CODE:THE CONTMCTORS UCENSE UW DOES NOT APPLV TO AN OWNER OF � �
PiqPEHTY N7q BULLDS OR W PROVES 7HEREON,M1D NMO DOES SUCH WORK HIMSELF OR HERSELF OR
� THROUGH H19 OR HER OWN EMDLOYEES,VROVIDED 7HAT SUCH 14PROVEMENTS ARE NO7 PITENOED OR m
Q OFFERmFORSALE1F,FqWEVER7HE&10.DINOORIMPHOVEMENTISSOLDWfTHWONEVEAROFCOMPLE�
Z �'TION,iHE OWNEH�UIIDER WILL HAVE 7HE BURDEN OF PROVINO 7HAT HE OR 6ME DID NOT BUfLD OR
� IMPROVE FOR 7HE PURP0.SE OF SALE�
�y,� O 4��MMER OF THE PROPEfifY,AM IXCLU9NELV CAMRACTPIO WITH IICENSED COMMC70RS
� TO CONS7RUCT hIE PqOJECT(SEC.7osa,&1SINESS AND PROFESSIONS CODE:THE CONTRACTORS U- V81U8�1On qp,J,qqEq
CENSE UW DOES NOTMPLY TO AN OMNER OF A PROPEHTV WFIO BURDS OR IMPROVE9 7HERC-0N,AND
� NTIOCONTMCT9FORSUqiPHWECTSWITHACONTRACTOR�SjLICENSEDPURSUANTTOTHECONTMC- pUANTITY DESCRIPTION �E .
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� ❑I AM E%EMPT UNDER SEC. B.6 P.C.FOR THIS REASON �
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� � � LICENSED CONTRACTORS DECLAFlATION W
� I HEREBV AFFIRAI UNDEP PENALTV OF PERIURV TIAT I AM LICENSED UNDER PROVISIONS OF CHAPTER �
(� Y(COMMEHClq WITH SECTION 7000)Of DNISION 9 OF 7HE BUSINE55 AND PROFESSIONS CODE,AND Z �
X W LICENSE IS IN FULL FORCE AND EFFECT.
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� LICENSE CLASS LIC.NO. - �
U DATE CONTRACTOR d
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� � WORKERS'COMPENSATION DECLARATION a
� I HEREBV�FFlRM UNDER PENALTY OF PE0.)URY ONE OF 7HE FOLLOWINO DECLARATIONS: Z
� _IMAVE/WDWILLMAINTNHACERTIFICATEOFCONSENTTOSELF-INSUREf-0RWORKEHS' a
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Q COMPEHSATION,AS�ROV1Dm BV SECTION 370o OF 7HE LABOq COOE,FOR THE PEHFORMANCE U
OF T1/E WOPo(FOR WHICH THIS PERMIT IS ISSUED. W
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Q _I HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSURANCE,AS REOUIRED BV SECTION
'3700 OF THE IABOH COOE.FOH T/1E PERFOHIAANCE OF THE WORN FOR WHICM THIS PERMR IS ( �
� ISSUED.MV WOR)(ERS COMPENSATION INSUHANCE CARRIER AND POLICV NUMBER ARE: CONSTRUCTION
> CAARIER PIAN REVIEW �.�?2, ��
0 POLICV NUMBER
� ELECTRIC
� (nassEcnoNNE�MorBENA�LEr�oFnEPEw.�fswaotEFiIR�OR�ooua0.s(f�m)oqLESs} PLUMBING
Z 1 CERTIFV THA7 1N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERAIIT IS ISSUED.1 MECHANIC
(3 SHALL NOT EMPLOY ANY PERSON IN ANY MANNER SO AS TO BECOME SU&IECT TO THE
(n WORKER5 COMPENSATqN UWS OF CALIFOqNIA,AND AOREE THAT IF I S110ULD BECOME INSPECTIO F
S SUBJECT TO THE M/OH)(ERS'COMPENSATION PROVISIONS OF SECTION 37a00F THE LABOR
CODE,�SHALL WPTHWITH COMPLV WITH TFIOSE PROVISIONS. ISSUANCE ►
� SMIP •
p DATE: � APPLICANT.
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J WARNINO:FAILURE 70 SECURE WORKERS'COMPENSATION COVEMGE IS UNLAWFUL,AND SHALL BE ENERGY P/
� SUBJECTAN EMPLOYER TO CRIMINAL PENA�TIES AND CML FINES UP TO ONE HUNDRED THOU9AND ENERGY P '�.T
DOLLARS(f100.000),W/�DDITION TO THE CQST OF COMPENSATION,DAMAOES AS PROVIDED FOR IN •y:
� SECTqN 370E OF THE UBOR CODE,w7ERE5T.AND ATTORNEV'S FEES. � RETENTION 1
d CONSTRUCTION LENDING AGENCY PRE-ALT FEE:
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� I HEREBY AFFIRM UNDER VENALTV OF PERIURV THAT THERE IS A CONSTRUCTION LENDINO AOENCV
FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PEfiMR IS ISSUED(SEC.3007,CfV.CJ. . ,
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� LENDERS NAME
F— LENDERSADDRESS
� TOTAL FEES � �D. •
¢ I CERT THAT I HAVE REM THIS APPUCATION AND STATE 7}IAT 7HE ABOVE INFORMATqN IS CORRECT.
W I AOR TO COMPLV WITH ALL CRY M!D COUNTY ORDWANCES AND STATE UWS REUTINO TO BUIlAWO ,
� RUCTION,AND HEFEBY AUIHORIZE REPRESENTA7NE5 OF THIS COUNTV TO ENTER UPON iTiE '
Z E�MENTIONED PROPER7V FOR INSPECTION PURPOSES. �
Q � � COMMENTS
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IO NR OF PERAIITTEE D�7E RECPT.N0. �PA1D BV VALIDATION
� WHITE—DepaRment Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GREEN—ApplicanY Copy
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FTGS/FORMS/STEEL � � � - FHA REQMTS � ' '
ELECTRIC GROUND � � UNDER FLOOR DUOT =• • '
GROUND PLUMBING UNDER FLOOR COMDUIT ' ' ' '
SLAB GRADE FIREP CE FO11Np�:TION � �.� � �
TEMP POWER FIREPLACE BOND BEAM -• ' � - � ..
WATER SERVICE MID HT. BOND BEAM
ROOF SHEATHfNG . - 8 FT. BOND BEAM
FRAMINGNENTILIAi'ION FINAL BOND BEAM
ROOF COUFR PRE-GRADING
AOUGH HEAT1iVG BENCHING .
R�UGH ELECTRIC ROUGH GRADING "
ROUGH PLUtv1BING FINISH GRADING
SNOWERlTUB TEST POOL ELECTRIG
EXT. IATH/S�DING � -� POOL FENCING
WALL INSULATION P�OL FINAL
CEILING If�lSULATION OFF SITE IMPS. -
DRYWALL NAILING DEDICATIONS
SEWER FItVAL ENG.
SEPTIC TANK lANDSCAPE/IRRIG.
SEEP P1TJL.L. ! '� ON SITE IMPS.
GAS A1R TEST FINAL ZONING
FINAL CONST. FIRE DEPT. FINAL
FlNAL HEATING HEALT'H DEPT; FINAL ..
FINAL ELECTRIC DEV. FEES PAID �
FlNAL PLUMBING ENERGY
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SEPTIG TANK SIZE � . ��_,,
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