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CTTY OF DIAMOND BAR
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21825 E.Copley Drive
(909)860-3195 Fax(909)861-3117 PRESS
'�� BUILDING PERMIT APPLICATION FIRMLY
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r �� � APPLICATION PERMIT p/C
o ADDRESS � DATE �-I D � E NUMBER � #
� APN LOT TRACT ISSUE TYPE OCC
DATE �� U�- CONST. GROUP
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o ADDRESS �, _ _ ,L3 6l✓F�EJc1 ZONING SETBACKS
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a ADDRESS NO.DWEL. NO. NO.
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� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREA/VALUATION
� OWNER-BUILDER DECLAAATION
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p I HEREBV AFFIqM UNDER PENALTY OF PEPJURV THAT 1 AM EXEMPT FROM THE CqNiRACTORS LI- G8f8JB/CafpOff
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U �Jp/J`/WHICHREOUIRESAPERMITTOCONSTRUCT,ALTER,IMPROVE,OEMOLISH,ORREPAIRANV;TRUC- W
w TURE,PRIOR TO ITS ISSUANCE.ALSO REOUIRES THE APPLICANT FOR SUCH PERMIT TO FILE A SIGNED w Patlo/Deck
� STATEMENT THAT NE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CANTRACTORS LI�
� CENSE UW(CHAPTER Y(COMMENCINO WITH SECTION 7000)OF DIVISION 3 OF THE BUSINESS AND PRO� � POOVSPB
� FESSIONSCODE)ORTHATHEORSHEISE%EMPTTHEREFROMANOTHEBASISFORTHEALIEOEDEXEMP- (�
V TION.ANV VIOLATqN OF SECTION 70�7.5 BY ANV APPLICAN�FOR A PERMIT SU9JECT5'(HE APPLICANT TO Z Re-Root •
A CIVIL PENALTV OF NOT AqRE THAN FIVE HUNDRE�DOlLARS(f5a0�.): �
� ❑I,ASOWNEROFTNEPROPERTY,OHMVEMPLOYEESWITHWAGESASIHEIRSOLECOMPENSAT'iON, � COrt1fi18fCi8I
Z WIIL DO THE WORK,AND THE STRUCTURE IS NOT INiENDED ON OFFERED fOR SALE(SEC.70as,BU51� J
� NE55 AND PROFESSIONS CODE:THE CONTRACTORS LICENSE UW DOES NO'APPLV i0 AN OWNER OF �
PROPERTY NRiO BUILDS OR IMPROVES THEREON,AND WHO DOES SUCH WORN HIMSELF OR HEHSELF OR
w TMROUGH HIS OR HER OWN EMPLOVEES,PROVIDED THAT SUCH IMPFlOVEMENTS ARE NOT INTEN�ED OR m
0 OFFEREDFORSALEIF,MOWEVER,7HEBUILDINOORIMPROVEMEN71550LDWITHINONEVEAROFCOMPLE�
Z TqN,THE OWNER-BUILDER WILL HAVE TNE BURDEN OF PROVING'HA7 HE OR SHE DID NOT BUILD OR
� IMPROVE FOR THE PURPOSE OF SALE).
w OI,ASOWNEROFTHEPROPERTV,AMEXCLUSIVELYCONTRACTINGWfTHLICENSEDCANiRACTORS
� 70 CONSTRUCT iHE PRQIECT(SEC.7aN,BUSINESS AND PROFESSIUNS CODE:THE COMRACTORS LI� V01118t1Of1 � ADJ.AREA '
W CENSELAWDOESNOTAPPLYTOANONRJEROFAPROPERiVWHOdUILD50RIMPROVESTHEREON,AND
� NM1iOCONTRACTSFORSUCNPR0.1ECT5WITMACONTRACTOR(5)I.ICENSEDPURSUANTTOTHECONTRAG QUANTITY DESCRIPTION FEE
TOqS UCENSELAW.).
� O I AM E%EMPT UNDER SFC. 8.8 P.C.FOR THIS REASON Q
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� DA7E OWNER H
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� LICENSED CONTRACTORS bECLARATION w
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I HEREBY AFFIqM UNDER PENALTY O'PERIURV THAT I AM LICENSED UNDER PROVi510N5 OF CHAPTER � � /��
� V(COMMENCWO WITH SECTION 7000 OF DIVISION�OF THE BUSINE55 AND PP.OFESSIONS CODE,AND Z
�� MY UCENSE IS IN FULL FORCE AND EFFECT, m
� LICENSE CLASS C b� UC.NO. _��'G��w �
U DATE �0 Z CONTfiACTOR �� S� /Q�I/ArE�C d
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� WORKERS'COMPENSATION DECLARATION � Q
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� I HEREBY AFFIRM UNDER PENALTV OF PERJURV ONE OF THE fOILOWING DECLARATIONS: Z �
� _I HAVE M!D WILL MAINTAIN ACEHTIFICATE OF CONSENTTO SELF�INSURE FOR WOflKERS' ¢
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COlAPENSATqN,AS PROVIDE�BV SECTION 370o OF THE IABOR CODE.FOR THE PERFORMANCE U
OF THE WORK FOR WHICH THIS PEPMIT IS ISSUED. w
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w �1 HAVE AND WILL MAINTAIN WORKERS'COMPENSATION INSUMNCE.AS REOUIFlED BV SECTION
Q 370o OF THE LABOR CODE,FOR THE PERFORMANCE OF THE WORK FOR WHICH THIS PEHMIT IS �
ISSUED.MY WORKERS'COMPENSATION INSURANCE CARRIER AND POLICV NUMBER AAE: CONSTRUCTION
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� CARRIER T � Fd/'�O PLAN REVIEW �
Z POLICV NUMBER_���I y ELECTRIC
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o (nussEcr�r�raiee�n,wF'rIDOFn+ea�aur�sra�or�E�000u.uis�s,ro)oa�Ess). PLUMBING . - -
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Z �CERTIFV THAT IN THE PERFORMANCE OF THE N'ORK FOR WHICH THIS PERMIT IS ISSUEO.I MECHANICAL
C•} SHALL NOT EMPLOV ANV PERSON IN ANV MANNER 50 AS TO BECOME SUBIEf.T TO THE
(/j WORKERS'COMPENSATION UWS OF CALIFORNIA,AND AGREE THAT IF 1 SHOULO BECOME INS?ECTION FEE
= SU&IECTTO THE WORNERS'COMPENSATION PROVISbNS OF SECTION 3700 OF THE OR �
CODE,I SHALL FORTHWITH COMPLV WITH THOSE P OVISIONS. ISSUANCE 6
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p DA7E:�L`s�"APPLICANT: SMIP
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J WARNING:FAILURE TO SECURE WORKERS' PENSAT N COVERAG UNLAWFUL,ANO SHALL BE ENERGY P/C
LL SUBJECTAN EMPIOVER TO CRIMINAL PENALTIES AND CfVIL FINES UP IOONE HUNOPED THOUSAND ENERGY PERMIT
DOlURS(S10o.000),IN ADDITION TO THE COST OF COMPENSATION,DAMAGES A$PROVIDED FOR IN
� SECTION 3'!OE OF THE LABOR CODE,INTEREST,AND ATTORNEv'S FEES.
w RETENTION FEE: ( G�
O - CONSTRUCTION LENDING AGENCY PRE-ALT FEE: �
� I HEFEBV AFFIRAI UNDER PENALTV OF PERIURV TMAT THERE IS ACANSTRUCTION LENDING AGENCV
� FOR THE PERFOFMANCE OFTHE WORK FOR WHICH THIS PERMIT IS ISSUE�(SEC.300],CIV,C.).
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� LENDER'S NMIE
F— LENDER'SADORESS
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w I CERTIFY THAT I HAVE READ THIS APPLICATION AND STATE THAT TME ABOVE INFORMATION IS CARRECT. TOTAL FEES �
� I AGREE TO CAMPLV WITH ALL CITV AND COUNTV ORDINANCES AND STATE UWS REUTING TO BUILDING .
� CONSTRUCTION,AND HEREBV AUTHORIZE REPRESENTATIVES OF THIS CWNTV TO ENTER UPUN THE
Z ABOVE�MENTIONED 7ROPERTV FOH INSPECTION PURPOSES. COMMENTS
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¢ PERAIITTEE NAME � �/Q �
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� SIGN OF PER EE DATE
= RECPT.�O. PAID BY �ALIDATION
~ WHITE-0epartment Copy,YELI.OW—Finence Copy,PINK—Assessor Copy,GOLDENROD—File Copy,GRE N—Applicent's Copy
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FTGS/FORMS/STEEL � FHA REQMTS
ELECTRIC GRnUND ___ �__ i UNDER FLOGR DUCT _
GRCaUND PLUMBING UNDER FLOOR CUNQUIT• .
SLAB GRADE FIREPLACE F(JUNDATION ' V
TEMP POWER FIREPLACE BOND BEAM
WATER SERVICE ` MIQ HT. E30ND BEAM'
ROOF SHEATHING 8 F-f�. BOND BEAM � •
FRAMINGNENTILIATION FiNA�F30ND BEAM
ROOF COVER PRE-GRAaING
ROUGH HEATiNG BENCHINC
ROUGH ELECTRIC , ROUz,H GRADING
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SHOWER/TUB TEST •—f POOL ELECTRIC �
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WALL INSULATION A POQL FINAL
CEILING INSULATION OFF SITE IMPS.
RRYWALL NAIUNG DEDICl�T1C7NS
SEWER � FINAL ENG. ��
SEPTIC TANK LANDSGAPE/IRRIG. �
SEEP PfT/L.L V ON S4TE IMPS.
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FINAL CONST. � �,l� FIRE DEPT. FtNAL
FINRL HEATING I HEALTH QEP7. FINAL
FiNAL ELEGTRIC � ! QEV. FEES PAID ^
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